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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2013  |  Volume : 24  |  Issue : 4  |  Page : 816-817
Primary renal lymphoma: Is prognosis really that bad?


Deaprtment of Urology, Sir Ganga Ram Hospital, New Delhi, India

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Date of Web Publication24-Jun-2013
 

How to cite this article:
Pahwa M, Gupta N, Tyagi V, Chadha S. Primary renal lymphoma: Is prognosis really that bad?. Saudi J Kidney Dis Transpl 2013;24:816-7

How to cite this URL:
Pahwa M, Gupta N, Tyagi V, Chadha S. Primary renal lymphoma: Is prognosis really that bad?. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Oct 19];24:816-7. Available from: http://www.sjkdt.org/text.asp?2013/24/4/816/113905
To the Editors,

Secondary renal involvement by non-Hodgkin's lymphoma is frequent and usually occurs in disseminated cases. However, isolated primary renal lymphoma (PRL) is a rare disease and represents less than 1% of the lesions in this organ. [1] PRL is also a debated disease as the kidney is devoid of lymphatic tissue. We report herein a case of isolated PRL of the kidney without the involvement of any other organ.

A 39-year-old man presented with a dull pain in the epigastrium and left flank associated with loss of appetite and weight, with no urinary or bowel symptoms. Clinical examination revealed pallor, enlarged left kidney and no peripheral lymphadenopathy; all other systemic examinations were within normal limits. On evaluation, ultrasound revealed a large solid mass in the left kidney with local invasion and no hepatosplenomegaly or lymphadenopathy. Contrast-enhanced computerized tomography (CT) showed a large soft tissue-enhancing mass involving the upper and middle poles of the left kidney (19 cm × 18.5 cm × 8.2 cm), with no separate planes from the adrenal glands, body and tail of the pancreas and posterior wall of the stomach and spleen. The renal veins could not be identified [Figure 1]. A CT-guided fine needle aspiration biopsy (FNAB) of the mass was obtained elsewhere prior to consulting us, and it was diagnosed as adenocarcinoma (grade II). Further radiological work-up with chest X-ray, high-resolution CT chest and bone scan was unremarkable. Angioembolisation of the mass was performed, followed by radical nephrectomy. The histopathological exam of the mass concluded a tumor in the kidney, which was characterized by the presence of sheets of round lymphoid cells. These cells on immunohistochemistry stained positive for leukocytes common antigen (LCA), B-cell Marker-CD 20 and negative for cytokeratin and were thus compatible with non-Hodgkin's lymphoma-B cell type of kidney [Figure 2]. Post-operative bone marrow aspiration was free of lymphoid malignant cells. In view of PRL of the kidney, the patient was started on the CHOP regimen (cyclophosphamide, doxorubicin, vincristin and prednisone) and he responded to therapy with no evidence of recurrence after a follow-up of two years.
Figure 1: Abdominal CT scan showing a large enhancing mass in the left kidney.

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Figure 2: (a) Section from the renal mass (H&E). (b) Immunohistochemistry was positive for LCA and (c) negative for CK.

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Renal involvement in NHL is usually seen as a part of disseminated disease. The reported incidence is as high as 47% in autopsy series of lymphoma, but clinically recognized in only up to 15% of the patients. [2] The term primary renal lymphoma can be used either when the initial manifestation involves the kidney or when the lesion is limited to it. The very existence of renal lymphomas has been questioned by some investigators as the kidney lacks lymphoid tissue. The proposed pathogenetic mechanisms include origin in the subcapsular lymphatic tissue, seeding via the hematogenous route, extension from retroperitoneal disease or inflammatory disease with lymphoplasmacytic infiltrate. [3] Lymphoma may present as a solitary mass (10-20%) or multiple masses (60%), and extends by contiguity (25-30%), diffuse infiltration (20%) or perirenal involvement (10%). [4] It affects middle-aged subjects and is usually of the B-cell lineage. [2] Clinical presentation includes flank pain and renal insufficiency if bilateral. It is a diagnostic challenge to differentiate renal lymphoma from carcinoma, especially in cases of unilateral lesions. Renal lesions that lack typical radiological features of renal cell carcinoma or multi-nodular involvement of the kidney along with lymphadenopathy and positive family history merit FNAB. Although it is a rare tumor type, it must be taken into account when making the differential diagnosis of any renal mass.

The patients with unilateral disease whose lymphomatous mass was removed completely by surgical resection followed by combination chemotherapy had longer disease-free and overall survival.

The earlier limited literature reviews reported a poor prognosis of patients with PRL, with a median survival of less than one year, [2] but the recent case reports have all suggested a survival of more than one year. [1],[5] Although most PRL disseminate rapidly from their origin, our patient not only presented with localized disease but also did well, with no local or distant recurrence after a follow-up of two years. We believe that both the delayed diagnosis and the histological aggressive behavior of the disease are responsible for the poor prognosis of PRL, and that if diagnosed early, cure of renal lymphoma is possible. Addition of rituximab to the combination chemotherapy has further prolonged the disease-free period and survival. 6

Conflict of interest: None

 
   References Top

1.Vázquez Alonso F, Sánchez Ramos C, Vicente Prados FJ, et al. Primary renal lymphoma: Report of three new cases and literature review. Arch Esp Urol 2009;62:461-5.  Back to cited text no. 1
    
2.Okuno SH, Hayer ID, Ristow K, Witzig TE. Primary renal non-hodgkins lymphoma. Cancer 1995;75:2258-61.  Back to cited text no. 2
    
3.Omar HA, Hussein MR. Primary renal lymphoma. Nephrology 2007;12:314-5  Back to cited text no. 3
    
4.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. 4
    
5.Diskin CJ, Stokes TJ, Dansby LM, et al. Acute renal failure due to a primary renal B-cell lymphoma. Am J Kidney Dis 2007;50: 885-9.  Back to cited text no. 5
    

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Correspondence Address:
Mrinal Pahwa
Deaprtment of Urology, Sir Ganga Ram Hospital, New Delhi
India
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DOI: 10.4103/1319-2442.113905

PMID: 23816741

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