|Year : 2014 | Volume
| Issue : 2 | Page : 410-412
Adult acute lymphoblastic leukemia mimicking renal cell carcinoma with wide spread bone metastasis
Urmila Majhi1, Kanchan Murhekar1, Parthasarthy Saikrishnan2, Shirley Sunder Singh1
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 Publication||14-Jul-2014|
Department of Pathology, Cancer Institute (Women's India Association), 38, Sardar Patel Road, Chennai - 600 036
Source of Support: None, Conflict of Interest: None
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.
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|| |
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.  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|| |
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|
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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|
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|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|
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| > Discussion|| |
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.  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.  Similar to lymphomas, leukemic infiltration of kidneys is also common but occurs in the late stage of ALL in all age groups. ,,,, It has been reported to occur in 7-42% of childhood leukemia cases. ,,, In a series of 81 adult patients with established hematological malignancies, Banday et al.,  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. 
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. 
In conclusion, acute leukemic infiltration should be considered as one of the differential diagnosis in bilateral renal parenchymal lesions.
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[Figure 1], [Figure 2], [Figure 3]