Sonmezer M, Ensari A, Ustun Y, Gungor M, Ortac F.
Primary Lymphoma of the Urinary Bladder presenting as a Large Pelvic Mass.
J Pak Med Assoc Jan ;52(5):228-30.

A 58 years old woman suffering from chronic pelvic pain, pelvic pressure and mass, dysuria and genitourinary bleeding for 2 months was admitted for evaluation. On gynecologic examination uterus was semifixed, cervix was mobile and a solid, irregular mass with a size of 10 cm that was located anterior to uterus and involved the right adnexa was detected. Ultrasonographic examination confirmed a solid mass with indefinite borders. CA 125 level was normal. On digital examination the rectal mucosa was normal. PAP smear and endometrial biopsy were without any pathology. To find out the origin of the bleeding, a cystoscopic evaluation and an intravenous pyelogram were performed and an irregular, necrotic, solid submucosal mass was observed at the dome of the bladder. Histopathologic and imnunophenotypic evaluation of the biopsy specimen performed thereafter by immunoperoxidase methods using Streptavidin-Biotin peroxidase system revealed a high grade B type malignant lymphoma (figures 1 and 2). After establishment of diagnosis as postmenopausal adnexal mass and lymphoma of the urinary bladder, patient was re-evaluated. In clinical (including complete blood count, tumor markers, peripheral blood smear and bone marrow biopsy) and in radiological investigations (including computed tomography) there was no evidence of tumor found elsewhere. On exploratory-laparotomy, urinary bladder was observed to have strict adhesions with anterior abdominal wall, omentum, uterus and right adnexa forming a conglomerate mass. Peritoneal surface was free of any metastatic spread. There was no sign of fistula formation. After mobilization of the bladder, a cystotomy was performed and a solid, necrotic mass originating from bladder mucosa at the dome was observed which also invaded bladder wall. The mass was removed completely by partial cystectomy with a 2 cm margin of normal tissue. Total abdominal hysterectomy and bilateral salphingoopherectomy was also performed. Retroperitoneal lymph nodes were not found to be enlarged by palpation. Four courses of CHOP regimen (cyclophosphamide, vincristine, doxorubucin, prednisolone) were implemented. The re-biopsy performed from the dome of the bladder on the 3rd and 6th months were normal. The patient was complaint-free and no local or distant recurrence was found during the 6 years follow up.

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