An Uncommon Presentation of Large B-cell Lymphoma of the kidney A Case Report and Literature Review

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1 An Uncommon Presentation of Large B-cell Lymphoma of the kidney A Case Report and Literature Review CHRISTOPHER ADILETTA M.D., AJAZ SHAWL M.D. ST. JOSEPH S HEALTH, SYRACUSE, NY

2 Our Patient Case We present a 77 year old female with history of DMII, HTN, and CAD with 6 months of fatigue, significant unintentional weight loss, and early satiety. She was admitted to the hospital for further workup.

3 Physical Exam Constitutional: Frail; Malnourished HEENT: Normocephalic, PERRLA No cervical lymphadenopathy Cardiac: RRR, S 1 /S 2, No murmurs Vital Sign Value Temperature 97.3 O F Blood Pressure 108/70 Heart Rate 85 SpO 2 97% Pulmonary: CTAB, no wheezing GI: Soft, Non-tender, non-distended Right upper quadrant pain to palpation with palpable mass. Neurological: CN II-XII grossly intact, generalized weakness and fatigue

4 Significant Labwork CBC Value WBC 5.2 Hemoglobin 11.1 Hematocrit 31.2 Platelets 360 Neutrophils 70% Abs Lymph 0.6 (L) CMP Value Sodium 144 Potassium 4.8 Chloride 109 CO2 19 BUN 53 Creatinine 2.93 Glucose 40 Albumin 2.6 Bilirubin 0.5 AST/ALT 104 / 25

5 CT Abdomen & Pelvis 1. Marked abnormal appearance of the right kidney with neoplasm favored over subacute trauma or inflammatory disorder. 2. Mesenteric lymph nodes with omental caking and lymph nodes extending to the GE junction with wall thickening of the stomach and distal esophagus. Question from a renal tumor. 3. Right adrenal gland mass likely representing a metastatic lesion.

6 Histology Adrenal Gland Biopsy: DIFFUSE LARGE B-CELL LYMPHOMA The specimen consists of several thin cores that are replaced by a diffuse infiltrate of medium to large cells with fine chromatin, occasional small inconspicuous nucleoli and scant cytoplasm.

7 Outcome Oncology team intended to start R CHOP therapy. Unfortunately, patient suffered tumor lysis syndrome and cardiopulmonary failure resulting in death.

8 Diffuse Large B Cell Lymphoma Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-hodgkin lymphoma (NHL). DLBCL presents with rapidly enlarging symptomatic mass, usually with nodal enlargement in neck or abdomen. Systemic B symptoms are observed in about 30% of patients.

9 Rare Presentations 40% of cases arise in extra-nodal extramedullary tissues. Primary Renal Lymphoma is extremely rare and only about 30 cases have been reported

10 Primary Renal Lymphoma Diagnostic Criteria Diagnosis is based on tissue biopsy, negative bone marrow involvement, and CT abdomen & pelvis. Risk Factors for Lymphoma Age: Most cases occur in people > 60 years old Chemical exposure (i.e. benzene, insecticides) Previous chemotherapy or radiation therapy Radiation exposure Immunocompromised state HIV or history of Epstein-Barr virus infection Chronic infection with Hepatitis C virus

11 Summary Diffuse large B lymphoma is the most common presentation of non-hodgkin lymphoma. Extra-nodal presentation is most commonly seen in mediastinum or stomach. Primary renal lymphoma is an extremely rare primary location but should be considered when a renal mass is detected. There is an association with adrenal gland lymphoma and adrenal insufficiency. Primary renal lymphoma is responsive to R-CHOP chemotherapy.

12 References Chen, Xiaodong, et al. Primary Renal Lymphoma: A Case Report and Literature Review. Oncology Letters, 2016, doi: /ol Richards, M. A., et al. Renal Involvement in Patients with Non Hodgkin's Lymphoma: Clinical and Pathological Features in 23 Cases. Hematological Oncology, John Wiley & Sons, Ltd., 7 Mar. 2007, onlinelibrary.wiley.com/doi/ /hon /abstract. Vandermolen, L A, and R O Dillman. Primary Lymphoma of the Kidney: Complete Remission after Systemic Chemotherapy. Journal of the National Cancer Institute., U.S. National Library of Medicine, 17 Mar. 1993, Vandermolen, L A, and R O Dillman. Primary Lymphoma of the Kidney: Complete Remission after Systemic Chemotherapy. Journal of the National Cancer Institute., U.S. National Library of Medicine, 17 Mar. 1993, Vázquez-Alonso, F., et al. Primary Renal Lymphoma: Long-Term Results of Two Patients Treated with a Chemotherapy + Rituximab Protocol. Case Reports in Oncological Medicine, Hindawi, 11 Sept. 2012,

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