Primary uterine lymphoma of the uterine cervix in advanced age

Abstract

Vaginal bleeding (70%), perineal discomfort (40%), and persistent vaginal discharge (20%) [1] are the most common clinical symptoms of primary malignant lymphoma of the uterine cervix, which is an extremely rare malignancy of the female genital tract occurring at a median of 40 years of age [2].An 82-year-old parous woman presented with persistent vaginal discharge for one year despite several antifungal and antibiotic combination regimens. Her past history and systemic examination were unremarkable. Papanicolaou smear revealed normal findings. Detection of a 15x15 mm nodular lesion in chest X-ray was confirmed to be a 35x30 mm lesion in the middle lobe and a 20 mm lesion in the lower part of the right lung with thoracic computerized tomography (CT). Serum lactate dehydrogenase (S-LDH) level was 402 U/ml. Colposcopically directed punch biopsies showed inflammation and necrosis while punch biopsy of the bladder revealed chronic cystitis. Inflammation was confirmed on repeated punch and fine needle aspiration biopsies (FNAB). Magnetic resonance imaging (MRI) scan showed a 52x40x45 mm cervical mass in the cervix uteri. Despite the lack of histological evidence, cervical malignancy was suspected based on clinical and radiological findings. Total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed together with intraoperative frozen section procedure. The operative finding was a hard mass that infiltrated the uterus and cervix with pelvic wall extension. Macroscopic examination of the hysterectomy specimen revealed a cervical mass measuring 50x40x15 mm and pathological examination showed non-Hodgkin's lymphoma (NHL) and diffuse large B cells positive for LCA and CD20 and negative for CD3 and cytokeratin (Figure 1). Lymph nodes and appendectomy specimens were negative for tumor metastasis. Bronchoscopic biopsy following thoracic CT revealed no sign of malignancy. The patient was classified as stage IE according to the Ann-Arbor classification and received three cycles of postsurgical chemotherapy with R-CHOP protocol. She remains under follow-up and is disease-free.Suspicion of cervical malignancy with respect to radiological findings in our case seems to be in accordance with past studies concerning the benefits of preoperative imaging studies in the diagnosis of cervical lymphomas [3,4]. Given that the patient was in stage IE with better prognosis [5] and was free of fertility-related surgical limitations, complete surgical resection followed by three cycles of chemotherapy according to R-CHOP protocol seemed to be quite effective in this case.In conclusion, while factors such as rarity of the disease, absence of specific gynecological as well as systemic symptoms and limited value of cervical smears are likely to complicate the diagnosis of primary uterine NHL, MRI findings seem to be directive in construction of a frozen section-based definitive diagnosis. Associated with good prognosis, complete surgical resection followed by chemotherapy according to R-CHOP protocol is beneficial in the man...