Is the ovary a sanctuary for non-Hodgkin's lymphoma? Successful surgical management

Abstract

In May 1999, a 30-year-old woman presented with a 2-month history of lower back pain and symptoms of sacral root compression. Systemic examination revealed a large right inguinal lymph node and a palpable right iliac fossa mass arising from the pelvis. A computed tomography scan showed bilateral hydronephrosis with some compression of the collecting systems, gross retroperitoneal and pelvic lymphadenopathy and an enlarged right inguinal lymph node. The lactate dehydrogenase level was raised at 665 iu/litre (normal range < 450 iu/litre). A lymph node biopsy confirmed the diagnosis of diffuse large B-cell non-Hodgkin's lymphoma. It was bulky stage 2 at presentation with an International Prognostic Index score of 1. The patient received six courses of CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone). Following this there was no palpable disease but her computed tomography scan showed residual para-aortic lymphadenopathy with some calcification. A decision was taken to observe without further therapy. She remained clinically very well until March 2000, when a right pelvic mass was palpable on clinical examination. She had an ultrasound scan followed by a computed tomography scan which showed pelvic lymphadenopathy and adnexal mass. In view of this she had two courses of mini BEAM (carmustine, etoposide, cytarabine and melphalan) (Chopra et al, 1992) in April–May 2000. A repeat ultrasound of the abdomen showed a reduction in right iliac fossa nodes. This was followed by high-dose therapy (BEAM) with autologous bone marrow transplantation in July 2000. This was consolidated with radiotherapy (40 Gray in 20 fractions) to the site of recurrence in the right pelvis in September and October 2000, and subsequent evaluation was consistent with remission. Following mild elevation of lactate dehydrogenase levels in November 2002, she had an ultrasound and computed tomography scan which showed a complex ovarian mass of 7×4 cm on her right side, with no evidence of significant lymphadenopathy (Figure 1). A biopsy showed relapse of lymphoma and a bone marrow sample was normal. The pelvic mass was removed laparoscopically in June 2003, and turned out to be an ovary completely replaced by a solid lobulated tumour. Histology showed high-grade B-cell non-Hodgkin's lymphoma similar to her previous disease (Figures 2 and 3). She had three courses of adjuvant chemotherapy with R-ESHAP (Velasquez et al, 1994) (rituximab, etoposide, methylprednisolone, cytarabine and cisplatin) in July 2003. Following this she has remained in complete remission for more than 5 years.