Case Report Primary Prostate Lymphoma Presented as Urinary Wei-Ching Lee, Po-Hui Chiang

Case Report
Primary Lymphoma of the Prostate
Primary Prostate Lymphoma Presented as Urinary
Retention in a Young Male Patient: A Case Report
Wei-Ching Lee, Po-Hui Chiang
Department of Urology, Kaohsiung Medical Center, Chang Gung Memorial Hospital, and Chang Gung University,
Kaohsiung, Taiwan
We report a rare case of a primary malignant lymphoma of the prostate, which presented as urinary retention in a
32-year-old male patient. A digital rectal examination revealed an enlarged hardly prostate. B-cell lymphoma arising in
the prostate was diagnosed by a prostate biopsy and confirmed by an immunohistochemical examination. The patient
received doxorubicin-based combination chemotherapy, which showed a good outcome in terms of both decreasing the
size of the tumor and improving the associated symptoms during 9 months of follow-up. To our knowledge, there are
only a few reported cases of a primary malignant lymphoma arising in the prostate. We recommend that the digital
rectal examination be used in young male patients who reveal abnormal urinary voiding function. (JTUA 20:86-8,
Key words: malignant lymphoma, B-cell lymphoma, prostatic neoplasm.
To the best of our knowledge, there have only been
a few large-series studies on malignant lymphomas involving the prostate. A primary malignant lymphoma
of the prostate is especially rare, and represents 0.09%
of prostate neoplasms and 0.1% of all non-Hodgkin
lymphomas.1 Moreover, this type of lymphoma tends to
occur in elderly men at an average age of 62 years.2 We
report a case of primary lymphoma of the prostate in a
young male patient who presented with urinary retention.
The diagnosis was confirmed by histopathology and a
series of other examinations. The patient was treated with
doxorubicin-based combination chemotherapy, which
showed a good outcome.
there was no significant abnormality. Blood tests revealed a prostate-specific antigen (PSA) level of 3.63
ng/ml and serum creatinine level of 1.0 mg/dl.
Transrectal ultrasonographic imaging of the prostate
revealed an irregular contour with homogenous echogenicity, and the volume of the prostate measured 77
ml. The patient underwent needle biopsy of the prostate
under transrectal ultrasonographic guidance. A malignant prostate tumor was confirmed by the histopathological examination, and the tumor cells immunostained
positively for T200, CD20 (Fig. 1), and neuron-specific
enclose (NSE). Hence, the malignant lymphoma was
A 32-year-old male patient visited our hospital complaining of difficulty in urinary voiding for several
months, which led to urinary retention that was restored
by Foley catheterization. The patient underwent a digital rectal examination, and a large prostate with a hard
consistency was palpated. Urine analysis showed that
Address reprint requests and correspondence to:
Po-Hui Chiang, MD
Department of Urology, Chang Gung Memorial Hospital, 123 Ta-Pei
Rd., Kaohsiung 807, Taiwan
Tel: 886-7-7317123
E-mail: [email protected]
Fig. 1.
Positive CD20 stain (400×).
JTUA 2009 20 No. 2
W. C. Lee, et al
confirmed to be of B-cell lineage.
We then performed an abdominal and pelvic computed tomographic (CT) scan; the scan revealed a large
tumor in the prostate gland, which extended into the
posterior wall of the bladder (Fig. 2A). However, there
was no evidence of any systemic lymph node enlargement. Subsequently, a bone marrow biopsy of the left
iliac crest was performed; no lymphomatous involvement was observed. Since the patient was diagnosed with
a primary malignant lymphoma of the prostate, he received 6 courses of cyclophosphamide, hydroxydoxorubicin, oncovin (vincristine), and prednisolone
(CHOP) combination chemotherapy. The patient was
able to void urine without difficulty, and hence the Foley
catheter was removed after the second course of CHOP
chemotherapy. A CT scan performed during the followup revealed tumor size reduction (Fig. 2B). The size of
the prostate measured by transrectal ultrasonographic
imaging was originally 77 ml (Fig. 3A) and had decreased to 16 ml (Fig. 3B) after 8 months.
A primary malignant lymphoma of the prostate is
very rare and difficult to distinguish from other diseases
of the prostate. To our knowledge, there have been no
large-series studies of this condition except for a few
case reports.3,4 Approximately 40% cases of lymphoma
involve extranodal organs, including the gastrointestinal tract, skin, kidney, bone, and other organs and tissues.
Moreover, primary and secondary lymphomas involving the prostate are often found in elderly male patients.
We report a case of a 32-year-old male patient, who presented with a feature of urinary obstruction, and
subsequently, a primary lymphoma of the prostate was
confirmed. Taking into consideration the complications
of radical surgery and/or radiotherapy,5 such as incontinence and/or erectile dysfunction, we prescribed chemotherapy for this young patient. The patient received
6 courses of CHOP chemotherapy,6 which led to marked
tumor size reduction and restoration of good urinary
Fig. 2.
CT scan. (A) Before treatment; (B) after treatment.
JTUA 2009 20 No. 2
Fig. 3.
Transrectal ultrasonogram. (A) Before treatment; (B)
after treatment.
Primary Lymphoma of the Prostate
voiding function.
On the basis of the outcome of this case, we can
predict that young men can suffer from a primary lymphoma of the prostate. Although hematuria is sometimes
present in young patients,7 lower urinary tract symptoms
(LUTS) are the most frequent clinical obstruction in
cases of tumor infiltration that lead to an increase in prostate volume.8 Evaluation of the prostate by a digital rectal examination is important for any male patient presenting with LUTS, especially patients with a normal
serum PSA level. This patient had consulted several
urologists, who misdiagnosed his condition as prostatitis,
since a digital rectal examination was not performed. At
a time when PSA can be used as a tumor marker, the
importance of a digital rectal examination cannot be
overemphasized. If a digital rectal examination and imaging study indicate the presence of a prostate neoplasm,
the differential diagnosis includes benign prostate
hyperplasia, carcinoma or sarcoma of the prostate or
bladder, and prostate abscess or tuberculosis.9 The diagnosis is dependant on a histopathological examination.
In the literature, almost all primary lymphomas were
diagnosed with transurethral resection of the prostate
(TURP). However, it was not performed in this patient
since TURP may cause complications such as retrograde
ejaculation. Thus, we recommend a prostate biopsy instead of TURP for young male patients. The prognosis
of a prostate lymphoma is poor, and no long-term disease-free survival has been documented.10 However, our
patient was relieved of urinary symptoms with normalization of the prostate size and has led a disease-free life
for 9 months until the time of this writing. Long-term
follow-up is required to evaluate the outcome of a pri-
mary lymphoma of the prostate in young patients who
undergo the CHOP regimen treatment.
1. Sarris A, Dimopoulos M, Pugh W, Cabanillas F. Primary
lymphomas of the prostate: good outcome with doxorubicin-based combination chemotherapy. J Urol 1995;
2. Bostwick DG, Iczkowski KA, Amin MB, Discigil G,
Osborne B. Malignant lymphoma involving the prostate:
report of 62 cases. Cancer 1998;83(4):732-8.
3. Chen CW, Lin JT, Lee MC. Primary lymphoma of the
prostate gland - a case report. J Urol R.O.C. 1998;9(1):
4. Ambulkar I, Kulkarni B, Borges A, Advani SH. Primary
prostate non Hodgkin's lymphoma: a case report. Indian J Med Paed Oncol 2004;25(4):32-4.
5. Jhavar S, Agrawal JP, Naresh KN, et al. Primary
extranodal mucosa associated lymphoid tissue (MALT)
lymphoma of the prostate. Leuk Lymphoma 2001;41:
6. Leung TW, Tung SY, Sze WK, et al. Primary nonHodgkin's lymphoma of the prostate. Clin Oncol 1997;
7. Alvarez CA, Rodriguez BI, Perez LA. Primary diffuse
large B-cell lymphoma of the prostate in a young patient.
Int Braz J Urol 2006;32:64-5.
8. Antunes AA, Dall'Oglio M, Srougi M. Primary lymphoma
of the prostate: a rare cause of urinary obstruction. Int
Braz J Urol 2004;30(5):410-2.
9. Khandelwal KC, Moorjani VK, Mohan C, Udani RJ,
Patange VB. Non-Hodgkin lymphoma of the prostate. J
Assoc Can Radiol 1994;4:56-7.
10. Sarlis NJ, Knight RA, Salis I, Papadimitriou K, Kehayas
P: Non-Hodgkin lymphoma of the prostate gland. Int
Urol Nephrol 1993;25:163-8.
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