Renal involvement in malignant lymphomas: a survey of 49 cases

Near-future ocean warming and acidification alter foraging behaviour, locomotion, and metabolic rate in a keystone marine mollusc

Environmentally-induced changes in fitness are mediated by direct effects on physiology and behaviour, which are tightly linked. We investigated how predicted ocean warming (OW) and acidification (OA) affect key ecological behaviours (locomotion speed and foraging success) and metabolic rate of a keystone marine mollusc, the sea hare Stylocheilus striatus, a specialist grazer of the toxic cyanobacterium Lyngbya majuscula. We acclimated sea hares to OW and/or OA across three developmental stages (metamorphic, juvenile, and adult) or as adults only, and compare these to sea hares maintained under current-day conditions. Generally, locomotion speed and time to locate food were reduced ~1.5- to 2-fold when the stressors (OW or OA) were experienced in isolation, but reduced ~3-fold when combined. Decision-making was also severely altered, with correct foraging choice nearly 40% lower under combined stressors. Metabolic rate appeared to acclimate to the stressors in isolation, but was significantly elevated under combined stressors. Overall, sea hares that developed under OW and/or OA exhibited a less severe impact, indicating beneficial phenotypic plasticity. Reduced foraging success coupled with increased metabolic demands may impact fitness in this species and highlight potentially large ecological consequences under unabated OW and OA, namely in regulating toxic cyanobacteria blooms on coral reefs.

Diffuse large B-cell lymphoma with involvement of the kidney: outcome and risk of central nervous system relapse

BACKGROUND

Renal involvement is uncommon in diffuse large B-cell lymphoma. Recent data suggest that it is an independent risk factor for central nervous system relapse. We reviewed the clinical features, risk of central nervous system involvement, and survival of patients with diffuse large B-cell lymphoma with involvement of the kidney at diagnosis.

DESIGN AND METHODS

All patients with diffuse large B-cell lymphoma and renal involvement diagnosed from January 1, 1982 to December 31, 2008 at the British Columbia Cancer Agency were retrospectively identified in the Lymphoid Cancer Database. Patients were included if they were 16 years old or over, had advanced stage disease [stage III/IV, or stage I/II with B symptoms or bulky mass (>10 cm)] and were treated with curative intent. Central nervous system involvement was diagnosed by cerebrospinal fluid cytology, radiology or clinically.

RESULTS

We identified 55/2656 (2%) patients with diffuse large B-cell lymphoma and renal involvement at diagnosis. The male to female ratio was 2:1. The patients' median age was 58 years. Bilateral renal involvement was present in 24 (44%) and stage IV disease in 50 (91%). The International Prognostic Index score was 3, 4 or 5 in 52 (95%), the glomerular filtration rate was less than 30 mL/min/m² in 9 (16%) and elevated lactate dehydrogenase was recorded in 46 (84%). Twenty-five (46%) patients received CHOP plus rituximab and 30 (54%) received CHOP-like regimens without rituximab. In total, 20 (36%) patients had central nervous system involvement: four at the time of diagnosis and 16 at relapse. The median time to central nervous system relapse was 5.6 months (range, 1.2 months-4.6 years), and was not affected by the addition of rituximab (P=0.547). The 5-year overall and progression-free survival rates for the whole cohort were 29% and 25%, respectively. In patients who received rituximab, there were trends towards improved 5-year overall survival (43% versus 18%, P=0.071) and progression-free survival (40% versus 13%, P=0.057).

CONCLUSIONS

There is an exceptionally high incidence of central nervous system relapse in patients with diffuse large B-cell lymphoma and kidney involvement at diagnosis. The addition of rituximab may improve overall survival in this poor-risk population, likely through improved control of systemic disease.

[Metastatic renal failure]

A 52-year-old man, treated 15 months earlier for a poorly differentiated bronchial adenosquamous carcinoma, was admitted for oligoanuric renal failure preceded by macroscopic hematuria. Clinical and paraclinical investigations were unremarkable except ++proteinuria and mild echographic enlargement of both kidneys. Bilateral renal biopsy disclosed replacement of normal renal tissue by an adenocarcinomatous proliferation. Despite transient improvement and cessation of hemodialysis, the patient died one month later. Analysis of literature reveals that secondary kidney tumours -especially of bronchial origin- are more frequent than primary ones, but that cases of renal failure are uncommonly reported, probably because of underdiagnosis, poor prognosis and limited therapeutic issues. Features of previously published cases are listed in a synthetic table.

[Primary renal manifestation in malignant lymphomas and leukemia]

Primary manifestation of malignant lymphoma and/or leukaemia rarely occurs in the kidney. It can be the cause of a hitherto unexplained acute renal failure or it is incidentally detected as shown in the three cases under report.1.A 68-year-old man was operated on because of a symptomatic tumour in his right kidney. At nephrectomy, a conventional (clear cell) renal cell carcinoma was found simultaneously with an occult mantle cell lymphoma infiltrating the adjacent renal and extrarenal tissue. Clinical follow-up uncovered nodal and bone marrow involvement, so that a primary renal manifestation of mantle cell lymphoma was apparent.2.A 69-year-old man with suspected vertebral metastasis underwent partial renal resection because of a mass in his left kidney. Histologically and immunohistochemically, the renal infiltration was diagnosed as a precursor B-lymphoblastic lymphoma. After chemotherapy and irradiation, leukaemic blood cell counts with 50% lymphoblasts proved a primary renal manifestation of precursor B-lymphoblastic leukaemia/lymphoma.3.A 13-year-old boy presented clinically with renal failure, enlarged kidneys, and normal urinalysis. Renal biopsy showed a diffuse interstitial infiltration with atypical T-lymphoblasts compressing tubules and surrounding preserved glomeruli. Subsequent clinical bone marrow smears presented 60% T-lymphoblasts, so that the final diagnosis of a primary renal manifestation of acute T-lymphoblastic leukaemia of mature thymic cortex type was made. Immediate chemotherapy resulted in total recovery of renal function and bone marrow findings.

Oliguric acute renal failure in mycosis fungoides with lymphomatous infiltrates in the kidneys

OBJECTIVE

To present the clinical picture of acute renal failure in patients with mycosis fungoides (MF) and renal lymphomatous infiltrates. To analyze the pathogenesis of renal failure.

METHODS

Correlation of clinical picture, urinary findings, imaging reports and autopsy findings in two patients with long-standing MF who died with renal failure.

CASE SUMMARIES

Both subjects had sustained oliguria in the last 2 weeks. One patient had persistent hypotension, normal urinalysis, normal renal sonogram, and scarce interstitial lymphomatous infiltrates with preservation of renal parenchymal architecture. He was thought to have ischemic acute renal failure not directly linked to the lymphomatous infiltrates. The second patient developed hypertension one month prior to death, and had moderate proteinuria, hematuria, pyuria, grossly enlarged kidneys with hypoechoic masses, and extensive replacement of the renal parenchyma by lymphomatous infiltrates. This picture is typical of renal failure secondary to lymphomatous replacement of the kidneys.

CONCLUSIONS

The development of oliguric renal failure in MF with renal lymphomatous infiltrates may have varying clinical and imaging manifestations and pathogeneses. Potentially reversible pathogenic mechanisms should be systematically investigated, particularly if the overall clinical picture is not characteristic of renal failure secondary to lymphomatous replacement of the parenchyma.

Acute renal failure as presentation of a Burkitt's lymphoma

Acute renal failure due to diffuse renal infiltration is rarely the presenting manifestation of non-Hodgkin's lymphoma. We report a patient with acute renal failure secondary to diffuse bilateral renal infiltration by a Burkitt's lymphoma. The presence of bilateral renal enlargement, an elevated serum lactate dehydrogenase (LDH), and lymphopenia should suggest the diagnosis, which can be confirmed by renal biopsy.

Lymphoma at uncommon sites

Lymphoma can often present in unusual situations. This article provides a comprehensive review of the literature in which both non-Hodgkin's lymphoma and Hodgkin's disease are discussed.

Association of primary renal non-Hodgkin's lymphoma with mesangioproliferative glomerulonephritis

A 27-year-old male developed nonoliguric renal failure. Renal biopsy of the left kidney showed infiltration by a diffuse large-cell non-Hodgkin's lymphoma (NHL). Laparoscopy, CT scans of the abdomen and thorax, and bone-marrow biopsy revealed no further manifestations of lymphoma. Primary renal NHL was diagnosed. The patient attained complete remission with cyclophosphamide, adriamycin, vincristine, and prednisone (CHOP) chemotherapy and remained disease-free for 13 years. Eight years after his first presentation, the patient developed acute oliguric renal failure with nephrotic syndrome. Mesangioproliferative glomerulonephritis was diagnosed in a biopsy of the left kidney. Chronic hemodialysis was required until cadaver kidney transplantation was successfully performed 5 years later. Although the association of NHL and glomerulonephritis has been described several times before, to our knowledge this is the first report of glomerulonephritis in primary renal lymphoma.

Acute renal failure secondary to solid tumor renal metastases: case report and review of the literature

Renal metastases from solid tumors to both kidneys rarely result in acute renal failure (ARF). We present a case of squamous cell pulmonary carcinoma responsible for ARF due to (1) extensive (50% to 75%) bilateral parenchymal infiltration and replacement accompanied by tissue destruction, (2) widespread vascular invasion and thrombosis resulting in ischemia, and (3) histological evidence for foci of distal intratubular obstruction and pyelonephritis. Five additional cases, including one pulmonary cancer, causing ARF from extensive tissue replacement and destruction are reviewed. In a separate case, ARF resulted from lymphatic metastases rather than from parenchymal destruction or obstruction. Common findings in all six reported cases include bilaterally enlarged kidneys and progressive oligoanuria despite correction of prerenal or postrenal conditions. In our patient and in one other prior reported case, extrarenal obstruction was not considered important because invasive therapeutic procedures were unsuccessful in reversing ARF. In one case, irradiation of kidney tumor resulted in reversal of ARF. These cases emphasize the rare potential for solid tumors to metastasize to both kidneys and result in irreversible oligoanuric ARF. A high level of suspicion is required, and an early diagnosis may result in reversible ARF if the tumor is amenable to chemotherapy or irradiation.

Diagnostic imaging in the evaluation of renal lymphoma

Renal lymphoma usually is a manifestation of disseminated disease and often is asymptomatic. Occasionally, the kidney(s) may be the major or only demonstrable site of disease, which may then present with a variety of urologic symptoms. The imaging studies should be tailored according to the presenting symptoms and prior history. Currently CT with intravenous contrast material enhancement is the study of choice for both the evaluation of renal involvement as well as staging of the disease. When necessary, CT or sonography may be used to guide percutaneous needle biopsy of suspicious masses. The role of the various imaging techniques, including MR and positron emission tomography, in the evaluation of renal lymphoma is discussed.

Aggressive lymphomas with renal involvement: a study of 48 patients treated with the LNH-84 and LNH-87 regimens. Groupe d'Etude des Lymphomes de l'Adulte

In order to describe renal involvement in aggressive non-Hodgkin's lymphomas (NHLs) and its prognostic significance, we reviewed the outcome of 48 patients with renal involvement treated with the LNH-84 or LNH-87 regimen. Histology was diffuse large cell in 29 (60%) patients; immunoblastic, diffuse mixed cell and lymphoblastic in four each; follicular large cell, diffuse small cleaved cell and diffuse small non-cleaved cell in one each; and unclassified in four. Ann Arbor stage was IV in 44 patients, and IE or IIE in four. Tumour mass > or = 10 cm, performance status (ECOG scale) > 2 and increased LDH level were present in 69%, 20% and 76% of patients respectively. Fifteen patients (31%) had multiple intraparenchymal nodules, 14 (29%) had direct spread into the kidney from a perirenal mass, ten (21%) had a single intraparenchymal nodule and nine (19%) had diffuse infiltration. Twenty-one patients (43%) presented with bilateral lesions. Three patients (6%) presented with acute renal failure. Ten other patients (21%) had serum creatinine > 120 mumol l-1. In 12 of these 13 patients renal function was restored with chemotherapy. Twenty-eight patients (57%) achieved complete remission. Estimated 4 year disease-free survival was 39%. Disease-free survival and actuarial survival at 4 years were estimated to be 58% respectively. Two renal parameters had adverse prognostic significance for survival: renal hilum involvement (P = 0.02) and diffuse renal infiltration (P = 0.01). A Cox model identified only two independent prognostic factors for survival, namely performance status > or = 2 and tumour size > or = 10 cm. We conclude that alteration in renal function occurs in 27% of patients with renal involvement. Systemic chemotherapy improves renal function rapidly. Long-term outcome is similar to that expected in NHL patients presenting with the same prognostic factors.

Non-Hodgkin's lymphoma can mimic renal adenocarcinoma with inferior vena caval involvement

Genitourinary involvement in both Hodgkin's and non-Hodgkin's lymphomas is common and can be confused with other benign and malignant urologic conditions. While lymphoma commonly produces vascular and ureteral encasement, intraluminal vascular involvement is rare. Indeed, there are no previous reports of renal lymphoma with tumor thrombus extending into both the renal vein and inferior vena cava. We describe the first reported case of lymphoma mimicking a Stage IIIA renal adenocarcinoma with tumor thrombus in the renal vein and the inferior vena cava. Renal lymphoma should be considered in the differential diagnosis even when tumor thrombus is present in the renal vein or vena cava.

Follicular dendritic cells in extranodal non-Hodgkin lymphomas of MALT and non-MALT type

Extranodal lymphomas of the thyroid (n = 19), kidney (n = 15) and testis (n = 30) were investigated histologically and immunohistochemically for follicular dendritic cell pattern using the monoclonal antibody Ki-FDClP. This recognizes follicular dendritic cells in paraffin sections. Follicular dendritic cells were most predominant in lymphomas of the thyroid. These thyroid lymphomas showed the morphological features of mucosa-associated lymphoid tissue (MALT) type lymphomas in 18 of 19 cases and were classified as high-grade malignant lymphoma of MALT type with evidence of a low-grade malignant component (n = 18). Ten of these cases contained destroyed reactive follicles of follicular dendritic cells. In 6 of these 10 cases follicular dendritic cells occurred in a pattern of tumour-associated abortive follicle type. The remaining lymphoma of the thyroid was an immunoblastic lymphoma of B-cell type showing no detectable follicular dendritic cells. In extranodal lymphomas of non-MALT type follicular dendritic cells occurred in only two cases where immunocytoma involved the kidney. Malignant lymphomas of the kidney (chronic lymphocytic leukaemia, n = 2; immunocytoma, n = 4; centroblastic lymphoma, n = 9) and of the testis (immunocytoma, n = 2; centroblastic lymphoma, n = 27; immunoblastic lymphoma of B-cell type, n = 1) revealed no characteristics of MALT type lymphoma, cytologically or with respect to follicular dendritic cells. Classical lymphoepithelial lesions formed by centrocyte-like cells, a hallmark of MALT, occurred exclusively in thyroid lymphomas of MALT type. Although occurrence of classical lymphoepithelial lesions formed by centrocyte-like cells was limited to thyroid lymphomas of MALT type, a growth pattern of lymphoid blasts, with formation of lesions mimicking lymphoepithelial lesions superficially, was found in 6 of 27 testicular centroblastic lymphomas. Follicular dendritic cells in non-Hodgkin's lymphomas of MALT type show distinct follicular patterns not found in other extranodal lymphomas such as those found in the kidney and testis.

B-cell lymphoma presenting as infiltrative renal disease

Acute renal failure is rarely the presenting manifestation of non-Hodgkin's lymphoma. Of the reported cases of renal insufficiency secondary to diffuse renal infiltration with lymphoma, few have presented with acute renal failure. We present a patient with acute renal failure secondary to diffuse bilateral renal infiltration by a B-cell non-Hodgkin's lymphoma. The findings of an elevated serum lactate dehydrogenase (LDH), lymphopenia, and homogenous bilateral renal enlargement on computed tomographic (CT) imaging were important in suggesting the diagnosis of primary renal lymphoma. Renal biopsy with immunohistochemical and ultrastructural analysis was instrumental in confirming this diagnosis.

Acute renal failure secondary to carcinomatous lymphatic metastases to kidneys

We report a rare case of acute renal failure secondary to bilateral renal parenchymal metastases from carcinoma. Despite clinical investigation the cause of the renal failure remained undiagnosed and was discovered only upon microscopy at autopsy, which revealed metastatic gastric adenocarcinoma. The pattern of tumor infiltration was predominantly lymphatic involvement limited to the vascular bundles at the corticomedullary junction, and the lymphatics adjacent to the calices and pelves. The significance of lymphatic obstruction in the pathogenesis of renal failure is discussed. Renal parenchymal metastases should be considered in the differential diagnosis of acute renal failure in patients with carcinoma.

CT in renal and perirenal lymphoma: a further look

The CT appearances of renal and perirenal lymphoma detected in 26 patients are presented. Twenty-four patients had non-Hodgkin's lymphoma and two patients Hodgkin's disease. This represented 3% of all patients scanned for routine staging of known lymphoma. Eleven patients had involvement at the time of relapse only, having had no previous evidence of renal involvement. Forty-three per-cent of all patients with renal lymphoma had no retroperitoneal lymph node involvement. Most patients had other extranodal disease at the time of presentation, most commonly bone.

Diagnosis and characterization of non-Hodgkin's lymphoma in a patient with acute renal failure

This case illustrates the relatively rare occurrence of malignant lymphoma presenting as acute renal failure due to renal parenchymal infiltration. To our knowledge, it is the first report in which the phenotype of a non-Hodgkin's lymphoma was established using renal biopsy tissue. The dangers of treatment of renal lymphoma in the patient whose disease has not been adequately characterized have been noted by Coggins.

Varicocele as the presenting sign of an abdominal mass

A patient with a varicocele on the right side as the presenting sign of intra-abdominal Burkitt's lymphoma is reported. The incidence and etiology of varicocele are discussed.

Primary renal lymphoma. Does it exist?

Although secondary renal involvement from systemic lymphoma is common, primary lymphoma of the kidney is not well recognized. One case is reported and 27 cases purported to be primary tumors are reviewed. From these cases three conclusions have been drawn: it is reasonable to assume that renal lymphoma can be a primary lesion; almost all patients with primary renal lymphoma will develop extrarenal lymphomatous disease shortly after diagnosis of their renal tumor; and survival for more than 1 year after diagnosis is rare.

Primary renal lymphoma presenting as acute renal failure

Diffuse bilateral infiltration of the kidneys by lymphoma cells is a rare but well-documented cause of acute renal failure (ARF). Only 51 such cases have been reported, 15 of which had ARF as the initial presentation of lymphoma. The clinical and pathologic features of these 15 cases and of two additional cases reported herein are reviewed. The diagnosis should be suspected in a patient with ARF, bilateral enlargement of the kidneys, minimal proteinuria, nonspecific findings on urinalysis, and absence of features of allergic tubulointerstitial nephritis. Renal imaging techniques may suggest the possibility of lymphomatous infiltration, but only renal biopsy or autopsy can provide a definitive diagnosis. Although modern chemotherapy and/or radiation therapy usually leads to a dramatic normalization of renal function, almost all patients eventually die of widespread recurrent lymphoma, despite the absence of clinical or pathologic involvement of the kidneys at the time of death.

Organ envelopment in lymphoma visualised by computed tomography

In 12 patients computed tomography revealed an unusual pattern of lymphomatous growth resulting in envelopment or engulfment of an organ. The kidneys were involved in eight cases, and the mediastinum and pericardium, oesophagus, stomach and rectosigmoid colon, and psoas muscle in one case each. Ten patients had non-Hodgkin's lymphoma and two had Hodgkin's disease; in every case, lymphomatous masses surrounded but did not destroy the affected tissues. The potential for both Hodgkin's and non-Hodgkin's lymphomas to enwrap both renal and non-renal tissues has not previously been emphasised.

Renal failure due to lymphomatous infiltration of the kidneys. Report of three new cases and review of the literature

Three new cases of renal failure due to lymphomatous infiltration of the kidneys are described and the clinical features of 14 similar patients in the literature are reviewed. The diagnosis of renal failure secondary to lymphomatous infiltration was made by ruling out other causes of renal failure and demonstrating prompt improvement in renal function after systemic chemotherapy or local irradiation of one or both kidneys. Histiocytic lymphoma was the most common underlying disease. In the setting of diffuse lymphoma with other causes of renal failure reasonably excluded, radiographic demonstration of enlarged kidneys without obstruction suggests the need for intensive combination chemotherapy in most cases.

Urinary cytodiagnostic abnormalities in 50 patients with non-Hodgkin's lymphomas

Urinary cytodiagnostic evaluation was performed on 50 consecutive patients with non-Hodgkin's lymphomas. In 14 patients (28%) the urine sediment contained characteristic lymphoma cells. The groups with or without a positive urine cytology were comparable with respect to type of lymphoma, stage and course of disease, and recent treatment with chemotherapy. However, those with a positive urine cytology were more likely to have clinical evidence of kidney disease (43% vs 8%), although this was rarely attributed to disseminated lymphoma. In fact, in three patients, a positive urine cytology was the sole or presenting evidence for disseminated lymphoma. Although the groups with or without a positive cytology were similar with regard to physicochemical urinary findings, there were marked differences in the frequency of microscopic abnormalities. All patients with a positive cytology had evidence of renal parenchymal necrosis, renal tubular injury, or pathologic cast formation as compared with only 56% of those with a negative cytology. Thus, urinary cytodiagnostic evaluation may provide an important adjunct in the staging and evaluation of patients with malignant lymphomas.

Acute Anuric Bilateral Ureteral Obstruction in Malignant Lymphoma

Two cases of bilateral ureteral obstruction in malignant lymphoma are reported. In one case, primary infiltration of the ureters by Hodgkin's disease was demonstrated, while in the other the obstruction was due to ureteral compression by enlarged lymph nodes. The diagnostic procedures and the management of such cases are discussed.

Malignant lymphoma presenting with nonoliguric renal failure

Nonoliguric renal failure was observed as a presenting complaint in a 14-year-old boy with a malignant lymphoma. The diagnosis was made by a renal biopsy, and the renal failure was treated successfully with peritoneal dialysis while the lymphoma was being treated with radiotherapy.

Early renal involvement in acute lymphoblastic leukemia and nonHodgkin's lymphoma in children

Clinical manifestations of kidney disease, particularly renal failure, caused by malignant infiltration in patients with acute lymphoblastic leukemia or nonHodgkin's lymphoma have been described rarely. We report 1 case of acute lymphoblastic leukemia and 3 cases of nonHodgkin's lymphoma in which renal disease was the only or one of the presenting manifestations of malignancy. Of these patients 2 had rapidly progressive renal failure with nephromegaly, 1 presented with bilateral abdominal masses caused by severe nephromegaly and with microscopic hematuria, and 1 had microscopic hematuria without nephromegaly. In all 4 patients kidney biopsy revealed malignant infiltration. In the 2 patients who presented with renal failure kidney function promptly returned to normal after chemotherapy and irradiation of the kidneys. Prompt and correct diagnosis of nephropathy, when it is the only or one of the presenting signs of acute lymphoblastic leukemia or nonHodgkin's lymphoma, is necessary to expedite initiation of specific antitumor therapy.

Renal manifestations of extrarenal neoplasms

In a study of 1270 consecutive autopsies there were 314 patients with malignant neoplasms arising in sites other than the kidney and central nervous system. In over 50 per cent of these there was significant renal damage related to cancer. Renal damage was produced by direct involvement of one or both kidneys by the neoplasm or by indirect effects. The latter included ischemic damage, metabolic injury, immunologic injury, and effects of therapy directed at the malignant tumor. In patients with cancer, tumor bulk and invasion of vital organs do not always explain the clinical deterioration and cause of death. Recognition of the indirect effects of tumors on the kidney and other organ systems is essential to the understanding of the generalized host response to malignant disease.

Acute renal insufficiency due to lymphomatous infiltration of the kidneys: report of six cases

Described are six patients with acute renal insufficiency due to histologically proven massive lymphomatous infiltration of the kidneys. All patients were admitted to a renal intensive care unit over a period of six years. Oliguria was the presenting symptom in two of the patients. This complication of lymphoma is suggested by enlargement of the kidneys and mild proteinuria in the absence of other causes of uremia and can be demonstrated by renal biopsy. Local radiation therapy performed in two patients produced improvement of renal function.

Malignant lymphoma with genitourinary symptoms

Two cases are reported of patients with widespread intra-abdominal malignant lymphoma who althoug they initially presented with urologic complaints had no evidence of direct genitourinary involvement. Transrectal biopsy established the diagnosis in both cases. This unusual presentation of lymphoma is discussed together with a review of urologic involvement. The necessity for accurate diagnosis is stressed since effective treatment with radiation and chemotherapy is available.