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Lymphoproliferative Disorders
0022-534 7/87 /1375-0958$02.00/0 Vol. 137, May Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
Editorial LYMPHOPROLIFERATIVE DISORDERS Genitourinary lymphoproliferative involvement as the primary manifestation of a systemic process is uncommon but it has been reported previously on several occasions. 1- 4 The importance of diagnosing the lymphoproliferative disease lies in the fact that systemic treatment with chemotherapy may lead to resolution of the genitourinary symptoms. Furthermore, if surgical exploration is necessary, complete staging of the process is mandatory to plan therapy and to avoid secondary procedures. Previously, we noted prostatic involvement in 127 of 1,571 (8 per cent) autopsy cases of lymphoproliferative disease. 1 This incidence was more common in patients with Hodgkin's lymphoma (0.5 per cent). Although the majority of cases of secondary involvement of the prostate have been noted at autopsy, clinical manifestations of outlet obstructive problems as a result of prostatic infiltrate by the tumor have been described. 5 It is important that clinicians are aware of this presentation, since the frequently associated blood dyscrasias could lead to disasterous consequences in the event of surgery. Urinary problems that have been described occasionally as neurogenic bladder resulting from meningeal involvement could mimic outlet obstructive symptoms. 5 Unless an operation is absolutely necessary treatment of the systemic disease takes priority, since it may result in improvement of the genitourinary symptoms. If an operation is necessary it should be undertaken when the condition is in remission and the hematological profile is normal. In the case of lymphomatoid granulomatosis described by Feinberg and associates in this issue of the Journal (page 989) transurethral pros tatic resection and thoracotomy /lung biopsy were performed in a patient with significant outlet obstructive symptoms. Although these procedures led to the diagnosis of lymphoproliferative disease with prostatic involvement, one questions the decision to perform 2 unrelated procedures simultaneously, especially in the face of significant clinical evidence of a systemic process. We wonder if present socioeconomic pressures associated with limitation of hospital stay, disease related groups, had a role in this decision. It is possible that with treatment of the systemic disease the outlet obstructive symptoms would have subsided. In the other case reported in this issue of the Journal by Touhami and associates (page 991) a mass in the external meatus of an elderly woman was the primary manifestation of nonHodgkin's lymphoma. As indicated previously, nonHodgkin's lymphomas are more prone to give genitourinary manifestations than Hodgkin's lymphomas. 1 This case underscores the fact that when meatal lesions, which usually are caruncles, do not respond to traditional conservative therapy, biopsy should be performed. The care of patients with lymphoproliferative disease requires a multidisciplinary approach, involving the medical oncologist and pathologist. The clinical and laboratory physicians should work closely together to ensure the most precise pathological classification of the disease process. Previously, it was sufficient simply to "pickle" tissue in the operating room and to send it to the pathologist. Such an approach obviates the use of new immunotyping and genotyping technology in the evaluation of these difficult disorders. Fresh tissue is required for nearly all immunohistological, immunocytometric and genotypic studies with the reagents currently available. Under optimal conditions the pathologist should develop a protocol to 958
handle prospectively biopsies suspected of containing lymphoproliferative disease. Fresh frozen tissue for immunohistology and genotyping if needed, and a fresh cell suspension for immunocytometry should provide information to help corroborate good light microscopic classification. Evidence of immunoglobulin light chain clonal excess and delineation of stageassociated differentiation antigens peculiar to distinct stages of T /B cell maturation is useful information. G-s Such an approach could have provided helpful information in the case reported by Touhami and associates. The description of a homogeneous population of small lymphocytes certainly could represent small lymphocytic lymphoma (diffuse well differentiated lymphocytic lymphoma of Rappaport). Although such areas may occur in inflammatory pseudotumors, evidence of immunoglobulin light chain clonal excess or coexpression of Leu-1 and a monoclonal light chain would have been helpful corroborative evidence for the light microscopic diagnosis of small lymphocytic lymphoma. The plethora of classifications of nonHodgkin's lymphomas has resulted in consternation among clinical and laboratory physicians. Recently, the National Cancer Institute sponsored a study that resulted in an International Working Formulation, a nomenclature that translates the variety of morphological and immunomorphological designations of lymphoma into morphological subtypes with biological relevance. 9 Until an immunological classification is developed for which specific reagents exist that identify each particular lymphoma with objective certainty, studies of nonHodgkin's lymphoma should rely on the International Working Formulation to provide a standard conventional nomenclature. Tissue accessioned by protocol will ensure the availability of special immunotyping and genotyping data to classify more precisely lymphoproliferative disease. A team approach between urologists and pathologists is in the best interest of the patient.
J. Edson Pontes and Raymond R. Tubbs Section of Urological Oncology and Department of Pathology Cleveland Clinic Foundation Cleveland, Ohio 1. Zein, T. A., Huben, R., Lane, W., Pontes, J. E. and Englander, L. S.: Secondary tumors of the prostate. J. Urol., 133: 615, 1985.
2. Siegel, S. W., Risius, B., Tubbs, R., Shepard, K. V. and Pontes, J. E.: Bilateral solid renal masses in a young man. J. Urol., 135: 327, 1986. 3. Lalli, A. F.: Lymphoma and the urinary tract. Radiology, 93: 1051, 1969. 4. Chilcote, W. A. and Borkowski, G. P.: Computed tomography in renal lymphoma. J. Comput. Ass. Tomogr., 7: 439, 1983. 5. Melchior, J., Valk, W. L., Foret, J. D. and Mebust, W. K.: The prostate in leukemia: evaluation and review of the literature. J. Urol., 111: 647, 1974. 6. Cleary, M. L., Trela, M. J., Weiss, L. M., Warnke, R. and Sklar, J.: Most null large cell lymphomas are B lineage neoplasms. Lab. Invest., 53: 521, 1985. 7. Tubbs, R. R. and Sheibani, K.: Immunohistology of lymphoproliferative disorders. Sem. Diag. Path., 1: 272, 1984. 8. Nadler, L. M., Anderson, K. C., Bates, M., Park, E., Slaughenhoupt, B. and Schlossman, S. F.: Human B cell-associated antigens: expression on normal and malignant B lymphocytes. In: Leucocyte Typing. Edited by A. Bernard, L. Boumsell, J. Dausset, C. Milstein and S. F. Schlossman. Berlin: Springer-Verlag, pp. 354363, 1984. 9. Tubbs, R. R.: Lymphocyte markers in solid tissues. In: Manual of Clinical and Laboratory Immunology. Edited by N. R. Rosa, H. Friedman and J. L. Fahey. Washington, D. C.: American Society for Microbiology, p. 934, 1986.
THE JOURNAL OF UROLOGY
Copyright© 1987 by The Williams & Wilkins Co.
Editorial LYMPHOPROLIFERATIVE DISORDERS Genitourinary lymphoproliferative involvement as the primary manifestation of a systemic process is uncommon but it has been reported previously on several occasions. 1- 4 The importance of diagnosing the lymphoproliferative disease lies in the fact that systemic treatment with chemotherapy may lead to resolution of the genitourinary symptoms. Furthermore, if surgical exploration is necessary, complete staging of the process is mandatory to plan therapy and to avoid secondary procedures. Previously, we noted prostatic involvement in 127 of 1,571 (8 per cent) autopsy cases of lymphoproliferative disease. 1 This incidence was more common in patients with Hodgkin's lymphoma (0.5 per cent). Although the majority of cases of secondary involvement of the prostate have been noted at autopsy, clinical manifestations of outlet obstructive problems as a result of prostatic infiltrate by the tumor have been described. 5 It is important that clinicians are aware of this presentation, since the frequently associated blood dyscrasias could lead to disasterous consequences in the event of surgery. Urinary problems that have been described occasionally as neurogenic bladder resulting from meningeal involvement could mimic outlet obstructive symptoms. 5 Unless an operation is absolutely necessary treatment of the systemic disease takes priority, since it may result in improvement of the genitourinary symptoms. If an operation is necessary it should be undertaken when the condition is in remission and the hematological profile is normal. In the case of lymphomatoid granulomatosis described by Feinberg and associates in this issue of the Journal (page 989) transurethral pros tatic resection and thoracotomy /lung biopsy were performed in a patient with significant outlet obstructive symptoms. Although these procedures led to the diagnosis of lymphoproliferative disease with prostatic involvement, one questions the decision to perform 2 unrelated procedures simultaneously, especially in the face of significant clinical evidence of a systemic process. We wonder if present socioeconomic pressures associated with limitation of hospital stay, disease related groups, had a role in this decision. It is possible that with treatment of the systemic disease the outlet obstructive symptoms would have subsided. In the other case reported in this issue of the Journal by Touhami and associates (page 991) a mass in the external meatus of an elderly woman was the primary manifestation of nonHodgkin's lymphoma. As indicated previously, nonHodgkin's lymphomas are more prone to give genitourinary manifestations than Hodgkin's lymphomas. 1 This case underscores the fact that when meatal lesions, which usually are caruncles, do not respond to traditional conservative therapy, biopsy should be performed. The care of patients with lymphoproliferative disease requires a multidisciplinary approach, involving the medical oncologist and pathologist. The clinical and laboratory physicians should work closely together to ensure the most precise pathological classification of the disease process. Previously, it was sufficient simply to "pickle" tissue in the operating room and to send it to the pathologist. Such an approach obviates the use of new immunotyping and genotyping technology in the evaluation of these difficult disorders. Fresh tissue is required for nearly all immunohistological, immunocytometric and genotypic studies with the reagents currently available. Under optimal conditions the pathologist should develop a protocol to 958
handle prospectively biopsies suspected of containing lymphoproliferative disease. Fresh frozen tissue for immunohistology and genotyping if needed, and a fresh cell suspension for immunocytometry should provide information to help corroborate good light microscopic classification. Evidence of immunoglobulin light chain clonal excess and delineation of stageassociated differentiation antigens peculiar to distinct stages of T /B cell maturation is useful information. G-s Such an approach could have provided helpful information in the case reported by Touhami and associates. The description of a homogeneous population of small lymphocytes certainly could represent small lymphocytic lymphoma (diffuse well differentiated lymphocytic lymphoma of Rappaport). Although such areas may occur in inflammatory pseudotumors, evidence of immunoglobulin light chain clonal excess or coexpression of Leu-1 and a monoclonal light chain would have been helpful corroborative evidence for the light microscopic diagnosis of small lymphocytic lymphoma. The plethora of classifications of nonHodgkin's lymphomas has resulted in consternation among clinical and laboratory physicians. Recently, the National Cancer Institute sponsored a study that resulted in an International Working Formulation, a nomenclature that translates the variety of morphological and immunomorphological designations of lymphoma into morphological subtypes with biological relevance. 9 Until an immunological classification is developed for which specific reagents exist that identify each particular lymphoma with objective certainty, studies of nonHodgkin's lymphoma should rely on the International Working Formulation to provide a standard conventional nomenclature. Tissue accessioned by protocol will ensure the availability of special immunotyping and genotyping data to classify more precisely lymphoproliferative disease. A team approach between urologists and pathologists is in the best interest of the patient.
J. Edson Pontes and Raymond R. Tubbs Section of Urological Oncology and Department of Pathology Cleveland Clinic Foundation Cleveland, Ohio 1. Zein, T. A., Huben, R., Lane, W., Pontes, J. E. and Englander, L. S.: Secondary tumors of the prostate. J. Urol., 133: 615, 1985.
2. Siegel, S. W., Risius, B., Tubbs, R., Shepard, K. V. and Pontes, J. E.: Bilateral solid renal masses in a young man. J. Urol., 135: 327, 1986. 3. Lalli, A. F.: Lymphoma and the urinary tract. Radiology, 93: 1051, 1969. 4. Chilcote, W. A. and Borkowski, G. P.: Computed tomography in renal lymphoma. J. Comput. Ass. Tomogr., 7: 439, 1983. 5. Melchior, J., Valk, W. L., Foret, J. D. and Mebust, W. K.: The prostate in leukemia: evaluation and review of the literature. J. Urol., 111: 647, 1974. 6. Cleary, M. L., Trela, M. J., Weiss, L. M., Warnke, R. and Sklar, J.: Most null large cell lymphomas are B lineage neoplasms. Lab. Invest., 53: 521, 1985. 7. Tubbs, R. R. and Sheibani, K.: Immunohistology of lymphoproliferative disorders. Sem. Diag. Path., 1: 272, 1984. 8. Nadler, L. M., Anderson, K. C., Bates, M., Park, E., Slaughenhoupt, B. and Schlossman, S. F.: Human B cell-associated antigens: expression on normal and malignant B lymphocytes. In: Leucocyte Typing. Edited by A. Bernard, L. Boumsell, J. Dausset, C. Milstein and S. F. Schlossman. Berlin: Springer-Verlag, pp. 354363, 1984. 9. Tubbs, R. R.: Lymphocyte markers in solid tissues. In: Manual of Clinical and Laboratory Immunology. Edited by N. R. Rosa, H. Friedman and J. L. Fahey. Washington, D. C.: American Society for Microbiology, p. 934, 1986.