Non-Hodgkin's lymphoma of the testis: a retrospective study of 84 patients treated in the French anticancer centres

A nomogram for predicting survival in patients with primary testicular lymphoma: A population-based study

BACKGROUND

Primary testicular lymphoma (PTL) is a rare malignancy whose epidemiology and prognosis have not been studied.

MATERIALS AND METHODS

PTL patient data were collected from the SEER online database, and the data were divided into a training cohort and a validation cohort according to random assignment. The training cohort was subjected to a one-way COX regression analysis, and statistically significant differences were included in the multi-factor COX regression analysis and constructed nomograms. Forest plots were constructed based on risk factors. The validity of the nomograms was verified by observing the C-index size of the nomograms, the percentage of area under the ROC curve, and the degree of fit of the prediction curve in the calibration plot. The validation cohort verified the accuracy and applicability of the nomograms.

RESULT

The patient's age, tumor histologic type, Ann Arbor stage, grade of differentiation, and whether or not they received radiation and chemotherapy were significantly associated with poor prognosis in PTL.

CONCLUSION

The nomogram constructed based on multivariate COX regression analysis can predict the prognosis of PTL patients. The online visualization nomogram can help clinicians calculate the survival rate of PTL tumor patients and conduct personalized prognostic assessments for PTL tumor patients.

Age related differences in primary testicular lymphoma: A population based cohort study

INTRODUCTION

Primary testicular non-Hodgkin's lymphoma (PTL) is a very rare disease, comprising 1% of all non-Hodgkin's lymphoma and <5% of all cases of testicular tumors. With a median age at diagnosis of 67 years, PTL is the most common testicular malignancy in men aged >60 years. There is limited published data on PTL incidence and outcomes in younger patients. The aim of this study is to compare the clinical parameters and survival outcomes between the patients older and younger than 50.

METHODS

The SEER database was queried for all patients diagnosed with PTL between 1983 and 2017. Data collected consisted of demographic, and clinical parameters, including staging, pathological assessments, and survival data. Patients were stratified according to their age and compared.

RESULTS

There was a total of 1,581 patients diagnosed with PTL between the year 2000 and 2017, of whom 215 (13.6%) were younger than 50 years old. The median age at diagnosis was 41 (interquartile range [IQR] 1-50), and 72 (IQR 51-95) years old for patients ≤50 and patients > 50 years of age, respectively. Comparison of younger and older patients detected similarities in disease laterality (92% vs. 94%, P = 0.38) and Ann Arbor stage I to II at diagnosis (76% vs. 75%, P = 0.59). The most common diffuse large B-cell lymphoma (DLBCL) subtype was more common in older patients (61% vs. 87%, P < 0.001). Radical orchiectomy (71% vs. 79%, P = 0.004) and radiation treatment (40% vs. 37%, P = 0.49) rates were comparable between both groups. However, a higher proportion of younger patients underwent chemotherapy (83% vs. 72%, P < 0.001). Patients ≤50 and >50 years old had a hazard ratio (HR) of 0.63 (95% CI: 0.57-0.71) and 0.34 (95% CI: 0.31-0.37), respectively, for 10-year OS with a median survival time for patients >50 of 5.75 years (95% CI: 5.25-6.33), P < 0.001. Patients ≤50 years old had a HR of 0.33 (95% CI: 0.26-0.40) compared to HR of 0.40 (95% CI: 0.37-0.43) in patients >50 years old for cumulative disease-specific mortality (DSM, P = 0.0204). Age >50 years was associated with worse DSM with a HR of 1.39 (95% CI: 1.05- 1.86, P = 0.024). Ann Arbor stage II and higher was also associated with worse DSM, while undergoing surgery, radiotherapy, and chemotherapy were associated with improved DSM.

CONCLUSIONS

PTL is the most common testicular malignancy in men older than 60 years of age, but more than a quarter of the patients are younger than 60 and more than 13% are ≤50 years. Younger patients are more likely to receive chemotherapy and radiation, and overall do better in terms of DSM. Being younger, having a lower Ann Arbor stage and being treated with chemotherapy and radiotherapy increase the chances of survival.

Testicular Diffuse Large B-Cell Lymphoma-Clinical, Molecular, and Immunological Features

Simple Summary

Testicular diffuse large B-cell lymphoma (T-DLBCL) is a rare and aggressive lymphoma entity that mainly affects elderly men. It has a high relapse rate with especially the relapses of the central nervous system associating with dismal outcome. T-DLBCL has a unique biology with distinct genetic characteristics and clinical presentation, and the increasing knowledge on the tumor microenvironment of T-DLBCL highlights the significance of the host immunity and immune escape in this rare lymphoma, presenting in an immune-privileged site of the testis. This review provides an update on the latest progress made in T-DLBCL research and summarizes the clinical perspectives in T-DLBCL.

Abstract

Primary testicular lymphoma is a rare lymphoma entity, yet it is the most common testicular malignancy among elderly men. The majority of the cases represent non-germinal center B-cell-like (non-GCB) diffuse large B-cell lymphoma (DLBCL) with aggressive clinical behavior and a relatively high relapse rate. Due to the rareness of the disease, no randomized clinical trials have been conducted and the currently recognized standard of care is based on retrospective analyses and few phase II trials. During recent years, the tumor microenvironment (TME) and tumor-related immunity have been the focus of many tumor biology studies, and the emergence of targeted therapies and checkpoint inhibitors has significantly modulated the field of cancer therapies. Testicular DLBCL (T-DLBCL) is presented in an immune-privileged site of the testis, and the roles of NF-κB pathway signaling, 9p24.1 aberrations, and tumor-infiltrating immune cells, especially immune checkpoint expressing lymphocytes and macrophages, seem to be unique compared to other lymphoma entities. Preliminary data on the use of immune checkpoint inhibitors in the treatment of T-DLBCL are promising and more studies are ongoing.

Adult primary testicular lymphoma: clinical features and survival in a series of patients treated at a high-volume institution in China

Background

To retrospectively investigate the clinical characteristics, initial treatment, relapse, therapy outcome, and prognosis of Chinese patients with primary testicular lymphoma (PTL) through analysis of the cases of our institute.

Methods

From December 2008 to July 2018, all patients with PTL were included in this study. Kaplan-Meier method was used to estimate PFS and OS. The Cox proportional hazards model was used to compare the survival times for groups of patients differing in terms of clinical and laboratory parameters.

Results

All 28 PTL patients (24 DLBCL, three NK/T lymphomas, and one Burkkit’s lymphoma) with a median age of 65.5 years were included in this study. Six patients were observed recurrence among all the 22 individuals evaluated. Following orchiectomy and systemic chemotherapy, with or without intrathecal prophylaxis, complete response was achieved in 15 (68%) patients. For DLBCL patients, the median progression-free survival (PFS) was 44.63 months (95% CI 17.71–71.56 months), and the median overall survival (OS) was 77.02 months (95% CI, 57.35–96.69 months). For all the DLBCL patients, the 5-year PFS and 5-year OS were 35.4% (95%CI, 14.8–56.0%) and 53.4% (95%CI, 30.1–76.7%). Without further chemotherapy following orchiectomy (HR = 3.4, P = 0.03) were associated with inferior PFS of DLBCL patients. Advanced Ann Arbor stage (HR =5.9, P = 0.009) and high (international prognostic index, IPI) score: 3–5 (HR =3.9, P = 0.04) were correlated with shorter OS of DLBCL patients.

Conclusion

This study confirms that PTL is an aggressive malignant with a poor prognosis. Limited Ann Arbor stage, further chemotherapy following orchiectomy, and low IPI score (less than 2) are correlated with superior survival for DLBCL patients.

Primary testicular lymphoma: A SEER analysis of 1,169 cases

Primary testicular lymphoma (PTL) is a rare lymphoid malignancy. The present retrospective study aimed to investigate the demographic characteristics and survival of patients with PTL, as well as the associated prognostic factors, using a population-based database. All adults diagnosed with PTL in the Surveillance, Epidemiology, and End Results database were identified between 1973 and 2013. The Kaplan-Meier method was used to estimate cause-specific survival (CSS). Log-rank test or multivariate Cox regression model was used to assess the influence of demographic and clinical parameters on CSS. A total of 1,169 patients with PTL were identified from the database, and the median age was 70 years. The predominant histological subtype was diffuse large B-cell lymphoma, which affected 82.9% (970/1,169) of patients, and 68.6% (802/1,169) of patients had early stage disease (stages I–II). Patients >70 years, those diagnosed at the earlier time period, or those who had advanced-stage symptoms had the worst 5-year CSS rates; however, treatment with rituximab significantly improved the 5-year CSS. In conclusion, this retrospective study presented data from the largest cohort of patients with PTL and described the effects of rituximab on the CSS of patients with PTL.

Primary Paratesticular Lymphoma with Testicular Sparing: Account of an Unusual Scrotal Mass

Tumours of the testicular adnexa include a heterogeous group of mesothelial, mesenchymal and germ cell tumours. Adenomatoid tumour, pseudosarcomatous myofibroblastic proliferations and rhabdomyosarcoma are the more frequently encountered neoplasms. Lymphoma/leukemic infiltration secondary to testicular involvement or primary tumour elsewhere is not unusual. However, Primary Para-Testicular Lymphoma (PPTL) involving spermatic cord and/or epididymis with sparing of the testicular parenchyma is extremely rare. Accurate staging and typing is crucial for effective management. We present a rare case of Diffuse Large B Cell Lymphoma (DLBCL) involving the left paratesticular tissue with testicular sparing in a young immunocompetant male patient.

[Testicular lymphoma: a clinicopathological study of 65 cases]

目的

观察睾丸非霍奇金淋巴瘤的临床病理表现及免疫表型，探讨其临床病理学特征。

方法

对2008年1月1日至2014年11月30日期间收治的65例睾丸非霍奇金淋巴瘤患者进行回顾性临床病理研究。

结果

全部65例患者中，46例（70.8%）为原发性睾丸淋巴瘤（PTL），19例（29.2%）为继发性睾丸淋巴瘤（STL）。PTL和STL患者均表现为睾丸不同程度的肿大，伴或不伴疼痛，且多为单侧受累（分别占91.3％和84.2%）。PTL患者中位发病年龄明显大于STL患者，分别为65(12~88）岁和13(1~75）岁，差异有统计学意义（P<0.001）；两组病例的组织学分型亦存在明显的不同，其中PTL中以弥漫大B细胞淋巴瘤（DLBCL）最为常见（87.0%）；而STL则以B淋巴母细胞淋巴瘤（B-LBL）最为常见（57.9%）。

结论

睾丸非霍奇金淋巴瘤以PTL多见，STL相对少见。与STL相比，PTL更多见于老年人。DLBCL是PTL最常见的组织学亚型，而STL中则以B-LBL更为常见。

FDG PET/CT images demonstrating epididymo-orchitis in a patient with HIV, acute kidney injury and known epididymo-orchitis on scrotal ultrasound

A 52-year-old man with HIV was referred for an F-FDG PET/CT scan for the cause of kidney injury. FDG PET/CT scan revealed increased renal cortical FDG activity, which can be seen in HIV nephropathy or acute interstitial nephritis. Diffuse increased FDG uptake was demonstrated within the right testicle and epididymis, consistent with the patient's known right epididymo-orchitis, as diagnosed on ultrasound 1 week before admission. Multiple enlarged lymph nodes with increased FDG activity were also found within the right inguinal and external iliac nodal chains, which were presumed to be reactive. The patient was treated with ciprofloxacin with symptomatic improvement.

Grayscale and color Doppler features of testicular lymphoma

Pooled data from 16 radiology centers were retrospectively analyzed to seek patients with pathologically proven testicular lymphoma and grayscale and color Doppler images available for review. Forty-three cases were found: 36 (84%) primary and 7 (16%) secondary testicular lymphoma. With unilateral primary lymphoma, involvement was unifocal (n = 10), multifocal (n = 11), or diffuse (n = 11). Synchronous bilateral involvement occurred in 6 patients. Color Doppler sonography showed normal testicular vessels within the tumor in 31 of 43 lymphomas (72%). Testicular lymphoma infiltrates through the tubules, preserving the normal vascular architecture of the testis. Depiction of normal testicular vessels crossing the lesion is a useful adjunctive diagnostic criterion.

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.

Primary testicular lymphoma

Primary testicular lymphoma (PTL) is a rare, clinically aggressive form of extranodal lymphoma. The vast majority of cases are histologically diffuse large B-cell lymphoma, but rarer subtypes are clinically important and must be recognized. In this review, we discuss the incidence, clinical presentation, and prognostic factors of PTL and present a summary of the recent advances in our understanding of its pathophysiology, which may account for the characteristic clinical features. Although outcomes for patients with PTL have historically been poor, significant gains have been made with the successive addition of radiotherapy (RT), full-course anthracycline-based chemotherapy, rituximab and central nervous system–directed prophylaxis. We describe the larger retrospective series and prospective clinical trials and critically examine the role of RT. Although rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone given every 21 days with intrathecal methotrexate and locoregional RT is the current international standard of care, a substantial minority of patients progress, representing an unmet medical need. Finally, we discuss new treatment approaches and recent discoveries that may translate into improved outcomes for patients with PTL.

[Treatment outcome in primary testicular non-Hodgkin lymphoma]

INTRODUCTION

Primary testicular lymphoma constitutes a rare subgroup among extranodal non-Hodgkin's lymphomas. Because of its aggressive clinical behaviour due to high grade histological features developing mainly in older population, patients with this disease usually have a poor prognosis. Orchidectomy followed by combination immunochemotherapy is a traditional treatment method with a rather inferior outcome.

AIM

In this retrospective survey the authors analysed the clinical presentation, pathological features and treatment results of patients with primary testicular lymphoma diagnosed and treated in their haematology centre between 2000-2012 METHOD: During this period 334 patients with aggressive non-Hodgkin's lymphomas were treated, of whom 8 patients (2.39%; age between 23 and 86 years; median, 60 years) underwent semicastration for primary testicular lymphoma (7 patients had diffuse, large B-cell lymphoma and one patient had Burkitt-like lymphoma). According to the Ann Arbor staging system a limited stage I-IIE was diagnosed in 7 patients and advanced stage was found in one patient. All but one patients were treated with rituximab added to CHOP regimen (6 or 8 cycles in every 21 or 28 days), whereas one patient received radiotherapy only. Central nervous system intrathecal prophylaxis was used in one case and no preventive irradiation of the contralateral testis was used.

RESULTS

With a median follow-up of 50 months complete remission was observed in 7 patients. However, two patients died (one due to progression and one in remission from pulmonary solid tumour). Complete remission rate proved to be 87.5%, disease-free survival was between 13 and 152 months (median 38 months) and overall survival rates were between 17 and 156 months (median 43 months). The 5-year disease-free and overall survival rates were 37.5 %.

CONCLUSIONS

The relatively favourable treatment outcome could be mainly explained by the high number of patients with early-stage of the disease, early surgical removal of testicular lymphomas and the use if immunochemotherapy. This therapeutic regimen was effective to prevent localized and distant relapses. Despite omission of regular prophylaxis of the central nervous system, no relapse was detected.

Immunohistochemical analysis of the expression of MAGE-A and NY-ESO-1 cancer/testis antigens in diffuse large B-cell testicular lymphoma

Background

Primary testicular lymphoma (PTL) is a rare and lethal disease. The most common histological subtype is diffuse large B-cell lymphoma (DLBCL). Standard treatments are frequently ineffective. Thus, the development of novel forms of therapy is urgently required. Specific immunotherapy generating immune responses directed against antigen predominantly expressed by cancer cells such as cancer-testis antigens (CTA) may provide a valid alternative treatment for patients bearing PTL, alone or in combination with current therapies.

Methods

Three monoclonal antibodies (mAbs), 77B recognizing MAGE-A1, 57B recognizing an epitope shared by multiple MAGE-A CTA (multi-MAGE-A specific) and D8.38 recognizing NY-ESO-1/LAGE-1 were used for immunohistochemical staining of 27 PTL, including 24 DLBCL.

Results

Expression of MAGE-A1 was infrequently detectable in DLBCL specimens (12.50%), whereas multi-MAGE-A and NY-ESO-1/LAGE-1 specific reagents stained the cytoplasms of tumor cells in DLBCL specimens with higher frequencies (54.17% and 37.50%, respectively) with different expression levels.

Conclusions

These results suggest that MAGE-A and NY-ESO-1/LAGE-1, possibly in combination with other CTA, might be used as targets for specific immunotherapy in DLBCL.

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.

Primary testicular non-Hodgkin's lymphoma associated with hemophagocytic syndrome: Case report and review of the literature

Primary testicular non-Hodgkin's lymphoma (TNHL) was first described as a clinical entity in 1866. It is a rare disease which accounts for 1% of all non-Hodgkin's lymphoma, 2% of all extranodal lymphomas and 5% of all testicular neoplasms. Hemophagocytic syndrome (HPS) is a rare but distinct condition caused by inappropriate and dysregulated activation of the immune system. We report a 47-year-old man with primary TNHL who developed HPS four months after occurrence of scrotal swelling. To the best of our knowledge, primary TNHL associated with HPS has not previously been reported.

Primary testicular lymphoma

Primary testicular non-Hodgkin lymphoma (PTL) comprises around 9% of testicular cancers and 1-2% of all non-Hodgkin lymphomas. Its incidence is increasing and it primarily affects older men, with a median age at presentation of around 67 years. By far the most common histological subtype is diffuse large B-cell lymphoma, accounting for 80-90% of PTLs. Most patients present with a unilateral testicular mass or swelling. Up to 90% of patients have stage I or II disease at diagnosis (60 and 30%, respectively) and bilateral testicular involvement is seen in around 35% of patients. PTL demonstrates a continuous pattern of relapse and propensity for extra-nodal sites such as the central nervous system and contralateral testis. Retrospective data have emphasised the importance of prophylactic radiotherapy in reducing recurrence rates within the contralateral testis. Recent outcome data from the prospective IELSG-10 trial have shown far better progression-free and overall survival than historical outcomes. This supports the use of orchidectomy followed by Rituximab- cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP), central nervous system prophylaxis and prophylactic radiotherapy to the contralateral testis with or without nodal radiotherapy in patients with limited disease. Central nervous system relapse remains a significant issue and future research should focus on identifying the best strategy to reduce its occurrence. Here we discuss the evidence supporting combination chemotherapy and radiotherapy in PTL.

Malignant lymphoma of the testis: a study of 12 cases

INTRODUCTION

Testicular lymphoma is a rare and deadly disease representing 1% to 2% of all non-Hodgkin lymphomas (NHLs) and approximately 5% of all testicular neoplasms. Our objective is this study was to identify the presenting signs and symptoms, treatment and outcome of patients with testicular lymphoma diagnosed at our institution from 1992 to 2005, and to identify any differences in survival based on Ann Arbor Stage and International Prognostic Index (IPI).

METHODS

A retrospective chart review was performed to identify demographic characteristics, presenting signs and symptoms, treatment and outcomes. Survival was assessed using Kaplan-Meier survival curves and log-rank testing.

RESULTS

Thirteen cases were identified; 1 of these cases was ultimately excluded due to a diagnosis of lymphoma a year before he presented with testicular involvement. Of the remaining 12 cases, the mean age was 65 years. Most patients presented with testicular and scrotal swelling or mass. B symptoms (weight loss, fever, night sweats) were present in 1 case. Of the 12 cases, 7 cases were stage I, 1 stage II and 4 stage IV. International Prognostic Index was low risk (</=1) in 7 cases and high risk (>1) in 4 cases. Orchiectomy was performed in all cases. Three patients received no further treatment. Of the remaining 9 patients, overall 7 received systemic chemotherapy, and 7 radiation therapy (prophylactic in 6). Three patients received intrathecal chemotheraphy prophylaxis. Seven patients achieved complete remission. Four patients (57%) relapsed following complete remission. Median time to relapse was 32 months (range 11 to 73 months). Six patients died. Median survival was 29 months, and was significantly different between early versus advanced stage (stage I/II disease: 71 months; stage IV: 5 months p = 0.007).

CONCLUSION

Testicular lymphoma is a rare and deadly form of extra-nodal lymphoma. Survival was significantly different in early stage I/II and IPI low-risk versus advanced stage IV and IPI high-risk disease. Randomized, prospective treatment trials may help to establish better treatment strategies.

Primary testicular diffuse large B-cell lymphoma shows an activated B-cell-like phenotype

The most common type of primary testicular lymphoma is diffuse large B-cell type, which has a poor prognosis relative to other extra-nodal diffuse large B-cell lymphomas (DLBCL). These constitute a heterogeneous group of lymphomas with germinal center B-cell-like and activated B-cell-like subtypes. Such a distinction theoretically utilizes the immunohistochemical expression of CD10, Bcl-6, and MUM1. The purpose of this study was that we could stratify primary testicular lymphoma of diffuse large B-cell type according to this scheme, and further elucidate the reason why primary testicular diffuse large B-cell lymphoma possesses a poor clinical outcome. Seventeen Chinese patients with primary testicular DLBCL were examined by means of a 3-antibody panel (CD10, Bcl-6, MUM1). Among these 17 cases, 16 were assigned to the activated B-cell-like subtypes. One case was classified as germinal center B-cell-like type. Twelve of these 17 cases expressed high proliferative activity (>or=40% Ki-67 labeling). The majority of primary testicular DLBCLs have activated B-cell-like subtype characteristics and high proliferative activity. These features might be a significant factor; moreover, they are associated with poor prognosis.

Testicular lymphoma--a retrospective, population-based, clinical and immunohistochemical study

From a population-based registry, 35 patients with histologically verified testicular lymphomas were identified: diffuse large B-cell lymphomas (DLBCL) in 33 and peripheral T-cell lymphomas in two cases. Twenty-two patients had localized disease (Pe stage I and II). Twenty-eight patients received systemic chemotherapy, 17 of whom also received intrathecal prophylaxis, and 12 out of these 17 also received radiotherapy to the contralateral testis. In the Pe stage I/II group, 7 out of 21 patients in complete remission (CR) relapsed. In 5 of them the CNS was involved (isolated CNS relapse in three). Remarkably late relapses occurred (up to 127 months). Intrathecal prophylaxis seemed to reduce the frequency of relapses involving the CNS, but the relatively short follow-up (median 45 months, range 34-88, for censored patients) prevents firm conclusions regarding efficacy. The outcome for the stage IV patients was poor, with only 1 out of 11 patients in continuous CR. Immunohistochemical analysis of the DLBCL tumours revealed that 31% had the germinal centre B-cell-like phenotype. CD44 was expressed in all the tumours of stage IV patients but in less than half of the Pe stage I/II patients. A high intratumoural microvessel density was correlated with a high degree of Ki-67 positive tumour cells and an inferior overall survival.

[Non-Hodgkin's primitive lymphoma of the testis: long-term prognosis associated with treatment combining systemic and intrathecal chemotherapy]

OBJECTIVES

To evaluate the long-term prognosis of a retrospective series of primitive malignant non-Hodgkin's lymphoma (MNHL) of the testicle treated by orchidectomy and combined systemic and intrathecal chemotherapy.

PATIENTS AND METHODS

From 1992 to 2006, eight consecutive patients were treated for a primitive MNHL of the testicle (stages : IA [n=1], IEA [n=5], IIEA [n=1], IVEA [n=1]) and retrospectively analyzed. All of these tumors were highly malignant. The average age of the patients at the time of diagnosis was 64 years old (46-78). All the patients benefited from an enlarged orchidectomy and received a combination of systemic and intrathecal CHOP and VACP chemotherapy. Six patients finished with some locoregional radiotherapy and three had cerebral radiotherapy.

RESULTS

Patients were treated over an average period of 90.5 months (12 to 168 months). Five patients (62.5%) responded successfully, one patient had a cerebral relapse stabilized by a second course of chemotherapy. Three patients died, one from septic shock during chemotherapy (IVEA stage), another from mesenteric infarction (IAE stage) and the third from acute coronary thrombosis while in complete remission.

CONCLUSION

In spite of a reputedly bleak prognosis, primitive MNHL of the testicle treated with a combination of systemic and intrathecal chemotherapy would seem to be associated with a good specific long-term survival. Unfortunately, the rate of mortality linked to chemotherapy is significant (close to 12.5% in our series) and would not appear to entirely protect against cerebral recurrence.

Benign and Malignant Neoplasms of the Testis and Paratesticular Tissue

Benign and malignant tumors of the testes and paratesticular tissues present an interesting spectrum of diagnostic entities often encountered in routine surgical pathology practice. Germ cell tumors are the most common tumors of the testes and, despite a rising incidence, have excellent prognosis because of their radiosensitivity and/or effective chemotherapeutic agents. The proper classification of these tumors aids in the choice of appropriate treatment options. This article reviews benign and malignant neoplastic entities of the testes and paratesticular tissues and illustrates the classic pathologic characteristics. The differential diagnosis, along with ancillary studies, clinical significance, and presentation are discussed also.

Testicular lymphoma: an update for clinicians

Testicular lymphoma is a lethal disease with a median survival of approximately 12 to 24 months. It is the most common testicular malignancy in men older than 60 years of age. Testicular lymphoma has a predilection for widespread dissemination to unusual sites, including the central nervous system, contralateral testis, Waldeyer's ring, skin, and lung. Doxorubicin based chemotherapy with prophylactic intrathecal chemotherapy and radiation to the contralateral testis seems most promising. This review article will focus on the presentation, pathology, patterns of relapse and challenges in improving the outcome of this disease.

Primary testicular non-Hodgkin's lymphoma--a review article

Primary testicular non-Hodgkin's lymphoma was first described as a clinical entity in 1866. It is a rare disease and accounts for 1% of all non-Hodgkin's lymphoma, 2% of all extranodal lymphomas and 5% of all testicular neoplasms. It is the most common testicular tumor in males between sixty and eighty years of age. Testicular non-Hodgkin's lymphoma is unique in its high incidence of bilateral involvement (8-38%), and it is also the most common bilateral testicular tumor. Testicular non-Hodgkin's lymphoma has a predilection for spreading to non-contiguous extranodal sites, especially the central nervous system. Advanced-stage disease is usually managed with doxorubicin-based chemotherapy. For early-stage disease, opinion is divided regarding systemic chemotherapy following orchidectomy. The high incidence of spreading, especially to the central nervous system, leads to advocacy of the use of central nervous system prophylaxis with intrathecal chemotherapy. Prospective multicenter trials incorporating a large number of patients may lead to better guidelines for optimal management of this subtype of non-Hodgkin's lymphoma.

Primary testicular and paratesticular lymphoma: a retrospective clinicopathologic study of 34 cases with emphasis on differential diagnosis

CONTEXT

Recent reports indicate the rate of primary testicular lymphomas is on the rise and misdiagnosis can still occur.

OBJECTIVE

To review and investigate the clinicopathologic features of primary testicular lymphoma with emphasis on the differential diagnosis. Discussion about the issue of misdiagnosis is also presented.

DESIGN

Retrospective review of pathology archives in 3 medical centers for cases fulfilling criteria of primary testicular lymphoma or paratesticular lymphoma was carried out. Clinicopathologic and immunohistochemical features were studied and analyzed.

RESULTS

The search identified 34 cases. Patients ranged from 4 to 87 years of age (mean, 55 years). All presented with a testicular/paratesticular mass and were stage I. The masses ranged from 2.5 to 13 cm (mean, 5.6 cm). Microscopically, the tumors often had an intertubular growth pattern or diffuse arrangement of predominantly large cells with pleomorphic, twisted nuclei and small nucleoli. Mitotic activity was brisk and apoptotic bodies were abundant. Thirty-two tumors were classified as diffuse large cell lymphomas; immunophenotype was determined in 21 of these and all were of B-cell type. The median survival was 96 months. The rate of initial misdiagnosis was unexpectedly high (5 cases, 15%).

CONCLUSIONS

Most cases of primary testicular lymphoma fall into the broad category of diffuse large cell lymphoma and the majority are B-cell type with particularly high proliferative activity when characterized by appropriate immunophenotyping. Misdiagnosis can occur, especially in those cases in which presentation occurs at an age similar to that for germ cell tumors, showing the need for caution and appropriate immunostaining when a testicular neoplasm has an atypical appearance for a germ cell tumor.

Primary Follicular Lymphoma of the Testis and Epididymis in Adults

Primary testicular lymphomas typically occur in patients over 60 years of age. Most are diffuse large B-cell lymphomas with frequent dissemination and a poor prognosis. Primary follicular lymphoma of the adult testis has not been well characterized. However, a small number of primary testicular follicular lymphomas have recently been described in children. These showed stage 1E disease, a lack of BCL2 gene rearrangement and Bcl-2 protein expression, and a good clinical outcome. Here, we describe 5 cases of primary follicular lymphoma of the testis and epididymis in adults. These presented as unilateral testicular masses 12 to 40 mm in diameter and were characterized histologically by small neoplastic follicles in a sclerotic background. The neoplastic cells expressed CD10 and Bcl-6, but not Bcl-2 and lacked t(14;18)(q32;q21)/IGH-BCL2 and BCL6 gene rearrangements. Four of the five patients were 35 years old or younger, and 4 presented with stage 1EA disease. Although follow-up is 12 months or less in 2 of the 5 patients, to date each has followed an indolent clinical course. These features are different from those of most adult nodal follicular lymphomas but are very similar to those of the pediatric primary testicular follicular lymphomas. Together, the pediatric and adult cases represent a discrete clinicopathologic entity of t(14;18)(q32;q21)/IGH-BCL2-negative primary follicular lymphoma of the testis and epididymis, which typically present as clinically indolent localized disease in young males and should be distinguished from the diffuse large B-cell lymphoma more frequently seen in the testes of older adults.

Primary testicular diffuse large B-cell lymphoma belongs to the nongerminal center B-cell-like subgroup: A study of 18 cases

The most common type of primary testicular lymphoma is diffuse large B-cell type, which has the potential for aggressive clinical behavior. Diffuse large B-cell lymphoma can be further subclassified into two major prognostic categories: germinal center B-cell-like and nongerminal center B-cell-like. Such distinction is made possible using the immunohistochemical expression of CD10, Bcl-6 and MUM1. The aim of this study was to stratify primary testicular lymphoma of the diffuse large B-cell type according to this scheme. Immunohistochemical stains for CD10, Bcl-6 and MUM1 were performed on 18 cases of primary testicular lymphoma of diffuse large B-cell type. Subclassification was carried out as previously described where CD10 and/or Bcl-6 positivity and negativity for MUM1 were considered indicative of germinal center B-cell-like type and the opposite expression as nongerminal center B-cell-like type. The proliferative activity was determined using immunostaining with the Ki-67 antibody. Of 18 cases, 16 (89%) were found to belong to the nongerminal center B-cell-like type. Two cases (11%) were classified as germinal center B-cell-like type; one had a CD10-positive, Bcl-6-positive and MUM1-negative profile, and the other was CD10 negative, Bcl-6 positive and MUM1 negative. The former occurred in a 38-year-old patient who was human immunodeficiency virus positive. All the cases expressed high proliferative activity (> or =50% Ki-67 labeling). We conclude that most (89%) primary testicular lymphomas of the diffuse large B-cell type belong to the nongerminal center B-cell-like subgroup and have high proliferative activity.

CNS prophylaxis in lymphoma: Who to target and what therapy to use

The purpose of this article is to review the current data on the risk of CNS relapse in patients with lymphoma and the efficacy of CNS directed prophylactic therapy. CNS relapse occurred in 30-50% of those with Burkitt lymphoma and acute lymphoblastic leukaemia/lymphoma prior to the introduction of intensified regimens that include CNS prophylaxis. Most patients with AIDS-related-lymphoma receive a short course of intrathecal prophylaxis but a re-evaluation of type and targeting of CNS prophylaxis is needed. Patients with diffuse large B-cell lymphoma (DLBCL) have a 5% overall risk of CNS relapse but a high risk sub-population can be identified on the basis of raised LDH and >1 extranodal site, testicular or primary breast involvement. CNS prophylaxis for selected patients with DLBCL may be justified by risk but its benefit is not yet proven. Intravenous methotrexate > or = 3 g/m(2) achieves therapeutic levels in CSF and parenchyma and in combination with intrathecal methotrexate would be a reasonable option for prophylaxis.

Diagnosis of a primary testicular lymphoma by echography and magnetic resonance imaging

We here describe a primary large B cell non-Hodgkin lymphoma of the right testicle in a 73-year-old male diagnosed with echography and magnetic resonance imaging. Treatment was based upon orchiectomy and chemotherapy, without any recurrence 2 years later. Ultrasonography and magnetic resonance findings with normal serum tumoural markers (AFP and B-HCG) can differentiate these tumors from germinal testicular tumors.

Testicular Lymphoma: Organ-Specific Treatment Did Not Improve Outcome

OBJECTIVES

To assess whether the use of an organ-specific treatment could improve event-free survival (EFS) and overall survival as endpoints in testicular lymphoma in the early stage: IE and IIE.

METHODS

Thirty-four patients were selected to be treated with orchiectomy following six cycles of anthracycline-based combined chemotherapy and radiotherapy (scrotum and contralateral testis in stage IE, contralateral testis and lymph nodes in stage IIE). Prophylaxis to the central nervous system was administered with four monthly cycles of a high dose of methotrexate: 6 g/m2.

RESULTS

Complete response was achieved in 33 cases (97%). However, relapses continue to be the rule; at a median follow-up of 74 months (range 61-120), 21 patients relapsed. Thus, actuarial curves at 5 years were 32% for EFS and 30% for overall survival, because all patients with failure and relapse died of tumor progression. Relapses were observed in uncommon sites: lung, bone marrow and as disseminate disease; no relapses were observed in irradiated sites of the central nervous system.

CONCLUSIONS

Testicular lymphomas remain a problem as regards defining the optimal treatment. The use of a specific treatment based on organ-involved sites did not show any improvement in outcome. It is evident that more specific therapies need to be explored.