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. Author manuscript; available in PMC: 2020 Oct 14.
Published in final edited form as: Clin Nucl Med. 2017 Nov;42(11):890–892. doi: 10.1097/RLU.0000000000001801

Lymphoma causing gastrosplenic fistula revealed by FDG PET/CT

Trent P Wang *, Mohan Doss †, Jeffrey Tokar ‡, Sanjay Reddy §, Stefan K Barta *, Jian Q Yu †
PMCID: PMC7556713  NIHMSID: NIHMS1634544  PMID: 28806244

Abstract

A 73-year-old man presented with fatigue and weight loss. He had CT-proven splenic mass with fistulous connection to the greater curvature of the stomach, which suggested abscess. FDG PET/CT-confirmed gastrosplenic fistula in addition to active lymph nodes in the gastrohepatic ligament and epigastric region. Pathological examination following the biopsy of the spleen was consistent with diffuse large B-cell lymphoma. Chemotherapy was administered with close clinical follow-up and resulted in the resolution of fistula without requirement for surgery.

Keywords: gastrosplenic fistula, lymphoma, FDG PET/CT

FIGURE 1.

FIGURE 1.

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Gastrosplenic fistula is a very rare. A 73-year-old man presented with fatigue and weight loss of 10 pounds in less than one month. Physical examination revealed splenomegaly, which prompted abdominal CT scan examination. The images at the spleen levels (A-C, from upper to lower) showed a 19 cm spleen with a centrally located splenic mass measuring 10.9 x 8.9 cm with fistulous connection to the greater curvature of the stomach (arrows). The findings suggested abscess.

Figure 2.

Figure 2.

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Considering that the most common cause of gastrosplenic fistula is lymphoma(1–10), FDG PET/CT scan was performed to evaluate possible malignancy(11–16). The maximum intensity project image (MIP, A) demonstrated a large heterogeneously increased activity in the left upper abdomen (large arrow), consistent with the known lesion in the spleen. In addition, there was additional activity (small arrow) in the midline upper abdomen. On axial PET (B), CT (C) and fusion (D) images, the known spleen lesion had peripherally increased activity (large arrow) with centrally photopenic region. The most intense activity was located in the region of gastrosplenic fistula (green arrowheads) with maximum standardized uptake value of 40.1. In addition, activity in the adjacent lymph node (small arrows) was also noted.

FIGURE 3.

FIGURE 3.

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Upper endoscopy (A) was performed, which revealed a cavitary and ulcerated mass in the gastric fundus with fistulization to the spleen with endoscope in a retroflexed position. The location of the gastric entrance of the fistula (yellow arrow) relative to the gastro-esophageal junction are visualized (green arrow) was presented. Pathological examination (B) of the biopsied fistula on the gastric side revealed diffuse large B-cell lymphoma (DLBCL), with proliferation index of ~90%.

FIGURE 4.

FIGURE 4.

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Given the concern for potential bleeding and perforation, a collaboration with a multidisciplinary team consisting of medical oncology, gastroenterology, surgery, and radiation oncology was established and a consensus of initial treatment with chemotherapy was reached. R-CHOP was administered with close clinical follow-up and resulted in the resolution of fistula without requirement for surgery. The MIP image (A) of the follow-up study showed normal tracer distribution. The axial CT (B) portion of the PET/CT showed adhesion between spleen and stomach (arrowhead) without internal connection while the fusion image (C) showed no increased FDG uptake (arrowhead) at the site of the adhesion. The findings are consistent with closure of the fistula.

Fistula between the spleen and stomach in the setting of the lymphoma is generally attributed to infiltration of the stomach by an aggressive and necrotic tumor. There was no defined guideline regarding how to best manage this clinical situation. Most prior publications prefer surgical repair of the fistula (3, 17, 18). Our case confirms the notion that chemotherapy to the lymphoma can also lead closure of the fistula without the need of surgery(5).

Acknowledgments

Conflicts of interest and source of funding: None

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