Concurrent Bladder Lymphoma and Bladder Cancer Presenting as Metastatic Bladder Cancer
A 71-year-old man presented to our urologic department with a history of gross hematuria and dysuria for 1 month. Initial laboratory findings showed normochromic normocytic anemia without thrombocytopenia and an elevated level of lactate dehydrogenase at 798 IU/L. Abdominal computed tomography (CT) revealed a large bladder mass in the base and the left lateral wall of the bladder associated with perivesical infiltration and regional lymphadenopathy (). Abdominal CT also revealed a low attenuated, homogeneous mass in the distal ileum. Homogeneous, enlarged lymph nodes in the right pericardiophrenic angle, and around the suprahepatic inferior vena cava, aortocaval, right lower quadrant mesenteric, and bilateral inguinal areas were also seen. Cystoscopy revealed a large papillary mass in the trigone and left lateral wall of the bladder (). For histologic confirmation, the patient underwent transurethral resection of the bladder tumor. Histopathologic examination of specimens from the trigone specimen and the lateral wall confirmed superficial low-grade UC. In the subepithelial connective tissue, infiltration of atypical medium to large lymphocytes showing vesicular nuclei, prominent multiple nucleoli, and an appreciable amount of basophilic cytoplasm was seen (). For the stage work-up, positron emission tomography (PET), and ultrasonography-guided percutaneous biopsy of the right inguinal and axillary regions were performed, in addition to bone marrow biopsy bilaterally in the superior iliac crest. PET showed abnormal uptake in the bladder, small bowel mesentery, cervical spine, and the lymph nodes in the right pericardiophrenic angle, around the suprahepatic inferior vena cava, aortocaval, and both superior inguinal lesions. The right inguinal lymph node specimen showed a vague follicular growth pattern with relatively monotonous small lymphocytes, plasma cells, and plasmacytoid lymphocytes. They were positive for immunohistochemical stains for CD20, CD79a, Bcl-2, CD43, and immunoglobulin M (IgM). The VS38 immunohistochemical stain was positive (). Magnetic resonance imaging of the spine revealed an intradural mass at the 7th cervical level of the spine. Malignant lymphoma was found to be marginal zone B-cell lymphoma (MZBCL) based on the normal serum monoclonal IgM level and non-involvement of the bone marrow and spleen.\nDuring preparation for chemotherapy, the patient underwent surgical exploration of the abdomen due to perforation of a lymphoma lesion in the distal ileum. At six months after transurethral resection of the bladder tumor, cystoscopy was performed for follow-up of the bladder tumor, which revealed a papillary tumor on the trigone and subsequent transurethral resection was conducted. The patient underwent 6 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisolone chemotherapy but died from pneumonia and heart failure at 1 year after the end of chemotherapy.