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Cases
Large Renal Mass
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Background
A 74-year-old man presents to the hospital with on-and-off abdominal pain for the past month. The man has a history of kidney stones, hypertension, and 2 strokes. He states that the pain is not related to food intake, movement, or exertion. He denies any weight loss, difficulty swallowing, diarrhea, hematochezia, or hematuria.
Two weeks ago, urinalysis showed mild urinary tract infection (UTI). The patient was treated with a 1-week course of antibiotics. Urine cytologic findings were negative.
Physical examination reveals no hepatosplenomegaly and no palpable mass. He has mild anemia, his serum creatinine is 1.4 mg/dL, his lactate dehydrogenase (LDH) level is 295 IU, and serum protein and immunofixation electrophoresis reveals a mild spike (0.43) in the alpha-1 region. CT and biopsy are performed.
What is the diagnosis?
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down for Hint and Answer
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***** HINT *****
This is an unusual cause of a kidney mass.
***** ANSWER *****
Lymphoma appearing as a kidney mass: Primary renal lymphoma (PRL) is a rare and distinct pathologic and clinical entity. The disease usually affects adults aged 60 years and older. It is more common in men than in women. The disease may occur with progressive renal failure of either the oliguric or the nonoliguric type.
Imaging studies for patients with PRL include ultrasonography and computed tomography. Bone scanning and bone marrow biopsy are performed to determine the stage. Renal biopsy is the most common method for confirming the diagnosis. Multidrug chemotherapy is mandatory in cases of high-grade lymphoma and in cases diagnosed preoperatively. The survival rate is extremely poor, as 75% of patients die within a year of the diagnosis. However, the prognosis is improved by early diagnosis.
This patient underwent renal biopsy. Pathologic results showed diffuse B-cell lymphoma that was CD20+ and CD30–. The patient will undergo treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone, followed by field irradiation. This case is presented to report its unique pathology and to emphasize the need to evaluate patients in whom symptomatic UTI does not respond to antibiotic treatment.
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Author:
Winston W. Tan, MD, FACP
Assistant Professor, Department of Hematology Oncology, Mayo Clinic Jacksonville
David Pinkstaff, MD
Staff Physician, Department of Urology
Michael Wehle, MD
Consulting Staff, Department of Urology, Mayo Clinic Jacksonville
eMedicine Editor:
Sat Sharma, MD
Associate Professor, University of Manitoba, Department of Medicine, Division of Pulmonary Medicine
Source
http://emedicine.com
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