攝護腺瀰漫性大型B細胞淋巴癌以反覆性尿滯留呈現

黃君平¹、顏敬恒²

¹國防醫學院三軍總醫院外科部泌尿外科；²國防醫學院三軍總醫院松山分院泌尿外科

Primary diffuse large B cell lymphoma (DLBCL) of the prostate presenting with repeated acute urine retention

Chun-Ping Huang¹, Jing-Heng Yan²

¹Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei 114024, Taiwan; ² Division of Urology, Tri-Service General Hospital, Songshan Branch, National Defense Medical Center, Taipei 114024, Taiwan

Introduction:

Diffuse large B-cell lymphoma (DLBCL) is the most common type of lymphoma, representing approximately one-third of all cases worldwide. However, primary lymphomas of the prostate are a rare entity. They account for 0.09% of prostate neoplasms and 0.1% of all non-Hodgkin lymphomas. The symptoms at presentation are similar to other prostatic diseases, and histopathological analysis with immunohistochemical techniques and molecular studies are mandatory to reach final diagnosis.

Case presentation:

A 79-year-old man with a 10-year history of benign prostate hyperplasia (BPH) and lower urinary tract symptoms (LUTS) under medical control presented at a local clinic in May 2023 due to repeated acute urine retention. Despite a month of combination therapy and bethanechol treatment, his condition did not improve, leading to a referral to our hospital's Outpatient Department of Urology.

The patient had no prior history of illness or family malignancies. He reported a recent weight loss of 4 kilograms without fever, night sweats, or bone pain. Physical examination revealed suprapubic distension and digital rectal examination (DRE) showed an asymmetrical right lobe with hard consistency (Grade II). Prostate-specific antigen (PSA) levels were at 0.266 ng/ml. Subsequent procedures included a prostate biopsy and transurethral resection of the prostate (TURP), which identified a primary diffuse large B-cell lymphoma (DLBCL), not otherwise specified (NOS), of the non-Germinal center B-cell like (GCB) subtype using the Hans algorithm. Immunohistochemical test were positive for CD20, BCL2, PAX8, and MUM-1 antibodies but negative for various other markers (CK, CD3, CD21, CD10, SOX11, cyclin-D1, ALK, INSM1, BCL6, PSA, p63, GATA3, NKX3.1, p504s, c-myc, and EBV). The Ki-67 marker showed an increasing level.

A chest, abdomen, and pelvic enhanced computed tomography (CT) scan revealed fibrotic linear/nodular opacities of the right upper lung with no signs of lymphadenopathy. The patient subsequently underwent a bone marrow biopsy and Flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT). The bone marrow biopsy revealed no marrow involvement and the absence of large tumor cells.

The whole body PET/CT scan unveiled multiple FDG-avid enlarged nodal lesions in various regions, including the peri-rectal region, pre-sacral space, bilateral internal/external/common iliac chains, abdominal para-aortic/caval spaces, as well as diaphragm crura, para-esophageal space, left axillary level Il-III and right supraclavicular fossa/infraclavicular fossa (SCF/ICF) regions. Additionally, a calcified nodule with fibrotic changes was observed in the right upper lobe of the lung, suggestive of a granuloma.

The final diagnosis was diffuse large B-cell lymphoma of prostate with multiple nodal involvement (pelvic, iliac chains, para-aortic/caval, para-esophageal, left axillary, and right SCF/ICF), non-GCB subtype, Ann Arbor stage IVE, International Prognostic Index (IPI) group 3, high-intermediate risk, and Eastern Cooperative Oncology Group (ECOG) Performance Status score of 1. The patient was currently undergoing the fifth cycles of R-mini-CHOP regimen (Rituximab, Cyclophosphamide, Doxorubicin hydrochloride, Vincristine sulfate, and Prednisone) and was under closely observation.

Conclusion:

The symptom of lymphoma involved in the prostate is untypical. The case reminds us about the importance of history taking, DRE and the biopsy of prostate in the reaching of correct diagnosis of the rare primary prostate lymphoma. Biopsy of the prostate is the only way to confirm the diagnosis of lymphoma involvement. In the diagnostic process of primary prostate lymphoma, various examinations, beyond routine tests, such as urological ultrasound, abdominal and pelvic CT, MRI, PET/CT scan, whole-body bone scan, bone marrow biopsy, PSA, LDH, and other assessments, are available as optional tools. These supplementary tests play a crucial role in achieving precise staging and evaluating prognosis. Notably, PET/CT is particularly valuable for both diagnosing and accurately staging primary prostate lymphoma.