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Non-Hodgkin's Lymphomas Involving the Uterus

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Non-Hodgkin's Lymphomas Involving the Uterus Non-Hodgkin’s Lymphomas Involving the Uterus: A Clinicopathologic Analysis of 26 Cases Russell Vang, M.D., L. Jeffrey Medeiros, M.D., Chul S. Ha, M.D., Michael Deavers, M.D. Department of Pathology, The University of Texas–Houston Medical School (RV), and the Departments of Pathology (LJM, MD) and Radiation Oncology (CSH), The University of Texas–M.D. Anderson Cancer Center, Houston, Texas KEY WORDS: B-cell, Immunohistochemistry, Non- Non-Hodgkin’s lymphomas (NHL) involving the Hodgkin’s lymphoma, Uterus. uterus may be either low-stage neoplasms that Mod Pathol 2000;13(1):19–28 probably arise in the uterus (primary) or systemic neoplasms with secondary involvement. In this Non-Hodgkin’s lymphoma (NHL) can involve ex- study, 26 NHL involving the uterus are reported. tranodal sites. Common extranodal locations in- Ten cases were stage IE or IIE and are presumed to clude the gastrointestinal tract and skin; however, be primary. The mean age of patients at presenta- the female reproductive system also may be af- tion was 55 years (range, 35 to 67 years), and abnor- fected, most commonly the ovary. Infrequently, mal uterine bleeding was the most frequent com- NHL may involve the uterus. Numerous studies of plaint (six patients). Nine of 10 tumors involved the NHL involving the uterus have been reported in the cervix. Histologically, eight were diffuse large B-cell literature, and we have identified at least 15 case lymphoma (DLBCL); one was follicle center lym- series that describe three or more patients (1–16). phoma, follicular, grade 1; and one was marginal However, in most of these studies, clinical zone B-cell lymphoma. At 5 years of clinical follow- follow-up is short and no comparisons are made up, five of six patients were alive after treatment. In between cervix and corpus involvement or between 12 cases, uterine involvement was part of a systemic primary and secondary neoplasms. Furthermore, disease at diagnosis, either stage IIIE or IV. The many studies were reported before the advent of mean patient age at the time that uterine involve- immunohistochemical analysis. ment was detected was 58 years (range, 22 to 75 In this study, we describe 26 cases of NHL involv- years); 6 of 12 had abnormal uterine bleeding. Six ing the uterus, most of which were treated within tumors involved both cervix and corpus, four cor- the same institution, thus representing the experi- pus, and two cervix. Six were DLBCL; two were ence at a tertiary care center. We further compare small lymphocytic lymphoma; three were follicle the clinicopathologic differences between primary center lymphoma, follicular, grade 1 (two cases) or and secondary NHL and report the results of im- grade 2 (one case); and one was precursor T-cell munohistochemical studies. lymphoblastic lymphoma. At 5 years of clinical follow-up, two of seven patients were alive after MATERIALS AND METHODS treatment. Four DLBCL arose in patients with in- complete clinical information; therefore, stage is Twenty-six cases of NHL involving the uterus unknown. We conclude that low-stage (presumably were collected from the files at M.D. Anderson Can- primary) uterine NHL are most commonly DLBCL, cer Center (MDACC) between 1981 and 1998. Of predominantly arise in the cervix, and cause abnor- this group, the initial biopsy or surgery in 19 pa- mal uterine bleeding. High-stage NHL are a hetero- tients was done at another institution, but the his- geneous group of B-cell neoplasms that can involve tologic slides were reviewed at MDACC; 11 of these the cervix or the corpus. patients were treated at MDACC. In seven addi- tional patients, initial biopsy or surgery and treat- ment were done at MDACC. Copyright © 2000 by The United States and Canadian Academy of Patients were staged according to the Harris and Pathology, Inc. VOL. 13, NO. 1, P. 19, 2000 Printed in the U.S.A. Scully modification (4) of the Ann Arbor staging Date of acceptance: July 19, 1999. system for extranodal lymphomas. Stage was as- Address reprint requests to: Michael Deavers, M.D., The University of Texas–M.D. Anderson Cancer Center, Department of Pathology Box 85, sessed at the time of the initial diagnosis of uterine 1515 Holcombe Boulevard, Houston, TX 77030-4095. involvement. Low-stage (presumably primary) neo- 19 plasms were defined as being either Stage IE or IIE. RESULTS High-stage (presumably secondary) neoplasms Low-Stage Uterine NHL were Stage IIIE or IV. Stage was considered uncer- tain if insufficient clinical information was avail- Clinicopathologic features able. Ten neoplasms were low stage; 7 Stage IE and 3 The distribution of the neoplasms was further Stage II . Patients ranged in age from 35 to 67 years categorized according to the region of involvement E (mean, 55 years). The most common presentation as cervix, corpus, or cervix ϩ corpus. Designation of was abnormal uterine bleeding (six patients [60%]). cervix or corpus was based on the predominant site The other patients presented with a pelvic mass, or of NHL in the uterus, determined by either patho- the NHL was an incidental finding. The pelvic exam- logic data or pathologic and clinical information. ination revealed cervical mass (two patients), cervico- The classification of cervix ϩ corpus indicated that vaginal mass (two patients), mass adjacent to cervix both regions had significant involvement. A subset (one patient), adnexal mass (mature cystic teratoma) of patients in all three groups had additional nonu- with bulky cervix (one patient), cervical polyp (one terine sites of involvement (e.g., lymph nodes). patient), endometrial polyp (on patient), and no doc- Clinical follow-up was available for 21 patients, umented abnormalities (one patient). The pelvic ex- obtained by review of the medical record. Four patients were lost to follow-up. amination findings were unknown in one patient. All NHL were histologically classified according Nine of 10 NHL predominantly involved the cervix to the revised European-American classification of (Table 1). lymphoid neoplasms. The immunophenotype was The diagnosis of NHL was established by cervical determined by immunohistochemical methods us- biopsy, curettage, conization, endometrial biopsy, or ing either frozen or fixed, paraffin-embedded tissue hysterectomy. The patients were treated by chemo- sections. For the paraffin section studies, the fol- therapy and radiation therapy (five patients) or che- lowing antibodies were used: LCA (CD45; 1:300), motherapy alone (two patients). One patient who was L26 (CD20; 1:700), anti-BCL-2 (clone 124; 1:10), and treated by chemotherapy and radiation therapy also anti-CD3 (1:150) (DAKO, Carpinteria, CA); Leu22 had total abdominal hysterectomy–bilateral salpingo- (CD43; 1:120) (Becton-Dickinson, San Jose, CA); oophorectomy. Two patients were treated only by and UCHL-1 (CD45RO; 1: 100). For the frozen sec- hysterectomy. One recent case has not been treated. tion studies, a number of B-cell and T-cell antibod- Clinical follow-up ranged from 7 months to 10 ies were variably used, including those specific for years (mean, 5.1 years) and was available for 7 of 10 CD3, CD4, CD5, CD8, CD10, CD19, CD20, CD22, patients. Five patients (Cases 3, 5–7, and 10) were and immunoglobulin heavy and light chains. The alive without disease at last follow-up. One patient immunohistochemical results were based on anal- (Case 8) had relapse and multiple recurrences of ysis of uterine specimens in 18 cases and on nonu- lymphoma with progression and death 1 year later terine tissues involved by the NHL in 8 cases. Flow (cause of death unknown). Another patient (Case 9) cytometry was used in one case. Gene rearrange- achieved complete clinical remission but died of ment studies were done by Southern blot analysis unknown cause 9 years later. Although follow-up of DNA extracted from frozen tissue in three cases was relatively short (7 months) for one patient and by a polymerase chain reaction method using (Case 2), a complete clinical response was achieved. DNA extracted from paraffin-embedded tissue in Case 4 is recently diagnosed. At 5 years of follow-up one case. for six patients, five (83%) were alive. TABLE 1. Primary Non-Hodgkin’s Lymphoma Involving the Uterus Case Age Presentation Stage/a Site Diagnosis Treatment Follow-up No. (yr) 1 35 AUB IE Corpus DLBCL TAH N/A 2 39 Vaginal mass IE Cervix DLBCL CT, RT A, 7 mo 3 46 Adnexal mass and pain IE Cervix DLBCL TAH-BSO A, 4.5 yr 4 53 Cervical dysplasia IE Cervix MZBCL Cervical conization Recent case 5 57 AUB IIE Cervix DLBCL CT, RT NED, 10 yr 6 57 AUB IIE Cervix DLBCL CT, RT NED, 5 yr 7 61 AUB IIE Cervix FCL-F, grade 1 TAH-BSO, CT, RT NED, 6 yr 8 65 AUB IE Cervix DLBCL CT D, 1 yr 9 67 Cervical mass IE Cervix DLBCL Cervical conization, CT D, 9 yr 10 67 AUB IE Cervix DLBCL Cervical conization, NED, 5 yr CT, RT AUB, abnormal uterine bleeding; DLBCL, diffuse large B-cell lymphoma; MZBCL, marginal zone B-cell lymphoma; FCL-F, follicle center lymphoma, follicular; TAH, total abdominal hysterectomy; CT, chemotherapy; RT, radiation therapy; BSO, bilateral salpingo-oophorectomy; A, alive; NED, no evidence of disease; D, dead. a Modified Ann Arbor stage (4). 20 Modern Pathology Histologic and immunophenotypic features The histologic types of NHL were diffuse large B-cell lymphoma (DLBCL; eight patients); follicle center lymphoma, follicular, grade 1 (one patient); and marginal zone B-cell lymphoma MZBCL (one patient). The DLBCL were composed of sheets of large neoplastic cells that infiltrated deeply through cervical stroma, frequently with interspersed resid- ual collagen bundles. Thick and densely hyalinized bundles of collagen were conspicuous in some cases. When the lower uterine segment was in- volved, preserved bundles of smooth muscle were pushed apart by sheets of lymphoma.
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