Lymphomas and lymphoproliferative disorders clinically presenting as renal carcinoma: A clinicopathological study of 14 cases

Recent Advances in Genitourinary Tumors: Updates From the 5th Edition of the World Health Organization Blue Book Series

CONTEXT.—

Urinary and Male Genital Tumours is the 8th volume of the World Health Organization Classification of Tumours series, 5th edition. Released in hard copy in September 2022, it presents an update to the classification of male genital and urinary tumors in the molecular age. Building upon previous volumes in this series, significant effort has been made to harmonize terminology across organ systems for biologically similar tumors (eg, neuroendocrine tumors). Genomic terminology has been standardized and genetic syndromes covered more comprehensively. This review presents a concise summary of this volume, highlighting new entities, notable modifications relative to the 4th edition, and elements of relevance to routine clinical practice.

OBJECTIVE.—

To provide a comprehensive update on the World Health Organization classification of urinary and male genital tumors, highlighting updated diagnostic criteria and terminology.

DATA SOURCES.—

The 4th and 5th editions of the World Health Organization Classification of Tumours: Urinary and Male Genital Tumours.

CONCLUSIONS.—

The World Health Organization has made several changes in the 5th edition of the update on urinary and male genital tumors that pathologists need to be aware of for up-to-date clinical practice.

Primary renal lymphoma presenting as renal failure: A case report and review of literature from 1989

BACKGROUND

Primary renal lymphoma (PRL) is extremely rare with an incidence of 0.7% among extranodal lymphomas. Occult renal lymphoma, which mimics medical renal disease and bilateral renal involvement, presents a diagnostic challenge to nephrologists and radiologists as the clinical and radiological findings are mostly non-specific or inconclusive. Acute kidney injury (AKI) is not an uncommon finding in renal infiltration due to malignant lymphoma. However, only 14% of cases are detected before death, and the low diagnostic rate may be due to the non-specific clinical manifestations of renal involvement, with only 0.5% of these cases presenting with AKI. Moreover, PRL is difficult to diagnose based on clinical, biochemical, and radiologic features, especially, in the case of bilateral diffuse involvement.

CASE SUMMARY

Herein, we report a 74-year-old woman with primary diffuse large B-cell lymphoma who presented with AKI diagnosed by ultrasound-guided needle biopsy. We also report the clinicopathologic findings of 121 PRL cases reported since 1989, by conducting a literature review of published cases.

CONCLUSION

A timely renal biopsy provides the most expedient means of establishing the diagnosis. Thus, early identification of the disease by the clinician facilitates early diagnosis toward effective treatment.

Renal involvement of lymphomas proven by kidney biopsy: report of 10 cases from a tertiary care center and comparison with the literature

Lymphomas localized in the kidney are a rare entity that may be challenging to diagnose. We analyzed data from 10 patients with renal involvement of lymphoma diagnosed between 2009 and 2019 on fine needle biopsy from our tertiary center, and compared these with findings of 160 cases reported in the literature. Diffuse large B-cell lymphoma was the main histology subtype (40 and 38% in our sample and in the literature, respectively), followed by low-grade B-cell lymphomas, mostly from the marginal zone (MZ). Altogether, 106 patients had urological inaugural symptoms and 64 had general symptoms. Patients with urological presentation more often had renal masses than diffuse infiltration (p < 0.001), unilateral tumors (p = 0.0036) and low-grade B-cell lymphomas (17 vs 6%, p = 0.043). In both groups, nearly one-fourth of patients had diffuse (stage IV) lymphomas. Overall survival did not differ by the presence of urological/systemic symptoms, stage or aggressive lymphoma status. Notably, 3 of 10 patients from our series had MZ lymphomas associated with primary Sjögren syndrome revealed by acute kidney injury, including one where the autoimmune disease was detected. Lymphoproliferative disorders localized in the kidney are a challenging condition that can lead to detection of aggressive or diffuse lymphomas.

FDG-PET/CT Variants and Pitfalls in Haematological Malignancies

Hematologic malignancies represent a vast group of hematopoietic and lymphoid cancers that typically involve the blood, the bone marrow, and the lymphatic organs. Due to extensive research and well defined and standardized response criteria, the role of [¹⁸F]FDG-PET/CT is well defined in these malignancies. Never the less, the reliability of visual and quantitative interpretation of PET/CT may be impaired by several factors including inconsistent scanning protocols and image reconstruction methods. Furthermore, the uptake of [¹⁸F]FDG not only reflects tissue glucose consumption by malignant lesions, but also in other situations such as in inflammatory lesions, local and systemic infections, benign tumors, reactive thymic hyperplasia, histiocytic infiltration, among others; or following granulocyte colony stimulating factors therapy, radiation therapy, chemotherapy or surgical interventions, all of which are a potential source of false-positive or negative interpretations. Therefore it is of paramount importance for the Nuclear Medicine Physician to be familiar with, not only the normal distribution of [¹⁸F]FDG in the body, but also with the most frequent findings that may hamper a correct interpretation of the scan, which could ultimately alter the patients management. In this review, we describe these myriad of situations so the interpreting physician can be familiar with them, providing tools for their correct identification and interpretation when possible.

The Differential Diagnosis of Medullary-Based Renal Masses

CONTEXT.—

Renal malignancies can be divided into cortical- and medullary-based tumors, the latter of which classically infiltrate the renal parenchyma by extending between nonneoplastic structures. Although high-grade cortical tumors can rarely exhibit the same growth pattern, the infiltrative morphology should elicit a differential diagnosis to be considered in each case. However, these diagnoses can be challenging to distinguish, especially on small renal biopsy samples.

OBJECTIVE.—

To provide an overview of the clinical, gross, and microscopic findings; genetic and molecular alterations; and immunohistochemical evaluation of medullary-based renal tumors and other tumor types with overlapping morphologies and growth patterns.

DATA SOURCES.—

Literature review and personal observations were used to compile the information in this review.

CONCLUSIONS.—

Collecting duct carcinoma is a prototypical medullary-based tumor, and although diagnostic criteria exist, it remains a diagnosis of exclusion, especially with ancillary techniques aiding the recognition of established as well as more recently described neoplasms. Other medullary-based malignancies included in the differential diagnosis include renal medullary carcinoma/renal cell carcinoma unclassified with medullary phenotype, fumarate hydratase-deficient renal cell carcinoma, and upper tract urothelial carcinoma. Moreover, other rare entities should be excluded, including metastatic carcinoma, lymphoma, and melanoma. In addition to potential prognostic differences, accurate diagnoses can have important surgical and clinical management implications.

Imaging features of immune-mediated genitourinary disease

PURPOSE

Imaging features of immune-mediated genitourinary diseases often overlap, and the same disease may manifest in different ways, so understanding imaging findings in the context of the patient's entire clinical picture is important in providing the correct diagnosis.

METHODS

In this article, diseases mediated by the immune system which affect the genitourinary system are reviewed. Examples of immune-mediated genitourinary disease including IgG4-related disease, post-transplant lymphoproliferative disorder, immunodeficiency-associated lymphoproliferative disorder due to immunosuppressive and immunomodulatory medications, lymphoma, leukemia, myeloma, amyloidosis, and histiocytosis.

RESULTS

Clinical and imaging features will be presented which may help narrow the differential diagnosis for each disease.

CONCLUSION

Recognition of immune-related genitourinary disease is important for appropriate medical management as they may mimic other diseases both by imaging and clinical presentation.

A primary retroperitoneal anaplastic lymphoma kinase-positive anaplastic large cell lymphoma with tumor thrombosis

Anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL) is a T cell subtype of non-Hodgkin’s lymphoma (NHL). Typically, lymphoma rarely infiltrates vascular structure. In this article, we present a case of retroperitoneal ALK-positive ALCL with splenic venous tumor thrombosis. A 62-year-old patient presented to our institute with the symptoms of epigastric pain, abdominal distension, and reduced bowel movement. Physical examination indicated no enlarged peripheral lymph nodes or abdominal mass. Laboratory workup revealed granulocytosis, abnormal coagulation function, and normal level of lactic dehydrogenase (LDH). Contrast-enhanced computed tomography (CT) showed a retroperitoneal mass with involvement of pancreas and duodenum and formation of splenic venous tumor thrombus. Ultrasonography-guided retroperitoneal lesion biopsy confirmed the diagnosis of ALK-positive ALCL. The patient was able to tolerate oral intake after two cycles of chemotherapy and showed no sign of lymphoma by positron emission tomography (PET)-CT after the fourth cycle of chemotherapy. In spite of its rarity, lymphoma should be taken into account as a differential diagnosis of other malignancies with tumor thrombosis.

Urologic Diseases Germane to the Medical Renal Biopsy: Review of a Large Diagnostic Experience in the Context of the Renal Architecture and Its Environs

The kidney is one of the most complicated organs in development and is susceptible to more types of diseases than other organs. The disease spectrum includes developmental and cystic diseases, involvement by systemic diseases, iatrogenic complications, ascending infections and urinary tract obstruction, and neoplastic diseases. The diagnosis of kidney disease is unique involving 2 subspecialties, urologic pathology and renal pathology. Both renal and urologic pathologists employ the renal biopsy as a diagnostic modality. However, urologic pathologists commonly have a generous specimen in the form of a nephrectomy or partial nephrectomy while a renal pathologist requires ancillary modalities of immunofluorescence and electron microscopy. The 2 subspecialties differ in the disease spectrum they diagnose. This separation is not absolute as diseases of one subspecialty not infrequently appear in the diagnostic materials of the other. The presence of medical renal diseases in a nephrectomy specimen is well described and recommendations for reporting these findings have been formalized. However, urologic diseases appearing in a medical renal biopsy have received less attention. This review attempts to fill that gap by first reviewing the perirenal anatomy to illustrate why inadvertent biopsy of adjacent organs occurs and determine its incidence in renal biopsies followed by a discussion of gross anatomic features relevant to the microscopic domain of the medical renal biopsy. Unsuspected neoplasms and renal cysts and cystic kidney diseases will then be discussed as they create a diagnostic challenge for the renal pathologist who often has limited training and experience in these diseases.

Imaging Manifestations of Hematologic Diseases with Renal and Perinephric Involvement

The kidneys and perinephric tissues can be affected by a variety of hematologic disorders, which usually occur in the setting of multisystem involvement. In many of these disorders, imaging is used to evaluate the extent of disease, guide biopsy, and/or monitor disease activity and patient response to therapy. Lymphoma, leukemia, and multiple myeloma commonly manifest as multiple parenchymal or perinephric lesions. Erdheim-Chester disease and Rosai-Dorfman disease, rare forms of multisystemic histiocytosis, are often identified as perinephric and periureteral masses. Renal abnormalities depicted at imaging in patients with sickle cell disease include renal enlargement, papillary necrosis, and renal medullary carcinoma. Sickle cell disease, along with other causes of intravascular hemolysis, can also lead to hemosiderosis of the renal cortex. Thrombosis of renal veins is sometimes seen in patients with coagulation disorders but more often occurs in association with certain malignancies and nephrotic syndrome. Immunoglobulin G4-related sclerosing disease is another multisystem process that often produces focal renal lesions, seen along with involvement of more characteristic organs such as the pancreas. Perinephric lesions with calcifications should raise the possibility of secondary amyloidosis, especially in patients with a history of lymphoma and multiple myeloma. Although the imaging patterns of renal and perinephric involvement are usually not specific for a single entity, and the same entity can manifest with different or overlapping patterns, familiarity with these patterns and key clinical and histopathologic features may help to narrow the differential diagnosis and determine the next step of care. (©)RSNA, 2016.

Primary renal lymphoma: a case report and literature review

Primary renal lymphoma (PRL) is a rare disease which is often mistaken for renal cell carcinoma. In the present study, a 56-year-old man visited a clinic complaining of an intermittent fever and right flank pain. A computerized tomography examination revealed a hypoenhancing mass in his right kidney. Radical nephrectomy was conducted, and a diagnosis of diffuse large B-cell lymphoma was confirmed. The present case was determined to be a true PRL according to the results of a positron emission tomography examination and a bone marrow biopsy to rule out any lymphoma invasions apart from the right kidney.

Nephron sparing surgery for De Novo kidney graft tumor: results from a multicenter national study

Nephron sparing surgery (NSS) results in the transplanted population remain unknown because they are only presented in small series or case reports. Our objective was to study renal sparing surgery for kidney graft renal cell carcinomas (RCC) in a multicenter cohort. Data were collected from 32 French transplantation centers. Cases of renal graft de novo tumors treated as RCC since the beginning of their transplantation activity were included. Seventy-nine allograft kidney de novo tumors were diagnosed. Forty-three patients (54.4%) underwent renal sparing surgery. Mean age of grafted kidneys at the time of diagnosis was 47.5 years old (26.1-72.6). The mean time between transplantation and tumor diagnosis was 142.6 months (12.2-300). Fifteen tumors were clear cell carcinomas (34.9%), and 25 (58.1%) were papillary carcinomas. Respectively, 10 (24.4%), 24 (58.3%) and 8 (19.5%) tumors were Fuhrman grade 1, 2 and 3. Nine patients had postoperative complications (20.9%) including four requiring surgery (Clavien IIIb). At the last follow-up, 41 patients had a functional kidney graft, without dialysis and no long-term complications. NSS is safe and appropriate for all small tumors of transplanted kidneys with good long-term functional and oncological outcomes, which prevent patients from returning to dialysis.