PRIMARY RENAL NON-HODGKINS LYMPHOMA PRESENTING: CASE REPORT
A 79-year-old Caucasian male presented to our unit with symptoms of generalized body aches, weakness and decreased urine output. He is a known patient with chronic renal insufficiency, well-controlled type II diabetes, and myocardial infarction. Physical examination revealed a blood pressure of 154/65 mm Hg and pitting edema of the lower left lumbar region. There was no peripheral lymphadenopathy or pulmonary edema.
Laboratory investigations showed a hematocrit of 32%, with a normal platelet count and morphology The white count and differential also were normal. Electrolytes and urea showed azotemia (Table 1). Other results: serum blood urea nitrogen (BUN) 67mg/dl, serum creatinine 7.7mg/dl (baseline BUN 66mg/dl, creatinine 2.6mg/dl), urine specific gravity 1.018, proteinuria, moderate hematuria and absence of active urinary sediment. Apcalis Oral Jelly
| Table 1. | |||
| Dates | BUN | Creatinine | |
| 04/25/00 | 80 | 3.1 | Baseline |
| 06/23/00 | 77 | 3.1 | |
| 12/26/01 | 140 | 8.3 | Admission ; surgery |
| 02/07/02 | 32 | 5.2 | Post surgery |
| 03/26/02 | 23 | 4.1 | |
The liver function tests were normal, and the hepatitis serologies were non-reactive. There were normal ANA and anti-DNA titers, and the spot urine protein/creatinine ratio was 2.6g/1.73m2. There were no paraproteins on serum and urine electrophoresis. The chest x-ray was essentially normal. Renal ultrasound revealed a 10cm mass on the upper pole of left kidney without associated hydronephrosis or ureteral obstruction. Computerized tomography (Figure 1) and MRI evidence of neoplastic disease. CT scan of the liver also was negative. The peripheral blood count and smear showed no evidence of unusual lymphoid proliferation. A renal neoplasm was suspected, and a surgical consultation was obtained, after initiating hemodialysis.
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Figure 1. Non-contrasted CT reveals 10cm solid mass (long arrows) of left kidney with hypodense (open arrow) area centrally.
Examination of the adrenal glands and the liver during surgery revealed no neoplastic involvement.
En block resection of the left kidney, spleen, and distal pancreas was performed. The lesion did not penetrate into the spleen, which ultimately was found to have no parenchymal lesions. Although the mass extended into the surrounding tissues, and involved the pancreatic tail and periaortic connective tissue, the bulk of the mass, measuring 10.0 x 9.0 x 6.5 cm, was present in the kidney, therefore, the kidney could only be the primary source of the mass. cialis canadian pharmacy
Figure 2. Coronal T2 weighted images reveals the iso-intense left renal mass (long arrows), and central hyperintense cystic-appearing area (open arrow).
Microscopic ex (Figure 2) of the kidneys were performed and revealed a 10cm left renal mass with a central area of hypodensity suggesting necrosis or cystic changes. The mass involved the superior pole and mid portion of the left kidney. It extended cephal-ically to abut and probably involve the splenic hilum and medial margin of the spleen. There was probable involvement of the pancreatic tail and distal splenic vein. A focal area of cyst or cystic change was present at the infero-anterior margin of the mass and was presumably an enveloped simple cyst. Ultrasound (Figure 3) also confirmed the presence of a cyst within this mass.
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Abdominal and peri-aortic lymph nodes were found to be tumor-free by magnetic resonance imaging (MRI). A bone Gallium scan showed no amination revealed the cellular infiltrate consisted of a diffuse proliferation of neoplastic lymphocytes that infiltrated into the renal parenchyma. Small lymphocytes with dark, condensed nuclear chromatin and convoluted nuclei predominated, mixed with lesser numbers of larger lymphocytes with vesiculated nuclei and prominent nucleoli. Flow cytometry analysis of the tissue revealed the following: dim expression of CD5, and expression CD 19, CD20, HLA-DR, and clonal kappa markers. The tumor immunophenotyped on formalin-fixed tissue showed:
♦POSITIVE-CD20 and kappa.
♦NEGATIVE-CD3, CD5, CD10, Cyclin Dl, and lambda.
Cytogenetic studies revealed deletion of 69, and extra copies of chromosomes 3 and X. The histologic features, flow cytometry, immunohisto-chemical markers and cytogenetic results were consistent with a diffuse low grade В cell non-Hodgkins lymphoma. This tumor was best categorized as a marginal-zone В cell lymphoma, extra-nodal (MALT-like). This lesion had features that overlap those of monocytoid-cell lymphoma, and a close relationship between the two lesions has been suggested.
Figure 3. Ultrasound reveals relatively hypoecho-genic mass with cystic area (open arrow) interiorly.
Adjuvant therapy was not administered due to the patient’s renal failure. Two months after the surgery follow up of patients renal function was almost back to baseline with BUN/creatinine of 50 and 3, respectively, thus the patient did not need subsequent hemodialysis.
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