Introduction
Testicular lymphoma is a rare malignancy among urogenital malignancies. It constitutes 5-9% of testicular tumors, 2% of extranodal lymphomas, and 1-2% of non-Hodgkin lymphomas. Generally, it appears as an aggressive tumor in an advanced stage. Approximately 80% of patients have diffuse large B-cell lymphoma as the histopathological type of primary testicular lymphoma (1). Diffuse large B-cell lymphoma is often observed in male patients aged 60 years and over (2). Median survival time was reported as 4.6 years in a study (3). Remission may occur with combined treatment, but extranodal relapse is frequently observed (4). This study aimed to present a case with primary testicular diffuse large B-cell lymphoma.
Case Report
A 53-year-old male patient was admitted at our clinic with a complaint of painless, solid, scrotal swelling for approximately 25 days. On physical examination, a solid, irregular, painless mass with a size of 6×6×6 cm was palpated on the right testis, with an intact spermatic cord. Patient history revealed no comorbid diseases and he is a smoker. Laboratory evaluation revealed serum tumor markers of β-human chorionic gonadotropin <0.1 IU/mL, alpha-fetoprotein=2.3 ng/mL, lactate dehydrogenase=158 IU/L, and other laboratory parameters within normal limits. Scrotal colored Doppler ultrasonography was performed to determine the characteristic of the testicular mass for radiological evaluation. Any pathological image was not observed on the left testis; however, a 69×35 mm in size hypoechogenic structured mass with increased vascularization was found on the right testis. Non-contrast enhanced thoracoabdominal tomography was performed to evaluate the existence of metastasis, which revealed no metastasis. After obtaining the patient’s consent, right inguinal orchiectomy was performed with the diagnosis of a right testicular tumor according to these findings.
Pathological Evaluation
Macroscopic examination: The surgical resection material contained 6.5×4.5×4.5 cm sized testis and 6.5×1.5 cm sized spermatic cord. On the testicular side, a solid-structured mass formation with a size of 6×6×5 cm was observed. Areas of bleeding were shown in yellow-white color (Figure 1).
Microscopic examination: Medium-large-sized diffuse neoplastic cell infiltration with a high mitotic index was observed (Figure 2B).
Immunohistochemical examination: In the immunohistochemical staining of neoplastic cells, focal involvement was observed for multiple myeloma oncogene (MUM)-1, cluster of differentiation (CD) 43, CD5, and CD10. Positive staining was observed for paired box 5, CD79, and CD20. In addition, approximately 40% positive staining for C-myc and >70% positive staining for Bcl-2 were observed. Coexpression of CD10 and MUM-1 is observed, and the case with a high Ki-67 proliferation index was diagnosed as diffuse large B-cell lymphoma due to the C-myc detection as well as Bcl-2 positivity although classification is not made according to the Hans algorithm (Figure 2).
The patient consulted with the hematology specialist after surgical treatment. The patient was diagnosed with primary testicular lymphoma and started chemotherapy since other primary lymphoma sources were not detected. No signs of relapse or metastasis were observed in the postoperative 6th month follow-up of the patient.
Discussion
This case report aimed to present a patient with a rare testicular mass diagnosed with diffuse large B-cell lymphoma, which is generally observed after the 6th decade.
Extranodal localization of testicular B-cell lymphoma increased the risk of relapse and tumor aggressiveness (5). Germinal center B-cell is defined according to the immunohistochemical evaluation and characterized with positive staining of MUM-1, CD10, and Bcl-6 (6). In the study of Pătraşcu et al. (7), Bcl-2 positivity was reported as common in the range of approximately 50%. Our patient had MUM-1, CD10, and Bcl-2 positive staining in the immunohistochemical evaluation.
No consensus about the treatment of primary testicular diffuse B-cell lymphoma was made. Despite the recent treatment developments, the prognosis is often poor (6). Relapse risk is high due to the lack of standard treatment for primary testicular diffuse large cell lymphoma. Recommended therapy is a combination of surgery and chemotherapy especially for central nervous system relapse due to high relapse risk. Additionally, radiotherapy with 30 Gy to the contralateral testis for patients with high relapse risk is recommended (5,8). A 5-year survival rate may increase from 30% to 86.6% with multimodal therapy (9). In our case, combined therapy including surgery and chemotherapy was performed and no relapse was observed. Radiotherapy was not performed.
Conclusion
Primary testicular lymphoma is a rare type of extranodal lymphoma, but it can be difficult to treat with reduced survival if diagnosed late. Early diagnosis and initiation of combined therapy including surgery, chemotherapy, and radiotherapy at the contralateral testis is the only curative therapy in these patients.
Ethics
Informed Consent: Informed consent was obtained.
Peer-review: Externally peer-reviewed.
Authorship Contributions
Surgical and Medical Practices: G.A., Concept: M.O.H., Design: M.O.H., S.S.T., Data Collection or Processing: M.O.H., G.A., S.S.T., Literature Search: M.O.H., G.A., S.S.T., Writing: M.O.H., S.S.T.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
