Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CORRESPONDENCE
Year : 2014  |  Volume : 10  |  Issue : 2  |  Page : 410-412

Adult acute lymphoblastic leukemia mimicking renal cell carcinoma with wide spread bone metastasis


1 Department of Pathology, Cancer Institute (Women's India Association), Adyar, Chennai, India
2 Department of Radiology, Cancer Institute (Women's India Association), Adyar, Chennai, India

Date of Web Publication14-Jul-2014

Correspondence Address:
Urmila Majhi
Department of Pathology, Cancer Institute (Women's India Association), 38, Sardar Patel Road, Chennai - 600 036
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.136674

Rights and Permissions
 > Abstract 

A few cases with bilateral renal enlargement in acute lymphoblastic leukemia (ALL) are reported in literature. In this article, we report an unusual case of ALL in an adult presenting as multiple lesions in both kidneys and multiple bone lesions.

 > Abstract in Chinese 

成人急性淋巴细胞白血病酷似广泛骨转移的肾细胞癌
摘要
几例急性淋巴细胞白血病(ALL)双侧肾肿大的病例有在文献中报道。在本文中,我们报告一个不寻常的成人ALL病例,表现为多发病变,同时有双肾病变及多发性骨病变。
关键词:急性淋巴细胞白血病,免疫组化,肾细胞癌


Keywords: Acute lymphoblastic leukemia, immunohistochemistry, renal cell carcinoma


How to cite this article:
Majhi U, Murhekar K, Saikrishnan P, Singh SS. Adult acute lymphoblastic leukemia mimicking renal cell carcinoma with wide spread bone metastasis. J Can Res Ther 2014;10:410-2

How to cite this URL:
Majhi U, Murhekar K, Saikrishnan P, Singh SS. Adult acute lymphoblastic leukemia mimicking renal cell carcinoma with wide spread bone metastasis. J Can Res Ther [serial online] 2014 [cited 2019 Dec 8];10:410-2. Available from: http://www.cancerjournal.net/text.asp?2014/10/2/410/136674


 > Introduction Top


Several malignant tumors in adults can present as multiple bilateral lesions in kidneys. These include multifocal renal cell carcinomas (RCC), hematolymphoid malignancies, and metastasis from primary elsewhere. Renal involvement is fairly frequent in patients with acute lymphoblastic leukemia (ALL), but palpable renal enlargement at time of diagnosis is very unusual. [1] We present a rare case of acute lymphoblastic leukaemia in an adult presenting as multiple lesions in both kidneys and multiple bone lesions.


 > Case report Top


A 26-year-old female patient was apparently well 2 months back when she started having dull aching pain on the left side of hip and lower limb. She was evaluated elsewhere and underwent computed tomography (CT) and magnetic resonance imaging (MRI) of pelvis and spine. MRI showed multiple lesions in both kidneys. There was no contrast enhancement of renal lesions on the CT. She underwent positron emission tomography-computed tomography (PET-CT) which showed multiple lesions in both kidneys along with increased uptakes in multiple vertebrae, pelvis, humerus, scapulae, and femur [Figure 1]. Both kidneys showed standardized uptake value (SUV) value of 7.3. Multiple metabolically active lesions were seen in D1, D4, D6, D11, L2, L5, S1, S2, sternum, clivus, and mandible. Metabolically active foci were also noted in the segment IV of left lobe of liver, paraaortic nodes, and anterior body of pancreas with SUV value of 2.9. We could not detect any primary tumor elsewhere on PET-CT thereby ruling out metastasis to kidneys. The patient had no preceding history to suggest renal abscess or healing infective/inflammatory lesion.
Figure 1: PET-CT showing multiple lesions in both kidneys along with increased uptakes in multiple bones

Click here to view


On examination, her right kidney was palpable on deep inspiration. Total while blood cell count was 7600/cmm with no abnormal cells in peripheral blood. The red blood cell count was 4.19 millions/cmm and erythrocyte sedimentation rate (ESR) was 30 mm at the end of the first hour. Her liver and renal function tests were within normal limits. Cardiovascular system and respiratory systems were normal. Trucut biopsy of left kidney revealed lymphoblastic lymphoma/ALL infiltration [Figure 2]a. Bone marrow aspiration revealed features of acute lymphoblastic leukaemia [Figure 2]b. IHC reactions revealed positivity for LCA [Figure 3]a, TdT [Figure 3]c, CD 99, CD 10 [Figure 3]b. Ki 67 index was 90% [Figure 3]d. IHC on marrow aspirate showed positivity for CD 5, CD 19, CD 22, CD 13, CD 10, HLA-DR, CD 45, and TdT (precursor B with aberrant myeloid markers). Translocation assay revealed Philadelphia chromosome (Ph) positive ALL-BCR/ABL P 210. CSF was normal.
Figure 2: (a) Kidney biopsy H and E, ×100 shows infiltration by leukemic cells. One renal tubule is also seen in the picture, (b) Bone marrow smear Leishman ×100 shows lymphoblasts of varying sizes. Some of them show nucleoli

Click here to view
Figure 3: Kidney biopsy, (a) IHC ×40: LCA showing positive reaction by leukemic cells, (b) IHC ×40: TdT showing nuclear positivity by leukemic cells. Normal tubules are seen in between, (c) IHC ×40: CD 10(CALLA) showing positive reaction by leukemic cells. One renal tubule is also seen in the picture, (d) IHC ×40: Ki 67 showing high proliferative index by leukemic cells

Click here to view



 > Discussion Top


The possible differential diagnosis for multiple bilateral lesions in kidneys in adult includes hematolymphoid malignancies, metastasis from primary elsewhere, and multifocal renal cell carcinomas. In this particular case, we suspected multifocal RCC in view of the following points: (1) SUV in renal and bone lesions was high, (2) we could not detect any primary tumor elsewhere on PET-CT thereby ruling out renal metastasis, and (3) the patient had no preceding history to suggest renal abscess or healing infective/inflammatory lesion. However, with multiple bone metastasis and paraaortic nodes, diagnosis of hematolymphoid malignancies was also considered and the patient subsequently underwent biopsy from the renal mass which revealed ALL.

Lymphocytic infiltration of renal parenchyma occurs commonly in patients with Hodgkin's as well as non-Hodgkin's lymphoma. [2] However, as the biopsy is performed infrequently in lymphoma patients, it is likely that the involvement of kidneys in lymphoma patients is overlooked. In a large case series of autopsies performed on lymphoma patients, 34% showed signs of parenchymal invasion, but only 14% had been diagnosed with lymphocytic infiltration of kidneys before the time of death. [3] Similar to lymphomas, leukemic infiltration of kidneys is also common but occurs in the late stage of ALL in all age groups. [1],[4],[5],[6],[7] It has been reported to occur in 7-42% of childhood leukemia cases. [4],[5],[6],[7] In a series of 81 adult patients with established hematological malignancies, Banday et al., [8] reported renal enlargement as a frequent findings, occurring in 21% (8 of 39) patients of lymphoma and 57% (21 of 37 leukemia patients). In contrast, isolated bilateral symmetrical renal enlargement as a primary finding in ALL patients is rare. [9]

In our case, patient had several poor prognostic factors including adult age, nephromegaly, and Ph positivity (BCR/ABL p210). Translocation (9:22) is the most frequent genetic aberration in adult (ALL and is found in 20-30% of patients overall. Notably, it is found almost exclusively in CD 10+ precursor B-cell ALL (c-ALL) and pre-B-ALL); Clinically, patients present with a variable white blood cell count, surface expression of CD 19, CD 10, and CD 34 antigens and frequent coexpression of myeloid markers. The patient was started on ALL protocol along with imatinib. [10]

In conclusion, acute leukemic infiltration should be considered as one of the differential diagnosis in bilateral renal parenchymal lesions.

 
 > References Top

1.Erdem E, Kayýran P, Ozcelik G, Ozel A, Yildiz Yildirmak Z. Rare presentation of pediatric acute lymphoblastic leukemia: Nephromegaly at time of diagnosis. Indian J Hematol Blood Transfus 2011;27:43-5.  Back to cited text no. 1
    
2.Cohen LJ, Rennke HG, Laubach JP, Humphreys BD. The spectrum of kidney involvement in lymphoma: A case report and review of the literature. Am J Kidney Dis 2010;56:1191-6.  Back to cited text no. 2
    
3.Richmond J, Sherman RS, Diamond HD, Craver LF. Renal lesions associated with malignant lymphomas. Am J Med 1962;32:184-207.  Back to cited text no. 3
[PUBMED]    
4.Ali SH, Yacoub FM, Al-Matar E. Acute lymphoblastic leukemia presenting as bilateral enlargement in a child. Med Princ Pract 2008;17:504-6.  Back to cited text no. 4
    
5.Hann IM, Lees PD, Palmer MK, Gupta S, Morris JP. Renal size as a prognostic factor in childhood acute lymphoblastic leukaemia. Cancer 48:207-9.  Back to cited text no. 5
    
6.Taccone A, De Bernardi B, Comelli A, Dini G, Bartolini M, Banderali A, et al. Renal changes in acute leukemia in children at onset. Incidence and prognostic value. Pediatr Med Chir 1982;4:107-13.  Back to cited text no. 6
[PUBMED]    
7.Rajantie J, Jaaskelainen J, Perkkio M, Siimes MA. Kidneys very large at diagnosis are associated with poor prognosis in children with acute lymphoblastic leukemia. Am J Pediatr Hematol Oncol 1986;8:87-90.  Back to cited text no. 7
    
8.Banday KA, Sirwal IA, Reshi AR, Najar MS, Bhat MA, Wani MM. Renal involvement in hematological neoplasia. Indian J Nephrol 2004;14:50-2.  Back to cited text no. 8
  Medknow Journal  
9.Basker M, Scott JX, Ross B, Kirubakaran C. Renal enlargement as primary presentation of acute lymphoblastic leukemia. Indian J Cancer 2002;39:154-6.  Back to cited text no. 9
    
10.Stock W. Current treatment options for adult patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. Leuk Lymphoma 2010;51:188-98.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction>Case report>Discussion>Article Figures
  In this article
>References

 Article Access Statistics
    Viewed1976    
    Printed42    
    Emailed0    
    PDF Downloaded83    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]