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Case 98

Renal lymphoma

Unusual case of bilateral renal masses

Gavin Low, Richard Edwards

A 23 year old woman presented with a golf ball sized lump in her left axilla. Clinical examination revealed the solitary finding of an enlarged left axillary lymph node. Blood tests showed a Hb of 10.6g/dl, CRP 73mg/l and ESR 28mm/first hour. White cell count and urea and electrolytes were normal. A fine needle aspirate was performed on the left axillary lymph node. This revealed only reactive lymphoid tissue. However, the patient subsequently complained of flu like symptoms, back pain and weight loss. The decision was taken to perform a lymph node excision biopsy, a CT scan and a Bone scan.

Findings

1. Left axillary lymphadenopathy
2. Multiple bilateral non-enhancing renal masses
3. Bilateral renal enlargement

Excision biopsy revealed B cell lymphoma. A renal biopsy performed later on, post chemotherapy, revealed only focal scarring but no viable lymphomatous tissue. Renal function remained normal. Bone scan revealed hot spots in both humeri, the right first rib and left hip.

These images post chemotherapy show improvement with a reduction in volume of the lymphomatous renal involvement. The patient's clinical symptoms improved and haematological parameters returned to normal.

Diagnosis

Renal lymphoma

Differential diagnosis of multiple renal masses

1. Lymphoma
2. Metastases (e.g. breast,bronchus,colon)
3. Bilateral renal cell carcinomas
4. Infiltrating transitional cell carcinomas
5. Multiple renal infarcts
6. Multiple renal abscesses

Discussion - renal lymphoma

Incidence of renal lymphoma

• 33% - 50% involvement in autopsies of patients who died of lymphoma
• 6% involvement in suspected or known lymphoma
• 11% involvement in AIDS related lymphoma
• More common in Non Hodgkin’s Lymphoma than Hodgkin’s Lymphoma
• Bilateral versus unilateral 3:1

Pattern of involvement

Hematogenous dissemination

This is the commonest manifestation (45% of cases). It may present as single or multiple foci or as diffuse infiltration pattern.

Direct invasion from contiguous paracaval or para aortic lymphomatous disease

(11% of cases)

Primary renal lymphoma

This is very rare with very few cases in the literature. It is difficult to distinguish from other renal neoplasms.

Mortality/ Morbidity

Renal involvement frequently indicates disseminated disease, so prognosis is poor if proper treatment not instituted. However, following treatment, renal lesions may completely regress, with minimal scarring of renal parenchyma.

Clinical Details

• Clinically silent (50%)
• Flank/back pain, palpable mass, weight loss
• Haematuria
• Deranged renal function (obstruction, renal vein compression, diffuse renal infiltration, infarct, amyloidosis, hypercalcemia)

Radiological Investigations

CT

This is the modality of choice. It has a high sensitivity, depicts accurately the extent of renal involvement and provides information on staging. In addition, results of treatment can be assessed on follow up imaging. On CT, renal lymphoma usually appears as poorly marginated masses less dense than renal parenchyma.

MRI

This provides a degree of confidence probably equal to CT. Renal lymphoma usually appears low signal on T1 and either isointense or moderately hyperintense on T2.

US

Appearances are varied and the kidneys may instead appear totally normal. Positive findings may include

1. Perirenal hypoechoic halo said to be characteristic of renal lymphoma
2. Renal enlargement
3. Single or multiple anechoic/hypoechoic areas
4. Hydronephrosis due to renal pelvis compression by lymph nodes

Nuclear Medicine

Gallium 67 citrate is a radioisotope that is taken up by lymphomatous tissues in the kidneys. It has an overall sensitivity of 80%.

IVU

This is an unreliable investigation as it has a high false negative rate. Positive findings include renal enlargement and distortion of collecting systems.

References

Kidney, lymphoma. Shirkhoda A
http://www.emedicine.com/radio/topic373.htm

Radiology Review Manual. Dahnert W

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