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A 66-year-old male known case of diabetes and hypertension presented to the urology clinic with a 2-month history of lower urinary tract symptoms (LUTS), particularly poor flow, sense of incomplete bladder emptying, dysuria and hesitancy. Family history was negative for prostate or breast cancer.
On examination, there were signs of anaemia or lymphadenopathy. His abdominal examination was unremarkable with no hepatosplenomegaly, and his digital rectal examination (DRE) revealed an irregular, moderately enlarged nodular prostate.
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The patient underwent the following investigations in chronological order:
Laboratory investigations Haemoglobin: 134 g/L. Total leucocyte count: 8.6×109/L without any atypical cells. Platelets: 286×109/L. Prothrombin time/ International normalized ratio (PT/INR): 13/1.1. Creatinine: 1.1 mg/dL. Electrolytes: normal. Urine detailed report: normal. Urine culture and sensitivity: no bacterial growth. Prostate-specific antigen (PSA): 1.54 ng/mL. Radiological imaging Ultrasound of the kidney, ureter and bladder: normal non-hydronephrotic kidneys with 38 g prostate, with post void residual urine volume of 76 mL.
Based on suspicion of prostatic malignancy, he underwent MRI of the pelvis and lumbosacral (L/S) spine, whole body bone scan, and transrectal ultrasound (TRUS) guided 12-core needle biopsy of the prostate.
Bone scan: negative. MRI of the pelvis: 4.8×4.1×3.2 cm prostate with abnormal signal intensity area in the central zone appearing hypointense on T2-weighted image. The prostatic capsule and neurovascular bundles were intact.
Gross examination: TRUS biopsy showed 12 linear core tissues from both the right and left lobes of the prostate, with the largest measuring 1.1 cm.
Microscopic examination: sections from 4 cores out of 12 (2 each from the apical prostatic tissues of the right and left lobes) revealed prostate parenchyma infiltrated by atypical medium-sized to large-sized lymphoid cells arranged in diffuse sheets. These lymphoid cells exhibited scant to moderate amount of eosinophilic cytoplasm and nuclei with irregular contours, dispersed chromatin and occasional prominent nucleoli. The rest of the eight prostate tissue cores revealed benign prostate parenchyma showing glands lined by double-layered epithelium.
Immunohistochemical studies: tumour cells were strongly positive for leucocyte common antigen, CD20 (Pan-B marker), BCL-2 and CD10.The patient received alpha-adrenergic blocker tamsulosin with finasteride for LUTS with good response. For his radicular pain, he received diclofenac sodium and pregabalin. Following discussion in a multidisciplinary tumour board meeting, he received six cycles of R-CHOP (Rrituximab, Cyclophosphamide, Doxorubicin hydrochloride, Vincristine sulfate, and Prednisone) regimen at an outside cancer treatment facility.
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