Abdominal B-Cell Lymphoma Mimicking Ovarian Cancer

Abstract

A 54-year-old patient presented in our clinic with pressure in the upper abdomen, dyspnea and abdominal distension. The clinical examination showed pleural effusion, ascites and an enlarged axillary lymph node on the right side. In gynecological sonography ascites, an ovarian cyst and peritoneal carcinosis in the pouch of Douglas were detected, which were potentially indicative of ovarian cancer. A staging laparoscopy was performed to confirm the diagnosis of ovarian cancer and to evaluate operability. Intraoperatively white milky ascites, white-yellow marbling of the liver and white stipple bedding on the diaphragm and liver were detected. The ovaries and the fallopian tubes were tumorously enlarged. Biopsies were taken from the right fimbrial funnel, the liver around the falciform ligament and the diaphragm. Histology of all abdominal biopsies and the axillary lymph node revealed high lymphatic infiltration matching a stage III B-cell-lymphoma. The patient was transferred to the hemato-oncological department for further therapy. Six cycles of cytostatic therapy with R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine sulfate, prednisone) were initiated. The patient is doing well and in stable disease 6 months after completion of cytotoxic therapy. This case report presents a rare case of manifestation of an extra nodal B-cell-lymphoma with abdominal presentation that mimicked ovarian cancer.

A 54-year-old patient presented in our clinic with pressure in the upper abdomen, dyspnea and abdominal distension. Patient’s anamnesis and family history were blank as well as screening for familial breast and ovarian cancer. The clinical examination showed pleural effusion, ascites and an enlarged axillary lymph node on the right side. In gynecological sonography and preoperative computed tomography ascites, an ovarian cyst and peritoneal carcinosis in the pouch of Douglas were detected, which were potentially indicative of ovarian cancer (Figure 1 and Figure 2). Laboratory results and blood count were normal except for tumor marker CA-125, which was increased at 531 U/mL. A staging laparoscopy was performed to confirm the diagnosis of ovarian cancer and to evaluate operability. Intraoperatively white milky ascites, white-yellow marbling of the liver and white stipple bedding on the diaphragm and liver were detected. The ovaries and the fallopian tubes were tumorously enlarged (Figure 3). Biopsies were taken from the right fimbrial funnel, the liver around the falciform ligament and the diaphragm. Histology of all abdominal biopsies and the axillary lymph node revealed high lymphatic infiltration matching a stage III B-cell-lymphoma (Figure 4). The postoperative course was uneventful, and the patient was transferred to the hemato-oncological department for further therapy. Six cycles of cytostatic therapy with R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine sulfate, prednisone) were initiated. The patient is doing well and in stable disease 6 months after completion of cytotoxic therapy. This case report presents a rare case of manifestation of an extra nodal B-cell-lymphoma with abdominal presentation that mimicked ovarian cancer. Primary Ovarian Non-Hodgkin’s Lymphoma is a rare condition and amounts to 0.5% of all Non-Hodgkin lymphoma [1]. Different cases have already been reported. In all but one of these, explorative laparotomy was carried out in order to confirm diagnosis and then aborted after histologic diagnosis. One case was diagnosed after biopsy of the ovarian mass [2,3]. In another case series, all patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy [1]. In our case, we first performed a laparoscopy to confirm diagnosis. Staging laparoscopy and biopsy were crucial steps to obtain the right diagnosis and initiate the right therapy. Laparoscopy was also less harmful than laparotomy and subsequent chemotherapy could start sooner. Interdisciplinary cooperation was crucial for a fast and adequate induction of the appropriate therapy.