Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 17, Number 3, March 2026, pages 115-120

Perforated Small Intestinal Diffuse Large B-Cell Lymphoma Successfully Managed With Surgical Resection and Staged Introduction of Polatuzumab Vedotin-Based Chemotherapy

Figures

Figure 1.
Figure 1. Initial findings prior to chemotherapy: PET–CT, endoscopy, contrast study, and surgical specimen. (a) Maximum intensity projection image showing extensive FDG uptake throughout the abdomen and pelvis. (b) Axial PET–CT view revealing a large hypermetabolic mass in the terminal ileum (white arrow) with a maximum standardized uptake value (SUVmax) of 27.0. (c) Coronal PET–CT view demonstrating the same mass, confirming its extensive distribution in the pelvis (white arrow). (d) FDG-avid lymphadenopathy in the internal thoracic and left axillary regions (white arrows). (e) Axial view showing FDG uptake in the pelvis, suggestive of peritoneal thickening or mesenteric involvement (white arrows). (f) Transanal enteroscopy showing an ulcerated mass at the terminal ileum. Biopsy from this site confirmed the diagnosis of diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS). (g) Contrast enema revealing localized extraluminal leakage of contrast medium (outlined in red), indicative of a contained perforation into the mesentery. (h) Macroscopic appearance of the resected specimen. The tumor, measuring approximately 25 cm at its greatest dimension, involved the right hemicolon and a segment of the terminal ileum, forming a single confluent mass. It was resected en bloc, and partial necrosis was observed on macroscopic examination. The scale at the bottom of the image is in centimeters. PET–CT: positron emission tomography–computed tomography; FDG: fluorodeoxyglucose.
Figure 2.
Figure 2. Clinical course with serum LDH kinetics, tumor response on CT imaging. LDH levels are plotted against days from initial presentation (day 1). The patient underwent right hemicolectomy with partial resection of the ileum on day 16. Chemotherapy was initiated with rituximab on day 27, followed by CHP on day 31. Polatuzumab vedotin was added from day 44 onward, completing the transition to the Pola-R-CHP regimen. CT images at days 1, 26, 43, 59, and 80 (red circles) demonstrate changes in the size of the pelvic tumor lesion over time, corresponding with the treatment response. Tumor diameters are indicated below each image. Colored boxes and symbols represent chemotherapy agents: rituximab (blue triangle), CHP (yellow box), and polatuzumab vedotin + CHP (orange box). The black arrow indicates the timing of surgery; red arrows indicate CT/PET–CT evaluation time points; and the blue-green triangle indicates the episode of colitis with bacteremia. CHP: cyclophosphamide, doxorubicin, and prednisone; CT: computed tomography; LDH: lactate dehydrogenase; PET–CT: positron emission tomography–computed tomography.