The patient was then transferred to intensive care unit (ICU) for further treatments because poor postoperative status and incapable of breath without the ventilator. After 25 days of intensive care, the general condition of the patients was stable and significantly improved. However, the patient died 3 months after discharge before he underwent any further treatments. The patient and his family gave informed consent and agreed to participate in this case report. On the other hand, our case does not need ethical approval from ethics committee or institutional review board.
Multiple primary malignant neoplasms (MPMNs) refer to at least 2 independent primary malignancies in an individual, with a prevalence range from 0.4% to 21.0% in various publications.[7,8] Though increased frequency of MPMNs has been found over the years, concomitant occurrence of PRL and colon cancer has not been reported before as far as we know.
Lymphoma is a malignancy that can affect any organ in the body and present with various symptoms. Extra-nodal manifestations in organs such as gastric tract and the central nerve system represent approximately 30% to 50% of NHL cases. The incidence of renal-involved cases in NHL ranges from 2.7% to 6%, while PRL only accounts for 0.7% of the extra-nodal lymphomas and 0.1% of all malignant lymphomas.[2,12] According to previous case reports, flank pain is the most common symptom in patients with PRL, which is also the main symptom of our patient. Furthermore, PRL usually has aggressive B cell histopathological characteristics, and since the most common pathology is DLBCL,[14,15] adrenal glands could also be affected,[16,17] which are all consistent with our case.
Though an increasing number of cases were reported in recent years, the presence of PRL was still controversial owing to the absence of lymphatic tissues in the kidney. To explain the development of PRL, many scientists have suggested the following: Some have suggested that PRL might originate within the kidney owing to intensive recall of the B lymphocytes in the parenchyma in response to persistent inflammation.[2,18] Others speculated that PRL might generate from adjacent lymph nodes such as renal capsule which is rich in lymphatics,[10,19] and manifest as focal masses, large infiltrative lesions to engulf the kidney, or diffuse bilateral to enlarge the kidneys.
Lacking in specific symptoms and laboratory indexes makes PRL difficult to diagnose before surgery.[21,22] To date, the diagnostic criteria of PRL made by Stallone in 2000 are still widely used, the criteria are as follows: lymphomatous renal infiltration, nonobstructive uni- or bilateral kidney enlargement, and no extra localization at diagnosis. The patient in our case fulfilled all 3 criteria. Due to poor status of the patient after operation, 18F-fluorodeoxyglucose positron-emission tomography/CT (FDG-PET/CT) and bone marrow biopsy which are important for staging[23,24] were not performed in our case. Thus, the stage of PRL is uncertain. Currently, there is no standard treatment strategy for patients with PRL, let alone its concurrence with another cancer. It has been reported that surgery can significantly improve the survival rate in patients with MPMNs. Many studies suggested that surgery should be performed in patients with MPMNs as long as no significant contraindication was found. Therefore, the patient in our case underwent radical nephrectomy and radical resection of colon cancer. However, aggressive chemotherapy was also suggested for patients with PRL; otherwise, patients may die within 1 year due to rapid dissemination from the primary site.[26,27] Many case reports demonstrated that R-CHOP regime (rituximab plus cyclophosphamide/ doxorubicin/ vincristine/ prednisone) with or without nephrectomy may confer survival benefit to PRL patients to a certain extent.[1,2,4,13,28,29] It has also been suggested that adjuvant chemotherapy is recommended for all patients with stage III colon cancer without contraindications after curative resection. In view of the poor condition, age of the patient, and potential intolerance of chemotherapy in our case, combined chemotherapy for treating PRL and stage IIIB colon cancer could be a huge challenge for oncologists. Actually, the patient in our case died 3 months after discharge, due to a malignancy of the synchronous cancers without receiving any other treatment.
XM and XS designed the study; JL was the major contributor in writing the manuscript; XS and YZ performed the histological examination and immunohistochemistry; BW collected the patient data. All authors read and approved the final manuscript.
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. Sagristani M, Caraglia M, Villa MR, et al. Concomitant occurrence of a primary renal NHL and of a papillary urothelial ureter cancer. J Exp Clin Cancer Res 2007;26:291–2.
. Hu R, Zhang R, Miao M, et al. Central nervous system involvement of primary renal lymphoma with diffuse large B-cell type lymphoma. Am J Case Rep 2013;14:292–4.
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. Etiz D, Metcalfe E, Akcay M. Multiple primary malignant neoplasms: a 10-year experience at a single institution from Turkey. J Cancer Res Ther 2017;13:16–20.
. Liu Z, Liu C, Guo W, et al. Clinical analysis of 152 cases of multiple primary malignant tumors in 15,398 patients with malignant tumors. PLoS One 2015;10:e0125754.
. Armitage JO, Gascoyne RD, Lunning MA, et al. Non-Hodgkin lymphoma. Lancet 2017;390:298–310.
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. Agochukwu NQ, Kilchevsky A, Hesse D. Primary renal large B-cell lymphoma imitating invasive renal cell carcinoma with inferior vena cava tumor thrombus. Urol Case Rep 2018;18:84–6.
. Kose F, Sakalli H, Mertsoylu H, et al. Primary renal lymphoma: report of four cases. Onkologie 2009;32:200–2.
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. Thawani R, Amar A, Patowary J, et al. Primary renal cell lymphoma: case report, diagnosis, and management. Indian J Med Paediatr Oncol 2017;38:545–7.
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. Parakh R, Cheng L, Tretiakova M. PAX8-positive B-cell lymphoma in adrenal gland masquerading as metastatic renal cell carcinoma. Int J Surg Pathol 2018;26:721–4.
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. Okuno HS, Hoyer JD, Ristow K, et al. Primary renal non-Hodgkin's lymphoma. Cancer 1995;75:2258–61.
. Rissman CM, Dagrosa LM, Pettus JR, et al. Primary renal lymphoma: an unusual finding following radical nephrectomy. Clin Nephrol Case Stud 2017;5:1–4.
. Nicolau C, Sala E, Kumar A, et al. Renal masses detected on FDG PET/CT in patients with lymphoma: imaging features differentiating primary renal cell carcinomas from renal lymphomatous involvement. AJR Am J Roentgenol 2017;208:849–53.
. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 2014;32:3059–68.
. Xu LL, Gu KS. Clinical retrospective analysis of cases with multiple primary malignant neoplasms. Genet Mol Res 2014;13:9271–84.
. Porcaro AB, D’Amico A, Novella G, et al. Primary lymphoma of the kidney. Report of a case and update of the literature. Arch Ital Urol Androl 2002;74:44–7.
. Butani L, Ducore J. Primary renal lymphoma presenting as end-stage renal disease. Case Rep Med 2017;2017:9210648.
. Tefekli A, Baykal M, Binbay M, et al. Lymphoma of the kidney: primary or initial manifestation of rapidly progressive systemic disease? Int Urol Nephrol 2006;38:775–8.
. Chen X, Hu D, Fang L, et al. Primary renal lymphoma: a case report and literature review. Oncol Lett 2016;12:4001–8.
. Jung SB, Lee HI, Oh HK, et al. Clinico-pathologic parameters for prediction of microsatellite instability in colorectal cancer. Cancer Res Treat 2012;44:179–86.