Non-Hodgkin’s lymphoma: A case of testis lymphoma metastasized to the gallbladder

doi:10.4236/ojim.2012.21003

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Open Journal of Internal Medicine, 2012, 2, 11-14 OJIM

http://dx.doi.org/10.4236/ojim.2012.21003 Published Online March 2012 (http://www.SciRP.org/journal/ojim/)

Non-Hodgkin’s lymphoma: A case of testis lymphoma

metastasized to the gallbladder

Yutaka Tsutsumi1*, Reiki Ogasawara1, Fumiyasu Yamamoto2, Yutaka Yamada3, Yasuyuki Komatsu1,

Kazuhiko Ichiki1, Shinich Ito1, Nobuaki Kurauchi4, Kazuhiro Kudo5, Norihiko Shimoyama5,

Junji Tanaka6, Masahiro Asaka7, Masahiro Imamura6, Hirohito Naruse2, Nobuo Masauzi1

1Department of Internal Medicine, Hakodate Municipal Hospital, Hakodate, Japan

2Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Japan

3Department of Urology, Hakodate Municipal Hospital, Hakodate, Japan

4Department of Surgery, Hakodate Municipal Hospital, Hakodate, Japan

5Department of Clinical Patholog y, Hakodate Municipal Hospital, Hakodate, Japan

6Department of Hematology and Oncology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan

7Department of Gastroentelology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan

Email: *[email protected]

Received 1 December 2011; revised 17 January 2012; accepted 29 January 2012

ABSTRACT

Testis lymphoma (diffuse large B cell lymphoma)

metastasized to the gallbladder. The gall bladder is

rarely involved in cases of the malignant lymphoma,

and lymphoma metastasis from the testis to the gall-

bladder has not been previously reported. These re-

ports may possibly change by the introduction of

PET/CT. Furthermore, although it was a struggle to

diagnose this particular case, there is a possibility

that we may have been able to recognize metastasis

from the testis at an earlier stage if PET/CT had been

conducted.

Keywords: Testis Lymphoma; Gallbladder; PET/CT

A 70-year-old male was hospitalized on 19 May 2008 for

swelling of the left testis without pain. He had no history

of gallstones, anorexia, weight loss, jaundice, fever, or

abdominal tenderness. Laboratory findings showed a

leukocyte count of 7.6 × 109 L, a total bilirubin of 0.4

mg/dl, an AST of 20 IU/L, an ALT of 35 IU/L, an alka-

line phosphatase of 315 IU/L, and a serum interleukin-2

receptor level of 574 U/mL. A left testis tumor and a

gal lblad der t umor were observed in a computed tomogra-

phy (CT) scan (Figure 1). Left-side orchiectomy was per-

formed on 26 May 2008, and cytological examination of

the testis indicated lymphoma invasion (Figure 2). The

gallbladder tumor was expected to be cancer of the gall-

bladder, therefore, ultrasonic endoscope, blood angiogra-

phy, ERCP, and bile cytology were used for the diagnosis.

Bile cy-tology predicted a malignant lymphoma, but did

not confirm the tissue-type. In addition, these exams did

not find gallstones. Positron emission tomography (PET)

was performed after these examinations and the result

strongly indicated the aggressive lymphoma of gall

bladder (Figure 1(c)). Therefore, Cholecystectomy was

performed on 23 June 2008, and the pathological finding

was diffuse large B-cell lymphoma (Figure 3). Speci-

mens from both the testis and gallbladder were positive

for CD20, CD79a, bcl6, and MUM1, and the patient was

diagnosed with diffuse large B-cell lymphoma of the

testis and metastatic lymphoma of the gall bladder. He

was treated with inverted-Y radiation therapy and six

courses of R-THP-COP therapy (375 mg/m2 rituximab

on day 1; 500 mg/m2 cyclophosphamide, 30 mg/m2 pira-

rubicin, and 1 mg/m2 vincristine on day2; and 30 mg/m2

prednisolone on days 2 - 6). The patient was in complete

remission on 1 July 2009. Periodic su rveillance examina-

tions with PET/CT were performed on the 22nd of March

2010 and multiple lymphoid lesions were observed. PET

standard uptake value (SUV) showed diffuse large B cell

lymphoma disease recurrence. An identical therapeutic

regimen of R-THP-COP was performed (six courses)

from the 31st of March 2010. Patients experienced a sec-

ond rem ission on the 17th of September.

Non-Hodgkin’s lymphoma (NHL) is a rare disease,

accounting for only about 5% of all testicular neoplasms.

Primary NHL of the testis has a poor prognosis, spread-

ing to unusual extra-nodal sites and recurring after re-

mission. This disease has a marked tendency to metasta-

size to the skin, lung, central nervous system, and con-

tralateral testis [1]. Involvement of the gallblad der is rare

in cases of malignant lymphoma, and metastasis of ma-

lignant lymphoma from the tstis to the gallbladder has e

*Corresponding a uthor.

OPEN ACCESS

Y. Tsutsumi et al. / Open Journal of Internal Medicine 2 (2012) 11-14

(a) (b) (c)

Figure 1. (a), (b) CT scans showing the left testis tumor and the dense soft tissue mass in the gallbladder; (c) PET showing the high

SUV lesion in gall bladder.

(a) (b) (c)

(d) (e)

Figure 2. (a) Testis swelling due to the NHL; (b) Microscope image showing the testis diffusely infiltrated with malignant cells;

(c)-(e) These cells were positive for CD20, bcl-6, and MUM1.

not been reported previously [2,3]. Lymphoma metasta-

sis is a complex series of the steps in which lymphoma

cells leave the primary tumor and migrate to other parts

of the body via the blood stream of the lymphatic system.

A testis lymphoma might spread to non-lymphoid organs

without lymphoid lesions at early stage of the disease

progression. The fact that the present testis lymphoma is

able to spread to an extra-nodal site might show the

bloodstream was part of metastatic system for this tumor.

On the other hand, only lymphoid lesions were observed

in disease-recurrent cases. Various characteristic changes

were suspected, however, lymph-node analysis was not

performed at the time of recurrence.

Recently, PET examination has been able to distin-

guish various types of malignant neoplasms [4]. PET/CT

is now a standard procedural tool used for staging ma-

lignant lymphomas. A strong association between resid-

ual 18F-fluorodeoxy glucose (FDG) positivity and poor

prognosis has also been established [5]. Furthermore,

FDG-PET performed early during treatment may predict

the prognosis of lymphoma patients [5-7]. PET is also

able to detect the existen ce of multiple organ neoplasms,

including kidney, pancreas, esophagus, hepatobiliary,

uterine, ovary, and others [4]. Although detection of

primary and metastatic gall bladder lymphomas is cur-

rently rare, the rate of detection may increase with con-

current use of PET/CT procedures. If PET/CT had been

performed initially in this case, metastatic lymphoma of

the gall bladder might have been diagnosed more easily.

Gall bladder tumor may be suspected in instances of

Y. Tsutsumi et al. / Open Journal of Internal Medicine 2 (2012) 11-14 13

(a) (b) (c)

(d) (e)

Figure 3. (a) Gallbladder showed wall thickness due to the NHL; (b) Malignant cells infiltrated the gallbladder wall; (c)-(e) These

cells were positive for CD20, bcl-6, and MUM1.

lymphoma originating in distant regions. PET/CT will be

of great assistance in diagnosis and staging, particularly

in these rare cases of disease progression. In addition, the

technique allows the avoidance of highly invasive exams

and surgeries and is expected to become a powerful tool

in diagnosis and disease staging. Unfortunately, given

that complications of diffuse large B cell lymphoma and

gallbladder lymphomas have been reported, cholecys-

tectomy may not be completely avoided [8]. Distinctive

characteristics exist in different types of lymphomas.

While gallstones are a common complication in cases of

primary gallbladder lymphomas, aged individuals suffer

from diffuse large B cell lymphoma and malt lymphoma

relatively more often, which would be expected to help

in differentiating metastatic lymphomas from these two

types [9]. In add ition, it has been reported that both PET

and SUV can detect the differences between low-grade

and aggressive lymphomas, therefore, it would help in

the evaluation of either the complications of a primary

gallbladder lymphoma or metastasis [10]. In the future,

more detailed characteristics of gallbladder lymphomas

(including primary and metastatic), and their relation to

other lymphomas, are expected to become clearer.

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