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

B‑cell lymphoblastic lymphoma‑associated renal damage: A case report and literature review

Lymphoblastic lymphoma (LBL) is a highly malignant form of lymphoma with rapid progression and high mortality. According to the World Health Organization immunophenotype, it is classified into T-lymphoblastic lymphoma (T-LBL) and B-lymphoblastic lymphoma (B-LBL). B-LBL often involves lymph nodes and extranodal locations, such as the skin, bones, and soft tissues. However, renal damage as an initial symptom is very rare in B-LBL. The present study presented a rare case of renal involvement in a 30-year-old male patient with B-LBL presenting with acute renal failure with bilateral renal enlargement. Renal involvement is rare in B-LBL, and nephrologists should improve the understanding of this disease.

Bilateral nephromegaly due to direct leukemic cell invasion in the initial and relapse phases of T-cell acute lymphoblastic leukaemia: A case report

RATIONALE

T-cell acute lymphoblastic leukemia is a relatively uncommon disorder in adults. Kidneys are not frequently invaded by leukemic cells, and patients with adult ALL showing nephromegaly as an initial presentation are rare.

PATIENT CONCERNS

A 54-year-old man was referred to our institution for mild anemia and thrombocytopenia. Laboratory tests showed bicytopenia with abnormal lymphoid cells in the peripheral blood and mild renal dysfunction.

DIAGNOSIS

Ultrasonography and computed tomography (CT) revealed bilateral enlargement of the kidneys. [18F]-fluorodeoxyglucose positron emission tomography/CT demonstrated a strong increase in metabolic uptake in the bilateral kidneys. A kidney biopsy revealed a leukemia invasion into the parenchyma. Based on the lymphocytic repertoire, the patient's condition was diagnosed as T-cell acute lymphoblastic leukaemia.

INTERVENTIONS

The patient received hyper-cyclophosphamide, vincristine, adriamycin, and dexamethasone and high-dose methotrexate and cytarabine as induction chemotherapy. After his leukemia relapsed, he received nelarabine as a second induction therapy and underwent haploidentical peripheral blood stem cell transplantation.

OUTCOMES

Complete remission (CR) was achieved after chemotherapy. Chemotherapy also improved renal function associated with the normalization of bilateral nephromegaly. Repeated [18F]-fluorodeoxyglucose - positron emission tomography/CT posttreatment showedregression of metabolic uptake in the bilateral kidneys. The patient underwent cord blood transplantation at the first CR, but his leukemia relapsed 9 months later. At relapse, bilateral nephromegaly reappeared. Then, the second induction therapy induced CR for at least 10 months after induction therapy.

LESSONS

Although rare, ALL in the initial and relapsed phases can be associated with bilateral nephromegaly and renal impairment due to the invasion of leukemic cells into the parenchyma with or without abnormal leukemic cells in circulation. Leukemia is an important differential diagnosis of renal impairment with bilateral nephromegaly.

Kidney injury and disease in patients with haematological malignancies

Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.

Lymphomas with kidney involvement: the French multicenter retrospective LyKID study

The LyKID study is a nationwide survey in France of lymphoma patients with renal involvement based on biopsy and/or imaging, to evaluate its impact on disease outcome and renal function. A total of 87 adult cases of B or T-cell lymphomas were retrospectively analyzed. Interstitial topography was observed in most of the kidney biopsies (54/66; 80%). Kidney failure (glomerular filtration rate <60 mL/min/1.73 m²) was present in 47% of patients and was associated with non-significantly different outcome. After lymphoma treatment, 44% of patients had persistent chronic kidney failure (CKF); kidney failure at diagnosis was the only parameter associated with CKF in multivariate analysis. DLBCL (diffuse large B-cell lymphomas) represented half of the series, with noticeably CNS (central neurological system) relapse in 17% patients, while fewer than one of two patients had received CNS prophylaxis. To our knowledge, the LyKID study represents the largest published non-autopsy lymphoma series with renal involvement.

Clinicopathological spectrum of renal parenchymal involvement in B-cell lymphoproliferative disorders

The clinicopathological characteristics of kidney infiltration in B-cell lymphoproliferative disorders remain poorly described. We retrospectively studied 52 adults with biopsy-proven malignant B-cell kidney infiltration, including Waldenström's macroglobulinemia (n=21), chronic lymphocytic leukemia (n=11), diffuse large B-cell lymphoma (DLBCL) (n=8), other lymphoma (n=11), and multiple myeloma (n=1). Kidney disease varied according to the underlying lymphoproliferative disorder. In DLBCL, malignant kidney infiltration was prominent, resulting in acute kidney injury (AKI, 75%) and kidney enlargement (88%). In the other types, associated immunoglobulin-related nephropathy (most commonly AL amyloidosis) was more common (45%), and chronic kidney disease with proteinuria was the primary presentation. All patients received chemotherapy. Over a median follow-up of 31 months, 20 patients died and 21 reached end-stage kidney disease. Renal response, achieved in 25 patients (48%), was associated with higher overall survival (97 vs. 37 months in non-renal responders). In univariate analysis, percentage of sclerotic glomeruli, kidney enlargement, and complete hematological response at 6 months were predictive of renal response. In multivariate analysis, concomitant immunoglobulin-related nephropathy was the sole independent predictor of poor renal outcome. In conclusion, clinical presentation of renal lymphomatous infiltration depends on the nature of the underlying lymphoproliferative disorder. In DLBCL, massive renal infiltration manifests with enlarged kidneys and AKI, and the diagnosis primarily relies on lymph node biopsy. In other B-cell lymphoproliferative disorders, the clinicopathological spectrum is more heterogeneous, with a high frequency of immunoglobulin-related nephropathy that may affect renal outcome; thus kidney biopsy is required for early diagnosis and prognostic assessment.

Lymphoblastic lymphoma presenting as bilateral renal enlargement diagnosed by percutaneous kidney biopsy: Report of three cases

Renal involvement by lymphoma can be a diagnostic challenge. Acute kidney injury (AKI) is an unusual manifestation of lymphomatous infiltration in the kidneys. We report three cases of lymphoblastic lymphoma, a very rare form of lymphoma, presenting with AKI and bilateral enlargement of kidneys, diagnosed by percutaneous kidney biopsy. Lymphomatous infiltration should be suspected with such clinical presentation. Kidney biopsy is a valuable diagnostic tool, to establish the correct diagnosis and subtype of lymphoma for timely initiation of therapy for these aggressive hematological malignancies.

Importance of Flow Cytometry in the Cytopathologic Evaluation of Lymphoid Lesions Involving the Kidney

BACKGROUND

Cytomorphology alone is often insufficient for the diagnosis and subclassification of lymphomas, so flow cytometry (FC) may be used as an adjuvant test.

METHODS

Renal fine-needle aspirations (FNAs) performed from January 1993 to August 2014 were reviewed for FC data or a diagnosis of lymphoma.

RESULTS

A total of 586 renal FNAs were collected. Thirty-three cases (5.1%) had FC analysis. Lymphoma was diagnosed 35 times (6%), and FC was performed in 21 (60%) cases. Both cytomorphology and FC were consistent with lymphoma in 20 cases. Cytomorphology alone was diagnostic of lymphoma in 15 cases. In 28 cases, biopsy from the kidney or another site was diagnostic of lymphoma. One subsequent biopsy revealed that a kidney FNA, which showed no definitive morphologic or FC evidence of lymphoma, likely represented necrotic diffuse large B-cell lymphoma.

CONCLUSION

FC is a useful adjuvant diagnostic test for renal FNAs, particularly for subclassification and confirmation of the diagnosis when there is insufficient material for immunohistochemistry. FC should be interpreted with caution when a sample is limited or when there is suspicion of Hodgkin lymphoma, and further work-up is warranted when cytomorphology suggests lymphoma but FC is negative.

Analysis of clinical characteristics and outcome of patients with previously untreated diffuse large B-cell lymphoma and renal involvement in the rituximab era

Renal involvement in patients with lymphoma is rare but associated with poor prognosis. We analyzed characteristics and outcome of 22 patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) and renal involvement treated with a rituximab-containing regimen in curative intent. The majority of patients presented in advanced disease, 86% were Ann Arbor stage ≥ III and had an IPI score ≥ 3. Renal impairment was present in 32%. Outcome was poor with three-year progression-free survival (PFS) 44% and three-year overall survival (OS) 52% and significantly worse compared to DLBCL without renal involvement (p < 0.01). Patients with high-risk IPI had a significantly inferior prognosis compared to intermediate-risk IPI (three-year OS 0% vs. 75%, p = 0.01) as did those with renal impairment. A high rate of central nervous system (CNS) relapse (8/22) was observed. Intravenous high-dose methotrexate and intrathecal therapy showed a trend toward prolonged time to CNS relapse. Implementation of CNS prophylaxis might therefore be considered in these high-risk patients.

Imaging of primary and secondary renal lymphoma

OBJECTIVE

This article reviews the CT and MRI patterns of primary and secondary renal lymphomas and discusses the role of percutaneous biopsy in diagnosis and management.

CONCLUSION

Renal lymphoma has a variable imaging spectrum and may mimic renal cell carcinoma. An awareness of the typical and atypical imaging features of both primary and secondary renal lymphomas can help the radiologist to suggest these diagnoses and recommend biopsy when appropriate.

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.

Isolated renal relapse of a case with non-Hodgkin's lymphoma

A 29-year-old woman with left pleural effusion and a mass in anterior mediastinum was admitted. Transthoracic needle aspiration from the mass revealed findings consistent with nodular sclerosis variety of Hodgkin's disease. The patient was in remission after six cycles of ABVD followed by mediastinal radiotherapy. Ten months later CT scan showed three hypodense masses in the right kidney. Ultrasound guided renal biopsy revealed diffuse large B cell lymphoma. Retrospective re-evaluation of the archival specimens of the mediastinal mass was also consistent with diffuse large B cell lymphoma. After induction chemotherapy (four cycles of DHAP) she underwent high dose chemotherapy (BEAM) and autologous peripheral blood stem cell transplantation. She is still in remission for 7 years after transplantation. In conclusion, renal involvement during advanced lymphoma is quite common but isolated renal relapse in NHL is a rare situation. Although renal infiltration generally shows a poor prognosis, long-term survival may be achieved with high dose chemotherapy and autologous peripheral blood stem cell transplantation.

[Genitourinary lymphomas]

Lymphomas of the genitourinary tract represent rare tumours for which the diagnosis is crucial regarding the specificity of the treatment. The most frequent localisations are the kidney (solitary tumour or multiple nodules) and the testis; other sites of the genitourinary tract are uncommon. One of the main challenges is to obtain an appropriate immunohistochemical diagnosis with a good staging which is necessary to adapt the therapeutic options. These are mostly based on chemotherapy (with immunotherapy in B-cell lymphomas), of which the intensity and number of cycles depend on initial prognosis factors.

[Lymphoma with initial renal involvement: four cases]

PURPOSE

To present a comprehensive description of the clinical features of patients with renal manifestations during lymphoma.

METHODS

Retrospective review of medical records from all patients diagnosed with lymphoma associated with kidney involvement in our hospital between 1996 to 2004. Four cases were identified and analysed.

RESULTS

Four patients presented a non-Hodgkin's lymphoma. One patient showed intravascular large B-cell lymphoma, revealed by proteinuria. Another patient had a nephrotic syndrome, and two had a renal mass. Renal histology allowed diagnosis of lymphoma in 3 cases.

CONCLUSION

The diagnosis of lymphoma associated with renal involvement is rather difficult, and more specifically in case of intravascular large B-cell lymphoma, or even primary renal lymphoma. We present here a comprehensive review of the literature and we discuss pathogenesis of these conditions.

Lymphomas diagnosed by percutaneous kidney biopsy

BACKGROUND

Occult renal lymphoma clinically mimicking renal medical disease constitutes a diagnostic challenge to nephrologists, radiologists, and renal pathologists. The clinical and radiological findings, mostly nonspecific or inconclusive, seldom obviate the need for a kidney biopsy.

METHODS AND RESULTS

We report 5 new cases of diffuse bilateral renal lymphoma diagnosed by percutaneous kidney biopsy, all presenting with acute renal failure (ARF) of unknown cause. Three cases showed an interstitial and 2 an intraglomerular/intravascular type of lymphomatous infiltration. All tumors were of B-cell lineage. Our cases add to 50 similar cases reported since 1980. Considering all 55 cases together, 39 (87%) of the 44 cases with interstitial and 5 of 11 (45%) of those with intraglomerular lymphoma presented with ARF. In contrast, 5 of 10 cases with intraglomerular but none with interstitial infiltration presented with nephrotic range proteinuria. All but 2 cases (95%) with ARF and interstitial lymphoma but none with ARF and intraglomerular lymphoma showed bilaterally enlarged kidneys. Signs of extrarenal lymphomatous involvement were detected in 24 cases (44%) at the time of kidney biopsy or shortly thereafter. However, in only 10 cases (18%), all with interstitial lymphoma, was a tumor suspected prior to biopsy, mainly based on radiographical evidence of enlarged kidneys.

CONCLUSION

Both types of diffuse bilateral renal lymphoma may clinically mimic renal medical disease. ARF in interstitial and in intraglomerular lymphoma may be due to increased intrarenal pressure and intraglomerular obstruction, respectively. Percutaneous kidney biopsy provides the most expedient means of establishing the diagnosis. Differential diagnosis includes interstitial nephritis and proliferative glomerulonephritis.

Renal lymphoma. The diagnostic and therapeutic roles of fine-needle aspiration

This study focused on 19 patients with renal lymphoma (RL) from whom 20 initial (1 patient with fine-needle aspiration [FNA] specimens of masses in both kidneys) and 1 repeated FNA specimen were obtained. Of the 19 patients, 10 had secondary RL, 8 primary RL, and 1 transplant RL. The FNA samples were studied by smears (all cases), tissues (11), phenotyping by immunostaining (13) or flow cytometry (4), and gene rearrangement (3). The final diagnoses included 1 T-cell lymphoma and 18 B-cell lymphomas. Of the 20 original specimens, 14 were reported as positive for lymphoma, 3 suggestive of lymphoma, 1 positive for transitional cell carcinoma, and 2 unsatisfactory. The follow-up specimen showed reactive changes. Tissue correlation, available in 11 cases, confirmed a positive cytodiagnosis (7), provided a final diagnosis in the cytologically inconclusive cases (3), or revised the misdiagnosis of transitional cell carcinoma from smears (1). The phenotyping elucidated the B vs T lineage of the lymphoma in all tested cases, confirmed the positive cytodiagnosis in 10 cases, confirmed the reactive cytodiagnosis in 1 case, and helped achieve a conclusive diagnosis in 2 cases suggestive of lymphoma. Gene rearrangement studies showed light chain restriction in the 2 tested cases. FNA has an essential role in treatment planning for RL. Although FNA usually is diagnostically conclusive, a high index of suspicion and awareness of atypical or misleading cytomorphologic features are important for a correct interpretation, especially for primary RL. Ancillary testing is essential for the diagnosis in problematic cases and lays the foundation for the differential diagnosis.

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.