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Hodgkin’s Disease of the Prostate: A Detailed Case Report
:)022-5347 /86/1356-1251$02.00/0 THE JOURNAL OF UROLCG"l
Copy,ight © 1986 by Th& Williass & Wilkins Co.
HODGKIN'S DISEASE OF THE PROSTATE: A DETAILED CASE
REPORT LAURENCE H. KLOTZ*
AND
HARRY W. HERR
From the Urologic Service, Memorial Sloan-Kettering Cancer Center, New York, New York
ABSTRACT
Malignant lymphoma of the prostate is an unusual entity, and nonHodgkin's lymphoma constitutes most reported cases. We report a well documented case of Hodgkin's lymphoma, initially involving the gastrointestinal tract and spleen, which recurred in the prostate following initial remission with chemotherapy. Treatment with external beam radiotherapy resulted in a rapid complete response that has been sustained for 18 months. Lymphoma of the prostate gland is a rare entity. The first recognized, histologically documented case was reported in 1877 by Coupland. 1 Earlier reports of large series of lymphomas include only sporadic cases of prostatic involvement. Freeman and associates reviewed 1,467 cases of nondisseminated extranodal lymphoma,2 and Rosenberg and associates reviewed 1,269 patients 3 and identified only 3 and 2 cases, respectively, all of which were nonHodgkin's lymphoma. In 1949 Waller and Shullenberger reviewed the literature and discovered 21 cases. 4 The mean patient age was 41 years and the mortality rate was high. More recent series have reported a frequency of prostatic involvement of 8 per cent in nonHodgkin's lymphoma and 10 per cent in leuke~ia. 5 ' 6 NonHodgkin's lymphoma of the prostate has been reported frequently as presenting as benign prostatic hyperplasia. 1 - 10 Prostatic involvement by Burkitt's lymphoma and immunocytoma also has been described. 11 • 1 2 A well documented case of Hodgkin's lymphoma involving the prostate has not been reported in detail. West referred to a single case of peripheral prostatic infiltration in 113 men with Hodgkin's disease (referenced as a personal communication by Wiseman). 13 In a recent autopsy review of secondary tumors of the prostate prostatic metastasis was present in 1 of 195 male patients with Hodgkin's disease. 5 In a review from the Armed Forces Institute of Pathology autopsy files 9 patients had lymphoma of the prostate, 1 of whom had Hodgkin's disease. 8 No details other than age (30 years) were provided, We report a detailed case of Hodgkin's disease involving the prostate. The patient's dramatic response to organ-sparing treatment illustrates the potential for a favorable outcome without extensive resection of tumor, providing preservation of voiding and sexual function,
dimethyl-triazeno imidazole carboxamine and bleomycin. In June 1982 closure of a cologastrocutaneous fistula and drainage of a subphrenic abscess were performed. Pathological examination of the resected tissue showed no evidence of lymphoma. From July 7 to July 26, 1982 the patient received 2,900 rad external beam (cobalt 60) radiotherapy to the upper abdomen, celiac axis and site of the gastrocolic fistula, and 1,900 rad to the para-amtic nodes down to L4. Subsequently, he remained well and was continued on chemotherapy until February 1983. At the present hospitalization the patient had urinary frequency and urgency. Examination revealed a 35 gm. diffusely hard and indurated prostate, with slight tenderness. Excretory urography showed grade III hydronephrosis bilaterally. An abdominal computerized tomography scan revealed thickening of the bladder wall. Serum creatinine was 2.2 mg. per cent. Cystoscopy showed a marked inflammatory reaction involving the prostate, trigone and orifices. Transurethral resection of the bladder and prostate, and needle biopsy of the prostate revealed malignant lymphoma replacing the entire prostate (fig. 2).
The treatment options of radical cystoprostatectomy and external beam irradiation were considered. In view of the previous incomplete surgical excision, progression after chemotherapy and the established responsiveness of nodular sclerosing Hodgkin's lymphoma to irradiation, we elected to use radiation therapy. The patient received 3,000 rad to the pelvis in 12 daily fractions using a 10 Mev. photon beam. There was dramatic regression after treatment, with marked improvement
CASE REPORT
A 41-year-old white man was referred to the urology service in January 1984 for evaluation of obstructive voiding symptoms. In September 1981 epigastric discomfort developed and a gastric mass was found. Exploratory laparotomy revealed a large mass involving the spleen, stomach, distal pancreas and adjacent soft tissue, A debulking excision was performed, including distal pancreatectomy, partial gastrectomy and splenectomy. Pathological examination revealed nodular sclerosing Hodgkin's lymphoma (fig. 1). Biopsy of enlarged left inguinal nodes also showed nodular sclerosing Hodgkin's lymphoma. The patient was placed on an 8-drug chemotherapy protocol, consisting of nitrogen mustard, vincristine, procarbazine and prednisone, followed by doxorubicin hydrochloride, vinblastine, Accepted for publication January 9, 1986. * Current address: Division of Urology, Sunnybrook Hospital, 2075 Bayview Ave., Room 1040, Toronto, Ontario M4N 3M5, Canada.
FIG. 1. A, low power view of Hodgkin's disease, nodular sclerosis type in lymph nodes. Nodules of lymphoma separated by sclerotic bands of collagen are apparent. Reduced from XlO. B, high power view of gastric wall shows typical binucleated Reed-Sternberg cell (arrow) characteristic of Hodgkin's lymphoma. Reduced from XlOO.
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sclerosis in the spleen, retroperitoneal lymph nodes and gastric mass. Specimens from the prostate taken 27 months later showed malignant lymphoma but they did not reveal characteristics of Hodgkin's lymphoma specifically. This could be explained because of either small tissue sample size or conversion from Hodgkin's to nonHodgkin's lymphoma following treatment. While the latter phenomenon has been well described14• 15 it is an unlikely explanation of this case in view of the short interval between initial treatment and the development of recurrent disease in the prostate (27 months). In reported cases the interval between diagnosis and onset of therapy for Hodgkin's disease and diagnosis of nonHodgkin's lymphoma has ranged from 3 to 10 years, with a median of 4 to 5 years. This is a well documented case of Hodgkin's lymphoma involving the prostate. Although long-term followup is not available the complete response to external beam radiotherapy, with no evidence of residual or recurrent disease 18 months after treatment, indicates that this entity may be managed successfully with conservative surgery and irradiation, permitting sparing of pelvic organs and the functional sacrifices their removal entails. REFERENCES
FIG. 2. Transurethral resection specimen of prostate shows extensive replacement of prostate by infiltrating small cell lymphoma. Reduced from X40.
in voiding symptoms and palpable shrinkage of the prostatic mass. Repeat cystoscopy and examination with the patient under anesthesia in May 1984 revealed a flat, indurated prostate and mobile bladder, with granular, heaped-up regions in the trigone, bladder neck and prostatic urethra. Multiple deep bites demonstrated ulceration, chronic inflammation and focal calcification but there was no evidence of tumor. The creatinine gradually decreased to 1.0 mg. per cent. The prednisone was tapered and the patient has remained well clinically without evidence of disease. He is sexually active and has a normal voiding pattern 18 months after radiation therapy. DISCUSSION
The prostate is not infrequently involved by cancer in patients with hematopoietic malignancies. Leukemia, particularly lymphocytic leukemia, has been reported to involve the prostate pathologically in 40 per cent of the patients. 6 NonHodgkin's lymphoma has been reported to involve the prostate at autopsy in as many as 8 per cent of the cases. In contrast to the frequency of involvement by nonHodgkin's lymphoma, a thorough review of the literature revealed only 3 cases of Hodgkin's disease involving the prostate. Of these 3 cases 1 provided no details 13 and the other 2 were autopsy findings on patients upon whom no clinical or pathological details were given. 5 •8 The diagnosis of Hodgkin's disease in our patient was made unequivocally on the basis of Sternberg-Reed cells and nodular
1. Coupland, S.: Lymphoma of the prostate. Trans. Path. Soc. London, 28: 179, 1877. 2. Freeman, C., Berg, J. W. and Cutler, S. J.: Occurrence and prognosis of extranodal lymphomas. Cancer, 29: 252, 1972. 3. Rosenberg, S. A., Diamond, H. L., Jaslowitz, B. and Craver, L. F.: Lymphosarcoma: a review of 1269 cases. Medicine, 40: 31, 1961. 4. Waller, J. I. and Shullenberger, W. A.: Lymphosarcoma of the prostate. J. Urol., 62: 480, 1949. 5. Zein, T. A., Ruben, R., Lane, W., Pontes, J. E. and Englander, L. S.: Secondary tumors of the prostate. J. Urol., 133: 615, 1985. 6. Viadana, E., Bross, I. D. and Pickren, J. W.: An autopsy study of the metastatic patterns of human leukemias. Oncology, 35: 87, 1978. 7. Doll, D. C., Weiss, R. B. and Shah, S.: Lymphoma of the prostate presenting as benign prostatic hypertrophy. South. Med. J., 71: 1170, 1978. 8. Smith, B. H. and Dehner, L. P.: Sarcoma of the prostate gland. Amer. J. Clin. Path., 58: 43, 1972. 9. Hampel, N., Richter-Levin, D. and Gersh, I.: Primary lymphosarcoma of prostate. Urology, 9: 461, 1971. 10. Cos, L. R. and Rashid, H. A.: Primary non-Hodgkin lymphoma of prostate presenting as benign prostatic hyperplasia. Urology, 23: 176, 1984. 11. Boe, S., Nielsen, H. and Ryttov, N.: Burkitt's lymphoma mimicking prostatitis. J. Urol., 125: 891, 1981. 12. Hales, D. S. M., Cassidy, M., Scott, R. and Lewi, H. J. E.: Immunocytoma of prostate. Urology, 22: 438, 1983. 13. West, W. 0.: Primary lymphosarcoma of prostate gland. Arch. Intern. Med., 109: 469, 1962. 14. Lowenthal, R. M., Harlow, R. W., Mead, A. E., Tuck, D. and Challis, D. R.: T-cell non-Hodgkin's lymphoma after radiotherapy and chemotherapy for Hodgkin's disease. Cancer, 48: 1586, 1981. 15. Kim, H. D., Bedetti, C. D. and Boggs, D. R.: The development of non-Hodgkin's lymphoma following therapy for Hodgkin's disease. Cancer, 46: 2596, 1980.
Copy,ight © 1986 by Th& Williass & Wilkins Co.
HODGKIN'S DISEASE OF THE PROSTATE: A DETAILED CASE
REPORT LAURENCE H. KLOTZ*
AND
HARRY W. HERR
From the Urologic Service, Memorial Sloan-Kettering Cancer Center, New York, New York
ABSTRACT
Malignant lymphoma of the prostate is an unusual entity, and nonHodgkin's lymphoma constitutes most reported cases. We report a well documented case of Hodgkin's lymphoma, initially involving the gastrointestinal tract and spleen, which recurred in the prostate following initial remission with chemotherapy. Treatment with external beam radiotherapy resulted in a rapid complete response that has been sustained for 18 months. Lymphoma of the prostate gland is a rare entity. The first recognized, histologically documented case was reported in 1877 by Coupland. 1 Earlier reports of large series of lymphomas include only sporadic cases of prostatic involvement. Freeman and associates reviewed 1,467 cases of nondisseminated extranodal lymphoma,2 and Rosenberg and associates reviewed 1,269 patients 3 and identified only 3 and 2 cases, respectively, all of which were nonHodgkin's lymphoma. In 1949 Waller and Shullenberger reviewed the literature and discovered 21 cases. 4 The mean patient age was 41 years and the mortality rate was high. More recent series have reported a frequency of prostatic involvement of 8 per cent in nonHodgkin's lymphoma and 10 per cent in leuke~ia. 5 ' 6 NonHodgkin's lymphoma of the prostate has been reported frequently as presenting as benign prostatic hyperplasia. 1 - 10 Prostatic involvement by Burkitt's lymphoma and immunocytoma also has been described. 11 • 1 2 A well documented case of Hodgkin's lymphoma involving the prostate has not been reported in detail. West referred to a single case of peripheral prostatic infiltration in 113 men with Hodgkin's disease (referenced as a personal communication by Wiseman). 13 In a recent autopsy review of secondary tumors of the prostate prostatic metastasis was present in 1 of 195 male patients with Hodgkin's disease. 5 In a review from the Armed Forces Institute of Pathology autopsy files 9 patients had lymphoma of the prostate, 1 of whom had Hodgkin's disease. 8 No details other than age (30 years) were provided, We report a detailed case of Hodgkin's disease involving the prostate. The patient's dramatic response to organ-sparing treatment illustrates the potential for a favorable outcome without extensive resection of tumor, providing preservation of voiding and sexual function,
dimethyl-triazeno imidazole carboxamine and bleomycin. In June 1982 closure of a cologastrocutaneous fistula and drainage of a subphrenic abscess were performed. Pathological examination of the resected tissue showed no evidence of lymphoma. From July 7 to July 26, 1982 the patient received 2,900 rad external beam (cobalt 60) radiotherapy to the upper abdomen, celiac axis and site of the gastrocolic fistula, and 1,900 rad to the para-amtic nodes down to L4. Subsequently, he remained well and was continued on chemotherapy until February 1983. At the present hospitalization the patient had urinary frequency and urgency. Examination revealed a 35 gm. diffusely hard and indurated prostate, with slight tenderness. Excretory urography showed grade III hydronephrosis bilaterally. An abdominal computerized tomography scan revealed thickening of the bladder wall. Serum creatinine was 2.2 mg. per cent. Cystoscopy showed a marked inflammatory reaction involving the prostate, trigone and orifices. Transurethral resection of the bladder and prostate, and needle biopsy of the prostate revealed malignant lymphoma replacing the entire prostate (fig. 2).
The treatment options of radical cystoprostatectomy and external beam irradiation were considered. In view of the previous incomplete surgical excision, progression after chemotherapy and the established responsiveness of nodular sclerosing Hodgkin's lymphoma to irradiation, we elected to use radiation therapy. The patient received 3,000 rad to the pelvis in 12 daily fractions using a 10 Mev. photon beam. There was dramatic regression after treatment, with marked improvement
CASE REPORT
A 41-year-old white man was referred to the urology service in January 1984 for evaluation of obstructive voiding symptoms. In September 1981 epigastric discomfort developed and a gastric mass was found. Exploratory laparotomy revealed a large mass involving the spleen, stomach, distal pancreas and adjacent soft tissue, A debulking excision was performed, including distal pancreatectomy, partial gastrectomy and splenectomy. Pathological examination revealed nodular sclerosing Hodgkin's lymphoma (fig. 1). Biopsy of enlarged left inguinal nodes also showed nodular sclerosing Hodgkin's lymphoma. The patient was placed on an 8-drug chemotherapy protocol, consisting of nitrogen mustard, vincristine, procarbazine and prednisone, followed by doxorubicin hydrochloride, vinblastine, Accepted for publication January 9, 1986. * Current address: Division of Urology, Sunnybrook Hospital, 2075 Bayview Ave., Room 1040, Toronto, Ontario M4N 3M5, Canada.
FIG. 1. A, low power view of Hodgkin's disease, nodular sclerosis type in lymph nodes. Nodules of lymphoma separated by sclerotic bands of collagen are apparent. Reduced from XlO. B, high power view of gastric wall shows typical binucleated Reed-Sternberg cell (arrow) characteristic of Hodgkin's lymphoma. Reduced from XlOO.
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sclerosis in the spleen, retroperitoneal lymph nodes and gastric mass. Specimens from the prostate taken 27 months later showed malignant lymphoma but they did not reveal characteristics of Hodgkin's lymphoma specifically. This could be explained because of either small tissue sample size or conversion from Hodgkin's to nonHodgkin's lymphoma following treatment. While the latter phenomenon has been well described14• 15 it is an unlikely explanation of this case in view of the short interval between initial treatment and the development of recurrent disease in the prostate (27 months). In reported cases the interval between diagnosis and onset of therapy for Hodgkin's disease and diagnosis of nonHodgkin's lymphoma has ranged from 3 to 10 years, with a median of 4 to 5 years. This is a well documented case of Hodgkin's lymphoma involving the prostate. Although long-term followup is not available the complete response to external beam radiotherapy, with no evidence of residual or recurrent disease 18 months after treatment, indicates that this entity may be managed successfully with conservative surgery and irradiation, permitting sparing of pelvic organs and the functional sacrifices their removal entails. REFERENCES
FIG. 2. Transurethral resection specimen of prostate shows extensive replacement of prostate by infiltrating small cell lymphoma. Reduced from X40.
in voiding symptoms and palpable shrinkage of the prostatic mass. Repeat cystoscopy and examination with the patient under anesthesia in May 1984 revealed a flat, indurated prostate and mobile bladder, with granular, heaped-up regions in the trigone, bladder neck and prostatic urethra. Multiple deep bites demonstrated ulceration, chronic inflammation and focal calcification but there was no evidence of tumor. The creatinine gradually decreased to 1.0 mg. per cent. The prednisone was tapered and the patient has remained well clinically without evidence of disease. He is sexually active and has a normal voiding pattern 18 months after radiation therapy. DISCUSSION
The prostate is not infrequently involved by cancer in patients with hematopoietic malignancies. Leukemia, particularly lymphocytic leukemia, has been reported to involve the prostate pathologically in 40 per cent of the patients. 6 NonHodgkin's lymphoma has been reported to involve the prostate at autopsy in as many as 8 per cent of the cases. In contrast to the frequency of involvement by nonHodgkin's lymphoma, a thorough review of the literature revealed only 3 cases of Hodgkin's disease involving the prostate. Of these 3 cases 1 provided no details 13 and the other 2 were autopsy findings on patients upon whom no clinical or pathological details were given. 5 •8 The diagnosis of Hodgkin's disease in our patient was made unequivocally on the basis of Sternberg-Reed cells and nodular
1. Coupland, S.: Lymphoma of the prostate. Trans. Path. Soc. London, 28: 179, 1877. 2. Freeman, C., Berg, J. W. and Cutler, S. J.: Occurrence and prognosis of extranodal lymphomas. Cancer, 29: 252, 1972. 3. Rosenberg, S. A., Diamond, H. L., Jaslowitz, B. and Craver, L. F.: Lymphosarcoma: a review of 1269 cases. Medicine, 40: 31, 1961. 4. Waller, J. I. and Shullenberger, W. A.: Lymphosarcoma of the prostate. J. Urol., 62: 480, 1949. 5. Zein, T. A., Ruben, R., Lane, W., Pontes, J. E. and Englander, L. S.: Secondary tumors of the prostate. J. Urol., 133: 615, 1985. 6. Viadana, E., Bross, I. D. and Pickren, J. W.: An autopsy study of the metastatic patterns of human leukemias. Oncology, 35: 87, 1978. 7. Doll, D. C., Weiss, R. B. and Shah, S.: Lymphoma of the prostate presenting as benign prostatic hypertrophy. South. Med. J., 71: 1170, 1978. 8. Smith, B. H. and Dehner, L. P.: Sarcoma of the prostate gland. Amer. J. Clin. Path., 58: 43, 1972. 9. Hampel, N., Richter-Levin, D. and Gersh, I.: Primary lymphosarcoma of prostate. Urology, 9: 461, 1971. 10. Cos, L. R. and Rashid, H. A.: Primary non-Hodgkin lymphoma of prostate presenting as benign prostatic hyperplasia. Urology, 23: 176, 1984. 11. Boe, S., Nielsen, H. and Ryttov, N.: Burkitt's lymphoma mimicking prostatitis. J. Urol., 125: 891, 1981. 12. Hales, D. S. M., Cassidy, M., Scott, R. and Lewi, H. J. E.: Immunocytoma of prostate. Urology, 22: 438, 1983. 13. West, W. 0.: Primary lymphosarcoma of prostate gland. Arch. Intern. Med., 109: 469, 1962. 14. Lowenthal, R. M., Harlow, R. W., Mead, A. E., Tuck, D. and Challis, D. R.: T-cell non-Hodgkin's lymphoma after radiotherapy and chemotherapy for Hodgkin's disease. Cancer, 48: 1586, 1981. 15. Kim, H. D., Bedetti, C. D. and Boggs, D. R.: The development of non-Hodgkin's lymphoma following therapy for Hodgkin's disease. Cancer, 46: 2596, 1980.