Renal Mass as the Initial Manifestation of Diffuse Large B-Cell Lymphoma: A Case Report
Poster #: 069
Session/Time: B
Author:
Samir A Shaikh, BS
Mentor:
Frances Lazarow, MD
Research Type: Case Report
Abstract
INTRODUCTION:
Lymphomas may present in many ways, but it is quite rare for diffuse large B-cell lymphoma to present primarily as a renal mass. Navigating the different presentations of lymphoma and keeping it on the differential for a renal mass allows for the proper sampling and treatment of the disease.
CASE INFORMATION:
A 60-year-old female with a history of gastric bypass and hypothyroidism, presented to the emergency department for epigastric and left upper quadrant abdominal pain that radiated into the left side of her chest. Physical exam was unremarkable except for significant abdominal tenderness in the epigastric and left upper quadrant. Labs were significant for anemia and dehydration. The chest radiograph was unremarkable. Computed Tomography (CT) imaging of her abdomen and pelvis with contrast demonstrated an ill-defined soft tissue infiltrative mass arising from the right kidney's lower pole measuring 9.1 x 8.8 x 7.7 cm (CC, AP, TRN) with low internal density and no definite invasion of the renal vein. Additionally, there was a bulky retroperitoneal soft tissue attenuating mass compressing the Inferior Vena Cava (IVC) and encasing the right renal artery and vein as well as possible compression of the duodenum causing outlet obstruction of the stomach. Initial differential diagnosis included Renal Cell Carcinoma, Renal Medullary Carcinoma, and possible lymphoma. Three days later, Interventional Radiology (IR) performed a CT guided drain placement into the gastric remnant to resolve the gastric outlet obstruction in addition to a biopsy of the right renal mass and retroperitoneal lymph node. Biopsy results of the right renal mass and associated lymph node concluded Epstein Barr Virus (EBV) positive diffuse large B-cell lymphoma (DLBCL), germinal center phenotype (GCB) with high proliferative index, Ki-57 100%; abnormal p53 expression. The Fluorescent In Situ Hybridization (FISH) analysis noted rearrangement of MYC gene, no rearrangement of BCL6, and monosomy 17 was noted. About two weeks later, IR performed a bone marrow biopsy as well as a mediport placement for systemic chemotherapy. Bone marrow biopsy redemonstrated EBV + DLBCL, GCB cell of origin, aggressive subtype (GCB2) with MYC gene rearrangement. Systemic chemotherapy with cyclophosphamide, hydroxydaunorubicin, vincristine, prednisone and Rituximab were initiated. An Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography (FDG PET/CT) of the skull base to mid-thigh was performed the following week which demonstrated hypermetabolic mesenteric and retroperitoneal mass/lymphadenopathy which was consistent with the diagnosis of lymphoma with a volume that had increased slightly from previous CT imaging. Additionally, the right renal mass was variably hypermetabolic, consistent with malignant involvement. Lastly, there was diffuse hypermetabolic activity throughout all the osseous structures. One month later, the patient decided to terminate chemotherapy and was transferred to hospice.
DISCUSSION:
The differential for renal mass can be narrowed by determining contrast enhancement on CT. Within enhancing lesions, renal cell carcinoma, transitional cell carcinoma, angiomyolipomas, and less commonly lymphomas.
CONCLUSION:
Lymphoma presentation as a renal mass is fairly rare. Certain imaging characteristics can further narrow the differential, guiding the diagnosis towards the less common renal lymphoma.
Lymphomas may present in many ways, but it is quite rare for diffuse large B-cell lymphoma to present primarily as a renal mass. Navigating the different presentations of lymphoma and keeping it on the differential for a renal mass allows for the proper sampling and treatment of the disease.
CASE INFORMATION:
A 60-year-old female with a history of gastric bypass and hypothyroidism, presented to the emergency department for epigastric and left upper quadrant abdominal pain that radiated into the left side of her chest. Physical exam was unremarkable except for significant abdominal tenderness in the epigastric and left upper quadrant. Labs were significant for anemia and dehydration. The chest radiograph was unremarkable. Computed Tomography (CT) imaging of her abdomen and pelvis with contrast demonstrated an ill-defined soft tissue infiltrative mass arising from the right kidney's lower pole measuring 9.1 x 8.8 x 7.7 cm (CC, AP, TRN) with low internal density and no definite invasion of the renal vein. Additionally, there was a bulky retroperitoneal soft tissue attenuating mass compressing the Inferior Vena Cava (IVC) and encasing the right renal artery and vein as well as possible compression of the duodenum causing outlet obstruction of the stomach. Initial differential diagnosis included Renal Cell Carcinoma, Renal Medullary Carcinoma, and possible lymphoma. Three days later, Interventional Radiology (IR) performed a CT guided drain placement into the gastric remnant to resolve the gastric outlet obstruction in addition to a biopsy of the right renal mass and retroperitoneal lymph node. Biopsy results of the right renal mass and associated lymph node concluded Epstein Barr Virus (EBV) positive diffuse large B-cell lymphoma (DLBCL), germinal center phenotype (GCB) with high proliferative index, Ki-57 100%; abnormal p53 expression. The Fluorescent In Situ Hybridization (FISH) analysis noted rearrangement of MYC gene, no rearrangement of BCL6, and monosomy 17 was noted. About two weeks later, IR performed a bone marrow biopsy as well as a mediport placement for systemic chemotherapy. Bone marrow biopsy redemonstrated EBV + DLBCL, GCB cell of origin, aggressive subtype (GCB2) with MYC gene rearrangement. Systemic chemotherapy with cyclophosphamide, hydroxydaunorubicin, vincristine, prednisone and Rituximab were initiated. An Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography (FDG PET/CT) of the skull base to mid-thigh was performed the following week which demonstrated hypermetabolic mesenteric and retroperitoneal mass/lymphadenopathy which was consistent with the diagnosis of lymphoma with a volume that had increased slightly from previous CT imaging. Additionally, the right renal mass was variably hypermetabolic, consistent with malignant involvement. Lastly, there was diffuse hypermetabolic activity throughout all the osseous structures. One month later, the patient decided to terminate chemotherapy and was transferred to hospice.
DISCUSSION:
The differential for renal mass can be narrowed by determining contrast enhancement on CT. Within enhancing lesions, renal cell carcinoma, transitional cell carcinoma, angiomyolipomas, and less commonly lymphomas.
CONCLUSION:
Lymphoma presentation as a renal mass is fairly rare. Certain imaging characteristics can further narrow the differential, guiding the diagnosis towards the less common renal lymphoma.