Open Journal of Internal Medicine, 2012, 2, 11-14 OJIM Published Online March 2012 (
Non-Hodgkin’s lymphoma: A case of testis lymphoma
metastasized to the gallbladder
Yutaka Tsutsumi1*, Reiki Ogasawara1, Fumiyasu Yamamoto2, Yutaka Yamada3, Yasuyuki Komatsu1,
Kazuhiko Ichiki1, Shinich Ito1, Nobuaki Kurauchi4, Kazuhiro Kudo5, Norihiko Shimoyama5,
Junji Tanaka6, Masahiro Asaka7, Masahiro Imamura6, Hirohito Naruse2, Nobuo Masauzi1
1Department of Internal Medicine, Hakodate Municipal Hospital, Hakodate, Japan
2Department of Gastroenterology, Hakodate Municipal Hospital, Hakodate, Japan
3Department of Urology, Hakodate Municipal Hospital, Hakodate, Japan
4Department of Surgery, Hakodate Municipal Hospital, Hakodate, Japan
5Department of Clinical Patholog y, Hakodate Municipal Hospital, Hakodate, Japan
6Department of Hematology and Oncology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
7Department of Gastroentelology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
Email: *
Received 1 December 2011; revised 17 January 2012; accepted 29 January 2012
Testis lymphoma (diffuse large B cell lymphoma)
metastasized to the gallbladder. The gall bladder is
rarely involved in cases of the malignant lymphoma,
and lymphoma metastasis from the testis to the gall-
bladder has not been previously reported. These re-
ports may possibly change by the introduction of
PET/CT. Furthermore, although it was a struggle to
diagnose this particular case, there is a possibility
that we may have been able to recognize metastasis
from the testis at an earlier stage if PET/CT had been
Keywords: Testis Lymphoma; Gallbladder; PET/CT
A 70-year-old male was hospitalized on 19 May 2008 for
swelling of the left testis without pain. He had no history
of gallstones, anorexia, weight loss, jaundice, fever, or
abdominal tenderness. Laboratory findings showed a
leukocyte count of 7.6 × 109 L, a total bilirubin of 0.4
mg/dl, an AST of 20 IU/L, an ALT of 35 IU/L, an alka-
line phosphatase of 315 IU/L, and a serum interleukin-2
receptor level of 574 U/mL. A left testis tumor and a
gal lblad der t umor were observed in a computed tomogra-
phy (CT) scan (Figure 1). Left-side orchiectomy was per-
formed on 26 May 2008, and cytological examination of
the testis indicated lymphoma invasion (Figure 2). The
gallbladder tumor was expected to be cancer of the gall-
bladder, therefore, ultrasonic endoscope, blood angiogra-
phy, ERCP, and bile cytology were used for the diagnosis.
Bile cy-tology predicted a malignant lymphoma, but did
not confirm the tissue-type. In addition, these exams did
not find gallstones. Positron emission tomography (PET)
was performed after these examinations and the result
strongly indicated the aggressive lymphoma of gall
bladder (Figure 1(c)). Therefore, Cholecystectomy was
performed on 23 June 2008, and the pathological finding
was diffuse large B-cell lymphoma (Figure 3). Speci-
mens from both the testis and gallbladder were positive
for CD20, CD79a, bcl6, and MUM1, and the patient was
diagnosed with diffuse large B-cell lymphoma of the
testis and metastatic lymphoma of the gall bladder. He
was treated with inverted-Y radiation therapy and six
courses of R-THP-COP therapy (375 mg/m2 rituximab
on day 1; 500 mg/m2 cyclophosphamide, 30 mg/m2 pira-
rubicin, and 1 mg/m2 vincristine on day2; and 30 mg/m2
prednisolone on days 2 - 6). The patient was in complete
remission on 1 July 2009. Periodic su rveillance examina-
tions with PET/CT were performed on the 22nd of March
2010 and multiple lymphoid lesions were observed. PET
standard uptake value (SUV) showed diffuse large B cell
lymphoma disease recurrence. An identical therapeutic
regimen of R-THP-COP was performed (six courses)
from the 31st of March 2010. Patients experienced a sec-
ond rem ission on the 17th of September.
Non-Hodgkin’s lymphoma (NHL) is a rare disease,
accounting for only about 5% of all testicular neoplasms.
Primary NHL of the testis has a poor prognosis, spread-
ing to unusual extra-nodal sites and recurring after re-
mission. This disease has a marked tendency to metasta-
size to the skin, lung, central nervous system, and con-
tralateral testis [1]. Involvement of the gallblad der is rare
in cases of malignant lymphoma, and metastasis of ma-
lignant lymphoma from the tstis to the gallbladder has e
*Corresponding a uthor.
Y. Tsutsumi et al. / Open Journal of Internal Medicine 2 (2012) 11-14
(a) (b) (c)
Figure 1. (a), (b) CT scans showing the left testis tumor and the dense soft tissue mass in the gallbladder; (c) PET showing the high
SUV lesion in gall bladder.
(a) (b) (c)
(d) (e)
Figure 2. (a) Testis swelling due to the NHL; (b) Microscope image showing the testis diffusely infiltrated with malignant cells;
(c)-(e) These cells were positive for CD20, bcl-6, and MUM1.
not been reported previously [2,3]. Lymphoma metasta-
sis is a complex series of the steps in which lymphoma
cells leave the primary tumor and migrate to other parts
of the body via the blood stream of the lymphatic system.
A testis lymphoma might spread to non-lymphoid organs
without lymphoid lesions at early stage of the disease
progression. The fact that the present testis lymphoma is
able to spread to an extra-nodal site might show the
bloodstream was part of metastatic system for this tumor.
On the other hand, only lymphoid lesions were observed
in disease-recurrent cases. Various characteristic changes
were suspected, however, lymph-node analysis was not
performed at the time of recurrence.
Recently, PET examination has been able to distin-
guish various types of malignant neoplasms [4]. PET/CT
is now a standard procedural tool used for staging ma-
lignant lymphomas. A strong association between resid-
ual 18F-fluorodeoxy glucose (FDG) positivity and poor
prognosis has also been established [5]. Furthermore,
FDG-PET performed early during treatment may predict
the prognosis of lymphoma patients [5-7]. PET is also
able to detect the existen ce of multiple organ neoplasms,
including kidney, pancreas, esophagus, hepatobiliary,
uterine, ovary, and others [4]. Although detection of
primary and metastatic gall bladder lymphomas is cur-
rently rare, the rate of detection may increase with con-
current use of PET/CT procedures. If PET/CT had been
performed initially in this case, metastatic lymphoma of
the gall bladder might have been diagnosed more easily.
Gall bladder tumor may be suspected in instances of
Copyright © 2012 SciRes. OPEN ACCESS
Y. Tsutsumi et al. / Open Journal of Internal Medicine 2 (2012) 11-14 13
(a) (b) (c)
(d) (e)
Figure 3. (a) Gallbladder showed wall thickness due to the NHL; (b) Malignant cells infiltrated the gallbladder wall; (c)-(e) These
cells were positive for CD20, bcl-6, and MUM1.
lymphoma originating in distant regions. PET/CT will be
of great assistance in diagnosis and staging, particularly
in these rare cases of disease progression. In addition, the
technique allows the avoidance of highly invasive exams
and surgeries and is expected to become a powerful tool
in diagnosis and disease staging. Unfortunately, given
that complications of diffuse large B cell lymphoma and
gallbladder lymphomas have been reported, cholecys-
tectomy may not be completely avoided [8]. Distinctive
characteristics exist in different types of lymphomas.
While gallstones are a common complication in cases of
primary gallbladder lymphomas, aged individuals suffer
from diffuse large B cell lymphoma and malt lymphoma
relatively more often, which would be expected to help
in differentiating metastatic lymphomas from these two
types [9]. In add ition, it has been reported that both PET
and SUV can detect the differences between low-grade
and aggressive lymphomas, therefore, it would help in
the evaluation of either the complications of a primary
gallbladder lymphoma or metastasis [10]. In the future,
more detailed characteristics of gallbladder lymphomas
(including primary and metastatic), and their relation to
other lymphomas, are expected to become clearer.
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