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Journal of Urology and Research

Cite this article: Almeida GL, Mota GO, Busato Júnior WFS, Ogata D, De Cobelli O (2015) Prostatic Lymphoma – an Atypical and Challenging Neoplasm of the Prostate. J Urol Res 2(4): 1038.

*Corresponding authorAlmeida GL, Department of Urology, University of Vale do Itajai, Avenida Marcos Konder 1120, Centro, Zip Code: 88301-302, Brazil, Tel: 55-47-3346-6700; Email:

Submitted: 16 September 2015

Accepted: 11 November 2015

Published: 26 November 2015

ISSN: 2379-951X

Copyright© 2015 Almeida et al.

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Keywords•Lymphoma•Prostate•Neoplasm

Case Report

Prostatic Lymphoma – an Atypical and Challenging Neoplasm of the ProstateAlmeida GL1,3*, Mota GO1, Busato Júnior WFS1, Ogata D2 and De Cobelli O3,4

1Department of Urology, University of Vale do Itajai, Brazil2Department of Infolaudo Pathology, University of Vale do Itajai, Brazil3Department of Urology, European Institute of Oncology, Italy4Department of Urology, University of Milan, Italy

Abstract

The prostatic lymphoma represents 0.2% of all prostatic neoplasms. The diagnostic of this pathology occurs accidentally in most cases. The present article intends to report a challenging clinical case of Prostatic Lymphoma and discuss the relevant aspects of the clinical and pathologic propaedeutic. The diagnostic was established accidentally, corroborating the literature. The patient was a young and had been initially diagnosed as a complicated prostatitis with suspicious of prostatic abscess. After the surgical approach, the definitive pathology confirmed as “double-hit prostate lymphoma”.

CASE REPORTJ.R.L, male, 33 years old, was attended to hospital admission

in our service on January 9th 2014. Initially, the patient present-ed as an acute prostatitis syndrome, with a suspicious of prostate abscess.

He presented with a low intensity pelvic pain with 30 days of evolution, accompanied with low urinary tract symptoms (LUTS). Five years ago, the patient was submitted to a bariatric surgery. Furthermore, he was an alcohol and cigarette addicted, drinking up to 2 liters of vodka and smoking 40 cigarettes a day. No other chronic diseases or drug use was identified. Sexual behavior was worrying, because the patient related sexual intercourse with multiple women in the latest 12 months.

The patient was in a good clinical condition, performing all his daily activities independently. His principal complaint was pol-lakiuria and low intensity pelvic pain, without dysuria or oligu-ria. In clinical examination, he had no fever, but a pallor mucosa (+2/+4) called our attention. Digital rectal examination revealed an increase in prostate volume (approximately 30-35cc) with no sings of fluctuation, and a discreet prostate pain.

Laboratory serum tests did not show important findings, ex-cept a mild anemia (hemoglobin 8,8 g/dL). Renal function, urine and liver tests were normal, and PSA value was 1,83 ng/dL. The HIV-Test was positive, confirming the immune compromised condition. CT scan revealed diffuse thickening in bladder wall, in-crease in prostate volume, densification of the bladder-prostatic fat interface, and a deficit in contrast drainage on distal right ure-

ter. Also, a right perinephric collection and homogeneous sple-nomegaly was identified (Figure 1). Flexible 6 uretrocystoscopy revealed a low-capacitance bladder and a discreet elevation of posterior bladder wall (apparently extrinsic).

After this propaedeutic, the main diagnostic hypothesis was an infectious disease (abscess, tuberculosis?) in an immune com-promised patient. A surgical intervention was indicated to drain the suspicious abscess. We started with a right Gibson incision, to access the retroperitoneal space and reach the posterior bladder wall and prostate. In dissection, some large and enlarged lymph nodes were found and excised to pathology exam. The access of prostate space revealed a very consistent tissue, limiting the mobilization of the bladder, without abscess. This tissue was in contiguity with the rectus abdominal fascia, and both were biop-sied and sent to pathology exam. Patient had a good recovery in the immediate post-operative period, and a trans-rectal prostate biopsy was performed.

Figure 1 (A-B): CT Scan - A) Bladder thickening, prostate enlargement B) right perinephric “collection”.

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The final pathology report of the lymph nodes, rectum-ab-dominal muscle and prostate biopsy revealed “Atypical lymph proliferative process�� The immune histochemical analysis re-�� The immune histochemical analysis re-� The immune histochemical analysis re-ported: “Lymph proliferative process, with starry-sky pattern, positive expression of CD20, CD10 e BLC2, elevated mitotic index (Ki-67), suggesting unclassified Lymphoma B, or even Burkkit Lymphoma� Furthermore, these characteristics description allied to the expression of MYC (in over 70% of the cells), suggests the double-hitlymphoma that has translocations in BLC2 and MYC gens, and encloses a worse prognosis”.

On February 17th, the patient was able to initiate the oncol-ogy treatment, however, he had a massive pulmonary embolism, and even with the intensive care, the patient died�

DISCUSSION AND FUTURE PERSPECTIVESThe PL is rare, representing until 0,2% of all primary prostate

cancer, and 10% of lymphoma or leukemia metastasis [1]� The definition of a primary PL must be consistent with three criteria, recommended by Bostwick and Mann [2]: 1) presenting symp-toms attributable to prostatic enlargement; 2) involvement of the prostate predominantly, with or without involvement of ad-jacent tissue; and 3) absence of involvement of the liver, spleen or lymph nodes within one month of diagnosis of the prostatic in-volvement� The clinical presentation resembles LUTS symptoms (in patients over 60 years old) with normal PSA, and the diag-nostic is usually accidental occurring in prostate biopsy or after a TURP [1-4]� The trans-rectal ultrasound evaluation shows a hypo echoic lesion, as the prostate adenocarcinoma (PCa) [5]�

Regarding to the pathology analysis, the majority of primary PL have been B-cell lymphomas of the small lymphocytic (SLL), marginal zone, large cell (diffuse large B-cell lymphoma) and fol-licular lymphoma� Rarely, the prostate can be evolved second-arily as part of systemic disease dissemination� When this occurs, SLL is the most common subtype� Microscopic findings reveals lymphoid infiltrate typically shows patchy or diffuse interstitial involvement of the prostatic stroma, preserving prostatic acini� Extension into extra-prostatic tissue can be observed� Other lym-phomas seen in other sites may become manifest in the prostate� These include undifferentiated (Burkitt-like) lymphoma, mantle cell lymphoma, angiotropic lymphoma, Hodgkin disease and T-cell lymphomas [2]�

Florid chronic inflammation should be differentiated from low-grade lymphoma� In chronic inflammation, the infiltrate is typically peri-glandular, mixed with plasma cells, whereas low-

grade lymphomas reveal a more diffuse infiltrate� In these cases, we can perform immune histo-chemistry tests [6]�

PL is a poor prognosis disease with overall survival ranging of 2 to 44 months, and no important difference is found between primary or secondary involvement [2,7]� This differential diag-nostic has to be included in some situations� A diagnostic of PCa in a patient with generalized lymphadenopathy must be alerted, knowing that rare cases of PCa have this pattern of presenta-tion [8]� Young middle-aged man, with refractory prostatitis, which does not respond to antibiotic therapy, should be inves-tigated [8,9]� The PL can also co-exist with PCa Ballario et al [9] reported a patient who had urinary obstructive symptoms with an enlarged prostate� After TURP, the pathological examination showed PCa in 5% of the tissue, and lymphocytic cells infiltrated in the remaining prostate specimen� The well-known risk factors for lymphoma should be remembered: immune compromised and previous lymphoma in other sites�

The treatment of PL is the same for other lympho prolifera-tive diseases, in charge of oncology protocols, usually chemother-apy� Antunes et al described a rare case of urinary obstruction by a primary PL, emphasizing that systemic chemotherapy rep-resents the initial and preferential therapeutic method [10]� Con-sidering the same method, Fukutani et al reported a patient with primary PL who had complete response with combination of che-motherapy [11], contradicting the prognosis of the disease� Sarris

Figure 2 (A-B) - Prostate biopsies showing atypical lymphocytic infiltrate (A: 40x and B: 400x)�

Figure 3 (A-D) - Atypical lymphocytic infiltrate� A(100x) and B(300x): abdominal mass; C(100X) and D (100x): Lymph nodes�

Figure 4 (A-C): Pathology, immunehistochemical evaluation (400x)� A) HE B) CD20 C) MYC�

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Almeida GL, Mota GO, Busato Júnior WFS, Ogata D, De Cobelli O (2015) Prostatic Lymphoma – an Atypical and Challenging Neoplasm of the Prostate. J Urol Res 2(4): 1038.

Cite this article

et al, reached a good outcome in a patient treated with doxorubi-cin combined chemotherapy [12]� The traditional chemotherapy drugs for non-Hodking Lymphomas are the CVP combination, which includes Cyclophosphamide, Vincristine and Prednisone� A combination with doxorubicin has been used too, the CHOP (Cyclophosphamide, Vincristine, doxorubicin and Prednisone), and eventually plus rituximab� Many combinations can be used in the same patient, according to drugs cycles, response and side effects [12-14]�

PL is rare condition and a high suspicious is essential for the diagnosis� Early and appropriate treatment can extend the specif-ic-free survival and improve the quality of life�

REFERENCES1� Zuazu JR, Iglesias R, Costa DR, Rincón Mayans A, Brugarolas i Roselló

X, Santos AP, et al� Prostatic lymphoma and review of the literature� Actas Urol Esp� 2009; 33: 686-690�

2� Bostwick DG, Mann RB� Malignant lymphomas involving the prostate� A study of 13 cases� Cancer� 1985; 56: 2932–2938�

3� Jimenéz A� Linfoma de células del manto da próstata, relato de caso� Hospital Arnau Vilanova de Valencia� Fevereiro� 2013�

4� Chu PG, Huang Q, Weiss LM� Incidental and concurrent malignant lymphomas discovered at the time of prostatectomy and prostate biopsy: a study of 29 cases� Am J Surg Pathol� 2005; 29: 693-699�

5� Rainwater LM, Barret DM� Primary lymphoma of prostate: transrectal ultrasonic appearance� Urology� 1990; 36: 522-525�

6. Bostwick DG, Iczkowski KA, Amin MB, Discigil G, Osborne B� Malignant

lymphoma involving the prostate: report of 62 cases� Cancer� 1998; 83: 732-738�

7. Heresi GA, Wang J, Taichman R, Chirinos JA, Regalado JJ, Lichtstein DM, et al� Expression of the chemokine receptor CCR7 in prostate câncer presenting with generalized lymphadenopathy: report of a case, review of the literature, and analysis of chemokine receptor expression� Urol Oncol� 2005; 23: 261-267.

8� Wang C, Jiang P, Li J� Primary lymphomas of the prostate: two case reports and a review of the literature� Contemp Oncol (Pozn)� 2012; 16: 456–459�

9� Ballario R, Beltrami P, Cavalleri S, Ruggera L, Zorzi MG, Artibani W� An unusual pathological finding of chronic lymphocitic leukemia and adenocarcinoma of the prostate after transurethral resection for complete urinary retention: case report� BMC Cancer� 2004; 4: 95�

10� Antunes AA, Dall’Oglio M, Srougi M� Primary lymphoma of the prostate: a rare case of urinary obstruction� Int Braz J Urol� 2004; 30: 410–412�

11� Fukutani K, Koyama Y, Fujimori M, Ishida T� Primary malignant lymphoma of the prostate: report of a case achieving complete response to combination chemotherapy and review of 22 Japanese cases; Nippon Hinyokika Gakkai Zasshi� 2003; 94: 621-625�

12� Sarris A, Dimopoulos M, Pugh W, Cabanillas F� Primary lymphoma of the prostate: good outcome with doxorubicin-based combination chemotherapy� J Urol� 1995; 153: 1852-1854�

13� De Vitta, Hellman, Rosenberg’s, Lippincot, Williams� Cancer: Principles & Pratice of Oncology� 8th ed� 2008; 2133-2144�

14� A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin’s lymphoma� The Non-Hodgkin’s Lymphoma Classification Project� Blood� 1997; 89: 3909–3918�