原发性膀胱淋巴瘤的诊治分析

Clinical features and management of primary bladder lymphoma

目的总结原发性膀胱淋巴瘤的诊治经验。方法回顾性分析2012年9月至2019年5月河南省肿瘤医院收治的8例原发性膀胱淋巴瘤患者的临床资料。男4例,女4例;年龄15~85岁,平均50.5岁。其中局限性膀胱淋巴瘤3例,转移性膀胱淋巴瘤5例。首发症状3例为无痛肉眼血尿,5例为腹痛腹胀。CT/MRI检查提示3例膀胱实性占位,5例盆腔肿块侵犯膀胱,部分病变可见肠道侵犯,肿瘤最大径3~22cm,平均11.3cm。术前诊断3例为膀胱肿瘤,5例为盆腔恶性肿瘤(其中4例合并肠梗阻,1例急腹症)。本组均行手术,2例行经尿道膀胱肿瘤切除术(TURBT),1例行腹腔镜膀胱部分切除术,5例行开放式盆腔肿块切除加膀胱部分切除术。结果术后病理诊断6例弥漫大B细胞淋巴瘤;1例黏膜相关淋巴组织淋巴瘤;1例间变大细胞淋巴瘤。术后随访时间3~60个月,平均28.1个月。2例术后分别出现膀胱阴道瘘和肠瘘并发症,未行后续放化疗治疗,至末次随访均存活。6例接受了以环磷酰胺+阿霉素+长春新碱+泼尼松(CHOP)方案为基础的静脉化疗,其中3例联用利妥昔单抗(R-CHOP方案)。3例死亡:1例局限性膀胱淋巴瘤患者,高龄(85岁),TURBT术后R-CHOP方案静脉化疗1周期后放弃后续治疗,术后10个月死亡;2例为转移性膀胱淋巴瘤,其中1例采取3周期CHOP方案静脉化疗后疾病进展,术后6个月死亡,另1例R-CHOP方案静脉化疗1周期后出现肺部感染,术后3个月死亡。3例化疗后至末次随访无复发转移,其中2例为年轻患者,在CHOP方案后序贯顺铂+依托泊苷+异环磷酰胺+地塞米松(DICE)方案化疗,1例化疗完全缓解后接受了盆腔巩固放疗。结论原发性膀胱淋巴瘤无特异性临床症状,病理是诊断的金标准,最常见的病理类型为弥漫大B细胞淋巴瘤。在满足诊断和解除急症的基础上应尽量减少手术创伤,可采取TURBT或穿刺活检明确诊断。主要治疗方式为以CHOP方案为基础的静脉化疗。膀胱外转移和高龄患者预后不良。

Objective To summarize the clinical experience of primary bladder lymphoma. Methods From September 2012 to May 2019, 8 cases of primary bladder lymphoma treated in our institute were analyzed retrospectively, including 4 males and 4 females. The mean age was 50.5 years old, ranged from 15 to 85. There were 3 cases of localized bladder lymphoma and 5 cases of metastatic bladder lymphoma. Three cases presented with painless gross hematuria primarily and 5 cases suffered from abdominal pain and bloating. Imaging examination showed the bladder tumor or pelvic mass with maximum diameter ranged from 3 to 22 cm, with 11.3 cm on average. Preoperative diagnosis of bladder tumor in 3 cases, and pelvic malignant tumor in 5 cases. Two patients underwent TURBT and 6 cases underwent pelvic mass resection and partial cystectomy. Results Postoperative pathological diagnosis showed 6 cases of diffuse large B-cell lymphoma, 1 case of mucosa-associated lymphoid tissue lymphoma, 1 case of anaplastic large cell lymphoma. Follow-up after surgery ranged 3 to 60 months, with 28.1 months on average. Two patients can not tolerate radiotherapy or chemotherapy for postoperative complications of vesico-vaginal fistula and intestinal fistula, and both were alive at the last follow-up. Six patients underwent CHOP regimen (cyclophosphamide, doxorubicin, vincristine, prednisone), 3 cases were addd with rituximab. Three patients died during the follow-up. One 85-year-old patient died 10 months after surgery. Two cases of metastatic bladder lymphoma died 3 or 6 months after surgery respectively. Three cases were alive after chemotherapy, including 2 young patients undergoing chemotherapy with DICE regime and one patient undergoing pelvic radiotherapy. Conclusion The primary bladder lymphoma has no special clinical symptoms, and TURBT and needle biopsy are critical for the diagnosis, based on the pathological and immunohistochemical examination. The most common pathological type is diffuse large B-cell lymphoma. R-CHOP chemotherapy is recommended, which can be followed by DICE regime for young patients. Metastasis and aging predict poor prognosis.