Case Report Primary lymphoma of mucosa associated lymphoid tissue (MALT lymphoma) in the urinary bladder mimicking recurrent urinary tract infection: a case report and literature review

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The patient with urinary frequency, urgency and suprapubic pain had several emergency room visits due to recurrent urinary tract infection. Both sonogram and cystoscopy identified bladder tumors near the bladder neck. An abdominal contrast-enhanced computed tomography scan revealed a polypoid lesion on the inferior bladder wall without enlarged lymph nodes. Transurethral resection of the bladder tumor was conducted. The pathology report confirmed extranodal marginal zone MALT lymphoma. The clinical stage was IEA. Follow-up imaging reported residual bladder tumors, prompting adjuvant radiotherapy. Primary lymphoma is an uncommon pathological subtype. Its clinical and radiological differentiation from urothelial carcinoma (UC) can be challenging, but treatment strategies differ significantly. A definitive diagnosis relies on histopathology and immunohistochemistry. Typically, bladder lymphoma has a favorable prognosis, but further research is required to identify the optimal treatment. Bladder lymphoma Mucosa associated lymphoid tissue lymphoma Case report Figures Figure 1 Figure 2 Introduction Primary lymphoma in the urinary bladder is rare, and its definitive diagnosis relies on histopathology and immunohistochemistry. We present the case of a 79-year-old woman with primary lymphoma of mucosa-associated lymphoid tissue (MALT) in the urinary bladder, mimicking urinary tract infection (UTI). The collaborative and multifaceted approach described in this study aims to provide the most appropriate and effective treatment for her rare condition. Case presentation A 79-year-old woman with a history of hypertension and diabetes mellitus presented to our urologic clinic with urinary frequency and urgency, as well as suprapubic pain. She was experiencing the symptoms for 6 months and visited the emergency room multiple times over this period due to recurrent urinary tract infections (UTIs). No significant findings were observed during the physical examination. The urine culture tests consistently revealed the presence of Escherichia coli . Upon her arrival at our outpatient department, she underwent a sonogram, reporting left renal cysts and a suspicious 3.2-cm bladder tumor. During cystoscopy, multiple bladder tumors were identified, predominantly in the anterior wall of the urinary bladder, near the neck. A biopsy was conducted, and the pathology results revealed atypical lymphoid infiltration. A high-contrast abdominal computed tomography (CT) scan revealed a 3.9-cm enhancement, identified as a polypoid lesion, on the inferior wall of the urinary bladder [Figure 1a-b]. Lymph nodes were not enlarged. A transurethral resection of the bladder tumor (TURBT) was conducted, where the bladder tumors were resected using a thulium laser under an Fr. 27 transurethral endoscope [Figure 1c-d]. On gross examination, the specimens were brownish and elastic tissue fragments. Microscopically, the urinary bladder revealed a widespread presence of various types of small B cells, such as marginal zone cells resembling centrocytes, monocytoid cells, small lymphocytes, immunoblasts, and centroblast-like cells. Additionally, a few nonneoplastic germinal centers are also observed. The tumor cells display uneven and angled nuclear shapes with indistinct nucleoli and pale cytoplasm [Figure 2a]. The pathology report confirmed the diagnosis of extranodal marginal zone lymphoma of MALT. Immunohistochemical staining was positive for CD20 and BCL2 but negative for CD3, BCL6, CD10, MNDA, CD5, CD23, and cyclin D1 [Figure 2b-d]. The patient’s ki-67 proliferation index was low [Figure 2e]. We referred her to the Hemato-oncology Department for a bone marrow biopsy. The resulting pathology report disclosed no evidence of malignancy. The whole body positron emission tomography was prepared and conducted, revealing no definite abnormal fluorodeoxyglucose metabolic lesions of the head, neck, chest, abdomen, pelvis, or bones. The comprehensive staging work-up indicated that the patient was at clinical stage IEA of her disease according to the Lugano classification for lymphoma staging. However, follow-up imaging revealed some residual bladder tumors. To provide local control, adjuvant radiotherapy was initiated. She underwent 20 sessions of radiation therapy, receiving a total dose of 2400 cGy specifically targeting the urinary bladder. Chemotherapy was not administered. Her recovery after irradiation was smooth, with only a slight discomfort during urination. She attains a complete response on imaging and cystoscopy during 3 months of follow-up. At present, she is attending follow-up appointments in our outpatient department. Discussion Primary lymphoma of the urinary bladder is a rare occurrence, accounting for approximately 1.0% and 0.2% of all bladder tumors and extranodal non-Hodgkin’s lymphomas [ 1 ]. It typically manifests with intermittent gross hematuria, urinary frequency and urgency, dysuria, nocturia, and suprapubic and abdominal pains [ 2 ]. Common risk factors include chronic inflammation, UTIs, and autoimmune diseases. Approximately 20% of cases have a history of chronic bladder inflammation [ 3 ], leading to the hypothesis that chronic cystitis is potentially associated with an increase in extranodal lymphoid tissue, ultimately progressing to lymphoma [ 2 ]. Regarding the association between Helicobacter pylori infection and gastric MALT lymphoma, the regression of bladder MALT lymphoma postantibiotic treatment of Escherichia coli -related UTIs has been documented by Oscier et al [ 4 ]. This lymphoma type is frequently observed dome or lateral walls of the bladder. Typically, it does not invade the ureteral orifice or spread throughout the bladder, making hydronephrosis an uncommon clinical presentation [ 5 ]. Distinguishing the clinical symptoms and imaging findings of primary lymphoma of the urinary bladder from urothelial carcinoma (UC) can be challenging. Therefore, diagnosing these tumors often relies on histopathology and immunohistochemistry. Strong positive immunohistochemistry staining for the markers LCA and CD20 indicates B-cell-derived lymphoma, while negative staining for cytokeratin (CK), CK7, and CD45RO excludes various carcinomas. Lymphomas of the bladder are categorized into low- and high-grades. Low-grade lymphomas produce positive stains for the cell markers CD20, CD43, and CD21, while high-grade lymphomas for CD20, CD3, and CD30 [ 6 ]. The most common low-grade type is B-cell-derived non-Hodgkin’s lymphomas of MALT, which includes Burkitt’s and plasmacytoid lymphomas [ 1 ]; these tend to have long disease courses and insidious onset but favorable prognosis [ 2 ]. Furthermore, MALT lymphomas produce positive stains for CD19 and FMC7, and negative for CD5, CD10, and CD11c [ 5 ]. The most common high-grade type is diffuse large B-cell lymphoma (DLBCL) [ 1 ]; further imaging studies such as chest and abdominal CT scans, bone marrow aspiration evaluations, and bone biopsies are recommended to rule out systemic lymphoma. Based on the current National Comprehensive Cancer Network (NCCN) guideline, the recommended first-line treatment for extranodal marginal zone lymphoma occurring outside of the stomach and skin is involved-site radiation therapy. TURBT may be used as a diagnostic and therapeutic procedure. Reportedly, the extent of surgical resection, whether it is total cystectomy, partial cystectomy, complete TURBT, or incomplete TURBT, does not significantly affect the overall prognosis. Moreover, the choice of surgical intervention may not be a major determinant of clinical outcomes. Rather, the primary goal of surgical intervention is to alleviate lower urinary tract symptoms [ 5 ]. In cases of local recurrence, it is advisable to contemplate the use of systemic chemotherapy, while radiation therapy can be a palliative approach to achieve local control. Patients experiencing systemic recurrence are treated similarly to those with nodal lymphomas, with systemic chemotherapy being the subsequent therapeutic choice. While there are no established guidelines on the most effective regimen for lymphoma of the bladder, CHOP (cyclophosphamide, hydroxydaunorubicin, oncovin and prednisolone) is commonly employed for four cycles. Incorporating rituximab into the treatment regimen is recommended, particularly for individuals who exhibit resistance to chemotherapy and have a BCL-2 gene translocation [ 7 ]. The mitochondrial pathway contributes to the development of non-Hodgkin's lymphoma, and Rituximab has been demonstrated to alleviate the chemotherapy resistance observed in individuals with BCL-2 overexpression. This is achieved by stimulating cell apoptosis through the BCL-2 regulated mitochondrial pathway [ 8 ]. Clinical observations of MALT lymphomas indicate that they typically manifest as indolent diseases with slow dissemination rates. The 10-year survival rate is approximately 90% [ 9 ]. To date, there are no formal guidelines on disease surveillance. Vempati et al. suggest annual cystoscopic monitoring for the first 2– 3 years with urine specimens obtained at each visit for cytology [ 10 ]. Conclusion Among bladder tumors, primary lymphoma is a relative rare and less malignant pathological subtype. Urologists should keep this less common diagnosis in mind before surgery. It is difficult to distinguish clinically and radiologically from UC, but treatment strategies differ significantly. Accurate diagnosis relies on histopathology and immunohistochemistry. More study is needed to determine the optimal treatment and prognosis. Declarations Ethics approval and consent to participate: This study received permission from the institutional review board of Changhua Christian Hospital. The patient consented to participate in this investigation. Consent for publication: The patient provided written informed consent for the publication of this case report and the inclusion of related pictures. Competing interests: The authors affirm that the research was carried out without any financial or non-financial affiliations that could be seen as a possible conflict of interest. Availability of data and materials: All data and figures produced or examined during this investigation are contained within this published paper and its additional material files. Funding: This research did not get any dedicated support from any public, private, or not-for-profit organizations. Authors' contributions: PS Liang wrote the main manuscript text and prepared figures. YC Chen raised the concept and supervised the manuscript. HJ Shih and SH Huang provided the resources and aided in literature review. All authors reviewed and proved the manuscript. References Leite KR, Bruschini H, Camara-Lopes LH. Primary lymphoma of the bladder. Int Braz J Urol. 2004;30:37-39; https://doi.org/10.1590/s1677-55382004000100009 Xu, H., Chen, Z., Shen, B., & Wei, Z. Primary bladder mucosa-associated lymphoid tissue lymphoma: a case report and literature review. Medicine. 2020,99.28; https://doi.org/10.1097/MD.0000000000020825 Aceñero MF, Rodilla CM, García-Asenjo JL, Menchero SC, Esponera JS. Primary malignant lymphoma of the bladder. Report of three cases. Pathol Res Pract. 1996;192:160–163; https://doi.org/10.1016/S0344-0338(96)80211-1 Oscier D, Bramble J, Hodges E, et al. Regression of mucosa-associated lymphoid tissue lymphoma of the bladder after antibiotic therapy. J Clin Oncol. 2002;20:882; https://doi.org/10.1200/JCO.2002.20.3.882 Venyo AK. Lymphoma of the urinary bladder. Adv Urol. 2014;2014:327917; https://doi.org/10.1155/2014/327917 Bates AW, Norton AJ, Baithun SI. Malignant lymphoma of the urinary bladder: A clinicopathological study of 11 cases. J Clin Pathol. 2000;53:458‐61; https://doi.org/10.1136/jcp.53.6.458 Simpson WG, Lopez A, Babbar P, Payne LF. Primary bladder lymphoma, diffuse large B-cell type: Case report and literature review of 26 cases. Urol Ann. 2015 Apr-Jun;7(2):268-72; https://doi.org/10.4103/0974-7796.152947 Tzu-Yu Chuang, Te-Wei Chang, Shiou-Sheng Chen, Chan-Chi Chang, Wei-Ming Cheng, Yau-Huei Wei. Mitochondrial Dysfunction in Patients with Urogenital Disease. Urol Sci 2021 Oct–Dec 32(4):p 143-150; https://doi.org/10.4103/UROS.UROS_47_21 Isaacson PG, Du MQ. MALT lymphoma: from morphology to molecules. Nat Rev Cancer. 2004;4:644–53; https://doi.org/10.1038/nrc1409 Vempati P, Knoll MA, Alqatari M, Strauchen J, Malone AK, Bakst RL. MALT Lymphoma of the Bladder: A Case Report and Review of the Literature. Case Rep Hematol. 2015;2015:9343; https://doi.org/10.1155/2015/934374 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Oct, 2024 Read the published version in BMC Urology → Version 1 posted Editorial decision: Revision requested 08 Aug, 2024 Reviews received at journal 06 Aug, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviews received at journal 04 Aug, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviewers invited by journal 29 Jul, 2024 Editor invited by journal 03 Jun, 2024 Submission checks completed at journal 03 Jun, 2024 Editor assigned by journal 03 Jun, 2024 First submitted to journal 15 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4426814","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":312584323,"identity":"a4bf39dd-7070-488a-b400-a4a5fdeeb9cb","order_by":0,"name":"Po-Sung Liang","email":"","orcid":"","institution":"Changhua Christian Hospital","correspondingAuthor":false,"prefix":"","firstName":"Po-Sung","middleName":"","lastName":"Liang","suffix":""},{"id":312584324,"identity":"0b1e80f0-e0a9-4e37-b850-d21f2ad84010","order_by":1,"name":"Hung-Jen Shih","email":"","orcid":"","institution":"Changhua Christian Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hung-Jen","middleName":"","lastName":"Shih","suffix":""},{"id":312584325,"identity":"f91fa36e-2c1d-4d2e-998d-32531d6ba992","order_by":2,"name":"Sheng-Hsien Huang","email":"","orcid":"","institution":"Changhua Christian Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sheng-Hsien","middleName":"","lastName":"Huang","suffix":""},{"id":312584326,"identity":"28d0e5e3-a6bc-4fc7-bc8b-c508caeeacb2","order_by":3,"name":"Yi-Zhong Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1ElEQVRIiWNgGAWjYFACHvYPHwxsGBgkSNDCxjijIA1JCxsRWph5PhwmQQt/+9ljD3gMzif2z24++IChxiaaQb7HAK8WiTN56QYSBrcTZ9w5lmzAcCwtt4GNB78Whhs8QB1ALQ03cswkGBsOA7XwbsCrQx6kJcHgXOJ8orUY3OAxkzhgcCBxA9FaDM/kJRs2GCQbb7yRlmyQAPRLG1v+B7xa5I6fPfj4zx872Xk3kg8++FBjk9vPfCwBrxYYcGwAkSC1hGMSCuyJVTgKRsEoGAUjEAAAvYlI9gHIfzYAAAAASUVORK5CYII=","orcid":"","institution":"Changhua Christian Hospital","correspondingAuthor":true,"prefix":"","firstName":"Yi-Zhong","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-05-15 18:06:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4426814/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4426814/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12894-024-01616-3","type":"published","date":"2024-10-12T15:57:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":58751384,"identity":"84fa9899-d66a-4789-a7b8-87154e7ec51f","added_by":"auto","created_at":"2024-06-20 16:08:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":387797,"visible":true,"origin":"","legend":"\u003cp\u003e(a-b) The CT revealed a 3.9cm mass on the inferior wall of the bladder. (c-d) During TURBT, the bladder tumors on the anterior wall near bladder neck were resected using a thulium laser under an Fr. 27 transurethral endoscope.\u003c/p\u003e","description":"","filename":"Figure1..png","url":"https://assets-eu.researchsquare.com/files/rs-4426814/v1/fd9efdef540cae20f1315eab.png"},{"id":58751383,"identity":"f6037ec2-c19d-421d-906f-a7a11aa8b8ad","added_by":"auto","created_at":"2024-06-20 16:08:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":979644,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Microscopically, the urinary bladder shows diffuse infiltrate of morphologically heterogeneous small B cells. The tumor cells have irregular angulated nuclear contours with inconspicuous nucleoli and pale cytoplasm. (b) Positive for CD20 (marker of low-grade lymphoma). (c) Negative for CD3 (marker of high-grade lymphoma). (d) Negative for BCL6. (e) Ki-67 proliferation index was low.\u003c/p\u003e","description":"","filename":"Figure2..png","url":"https://assets-eu.researchsquare.com/files/rs-4426814/v1/bc0a4c1eed01b4722f02b6f1.png"},{"id":66597263,"identity":"79b46eb7-1fd9-4f15-bece-6abcb853cddf","added_by":"auto","created_at":"2024-10-14 16:09:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1895463,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4426814/v1/eea48017-7009-4096-aef0-0de4216a95e5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Case Report Primary lymphoma of mucosa associated lymphoid tissue (MALT lymphoma) in the urinary bladder mimicking recurrent urinary tract infection: a case report and literature review","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePrimary lymphoma in the urinary bladder is rare, and its definitive diagnosis relies on histopathology and immunohistochemistry. We present the case of a 79-year-old woman with primary lymphoma of mucosa-associated lymphoid tissue (MALT) in the urinary bladder, mimicking urinary tract infection (UTI). The collaborative and multifaceted approach described in this study aims to provide the most appropriate and effective treatment for her rare condition.\u003c/p\u003e\n"},{"header":"Case presentation","content":"\u003cp\u003eA 79-year-old woman with a history of hypertension and diabetes mellitus presented to our urologic clinic with urinary frequency and urgency, as well as suprapubic pain. She was experiencing the symptoms for 6 months and visited the emergency room multiple times over this period due to recurrent urinary tract infections (UTIs).\u0026nbsp;No significant findings were observed during the physical examination.\u0026nbsp;The urine culture tests consistently revealed the presence of \u003cem\u003eEscherichia coli\u003c/em\u003e. Upon her arrival at our outpatient department,\u0026nbsp;she\u0026nbsp;underwent a sonogram, reporting left renal cysts and a suspicious 3.2-cm bladder tumor. During cystoscopy, multiple bladder tumors were identified, predominantly in the anterior wall of the urinary bladder, near the neck. A biopsy was conducted, and the pathology results revealed atypical lymphoid infiltration. A high-contrast abdominal computed tomography (CT) scan revealed a 3.9-cm enhancement, identified as a polypoid lesion, on the inferior wall of the urinary bladder\u0026nbsp;[Figure 1a-b]. Lymph nodes were not enlarged. A transurethral resection of the bladder tumor (TURBT) was conducted, where the bladder tumors were resected using a thulium laser under an Fr. 27 transurethral endoscope\u0026nbsp;[Figure 1c-d].\u0026nbsp;On gross examination, the specimens were brownish and elastic tissue fragments. Microscopically, the urinary bladder revealed a widespread presence of various types of small B cells, such as marginal zone cells resembling centrocytes, monocytoid cells, small lymphocytes, immunoblasts, and centroblast-like cells. Additionally, a few nonneoplastic germinal centers are also observed. The tumor cells display uneven and angled nuclear shapes with indistinct nucleoli and pale cytoplasm [Figure 2a].\u0026nbsp;The pathology report confirmed the diagnosis of extranodal marginal zone lymphoma of MALT. Immunohistochemical staining was positive for CD20 and BCL2 but negative for CD3, BCL6, CD10, MNDA, CD5, CD23, and cyclin D1\u0026nbsp;[Figure 2b-d]. The patient\u0026rsquo;s ki-67 proliferation index was low\u0026nbsp;[Figure 2e]. We referred her\u0026nbsp;to the Hemato-oncology Department for a bone marrow biopsy. The resulting pathology report disclosed no evidence of malignancy. The whole body positron emission tomography was prepared and conducted, revealing no definite abnormal fluorodeoxyglucose metabolic lesions of the head, neck, chest, abdomen, pelvis, or bones. The comprehensive staging work-up indicated that the patient was at clinical stage IEA of her disease according to the Lugano classification for lymphoma staging. However, follow-up imaging revealed some residual bladder tumors. To provide local control, adjuvant radiotherapy was initiated.\u0026nbsp;She underwent 20 sessions of radiation therapy, receiving a total dose of 2400 cGy specifically targeting the urinary bladder. Chemotherapy was not administered.\u0026nbsp;Her\u0026nbsp;recovery after irradiation was smooth, with only a slight discomfort during urination. She attains a\u0026nbsp;complete\u0026nbsp;response on imaging and cystoscopy\u0026nbsp;during\u0026nbsp;3 months of follow-up.\u0026nbsp;At present,\u0026nbsp;she is attending follow-up appointments in our outpatient department.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Discussion","content":"\u003cp\u003ePrimary lymphoma of the urinary bladder is a rare occurrence, accounting for approximately 1.0% and 0.2% of all bladder tumors and extranodal non-Hodgkin\u0026rsquo;s lymphomas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It typically manifests with intermittent gross hematuria, urinary frequency and urgency, dysuria, nocturia, and suprapubic and abdominal pains [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Common risk factors include chronic inflammation, UTIs, and autoimmune diseases. Approximately 20% of cases have a history of chronic bladder inflammation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], leading to the hypothesis that chronic cystitis is potentially associated with an increase in extranodal lymphoid tissue, ultimately progressing to lymphoma [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Regarding the association between \u003cem\u003eHelicobacter pylori\u003c/em\u003e infection and gastric MALT lymphoma, the regression of bladder MALT lymphoma postantibiotic treatment of \u003cem\u003eEscherichia coli\u003c/em\u003e-related UTIs has been documented by Oscier et al [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This lymphoma type is frequently observed dome or lateral walls of the bladder. Typically, it does not invade the ureteral orifice or spread throughout the bladder, making hydronephrosis an uncommon clinical presentation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDistinguishing the clinical symptoms and imaging findings of primary lymphoma of the urinary bladder from urothelial carcinoma (UC) can be challenging. Therefore, diagnosing these tumors often relies on histopathology and immunohistochemistry. Strong positive immunohistochemistry staining for the markers LCA and CD20 indicates B-cell-derived lymphoma, while negative staining for cytokeratin (CK), CK7, and CD45RO excludes various carcinomas. Lymphomas of the bladder are categorized into low- and high-grades. Low-grade lymphomas produce positive stains for the cell markers CD20, CD43, and CD21, while high-grade lymphomas for CD20, CD3, and CD30 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The most common low-grade type is B-cell-derived non-Hodgkin\u0026rsquo;s lymphomas of MALT, which includes Burkitt\u0026rsquo;s and plasmacytoid lymphomas [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; these tend to have long disease courses and insidious onset but favorable prognosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Furthermore, MALT lymphomas produce positive stains for CD19 and FMC7, and negative for CD5, CD10, and CD11c [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The most common high-grade type is diffuse large B-cell lymphoma (DLBCL) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]; further imaging studies such as chest and abdominal CT scans, bone marrow aspiration evaluations, and bone biopsies are recommended to rule out systemic lymphoma.\u003c/p\u003e \u003cp\u003eBased on the current National Comprehensive Cancer Network (NCCN) guideline, the recommended first-line treatment for extranodal marginal zone lymphoma occurring outside of the stomach and skin is involved-site radiation therapy. TURBT may be used as a diagnostic and therapeutic procedure. Reportedly, the extent of surgical resection, whether it is total cystectomy, partial cystectomy, complete TURBT, or incomplete TURBT, does not significantly affect the overall prognosis. Moreover, the choice of surgical intervention may not be a major determinant of clinical outcomes. Rather, the primary goal of surgical intervention is to alleviate lower urinary tract symptoms [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In cases of local recurrence, it is advisable to contemplate the use of systemic chemotherapy, while radiation therapy can be a palliative approach to achieve local control. Patients experiencing systemic recurrence are treated similarly to those with nodal lymphomas, with systemic chemotherapy being the subsequent therapeutic choice. While there are no established guidelines on the most effective regimen for lymphoma of the bladder, CHOP (cyclophosphamide, hydroxydaunorubicin, oncovin and prednisolone) is commonly employed for four cycles. Incorporating rituximab into the treatment regimen is recommended, particularly for individuals who exhibit resistance to chemotherapy and have a BCL-2 gene translocation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The mitochondrial pathway contributes to the development of non-Hodgkin's lymphoma, and Rituximab has been demonstrated to alleviate the chemotherapy resistance observed in individuals with BCL-2 overexpression. This is achieved by stimulating cell apoptosis through the BCL-2 regulated mitochondrial pathway [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Clinical observations of MALT lymphomas indicate that they typically manifest as indolent diseases with slow dissemination rates. The 10-year survival rate is approximately 90% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. To date, there are no formal guidelines on disease surveillance. Vempati et al. suggest annual cystoscopic monitoring for the first 2\u0026ndash; 3 years with urine specimens obtained at each visit for cytology [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAmong bladder tumors, primary lymphoma is a relative rare and less malignant pathological subtype. Urologists should keep this less common diagnosis in mind before surgery. It is difficult to distinguish clinically and radiologically from UC, but treatment strategies differ significantly. Accurate diagnosis relies on histopathology and immunohistochemistry. More study is needed to determine the optimal treatment and prognosis.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003c/p\u003e\n\u003cp\u003eThis study received permission from the institutional review board of Changhua Christian Hospital. The patient consented to participate in this investigation.\u003c/p\u003e\n\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eThe patient provided written informed consent for the publication of this case report and the inclusion of related pictures.\u003c/p\u003e\n\n\u003cp\u003eCompeting interests:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors affirm that the research was carried out without any financial or non-financial affiliations that could be seen as a possible conflict of interest.\u003c/p\u003e\n\n\u003cp\u003eAvailability of data and materials:\u003c/p\u003e\n\u003cp\u003eAll data and figures produced or examined during this investigation are contained within this published paper and its additional material files.\u003c/p\u003e\n\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eThis research did not get any dedicated support from any public, private, or not-for-profit organizations.\u003c/p\u003e\n\n\u003cp\u003eAuthors\u0026apos; contributions:\u003c/p\u003e\n\u003cp\u003ePS Liang wrote the main manuscript text and prepared figures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYC Chen raised the concept and supervised the \u0026nbsp;manuscript.\u003c/p\u003e\n\u003cp\u003eHJ Shih and SH Huang provided the resources and aided in literature review.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and proved the manuscript.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLeite KR, Bruschini H, Camara-Lopes LH. Primary lymphoma of the bladder. Int Braz J Urol. 2004;30:37-39; https://doi.org/10.1590/s1677-55382004000100009\u003c/li\u003e\n\u003cli\u003eXu, H., Chen, Z., Shen, B., \u0026amp; Wei, Z. Primary bladder mucosa-associated lymphoid tissue lymphoma: a case report and literature review. Medicine. 2020,99.28; https://doi.org/10.1097/MD.0000000000020825\u003c/li\u003e\n\u003cli\u003eAce\u0026ntilde;ero MF, Rodilla CM, Garc\u0026iacute;a-Asenjo JL, Menchero SC, Esponera JS. Primary malignant lymphoma of the bladder. Report of three cases. Pathol Res Pract. 1996;192:160\u0026ndash;163; https://doi.org/10.1016/S0344-0338(96)80211-1\u003c/li\u003e\n\u003cli\u003eOscier D, Bramble J, Hodges E, et al. Regression of mucosa-associated lymphoid tissue lymphoma of the bladder after antibiotic therapy. J Clin Oncol. 2002;20:882; https://doi.org/10.1200/JCO.2002.20.3.882\u003c/li\u003e\n\u003cli\u003eVenyo AK. Lymphoma of the urinary bladder. Adv Urol. 2014;2014:327917; https://doi.org/10.1155/2014/327917\u003c/li\u003e\n\u003cli\u003eBates AW, Norton AJ, Baithun SI. Malignant lymphoma of the urinary bladder: A clinicopathological study of 11 cases. J Clin Pathol. 2000;53:458‐61; https://doi.org/10.1136/jcp.53.6.458\u003c/li\u003e\n\u003cli\u003eSimpson WG, Lopez A, Babbar P, Payne LF. Primary bladder lymphoma, diffuse large B-cell type: Case report and literature review of 26 cases. Urol Ann. 2015 Apr-Jun;7(2):268-72; https://doi.org/10.4103/0974-7796.152947\u003c/li\u003e\n\u003cli\u003eTzu-Yu Chuang, Te-Wei Chang, Shiou-Sheng Chen, Chan-Chi Chang, Wei-Ming Cheng, Yau-Huei Wei. Mitochondrial Dysfunction in Patients with Urogenital Disease. Urol Sci 2021 Oct\u0026ndash;Dec 32(4):p 143-150; https://doi.org/10.4103/UROS.UROS_47_21\u003c/li\u003e\n\u003cli\u003eIsaacson PG, Du MQ. MALT lymphoma: from morphology to molecules. Nat Rev Cancer. 2004;4:644\u0026ndash;53; https://doi.org/10.1038/nrc1409\u003c/li\u003e\n\u003cli\u003eVempati P, Knoll MA, Alqatari M, Strauchen J, Malone AK, Bakst RL. MALT Lymphoma of the Bladder: A Case Report and Review of the Literature. Case Rep Hematol. 2015;2015:9343; https://doi.org/10.1155/2015/934374\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Bladder lymphoma, Mucosa associated lymphoid tissue lymphoma, Case report","lastPublishedDoi":"10.21203/rs.3.rs-4426814/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4426814/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report the case of a 79-year-old woman with primary lymphoma of the mucosa-associated lymphoid tissue (MALT) in the urinary bladder. The patient with urinary frequency, urgency and suprapubic pain had several emergency room visits due to recurrent urinary tract infection. Both sonogram and cystoscopy identified bladder tumors near the bladder neck. An abdominal contrast-enhanced computed tomography scan revealed a polypoid lesion on the inferior bladder wall without enlarged lymph nodes. Transurethral resection of the bladder tumor was conducted. The pathology report confirmed extranodal marginal zone MALT lymphoma. The clinical stage was IEA. Follow-up imaging reported residual bladder tumors, prompting adjuvant radiotherapy. Primary lymphoma is an uncommon pathological subtype. Its clinical and radiological differentiation from urothelial carcinoma (UC) can be challenging, but treatment strategies differ significantly. A definitive diagnosis relies on histopathology and immunohistochemistry. Typically, bladder lymphoma has a favorable prognosis, but further research is required to identify the optimal treatment.\u003c/p\u003e","manuscriptTitle":"Case Report Primary lymphoma of mucosa associated lymphoid tissue (MALT lymphoma) in the urinary bladder mimicking recurrent urinary tract infection: a case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-20 16:08:36","doi":"10.21203/rs.3.rs-4426814/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-08T13:48:11+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-06T22:21:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166169063866256852584010521157517138299","date":"2024-08-06T22:11:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-04T05:16:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"206836302253889165758259981278191031337","date":"2024-07-29T11:05:32+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-29T10:29:38+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-03T10:24:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-03T10:22:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-03T10:22:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2024-05-15T18:05:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b0f9d9be-bd86-4fe8-a247-7061279f28d5","owner":[],"postedDate":"June 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T16:03:29+00:00","versionOfRecord":{"articleIdentity":"rs-4426814","link":"https://doi.org/10.1186/s12894-024-01616-3","journal":{"identity":"bmc-urology","isVorOnly":false,"title":"BMC Urology"},"publishedOn":"2024-10-12 15:57:59","publishedOnDateReadable":"October 12th, 2024"},"versionCreatedAt":"2024-06-20 16:08:36","video":"","vorDoi":"10.1186/s12894-024-01616-3","vorDoiUrl":"https://doi.org/10.1186/s12894-024-01616-3","workflowStages":[]},"version":"v1","identity":"rs-4426814","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4426814","identity":"rs-4426814","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}