PRIMARY RENAL NON-HODGKINS LYMPHOMA PRESENTING: DISCUSSION
Primary renal lymphoma (PRL), describes non-Hodgkin’s lymphoma involving the kidney in the absence of any other organ or nodal disease focus. The majority of patients are older than 40 years and present with acute renal failure. Flank pain, hematuria, weight loss, and abdominal mass are other common manifestations, similar to renal cell carcinoma. PRL presenting with immune thrombocytopenia has also been reported. Lymphoid tissue is normally absent in renal histological architecture and consequently the existence of PRL has been questioned.
The pathophysiology of PRL is still speculative. Neoplasia of renal lymphatics and lymphoid transformation of renal tissue subjected to chronic inflammation are suggested etiologies, analogous to the formation of extra-nodal MALT-like neoplasms in other tissues such as skin, breast, and other non-lymphoid tissues. Lymphomatous infiltration of the kidney is mostly unilateral but bilateral disease does occur. Tubular dysfunction secondary to diffuse interstitial infiltration by malignant cells may be responsible for renal insufficiency. Our patient had prior chronic renal insufficiency which could occur secondary to PRL but had been initially attributed to diabetic nephropathy. Diagnosis and staging involves imaging, tissue biopsy, and immunohistochemistry. Some authors include staging laparotomy as a necessary diagnostic tool to rule out extrarenal disease that may not be detected by conventional imaging. Computed tomographic scan, magnetic resonance imaging, and/or gallium nuclear scan are the imaging techniques used. The use of a positive emission tomographic scan for staging diagnosis is still being studied. Gallium scan can be used to evaluate response to therapy. This case is particularly interesting in that the diagnosis was thought to be renal cell carcinoma until he underwent laparatomy during which contiguous structures, including lymph nodes, were biopsied. canadian antibiotics
The absence of involvement of lymphoid organs, including the lymph nodes and spleen, were verified by a tissue biopsy and MRI. A bone marrow biopsy was not performed, however, no neoplastic lesions were identified on the bone scan, and no atypical lymphoid proliferation was detected in the peripheral blood. These factors, combined with the pathological assessment of the tumor, were consistent with primary renal lymphoma (PRL). Disease staging has not been homogenous in different reports but most patients are in Ann Arbor stage IV.
Treatment of primary renal lymphoma depends on the grade of the mass. High grade lymphomas are best managed with single agent chemotherapy. Low-grade lymphomas of the MALT type, which this patient has, can be removed surgically or radiated. This is a type of non-Hodgkins lymphoma that can be primarily treated with surgery alone. Prognosis is poor, as most patients present with advanced disease and renal failure. Early detection and systemic therapy may improve prognosis. antibiotics online pharmacy
Primary renal lymphoma does exist. Improved understanding of predisposing factors to the development of malignant lymphoma in extranodal organs will help in earlier diagnosis and improved prognosis. The presentation of this patient emphasizes the importance of evaluating for other causes (particularly solid tumors) in patients with diabetic nephropathy and controlled diabetes who develop acute worsening of renal function.
