PRIMITIVE renal localization of NON-Hodgkin's malignant lymphoma (LMNH)
Key words: kidney, tumor, lymphoma. Authors: Khalid EL KHADER, Adel SADIQ, Tarik Kaly, Mohammed's, Mohamed Habibi, Ahmed Krissa citation: Prog Urol, 2004, 14, 78-80 download this file in PDF format
The primitive renal localization of non-Hodgkin's malignant lymphoma (LMNH) is very rare.
We report an observation of a low-grade, centrally-diagnosed, basal renal non-Hodgkin's malignant lymphoma of nephrectomy in a 53-year-old patient.
In the light of this observation and a review of the literature, the étiopathogéniques, diagnostic and therapeutic aspects of this condition are discussed.
Renal adenocarcinoma is the most common histological form of adult kidney cancer.
Renal impairment by a lymphomateuse tumor is rare [1]. The majority of these tumours are non-Hodgkin lymphomas and in more than 90% of cases this renal localization is secondary [13].
We report the observation of primitive non-Hodgkin's lymphoma diagnosed with nephrectomy in a 53-year-old patient.
Observation
Mr. A.K., aged 53 years, without a history was hospitalized for a total hematuria, straight lumbago and an alteration of the general condition.
The clinical examination found a sensitive right lumbar pit.
CBC showed anemia at 10.5 g/dl hemoglobin, normal leukocytes: 7 700 cells/mm3, creatinine was 12.5 mg/l, and cytobactériologique urine test was sterile.
On ultrasound, there was a solid échostructure mass of the right kidney. The Uro-CT confirmed the presence of a tumoral process of the upper pole of the right kidney of 8 x 5.5 cm, with tissue density increasing weakly after injection of the contrast product (Figure 1).
Figure 1: Scannographique Image that shows a weakly enhanced left renal tumor process after injection of the contrast product.
By way under the right side an enlarged nephrectomy has been carried out. The operative suites were simple. At the Anatomo-patholgique examination, the workpiece weighed 520 g and was 14 cm x 10 cm x 8 cm. After the opening of the room, a mid-lobar tumor was found with a slightly polycyclic, white-grisatre-coloured contour with whitish areas (Figure 2). The histological study showed a malignant tumour formation of lynphomateuse nature characterized by a diffuse cellular tablecloth made of pleomorphic and Centro-follicular origin elements. They were endowed with a sparse and basophile cytoplasm. Their nuclei were rounded or ovalaires but most often angular with dense chromatin. The Nucleoli were scarce. Mitoses and apoptosis images were few (Figure 3). This tumor partially or completely destroyed the underlying réanl parenchyma. The peripheral capsule was ruptured with the flooding of peri-renal fat.
Figure 2: nephrectomy piece measuring 14 cm x 10 cm x 8 cm. Mid-lobar tumor with polycyclic contours of greyish-white colors with whitish areas.
In conclusion, it was a renal localization of a LMNH of a low grade of Centro-follicular type malignancy of Grade 1 (centrocytic lymphoma centroblastic).
Figure 3: histological Study: A malignant formation of lymphomateuse nature.
The extension balance was negative: normal ostéomedullaire biopsy, negative ENT examination, pulmonary x-ray and normal abdominal ct. Adjuvant type chemotherapy (cyclophosphamide, Adriamycin, vincristine and prednisone) has been instituted.
After 2 years of recoil, the patient was free from any tumor recurrence.
Discussion
Lymphomateuse impairment of the kidney is not common. It is often secondary by direct extension from the retroperitoneal or blood-borne ganglia [5]. Primitive renal lymphoma (free kidney drainage ganglia and negative extension balance) is rare, only about 30 cases have been reported to date [2, 3, 10, 14]. Some authors [8] Question this primitive localization, however, because normally the kidney is devoid of its own lymphoid structure. Some assumptions have been made to explain such a localization: The first hypothesis evoked is that which involves the formation of lymphoid follicles from a renal parenchymatous inflammatory process [9]. The proponents of this theory are similar to the Mucosae Associated Lymphoma T (MALT) gastric lymphomas on chronic Helicobacter pylori gastritis [10]. The second hypothesis invokes parenchymatous invasion from the renal capsule rich in lymphatics [2]. Clinical symptomatology is not specific and corresponds to that of a habitual renal tumour [1, 4, 10]. On the radiological level, the CT aspect is sometimes evocative. Classical lymphoma appears in the form of a solid mass of tissue density, sometimes spontaneously hypodense without necrosis or calcifications. The mass increases weakly after injection of the contrast product unlike adenocarcinoma [11]. Other aspects may be encountered, multiple nodules, renal infiltration and périrénale of contiguousity from adenopathies metastasis in case of secondary renal lymphoma [5]. In fact, no radiological examination allows the differentiation of renal lymphoma from adenocarcinoma, only the ANATOMOPATHOLOGIC examination will provide diagnostic certainty.
The diagnosis of primary renal LMNH may be one of the few indications of the renal biopsy or scan-guided diagnostics (7, 12). In addition to the diagnostic approach, the puncture biopsy can condition the subsequent therapeutic conduct: first chemotherapy or resection surgery with complementary radio or chemotherapy [7, 8]. In the event of a negative puncture, a extemporaneous biopsy may be discussed.
Histologically, there are several classifications of non-Hodgkin malignant lymphomas, the most widely used is the Kiel classification [15] which takes into account the degree of lymphoma malignancy [15]. The majority of renal lymphomas are high-grade B-phenotypes of malignancies or intermediate malignancies [6].
The treatment of primary kidney lymphoma is based on resection surgery, chemotherapy and/or radiation therapy [1, 7, 10, 13]. The surgery will consist of an enlarged total nephrectomy associated with the lymph node.
Chemotherapy improves patient survival and decreases the frequency of recurrence. It also helps to reduce the indications of resection surgery in case of pre-operative diagnosis of lymphoma by puncture biopsy of the tumor under guidance ultrasound or scan [8, 11]. The most used protocol is the CHOP Association (cyclophosphamide, doxorubicin, vincristine, prednisone).
Radiotherapy is proposed by some authors in addition to surgery and/or chemotherapy on residual tumor residues and in case of recurrence [7, 11].
With regard to the indications, there is no standard therapeutic strategy due to the small number of cases of primitive renal lymphomas listed. Nevertheless, in the light of the literature, a therapeutic scheme can be proposed:
Whereas the treatment of secondary lymphomas is based on Polychimiothéapie, the attitude towards primary renal lymphoma depends on the diagnostic circumstances, the degree of malignancy and the scalability of the lymphoma;
If lymphoma is a pre-operative discovery by a percutaneous or peroperative biopsy by a extemporaneous examination, Polychemotherapy is the treatment of choice.
In the absence of pre-operative diagnosis, the loco-regional treatment by enlarged total nephrectomy with cleaning becomes predominant. The indication of adjuvant chemotherapy and/or radiotherapy will be dictated by the degree of malignancy of lymphoma and the quality of the initial resection.
The prognosis of primary kidney lymphomas is conditioned by age, stage, tumor grade, tumor volume, and histological type. Full and prolonged responses could be obtained by the surgical-chemotherapy association with excesses of 10 years for a few cases [8, 9].
Conclusion
Primitive kidney lymphoma is a rare tumor.
Pre-operative diagnosis remains difficult because the radio-clinical criteria are not specific.
Chemotherapy represents the treatment of choice especially in high-grade forms of malignancy.
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