血尿罕見的鑑別診斷- 瀰漫性大型B 細胞淋巴癌案例報告與文獻回顧

黃英哲¹ 、陳彥達¹

¹高雄長庚紀念醫院外科部泌尿科

Rare differential diagnosis of hematuria: A case report and review of diffuse large B-cell lymphoma

Ying-Che Huang¹、Yen-Ta Chen¹

¹Divisions of Urology, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital

Case description: A 79-year-old male presented to our outpatient department with a chief complaint of mild intermittent hematuria for one month. The patient’s medical history is significant for 1) Hepatitis C, 2) Hypertension, 3) L4 compression fracture, post vertebroplasty, 4) Depression. Physical examination did not find a palpable kidney, lower extremity edema, or costovertebral angle tenderness. A complete blood count revealed a normal white blood cell count of 4.5 × 103/µl, with a hemoglobin of 14.7 g/dL and platelets 160 × 103/ul. Blood chemistry showed sodium to be 140 mEq/l; potassium, 4.3 mEq/l; serum creatinine, 0.73 mg/dl. Urine examination found pyuria, bacteria and hematuria. The flexible cystoscope found large sessile, cauliflower tumors over right dome and lateral wall. The computed tomography (CT) showed 1) Polypoid enhancing mass lesion(19mm, 30mm) at right lateral urinary bladder wall, suspect bladder cancer. 2) No definite enlargement of retroperitoneal or pelvic LNs. Under the impression of hematuria with a bladder tumor, transurethral resection was performed. Pathological reports showed urinary bladder tissue infiltrated by variable numbers of large lymphoid cells, featuring prominent nucleoli and brisk mitosis. Immunohistochemical studies revealed positive for CD20, BCL2 and c-MYC. The final diagnosis was diffuse large B-cell lymphoma (DLBCL). Considering it was a high-grade tumor, the positron emission tomography (PET) scan was performed, which showed a large uptake in the bladder. The PET scan also showed hypermetabolic lesions at right supraclavicular region, bilateral mediastinal and pulmonary hilar

Regions and left thigh. The postoperative course was uneventful and was discharged in the following days. Currently, the patient may receive ritoximab, cyclophosphamide, duanorubacin, vincristine, prednisolone (R-CHOP) chemotherapy in our oncology outpatient department.

Discussion: Bladder lymphoma is an extra-nodal non-Hodgkin's lymphoma and is a rare type of bladder tumor. Bladder lymphoma only accounts for 0.2% of all extra-nodal non-Hodgkin's lymphoma¹. According to previous studies, most of them are low grade and the common type mucosa-associated lymphoid tissue (MALT) lymphoma. Only 20% of them are high grade tumor and the most common type is DLBCL^1,2.  DLBCL is a highly aggressive tumor, and 10 years younger than that of low-grade cases at diagnosis on average. DLBCL is corrected with BCL-2 and MYC gene translocations³. Currently, chemotherapy is recommend to use for DLBCL treatment because it can treat those has not been detected early systemic disease⁴. R-CHOP (ritoximab, cyclophosphamide, duanorubacin, vincristine, prednisolone) was reported to be successful in high grade lymphoma, especially for BCL-2 positive DLBCL⁵. As for the type of surgery, there is no consensus on techniques such as cystectomy due to the operative complications⁵. Thus, based on the previous reports, it is recommended to treat DLBCL using either solitary or combination therapy including the R-CHOP chemotherapy regimen.

Conclusions: DLBCL  is a rare extra-nodal non-Hodgkin's lymphoma. It is a high grade and aggressive lymphoma. Either solitary or combination therapy including the R-CHOP chemotherapy regimen is recommended to treat DLBCL.