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  Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 56  |  Issue : 4  |  Page : 449-452
Diffuse large B-cell lymphoma of the kidney: A rare neoplasm


1 Department of Pathology, I.P.G.M.E & R, Kolkata, West Bengal, India
2 Department of General Surgery, I.P.G.M.E & R, Kolkata, West Bengal, India

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Date of Web Publication18-Jan-2014
 

   Abstract 

Primary renal lymphoma is a rare neoplasm, but it should be kept in mind in the differential diagnosis of renal neoplasms. A middle aged man presented with symptoms of weight loss, anorexia and fullness of the abdomen after meals. On clinical and radiological examination, a renal mass was revealed and operated upon. A diagnosis of primary high grade renal lymphoma was made on histopathological examination and immunohistochemically it was further classified as diffuse large B-cell lymphoma. Unfortunately, the patient died after 5 months of diagnosis in spite of three cycles of chemotherapy following surgery. The pathological details of rare tumor are presented here.

Keywords: chemotherapy, nephrectomy, primary renal lymphoma

How to cite this article:
Das RN, Dasgupta S, Mondal S, Saha D, Chatterjee U. Diffuse large B-cell lymphoma of the kidney: A rare neoplasm. Indian J Pathol Microbiol 2013;56:449-52

How to cite this URL:
Das RN, Dasgupta S, Mondal S, Saha D, Chatterjee U. Diffuse large B-cell lymphoma of the kidney: A rare neoplasm. Indian J Pathol Microbiol [serial online] 2013 [cited 2019 Nov 12];56:449-52. Available from: http://www.ijpmonline.org/text.asp?2013/56/4/449/125368



   Introduction Top


Primary renal lymphoma is a rare lesion that represents lesser than 1% of the lesions of this organ. [1] The existence of primary renal lymphoma has been questioned as kidneys do not normally contain any lymphoid tissue. [2] The prognosis is very poor with a median survival of less than a year.

Here we discuss the case of a 50-year-old male patient who presenting with a solitary renal mass.


   Case Report Top


This was a case report of a 50-year-old male patient who presented with weight loss, anorexia and fullness of the abdomen after eating for the last 31/2 months. There was no history of fever or macroscopic hematuria. On examination, a large abdominal mass with fullness in the left flank and tenderness in the left renal angle was noted. Hepatosplenomegaly or lymphadenopathy was absent. Plain radiographs revealed a large, left-sided abdominal mass displacing the bowel across the midline. Computerized tomogram showed a mass (16.5 cm × 5.5 cm × 5 cm) involving the upper and middle poles of the left kidney. Contrast enhancement delineated the outline of still-functioning renal parenchyma near the lower pole, but the mass itself did not enhance. The right kidney was normal clinically and radiologically. There was no evidence of metastasis on bone scan. Chest X-ray was normal. Retroperitoneal or mesenteric lymph nodes were not enlarged. On fine needle aspiration cytology, it was reported as a round cell neoplasm. Hematological and biochemical reports were as follows: Hemoglobin - 7.6 g/dl, erythrocyte sedimentation rate - 86 mm in 1 st h, serum urea - 26 mg/dl, creatinine - 1.1 mg/dl. Routine and microscopical examination of urine showed 2-3 red blood cells/hpf, 1-3 pus cells/hpf, protein and urinary casts were absent.

The patient underwent a left radical nephrectomy and the specimen was sent to the Department of Pathology for histopathological examination. On gross examination, the mass was large and globular, with an irregular surface and measured 17 cm × 5.5 cm × 5 cm. The cut section was homogeneously soft, friable and grayish white in color. The growth appeared to arise from the kidney and also encased it. A small part of the kidney near its lower pole appeared to be spared [Figure 1]a and b]. Microscopic examination revealed monomorphic cells of lymphoid lineage in sheets with large vesicular nuclei and prominence of nucleoli. Occasional mature lymphocytes were present. The tumor cells had largely destroyed the renal parenchyma and were seen permeate through the Bowman's capsule into the uriniferous space [Figure 2]a-d. On immunohistochemical analysis, the tumor cells were positive for leukocyte common antigen and CD20, negative for CD3 and cytokeratin, characterizing a lymphoma originating in B lymphocytes. The case was diagnosed as a case of non-Hodgkin's lymphoma, diffuse large B-cell type, taking all the above features into consideration. Patient was treated by combination chemotherapy with cyclophosphamide, doxirubicin, vincristine and prednisolone (CHOP) after surgery, but the patient died after 5 months.
Figure 1

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Figure 2

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   Discussion Top


Primary renal non-Hodgkin's lymphoma (PRL) is defined as a lymphoma arising primarily in the renal parenchyma, not resulting from invasion of an adjacent lymphomatous mass. [3]

Although a number of reported PRL cases are in fact questionable due to incomplete staging or the presence of extra-renal involvement at the time of diagnosis, revision of the available literature suggests that PRL does exist. [2] Because the renal parenchyma does not normally contain lymphoid tissue, several mechanisms have been postulated to account for the development of lymphoma in the kidney. The tumor may originate in the lymphatic-rich renal capsule or the perinephric fat and invade the parenchyma, or it can arise from lymphocytes present in areas of chronic inflammation. [2],[4],[5] The tumor is usually a B-cell non-Hodgkin lymphoma and affects patients who are middle aged or older, with a mean age of 66 years. [6]

The infiltrative nature of lymphoma allows it to grow without disrupting renal structure or function. Thus, renal involvement is found late in the clinical course. The common presentation are pain, mass, or microscopic hematuria, [7] but some patients have proteinuria, nephrotic syndrome or renal stones from excess uric acid related to rapid metabolic turnover of nucleic acids. Uremia, hydronephrosis from ureteral compression and renovascular hypertension from renal artery compression are rare. Although renal involvement indicates advanced disease the prognosis may still be favorable. [8]

Lesions can be solitary masses (10-20%) or multiple masses (60%). They are generally bilateral and present as an extension by contiguity (25-30%), diffuse infiltration (20%) or perirenal involvement 10%. [9] Renal lymphoma generally presents as bilateral nodular infiltration of the renal parenchyma along with a diffuse invasion of the retroperitoneum. [6] Solitary unilateral renal mass, perirenal mass with distortion of the renal architecture on the computed tomography scan and absence of lymph node enlargement are more suggestive of renal cell carcinoma, [6] however the presence of solid masses can require a biopsy to rule out other pathologies. [9]

Solitary lesion, as seen in our patient, is differentiated from the more common renal cell carcinoma by the absence of calcification, post contrast homogenous attenuation, absence of renal vein thrombus and absence of a mass effect on renal vessels and pelvicalyceal system. However, this situation still demands a biopsy to rule out renal cell carcinoma. Other less commonly seen patterns include enlarged non enhancing kidneys, direct invasion of renal sinus and hilum by bulky retroperitoneal mass or a diffuse perirenal infiltration encasing the kidney. [10] Most of the patients also have adjacent retroperitoneal adenopathy. Magnetic resonance imaging is currently becoming the imaging modality of choice for evaluation of renal lesions. Lower signal intensity on unenhanced T1-weighted images than normal renal cortex and less enhancement on early gadolinium-enhanced images differentiates renal lymphoma from renal cell carcinoma.

The limited available literature reports that the prognosis of patients affected by PRL is poor, despite no disseminated disease. Chemotherapy usually improves or normalizes the renal function, but the few reported cases showed a high mortality due to rapid relapse or infections incurred in the course of neutropenia. Long-term survivors occasionally have been reported after combined surgery - chemotherapy treatment where one kidney was involved. [3]

Bilateral renal lymphomas are usually treated by aggressive chemotherapy as front line therapy. [3] This approach could preserve the organ function, but in general the prognosis is poor. Alternatively, bilateral nephrectomy invariably leads to the need for dialysis treatment. The treatment of renal lymphoma depends upon the primary histological subtype. The addition of Rituximab to the standard CHOP chemotherapy may improve the dismal outcome reported so far.


   Conclusion Top


This case report attempts to address primary renal lymphoma is a rare entity but it should be kept in the differential diagnosis while evaluating isolated renal masses to ensure the accuracy in diagnosis, proper and timely management.


   Acknowledgement Top


I particularly thankful to our technical staffs, Janababu, Ashimda and Dayal - also actively helped in our work. Hence they also owe special appreciation for their co-operation.

 
   References Top

1.Stallone G, Infante B, Manno C, Campobasso N, Pannarale G, Schena FP. Primary renal lymphoma does exist: Case report and review of the literature. J Nephrol 2000;13:367-72.  Back to cited text no. 1
    
2.Torrecilla García-Ripoll JR, Pascual Samaniego M, Martín Blanco S, Rivera Ferro J, Peral Martínez JI, Fernández del Busto E. Primary renal lymphoma. Actas Urol Esp 2003;27:555-8.  Back to cited text no. 2
    
3.Okuno SH, Hoyer JD, Ristow K, Witzig TE. Primary renal non-Hodgkin's lymphoma. An unusual extranodal site. Cancer 1995;75:2258-61.  Back to cited text no. 3
    
4.Karadeniz C, Oguz A, Ataoglu O, Citak C, Buyan N, Pinarli G, et al. Primary renal lymphoma and xanthogranulomatous pyelonephritis in childhood. J Nephrol 2002;15:597-600.  Back to cited text no. 4
    
5.Cupisti A, Riccioni R, Carulli G, Paoletti S, Tognetti A, Meola M, et al. Bilateral primary renal lymphoma treated by surgery and chemotherapy. Nephrol Dial Transplant 2004;19:1629-33.  Back to cited text no. 5
    
6.Dimopoulos MA, Moulopoulos LA, Costantinides C, Deliveliotis C, Pantazopoulos D, Dimopoulos C. Primary renal lymphoma: A clinical and radiological study. J Urol 1996;155:1865-7.  Back to cited text no. 6
    
7.Harris GJ, Lager DJ. Primary renal lymphoma. J Surg Oncol 1991;46:273-7.  Back to cited text no. 7
    
8.Jafri SZ, Bree RL, Amendola MA, Glazer GM, Schwab RE, Francis IR, et al. CT of renal and perirenal non-Hodgkin lymphoma. AJR Am J Roentgenol 1982;138:1101-5.  Back to cited text no. 8
    
9.Urban BA, Fishman EK. Renal lymphoma: CT patterns with emphasis on helical CT. Radiographics 2000;20:197-212.  Back to cited text no. 9
    
10.Sheth S, Ali S, Fishman E. Imaging of renal lymphoma: Patterns of disease with pathologic correlation. Radiographics 2006;26:1151-68.  Back to cited text no. 10
    

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Correspondence Address:
Ram Narayan Das
265, Purba Sinthee Bye Lane, Kolkata - 700 030, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.125368

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This article has been cited by
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[Pubmed] | [DOI]



 

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
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