Non-Hodgekin's lymphoma of female genital tract: a case report
A 35-year-old woman, with three children and last child born six year old, presented with complaints of increasing pain in the abdomen and dyspepsia of 3 months’ duration, fowl smelling vaginal discharge for one week and dizziness for one day. Previously, there was history of weight loss, anorexia, night sweats and low grade fever for 3 months. She had consultation from various doctors regarding lethargy and weakness. Her bone marrow biopsy which was done earlier for evaluation of anemia had no abnormality.\nPhysical examination revealed a tender mass of 22 weeks size in the left iliac fossa, which appeared to be arising from the pelvis and extending up to the umbilicus. On speculum examination, cervix was hypertrophied with irregular margins with fowl smelling vaginal discharge. Per vaginal examination revealed a mass in the pouch of Douglas pushing the uterus to the right side.\nUrgent baseline laboratory investigations along with tumor markers including CA-125, Lacatate dehydrogenase, serum beta HCG and alpha fetoprotein were analyzed. An abdomino-pelvic ultrasound revealed a left ovarian mass 12.1 x 10.4 cm with moderate vascularity and a right ovarian mass 6.7 x 4.9 cm with high vascularity along with free fluid in peritoneal cavity reaching up to paracolic gutters. Both CA-125 and Lactate dehydrogenase levels were high.\nAt the time of consultation, patient had a fainting attack, and went into shock. Resuscitation was done and patient rushed to E.R. Since it was an emergency case, there was no time for pre-op and she was arranged for needed frozen section at the time of operation.\nSince she suffered from acute pain in abdomen, exploratory laparotomy was done which revealed presence of three litres blood in peritoneal cavity with ruptured left ovarian cyst 10 x 8 cm with solid component and right ovarian mass of 5 x 5 cm with intact capsule and irregular surface. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and omenectomy were performed.\nOn gross examination, the left ovarian mass measured 9.0 x 6.0 x 4.0 cm. Right ovary measured 3.5 x 2.0 x 1.0 cm with intact capsule. Cut surface of both ovaries showed fleshy, grayish white homogenous cut surface. Separate multiple nodules were seen. Uterus weighed 120 grams and measured 10 cm from fundus to cervix,while ectocervix measured 3.5 x 2.5 cm. Cervix was shiny white with a greysih white nodular area measuring 3.5 x 2.5 x 1.0 cm on posterior aspect of the cervix.\nMicroscopic examination of ovarian masses and cervix revealed tissue being replaced by lymphoid atypical infiltrate comprising medium to large size lymphoid cells with pleomorphic, hyperchromatic nuclei, indisctict nucleoli and scanty cytoplasm. At places, starry-sky appearance was seen. Abundant mitosis and apoptosis was also noted. and\nImmunohistochemically, the cells were positive for LCA and negative for cytokeratin, which confirmed the diagnosis of lymphoma. Sections from the omentum revealed focal collections of these lymphoid indicating diffuse non-Hodgkin's lymphoma (probably diffuse large-cell lymphoma) involving the ovary.\nThe patient was evaluated postoperatively with an abdominal CT scan, which revealed multiple enlarged lymph nodes involving the common iliac, internal iliac and external iliac groups. Bone marrow aspirates and trephine biopsy confirmed marrow involvement. A diagnosis of stage IV (Ann Arbor staging) non-Hodgkin's lymphoma with secondary ovarian involvement with an initial clinical presentation of occult extra-ovarian disease was made.\nA chemotherapy protocol comprising 6 cycles of CHOP regime was administered to the patient, which responded well to the therapy.\nHaematoxylin- and eosin-stained section showing a diffuse population of medium to large sized cells with scattered macrophages.