Testicular lymphoma: an update for clinicians

Non-Hodgkin's primary lymphoma involving the genitourinary tract: histopathological experience from two tertiary hospitals, Western region, Saudi Arabia

BACKGROUND

Urinary tract and male genital organ lymphoid neoplasms are uncommon, accounting for less than 5% of all primary extranodal lymphomas. There have only been a few small case series and isolated case reports describing the primary sites and subtypes of these neoplasms. The aim of the study is to investigate the pathological characteristics of patients diagnosed with primary Genitourinary (GU) lymphoma in at two major hospitals.

MATERIAL AND METHODS

We obtained cases that were diagnosed with primary GU lymphomas between 2005 and 2020. Pathology and immunohistochemistry slides were retrieved and reviewed, additional immunohistochemical markers were done on selected cases.

RESULT

Herein we present a study of 11 patients. The mean age at diagnosis time was 46 years (range 24-71 years). Among urinary bladder, and ureter lymphomas, a slight female predominance was noted (3:2). Pathologic lymphoma subtype observed in our study were diffuse large B-cell lymphoma (DLBCL) (36%); mucosa-associated lymphoid tissue (MALT) lymphoma (18%); acute lymphoblastic lymphoma (B-LBL) (9%); high-grade B-cell lymphomas (27%) one of them with histomorphology of Burkitt-like large cell type, and a case of high-grade lymphoma, unclassifiable (9%). At the initial time of presentation, patients were commonly presented with non-specific signs and symptoms.

CONCLUSION

Even though this study reaffirms the prevalence of DLBCL in GU system, it also sheds light on the variable range of lymphomas that can arise in these sites. The variety of subtypes highlights the significance of thoroughly characterizing lymphoma classifications through ancillary studies such as immunohistochemistry and other molecular/cytogenetic tests if needed, as they are crucial for achieving an accurate pathology diagnosis.

Real-World Data Analysis of Survival Outcomes and Central Nervous System Relapses in Testicular Diffuse Large B Cell Lymphoma

Background

Primary testicular lymphoma is a rare type of non-Hodgkin lymphoma, mostly of the diffuse large B cell lymphoma (DLBCL). Although a consensus on standard treatment has been established, unresolved issues remain, such as recurrence in the central nervous system (CNS).

Methods

We retrospectively analyzed the clinical characteristics and survival outcomes of 65 testicular DLBCL patients according to clinical settings and treatment modalities.

Results

The median age of the patients in our study was 65 years, and two-thirds of them had disease limited to one testis. There was no right or left lateralization of testicular involvement. Over a median follow-up of 53.9 months (95% confidence interval 34.0-73.7 months), patients with stage I disease and a low international prognostic index score showed better survival outcomes than those in other categories. Orchiectomy, six cycles of chemotherapy, and radiation therapy (RT) to the contralateral testis demonstrated survival benefits, whereas CNS prophylaxis therapy did not reduce CNS recurrence. During the follow-up period, the survival curves showed continuous decline, mostly due to disease progression. CNS recurrence was observed in 15% of patients, and parenchymal involvement was dominant. However, no factors were associated with CNS recurrence in our analyses. Although our molecular analyses were performed in a small number of patients, MYD88, CD79B, and PIM1 mutations were frequent.

Conclusion

In our study, treatment with orchiectomy, six cycles of immunochemotherapy, and contralateral RT was effective. However, because CNS prophylaxis is an essential part of testicular DLBCL management, better treatment strategies than intrathecal therapy are required.

Current status of percutaneous testicular biopsy for focal lesions

OBJECTIVE

The purpose of this review is to evaluate the current role of percutaneous testicular biopsy in the diagnosis of focal testicular lesions.

CONCLUSION

Percutaneous testicular biopsy can be either fine needle aspiration biopsy or trucut core needle biopsy. It is a well-tolerated and effective procedure useful in small testicular lesions, multifocal lesions, hematological malignancies, and focal lesions in single testis.

Functional Parameters of 18F-FDG PET/CT in Patients with Primary Testicular Diffuse Large B-Cell Lymphoma

Fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) positron-emission tomography/computed tomography (PET/CT), a hybrid imaging technique that simultaneously provides functional and anatomical information, has been reported to be useful in lymphoma. The present study was to evaluate the functional parameters of ¹⁸F-FDG PET/CT in patients with testicular diffuse large B-cell lymphoma (DLBCL). We retrospectively reviewed medical records of 5095 patients with lymphoma who treated at West China Hospital between March 2003 and January 2017, and selected patients with ¹⁸F-FDG PET/CT findings and subsequently biopsy confirmed the invasion of testis with DLBCL. Maximum standardized uptake values (SUV_max), peak standardized uptake values (SUV_peak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the patients were measured. We evaluated the characteristics of ¹⁸F-FDG PET/CT in this population. Six patients ranged in age from 37 to 73 years (median age, 58 years) were included in the analysis. The mean SUV_max was 11.09 and varied between 7.20 and 19.75; mean SUV_peak was 9.56 and ranged between 6.79 and 14.39. In addition, mean MTV 42% was 18.4 and varied between 1.3 and 61.6; mean MTV 2.5 was 34.7 and varied significantly between 1.6 and 141.9. With regard to TLG, mean TLG 42% was 168.906 and ranged from 7.514 to 687.004, while mean TLG 2.5 was 253.972 and ranged from 8.400 to 1127.802. In conclusion, ¹⁸F-FDG PET/CT scan is a useful tool in patients with testicular DLBCL. SUV, MTV, and TLG may vary a lot in different patients. SUV_max of testicular DLBCL lesion is relatively higher than that of normal testis. Also, we provided a set of MTV and TLG data and firstly showed their significant correlation with overall survival, which indicated a potential prognostic value of MTV and TLG. However, studies with larger population are needed to confirm these findings.

Primary Germ Cell Tumor of Testes with Extensive Lymph Nodal and Splenic Metastases Masquerading Lymphoma on 18-F-FDG PET/CT

Germ cell tumors (GCT) account for the 95% of the malignancies associated with testes. They are the most common solid malignancies affecting the males in the age group of 15–35 years. It is known to be bilateral in 3% of cases. We herein present FDG PET-CT findings of a case with biopsy proven GCT with multiple lymph nodal and splenic metastases mimicking lymphomatous neoplasm.

Testicular fluorine-18 fludeoxyglucose uptake on positron emission tomography CT in patients with lymphoma: clinical significance and management impact

OBJECTIVE

This is the first case series examining the role of fluorine-18 fludeoxyglucose ((18)F-FDG) positron emission tomography-CT (PET-CT) in the diagnosis of lymphoma, and its impact on the clinical management of patients with secondary testicular involvement. This study explores the clinical significance of abnormal testicular uptake, maximum standardized uptake values and the diagnostic value of the CT component in PET-CT scans of these patients.

METHODS

The case notes and PET scans of 12 patients with diagnosis of lymphoma that were reported to have abnormal (18)F-FDG uptake in the testes were examined. Case notes were reviewed for the underlying diagnosis, indication for the scan and its effect on the management decision.

RESULTS

12 patients demonstrated abnormal (18)F-FDG uptake on the PET-CT scans (mean age, 63 years; range, 37-82 years). Seven patients were diagnosed with testicular lymphoma. Six out of the seven (86%) patients received additional intrathecal chemotherapy in addition to their systemic chemotherapy, and one patient had testicular radiotherapy.

CONCLUSION

This study establishes the importance of identifying and reporting abnormal (18)F-FDG uptake in the testes on PET-CT in patients with lymphoma. (18)F-FDG PET-CT is superior to conventional imaging in identifying testicular lymphoma and has significant management impact. It also emphasizes the importance of incorporating the testes as part of the scan coverage.

ADVANCES IN KNOWLEDGE

The appearances of testicular lymphoma on (18)F-FDG PET-CT can be variable and abnormal testicular uptake warrants further investigations and confirmation. FDG PET-CT is an important tool and can be used in addition to conventional imaging in the identification of testicular lymphoma.

Single-center experience in the treatment of primary testicular lymphoma

BACKGROUND

Primary testicular lymphoma (PTL) is a rare and highly aggressive extranodal non-Hodgkin's lymphoma.

PATIENTS AND METHODS

We evaluated the clinical and histopathological features and outcomes of 10 PTL patients treated in the period of 2003-2013 with multimodal therapy (rituximab, CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone), intrathecal prophylaxis, irradiation of the contralateral testis) following orchiectomy.

RESULTS

Complete remission was achieved in 8 patients after first-line therapy while 2 patients had disease progression. The median follow-up duration was 30 months (range 6-110 months). Relapse occurred in 3 patients. 1 patient relapsed in the contralateral testis, while the other 2 patients relapsed to the skin and the central nervous system (CNS), respectively. The time to relapse was 2, 8, and 9 months. Patients with disease progression and relapse received ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) as salvage treatment, except for 1 patient who was treated with palliative radiotherapy. After second-line therapy, only 1 patient had a short partial remission of 2 months. The median overall survival was 48 months, and the mean progression-free survival was 36 months (the median was not reached).

CONCLUSIONS

We evaluated 10 patients with PTL treated with rituximab plus CHOP, prophylactic intrathecal chemotherapy, and prophylactic irradiation of the contralateral testis, resulting in good outcome and low incidence of relapse in the contralateral testis; however, the benefit of intrathecal chemotherapy is not yet confirmed.

Testicular manifestation of a transformed mycosis fungoides

Testicular neoplasms occur in more than 90% of cases, due to primary testicular germ cell tumors. Other entities are non germ cell tumors of the testis, testicular manifestation of lymphomas or metastases. International and interdisciplinary co-operation has led to the development of urological guidelines and to good therapeutic success for testicular neoplasms. The gold standard for treatment of a testicular neoplasm is the radical orchiectomy. However, for individual cases with suspected lymphoma, a treatment decision differing from the guidelines may be reasonable. We present the case of a 38-year-old man with testicular manifestation of a transformed mycosis fungoides, which is the most common form of cutaneous T-cell lymphoma.

Clinical features of testicular lymphoma

Testicular lymphoma is a rare condition, so large scale prospective studies are difficult to conduct. Consensus regarding standard treatment is lacking. This study retrospectively reviewed 22 patients with testicular lymphoma. One patient with diffuse large B-cell lymphoma (DLBCL) was lost to follow-up after diagnosis. Two patients with Burkitt's lymphoma had poor outcomes regardless of treatment. Thus, we analyzed the clinical features, treatments, and outcomes of 19 patients with DLBCL. The median progression-free and overall survival was 28.3 and 36.3 months, respectively. A good response to treatment was a favorable prognostic factor. Because of the high relapse rate, the outcome is poor for testicular lymphoma. Therefore, long-term follow-up is strongly recommended.

Scrotal irradiation in primary testicular lymphoma: review of the literature and in silico planning comparative study

We examined adjuvant irradiation of the scrotum in primary testicular lymphoma (PTL) by means of a literature review in MEDLINE, a telephone survey among Dutch institutes, and an in silico planning comparative study on scrotal irradiation in PTL. We did not find any uniform adjuvant irradiation technique assuring a safe planning target volume (PTV) coverage in published reports, and the definition of the clinical target volume is unclear. Histopathologic studies of PTL show a high invasion rate of the tunica albuginea, the epididymis, and the spermatic cord. In retrospective studies, a prescribed dose of at least 30 Gy involving the scrotum is associated with best survival. The majority of Dutch institutes irradiate the whole scrotum without using a planning computed tomography scan, with a single electron beam and a total dose of 30 Gy. The in silico planning comparative study showed that all evaluated approaches met a D(95%) scrotal dose of at least 85% of the prescription dose, without exceeding the dose limits of critical organs. Photon irradiation with 2 oblique beams using wedges resulted in the best PTV coverage, with a mean value of 95% of the prescribed dose, with lowest maximum dose. Adjuvant photon or electron irradiation of the whole scrotum including the contralateral testicle with a minimum dose of 30 Gy is recommended in PTL. Computed tomography-based radiation therapy treatment planning with proper patient positioning and position verification guarantees optimal dose coverage.

Lymphoma of the scrotum in patients with Down's syndrome: US appearance. Mini-pictorial essay

Down's syndrome is relatively common, and patients who are affected have an increased risk of developing acute leukemia, but not solid tumors. Studies performed in larger patient populations have shown that solid tumors, including lymphomas, are significantly less frequent in Down patients than in children and adults who are not Trisomy 21-affected.Testicular lymphomas are rare and extremely aggressive. Ultrasound (US) combined with color Doppler is essential in the diagnosis and evaluation of treatment results in these lesions. As they are very rare, it was decided to publish this mini-pictorial essay.

Outcome of patients with diffuse large B-cell lymphoma of the testis by era of treatment: the M. D. Anderson Cancer Center experience

The purpose of this study was to assess the clinicopathologic characteristics and outcomes in patients with diffuse large B-cell lymphoma (DLBCL) of the testis, and to assess the impact of changes in the therapeutic approach that have occurred over the years. We reviewed the medical records of 75 patients between 1964 and 2008. Factors analyzed included: age, clinical stage, B-symptoms, serum levels of lactate dehydrogenase (LDH), beta(2)-microglobulin, treatment received, and outcome. Immunophenotypic data were available for 43 cases, all of which showed B-cell lineage. On univariate analysis, stages III and IV (p = 0.042), elevated serum LDH (p = 0.014), B-symptoms (p = 0.003), and high-intermediate or high International Prognostic Index (IPI) score (p = 0.010) were associated with a significantly decreased overall survival (OS) and progression-free survival (PFS). The 5-year OS and PFS for patients after 2000, treated predominantly with R-CHOP, intrathecal chemotherapy (ITC), and scrotal radiotherapy (RT), were 86.6% and 59.3%, respectively. This is compared to 56.3% and 51.7%, respectively, for patients treated between 1977 and 1999 with doxorubicin based chemotherapy without rituximab, who were not uniformly treated with ITC. Patients treated prior to 1977 had an OS and PFS of 15.4% and 15.4%, respectively, and were not treated with doxorubicin based chemotherapy or ITC (p = 0.019 for OS and p = 0.138 for PFS). Advanced stage, elevated serum LDH, B-symptoms, and high IPI are poor prognostic markers. R-CHOP based chemotherapy with intrathecal chemotherapy and scrotal RT is associated with an improved OS.

[Histological features and principles of treating testicle tumors in the elderly subject]

After the 6th decade, primitive lymphomas are the most frequent tumors of the testis (>30%). They are usually high grade lymphomas that commonly disseminate to the central nervous system. Chemotherapy depends on histological subtype. Germ cell tumors, mainly seminomas, represent less than 20% cases. Therapy do not differ from young adults germ cell tumors. Sex cord stromal tumors, mesenchymal benign tumors, sarcomas and metastasis represent approximately 10% of cases each. The first two are usually cured after orchidectomy. Prognosis of sarcoma is bad. The one of metastasis depends on primitive tumor (prostatic or pulmonary adenocarcinoma or melanoma mainly). Spermatocytic seminoma is a rare and benign tumor, if no sarcomatous component is observed. Mesothelioma are also very rare and of bad prognosis. Other histological subtype are extraordinary rare. This particular histological profile must be in mind when considering the appropriate therapeutic approach of testis tumors in elderly. This work is based on data collected between 1990 to 2005 by the french pathologists of the GELU.

Targeted testicular excision biopsy: when and how should we try to avoid radical orchidectomy?

Small, incidental testicular lesions are often benign, but in the past have usually been treated by orchidectomy. An alternative is an operative excision biopsy, with localization by ultrasound if necessary, and characterization of the lesion by frozen section analysis. The present review summarizes the indications for the procedure, lists the likely diagnoses, and describes the technique. Frozen section is accurate for distinguishing benign from malignant lesions, testicular function is usually preserved, and there is no evidence that oncological safety is impaired. Such testis-preserving surgery is a rewarding ground for collaboration between urologists, radiologists, and pathologists.

Lymphoid neoplasms of the urinary tract and male genital organs: a clinicopathological study of 40 cases

Lymphoid neoplasms of the urinary tract and male genital organs are relatively rare, comprising less than 5% of all primary extranodal lymphomas; only a handful of small case series and isolated case reports have been published describing their predominant sites and subtypes. We identified 40 patients with lymphoid neoplasms of the urinary tract and male genital organs. Hematoxylin and eosin slides and immunohistochemical stains were reviewed, and follow-up data were also obtained. Twenty-six of 40 cases (65%) were primary genitourinary lymphomas. Mean age at diagnosis was 56 years (range 4-86 years). Among renal, bladder, and ureter lymphomas, a male predominance was noted (1.6:1). The subtypes of the lymphoid neoplasms observed were diffuse large B-cell lymphoma (17 cases, 43%); Burkitt lymphoma, extranodal marginal zone lymphoma, SLL/CLL, and follicular lymphoma (4 cases, or 10% each); B-cell ALL (2 cases, 5%); B-cell lymphoma, unclassifiable, with features intermediate between diffuse large B-cell lymphoma and Burkitt lymphoma, mantle cell lymphoma, plasmacytoma, polymorphic post-transplant lymphoproliferative disorder, and peripheral T-cell lymphoma NOS (1 case, or 2.5% each). In most cases, the genitourinary tract was the site of initial presentation. Genitourinary tract lymphomas most commonly occurred in the kidney. B-cell non-Hodgkin's lymphomas predominated, with diffuse large B-cell lymphoma being the most common subtype in the entire group. Extranodal marginal zone lymphoma was seen only in the kidney, rather than the bladder, where it is typically thought to be more common. Although this study confirms the predominance of diffuse large B-cell lymphoma in extranodal sites, the findings also highlight the variety of lymphomas that may occur in the genitourinary tract. This diversity of subtypes affirms the importance of fully characterizing lymphomas by immunohistochemistry and other modalities, which are indispensable for accurate diagnosis.