Teaching Case

Bilateral renal involvment of a thoracic and adrenal lymphoma.

Since June 2000 a 42 - year old woman, has been taken in charge in our institution for a large-cell lymphoma grade IV phenotype B (pulmonary, mediastinal and adrenal gland attempt). The patient had undergone successful chemotherapy treatment (four cycles of an association of Adriamycine, Endoxan and Methotrexate) and was considered being in complete remission since august 2000. A routine computed tomography and a abdominal ultrasonography were performed respectively in august and november 2000, which where normal (Figure 1). However, mid november an LDH-increase had been detected without either clinical or biological features, motivating a abdominal ultrasound and a computed tomography of the chest and the abdomen (Figure 2). Both modalities depicted renal abnormalities, revealing bilateral renal masses secondary to a lymphoma relapse.

Renal lymphoma is most often seen in multisystemic, disseminated lymphoma. Clinical detection of renal involvement in patients with lymphoma is useful whether the kidney is the primary site of disease or a site of dissemination involvement. More commonly, renal lymphoma results from hematogenous dissemination or contiguous extension of retroperitoneal disease. Involvement usually occurs late in the course of the disease and is clinically silent.Acute renal failure from lymphomatous infiltration has also been described but is quite rare. CT-patterns include single and multiple masses, peritoneal disease and diffuse renal infiltration. The most commonly encountered pattern of involvement in patients with renal lymphoma is multiple masses. Involvement is typically bilateral but may also be unilateral. The presence of multiple masses reflects the widespread, advanced course of the disease. Since ultrasonography could depict only unspecific signs such as renal swelling or heterogenous mass, this technique is inadequate in the follow up of these patients. Since clinical symptoms of lymphomatous kidney involvment must be systematically searched;the diagnosis is made during routine follow-up radiological examinations of these patients. The radiologist could also perform ultrasonography or computed tomography guided biopsies allowing the histological proof of the renal involvment.