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Primary Burkittʼs Lymphoma of the Ovary in Early Weeks of Pregnancy – a Case Report Primäres Burkitt-Lymphom Des Ovars in Der Frühschwangerschaft – Fallbericht

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Primary Burkittʼs Lymphoma of the Ovary in Early Weeks of Pregnancy – a Case Report Primäres Burkitt-Lymphom Des Ovars in Der Frühschwangerschaft – Fallbericht Case Report 949 Primary Burkittʼs Lymphoma of the Ovary in Early Weeks of Pregnancy – A Case Report Primäres Burkitt-Lymphom des Ovars in der Frühschwangerschaft – Fallbericht Authors H. Steininger, J. Gruden, H. Müller Affiliation Pathologisches Institut, Friedrichshafen Key words Abstract Zusammenfassung l" adolescence ! ! l" ovarian tumour Primary ovarian Burkittʼs lymphoma is a rare Das primäre ovarielle Burkitt-Lymphom ist ein l" pregnancy tumour predominantly affecting children and seltener Tumor, der bei Kindern und jungen Er- Schlüsselwörter young adults. We report here on a 17-year-old wachsenen auftreten kann. Im vorliegenden Fall l" Adoleszenz pregnant woman with a Burkittʼs lymphoma of handelt es sich um eine 17-jährige, schwangere l" Ovarmalignom the left ovary. After tumour removal and induced Patientin mit Befall des linken Ovars. Nach Entfer- l" Schwangerschaft abortion, the patient underwent polychemother- nung des Tumors und Abortinduktion wurde eine apy. Full remission was achieved 7 months after Polychemotherapie durchgeführt, unter der es the initial diagnosis. 7 Monate nach Diagnosestellung zur Vollremis- sion kam. Introduction rump length of 4 cm. A 7.5 cm large solid pelvic ! mass was visible at the left adnexa. Malignant lymphomas of the female genital tract Laparoscopic investigation showed a tumour of are unusual, and less than 1% of patients with a the left ovary of unclear malignancy and origin. diagnosis of malignant lymphoma present with The patient underwent laparatomy with removal an enlarged ovary as the initial manifestation [1, of the left ovary. There were no other pathological 2]. In more than 90% of cases, the malignancy is a intra-abdominal findings. The peritoneum was B-cell non-Hodgkin lymphoma, often with sec- smooth; the right adnexa, omentum and liver ondary involvement due to systemic disease [2, were unremarkable; no enlarged lymph nodes 3]. were noted. As lymphatic tissue is normally not present in the Macroscopically, the resected specimen consisted ovary, primary malignant lymphomas of the ova- of a pear-shaped tumour weighing 114 g and ry are rare. They constitute less than 1% of all ma- measuring 7.5 × 6.5 × 4 cm (l" Fig. 1). The cut sur- lignant lymphomas and the literature on primary face of the tumour had a homogeneously light received 17.7.2012 malignant ovarian lymphomas consists only of grey to light brown colour, with small cysts and a revised 21.8.2012 case reports or small series [4–10]. central blood supply. It was not possible to differ- accepted 31.8.2012 Some authors have proposed criteria which could entiate the tumour from normal ovarian tissue ei- Bibliography be used to differentiate between secondary and ther macroscopically or histologically. DOI http://dx.doi.org/ primary malignant lymphomas [1–3,10], and Microscopic investigation showed a lymphoid tu- 10.1055/s-0032-1327777 these criteria will be discussed below. mour with blast tumour cells, some areas of cohe- Geburtsh Frauenheilk 2012; 72: sive growth, and interspersed macrophages, giv- 949–952 © Georg Thieme “ ” l" Verlag KG Stuttgart · New York · ing it a starry sky appearance ( Fig. 2). Tumour ISSN 0016‑5751 Case Report and Morphological Findings cells were strongly positive for CD45, CD20, CD10 ! and CD38. Positivity for bcl-6 was slightly weaker, Correspondence Prof. Helmuth Steininger A 17-primagravida was admitted to hospital in and the tumour was bcl-2 negative. The tumour Pathologisches Institut the 11th week of pregnancy (10 + 5) for strong, proliferation fraction (Mib 1) was approx. 90% Röntgenstraße 2 acute onset, primarily left-sided, abdominal pain. (l" Fig. 3); the tumour was EBV‑LMP negative and 88048 Friedrichshafen helmuth_steiningerpath@ Vaginal sonography showed an enlarged uterus both oestrogen receptor-negative and progester- hotmail.com containing a vital single foetus with a crown- one receptor-negative. Steininger H. Primary Burkittʼs Lymphoma … Geburtsh Frauenheilk 2012; 72: 949–952 950 GebFra Science Table 1 Ann Arbor staging system (1971). Stage Involvement I Cancer is located in a single lymph node region (I) or a single extra- lymphatic organ (IE) II Involvement of two or more lymph node regions (II) or localised involvement of extra-lymphatic organ or tissue with involvement of one or more lymph node regions (IIE) on the same side of the diaphragm III Cancer is located in lymph node regions on both sides of the diaphragm (III), sometimes accompanied by localised extra-lym- phatic organ or tissue involvement (IIIE) or splenic involvement (IIIS) or both (IIISE) IV Diffuse or disseminated involvement of one or more extra-lym- phatic organs or tissues, with or without enlarged lymph nodes resulting in a clinical diagnosis of a stage III lymphoma according to the Ann Arbor staging system (l" Table 1). Polychemotherapy was indicated based on the recommendations of the German Multi-centre Study Group for Adult Acute Lymphoblastic Leukae- Fig. 1 Macroscopic image of the left ovary showing complete invasion of mia (GMALL B‑ALL/B‑NHL protocol 2002). the ovary (scale in cm). Because of the embryotoxicity of the cytostatic drugs and the in- calculable risks during the therapy-induced aplasia phases, an abortion was induced 14 days after diagnosis in the 13th week of pregnancy with subsequent curettage. The embryo was a male Cytogenetic investigations showed a break in the area of the foetus with appropriate foetal development for age, weighing c‑myc gene with translocation t(8:14) and a clonal immunoglob- 27 g with a crown-rump length of 7.5 cm and without visible ex- ulin heavy chain gene rearrangement. Histological, immunohis- ternal or internal abnormalities. A few days after the abortion, tochemical, and cytogenetic findings were consistent with the the disease had progressed rapidly, with pelvic bone pain and diagnosis of Burkittʼs lymphoma. pain in the lumbar vertebral column as well as night sweats. The No enlarged lymph nodes were found on investigation immedi- patient developed diffuse bone marrow disease and a left para- ately after the diagnosis of Burkittʼs lymphoma. uterine mass in the small pelvis. Enzyme-linked immunosorbent assay (ELISA) for HIV was nega- After pre-phase therapy with cyclophosphamide and predniso- tive. lone, port implantation was done and treatment block A1 of the Bone marrow investigation done 10 days after removal of the tu- B‑NHL protocol was administered (rituximab d 7, vincristine d 8, mour did not show the presence of any lymphoma. The liver, high-dose methotrexate d 8, ifosfamide d 8–13, etoposide d 11 spleen and other organs were unremarkable; the lymph nodes and 12, and 2 × triple intrathecal prophylaxis with methotrexate, were still not enlarged. Haemogram and differential blood count cytarabine and dexamethasone on d 10 and d 12). Morphine were normal. However, over the next few days the cervical lymph therapy and complete parenteral feeding were temporarily nec- nodes rapidly proliferated and became enlarged (up to 17 mm), essary for grade IV mucositis. The patient developed fever in the Fig. 2 Histological image showing lymphoblastic infiltrate and a starry sky Fig. 3 High tumour proliferation fraction of approx. 90%. Immunohisto- pattern (white arrows). Giemsa × 200. chemistry (MiB 1) × 200. Steininger H. Primary Burkittʼs Lymphoma… Geburtsh Frauenheilk 2012; 72: 949–952 Case Report 951 subsequent aplasia phase and was given antibiotics. HSV1 virus 2. Complete examination of the patient shows no indications for DNA in the pharyngeal aspirate made treatment with acyclovir disease in any other part of the body. necessary. After aplasia had ended, improvement was rapid and 3. Peripheral blood picture and bone marrow contain no abnor- medication was discontinued. Chemotherapy was then contin- mal cells indicative of leukaemia. ued with the administration of block treatments B1 and C1 ac- 4. No involvement of distant organs over a period of 6 months. cording to the B‑NHL protocol. Complications of fever and muco- sitis recurred. Chemotherapy was completed 7 months after Other authors [2,10] consider Ann Arbor stage IE (E = involve- diagnosis and after the administration of block treatments A2, ment of extra-lymphatic organs, l" Table 1) to be sufficient for B2 and C2. The disease was in complete remission and the patient the diagnosis of primary lymphoma, while other authors com- was in a stable general condition with a Karnofsky index of 90%. pletely dispense with giving their criteria [4–7, 9]. Even if the case described here did not comply with No. 4 of Kosariʼs criteria – as there was cervical lymph node involvement and infiltration of Discussion bone marrow already after one month – we are of the opinion ! that the tumour was a primary ovarian Burkittʼs lymphoma. At Burkittʼs lymphoma is a rapidly growing tumour with a generally diagnosis the tumour was stage IE; the lymphoma was already unfavourable prognosis. The entity was first described in 1958 by relatively large and examination done immediately after the di- Burkitt as a “sarcoma” occurring in African children [11]. In fact, agnosis showed no involvement of other organs. Bone marrow it is a highly malignant, B-cell non-Hodgkin lymphoma consist- and peripheral blood picture were unremarkable. ing of monomorphic, medium-sized cells with basophilic cyto- Most Burkittʼs lymphomas with involvement of the ovaries and plasma; it has a high proliferation fraction, a cohesive growth appendix affect children or young adults. Typical presenting pattern and displays a so-called starry-sky pattern [12]. Primary symptoms are abdominal tumours with swelling and pain and, extra-nodal manifestation is common. Almost all cases showed occasionally, ileal symptoms due to rapid growth of the tumour translocation of the c-myc proto-oncogene from its normal posi- [9]. tion on chromosome 8 to a region on chromosome 14, which The differential diagnosis of malignant ovarian lymphoma in- codes for heavy chains [12]. cludes granulosa cell tumours, dysgerminoma, hypercalcaemic Epidemiologically, Burkittʼs lymphoma is differentiated into 3 small cell ovarian carcinoma, poorly differentiated ovarian carci- main forms [12,13].
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