Gastro-Splenic Fistula Related to Large B Cell Lymphoma

Round 1

Reviewer 1 Report

This is a very interesting and well written case report about a 57 y/o woman that presented with a gastro-splenic fistula secondary to a DLBCL that was cured with chemotherapy only not needing surgery. This realization is extremely important, as surgery would have been very morbid and so learning from this experience may lead long term to a shift of paradigm for these rare cases.

My comments are minor and related to Figure 2 where it says that it will show a CT scan, but no CT scan is shown.

So, if the authors could provide a CT scan with images after completion of therapy would be great.

Another request to the authors is if you can comment on the risk of bowel perforation with rituximab in case of bowel involvement. Did you delay the administration of rituximab initially? do you think the administration of rituximab should have been delayed in hindsight? 

Author Response

Hello,

thank you for your comments.

Regarding Figure 2:

It shows a CT image of the stomach which is perforated (and here we wanted to show that RCHOP chemotherapy has been given to a patient with an already existing perforation).The pancreatic mass has infiltrated the greater curve of the stomach and the spleen. The spleen is necrotic.

I am not sure where figure 2 says we will show a CT scan.

We could add another image from the end of treatment PET CT scan if you agree, with the comment:

''End of treatment Axial PET image showing excellent response with minimal non specific residual FDG activity in spleen considered likely post inflammatory.''

With regards to the second question:

There was no bowel involvement in this patient. Definitely by administering RCHOP chemotherapy to a patient with  DLBCL involving the GI tract is always risky for perforation. In this case, the perforation was present from the beginning and we did not think that by delaying the rituximab, there would be any benefit. The patient was very unwell at that time. If her clinical picture was not that serious and she did not have perforation of the stomach, we would definitely think of delaying rituximab.  

Author Response File: Author Response.docx

Reviewer 2 Report

Figure 2 is missing, and legend belongs to figure 3,4

Figure 3, 4: Move figure to its proper legend

Figure 5: HE staining or what? Is the subsequent paragraph "They expressed a post germinal..." part of the figure legend or part of the Results section? CD30 expression detected by immunohistochemistry or Flow analysis?

In conclusion: The manuscript merits publication on the basis of the originality of the case.

Author Response

Hello and thank you for your comments.

Regarding Figure 2: I am not sure what is missing. The CT scan image shows the perforated stomach and the necrotic spleen. 

Figures 3 and 4 were discussed with the consultant gastroenterologist who believes figure 4 should be removed. He said to keep figure 3 only and to add the legend ''ulcerated area in the fundus of the stomach with blood oozing-Gastric opening of the fistula''. Do you agree with that? 2 similar images might confuse the reader.

The sentence'' they expressed a post germinal center'' is not part of the figure legend. I thought to add more information regarding the lymphoma cells after the figure though.

I agree that we should have mentioned that the staining used is haematoxylin and eosin. We can definitely add that.

CD30 expression was detected by immunohistochemistry.

I am looking forward to hearing from you,

Kind Regards,

Diana