A Case of Primary Lymphoma of the Bladder Managed With Multimodal Therapy

Kaya Horasanli; * Mustafa Kadihasanoglu; Oznur Tas Aksakal; Aysim Ozagari and Cengiz Miroglu

Disclosures

Nat Clin Pract Urol. 2008;5(3):167-70. 

In This Article

The Case

A 65-year-old Caucasian woman was admitted to a urology department after presenting with macroscopic hematuria, dysuria, urinary frequency and urgency. She did not have a history of weakness, fatigue, night sweating, fever, weight loss or recurrent urinary infection. Physical examination found no organomegaly or lymphadenopathy. One year earlier, she had experienced a 1-month episode of hematuria, dysuria, urinary frequency and urgency, which was treated with antibiotic and antimuscarinic agents. The patient had subsequently undergone simultaneous surgeries for resection of a basal cell carcinoma of the nasal skin and lymphoma of the bladder; no lymph node involvement had been observed at this time. Furthermore, no recurrence of the carcinoma was seen following the surgery. At presentation, the patient's serum levels of urea, creatinine and electrolytes were normal, as was her peripheral blood film.

Ultrasonography and intravenous pyelography demonstrated a mass involving the right lateral wall of the bladder and the right ureteral orifice (Figure 1). An abdominal ultrasound scan revealed hydronephrosis of the right kidney, asymmetric hypoechoic diffuse thickening of the bladder wall and a large solid mass, with the dimensions 10 mm x 45 mm x 30 mm, involving the right ureteral orifice on the right wall of the bladder. The mass was lobular and hypo–hyperechoic. Clinical and radiographic examinations, including CT of the upper abdomen and chest, did not identify any other tumors. Bone marrow aspirate and a bone biopsy sample were also normal, indicating no systemic disease.

Intravenous pyelogram demonstrating a mass within the urinary bladder. The image depicts a filling defect on the right lateral wall and dilatation of the right upper urinary tract.

Cystoscopy showed an irregular lobular, solid and ulcerative mass arising from the right wall of the bladder. The vesical tumor was transurethrally resected, and histopathologic examination showed a diffuse, dense infiltration of a highly pleomorphic population of large cells, a few of which had prominent nucleoli (Figure 2A). Tumor cells were strongly positive for leukocyte common antigen (LCA) and CD20, markers indicative of a B-cell-derived lymphoma (Figure 2B). Immunohistochemical analyses were negative for cytokeratin, cytokeratin 7 and CD45RO, ruling out the possibility of carcinoma. The tumor was diagnosed as primary lymphoma of the bladder.

Histopathologic appearance of the primary lymphoma of the bladder. (A) Light microscopy of a diffuse large cell lymphoma infiltrating the vesical wall (x 4 magnification; hematoxylin and eosin stain).The arrows show the prominent nucleoli (x 40 magnification). (B) Immunohistochemical staining with anti-CD20 antibody, a marker of B-lymphoid cells (x 100 magnification).

Three months after resection of the tumor, follow-up cystoscopy indicated no mass or suspicious areas in the bladder. A CT scan of the whole abdomen and pelvis performed 5 months after resection, however, identified multiple lymph nodes with diameters of around 25 mm in the common iliac, parauterine and para-aortacaval regions. The patient was administered cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) chemotherapy to prevent the progression of the disease (four 5-day cycles [weeks 1, 4, 7 and 10 after CT] of cyclophosphamide 1,000 mg/m,1 doxorubicin 100 mg/m,1 vincristine 2 mg/m2 and prednisolone 100 mg). Subsequently, radiotherapy was applied with a total of 46 Gy delivered in 23 equal fractions. After chemotherapy and radiotherapy, a CT scan of the pelvis and upper abdomen showed complete resolution of the disease. Tumor recurrence was monitored by cystoscopy and urinary immunocytologic examination on four occasions during the following year. The cystoscopic evaluations at months 3, 6, 9 and 12 after resection were normal, as were the results of immunocytologic analyses of urine samples that assessed reactivity to LCA and CD20. Furthermore, a biopsy specimen obtained from the site of resection after 12 months showed no sign of disease recurrence. Subsequently, the patient was monitored by cystoscopy and urinary immunocytologic examination every 6 months, with no evidence of recurrence.

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