Are Ovaries a Sanctuary for Lymphoma? Report of a Cure of Recurrent Lymphoma in Both Ovaries after Bilateral Oophorectomy.

Isolated bilateral ovarian lymphoma is extremely rare. Those reported are generally due to aggressive lymphoma and are associated with a poor outcome. We present a case of low grade abdominal lymphoma which had been treated with bowel resection and chemotherapy. The patient subsequently developed recurrence of lymphoma in both ovaries and underwent bilateral oophorectomy. She has remained free of lymphoma for 10 years without any therapy for lymphoma.

Case report: A Caucasian female was born in 1940. In July 1985, she underwent a surgical removal of a large mesenteric mass and a 72 cm length of small bowel. The pathology report indicated the involvement of small bowel, mesenteric nodes and mesenteric fat with: Diffuse poorly differentiated lymphocytic lymphoma (Rappoport), malignant lymphoma, follicular and diffuse, predominantly small cleave cells with focal sclerosis (working formulation). She was treated with chlorambucil until July 1992 when because of leucopenia, chemotherapy was discontinued. CT scan of the abdomen in August 1992 was normal. In August 1995, she presented with acute abdominal pain. She underwent a resection of both ovaries, of the Fallopian tubes and of the uterus. The pathology report indicated that both ovaries were involved with: Malignant lymphoma, lymphocytic, poorly differentiated, partly nodular. The Fallopian tubes and the uterus did not show any lymphoma. A post-operative bone marrow biopsy and a CT of the chest and abdomen did not show any abnormality. Because there was no evidence of residual lymphoma, no therapy was offered after the operation. She has remained disease free 10 years after resection of the ovaries. The CT scan of the chest and abdomen in May 2004 were normal. Because of the unusual course of the disease and long-term disease free survival post recurrence, all of the pathological specimens were reexamined and were found to be similar microscopically and immunohistochemically. The tumors of small bowel, mesentery, omentum as well as both ovaries were reclassified in modern terminology as: Follicular lymphoma, Grade 1. The tumors have a similar appearance in that they are composed predominantly of poorly formed nodules of lymphoma with diffuse area. They have similar immunohistochemical profiles. They are faintly positive for CD20, CD22, CD10 and strongly positive for Bcl-2. Both tumors are negative for CD43 and CD45RO.

Conclusion: There are two possibilities for why isolated bilateral lymphoma may have developed in this case. One is that the lymphoma of the ovaries in this case was a second lymphoma unrelated to the initial lymphoma of the bowel and mesentery. If this is the case, the identical features of the two tumors and the simultaneous appearance in both ovaries, sparing other tissues is extremely unusual. The second possibility is that the ovaries provided a sanctuary for the original lymphoma cells. The resection of the original tumor followed by chemotherapy, had destroyed all of the lymphoma cells in the other organs. But the ovaries had provided a sanctuary for the lymphoma cells, allowing them to grow locally. Removal of the ovaries provided a 10 year disease free survival.