Primary Non-Hodgkins Lymphoma of the prostate presenting as haematuria.

We report a rare case of Primary Non-Hodgkins lymphoma of prostate presenting as an emergency with gross haematuria. A review of literature is also discussed. A 71 year old man presented to Emergency department with gross haematuria and was found to have grossly enlarged right lobe of the prostate on digital rectal examination. Histology confirmed a diffuse large B-cell lymphoma of the prostate. CT scan revealed a para-aortic lymphadenopathy which resolved with chemotherapy followed by radiotherapy. The patient remains disease free more than 5 years after initial diagnosis. The treatment and prognosis of primary lymphoma of prostate is same as with other nodal lymphomas. Primary or secondary lymphoma of the prostate should also be considered in patients presenting with haematuria. Cystoscopy and prostate biopsies should be taken to confirm the diagnosis. Treatment with chemo-radiotherapy can provide lasting benefit. © JSCR.

INTRODUCTION

We report a rare case of Primary lymphoma of prostate gland in a 72 year old man, presenting as gross haematuria in the emergency department. During the literature search, we found only one citation for haematuria as a presenting complaint in patients with lymphoma of prostate. We could not find any case report of patient presenting with macroscopic haematuria in the emergency department and subsequently found to have prostatic lymphoma.

Prostatic lymphoma comprises 0.1% of all prostate neoplasms and represents 0.2 – 0.8% as extra nodal lymphoma.

CASE REPORT

A 71 year old Caucasian presented to Emergency department with gross haematuria of 4 hours duration. He also complained of right groin tenderness lasting 1 week. He was catheterised in the emergency department using a size 22Fr 3-way catheter draining 550 mls of urine mixed with blood.

His past medical history included hypertension and appendicectomy. He was an ex-smoker and rarely had alcohol.

On examination his abdomen was soft and non tender, with no inguinal or incisional hernia. Rectal examination revealed a grossly enlarged right lobe of prostate.

His blood tests showed a normal full blood count, liver and renal function tests. His sodium was mildly elevated and corrected with fluid resuscitation. The serum Prostate-specific Antigen was 0.7 ng/ml (Normal <4ng/ml).

On ultrasound examination left kidney was normal, but right kidney was small and moderately hydronephrotic. There was a mass at the base of the bladder.

Rigid cystoscopy showed a solid looking mass at the trigone, which was a continuous extension from the grossly enlarged right lobe of the prostate. The lesion was resected and sent for histo-pathological examination.

The patient had a successful post-operative recovery.

Histological and immuno-histochemical studies of the resected lesion showed a ‘diffuse large B-cell Lymphoma, originating from the prostate’.

CT scan performed 3 months after the initial diagnosis (as per Bosthwick’s quidelines) showed a para-aortic mass. Subsequent referral to a haematologist was made. Bone marrow biopsies showed a small infiltrate (<1% of total) of B cell NHL in his bone marrow. He underwent 6 cycles of RCHOP chemotherapy, followed by radiation therapy which cleared the para-aortic mass on subsequent CT imaging.

Follow up flexible cystoscopies and CT scans performed over a 5 year period since initial diagnosis showed no recurrence and the patient currently remains disease free.

DISCUSSION

Prostate cancer is the most common cancer in men. Adenocarcinoma is the most common prostatic malignancy, representing over 95% of all prostate cancers. Other rarer types include small cell carcinoma and squamous cell carcinoma. Involvement of the prostate by malignant lymphoma is a well-known late manifestation of advanced nodal disease. (1) Primary lymphoma of the prostate is extremely rare representing only 0.2 to 0.8% of extra nodal lymphoma and 0.1% of all prostate neoplasms. (2)

The criteria for the diagnosis of primary prostatic lymphoma were defined by Bostwick et al. (3) Tumours were considered to be primary for patients having the following: symptoms of prostatic enlargement at the beginning of the disease; predominant involvement of prostate and no involvement of lymph nodes, blood, liver, or spleen. (3)

Primary or secondary lymphoma of prostate most commonly presents as Lower urinary symptoms, obstruction and incidental finding during routine histology or post-mortem. There is only one case series reported (3) where primary NHL of the prostate presents as haematuria.

According to the largest reported case series of Bostwick et al (3), 22 patients with primary lymphoma of prostate, the mean age at presentation was 66 years. 9 out of 22 patients died of lymphoma, with a median survival of 23 months (range 2 to 30 months). Seven patients were alive 5 years after diagnosis. Our patient is also currently disease free, 66 months after the initial presentation and diagnosis of lymphoma.

Haematuria is the most common presentation for carcinoma of kidney or bladder, calculi and infection. To our knowledge, gross haematuria presenting as an emergency in Non Hodgkins lymphoma is not reported.

Digital rectal examination reveals a diffusely enlarged, non tender, firm and/or nodular prostate. In our case report the prostate felt abnormal as its right lobe was nodular and firm, weighing 40gms on digital rectal examination. PSA was elevated in 20% of patients in the study by Bostwick et al.

The definitive investigation for any abnormal feeling prostate is resection or needle biopsy of the gland for histological analysis. The tumour architecture is similar to the one observed in the lymph nodes, but without evidence of nodularity. The most common histological finding in prostatic lymphoma is Diffuse large B-cell lymphoma, but primary prostatic small lymphocytic lymphoma, follicular lymphomas, Burkit lymphomas, MALT lymphomas, and mantle cell lymphomas have also been reported. (2,3,4)

Treatment is with surgery, chemotherapy and/or radiotherapy. RCHOP regimen is considered the as the standard treatment for patients with advanced diffuse large B cell lymphoma. (5) The prognosis of primary prostatic lymphoma is uncertain, due to the rarity of the disease. It has been suggested that the prognosis of nodal lymphoma may be similar to that of extra nodal lymphomas. (6)

Although malignant lymphoma of the prostate is rare, it should be considered in the differential diagnosis of patients presenting with macroscopic haematuria and abnormal feeling prostate.