Mantle cell lymphoma presenting as a pelvi-ureteric junction obstruction: a case report
© Naranji et al.; licensee BioMed Central Ltd. 2013
Received: 22 January 2013
Accepted: 21 March 2013
Published: 16 April 2013
Mantle cell lymphoma is one of the several subtypes of non-Hodgkin’s lymphoma. Mantle cell lymphoma is the rarest of the subtypes, accounting for about 6% of all non-Hodgkin’s lymphoma cases in the United States and Europe. Lymphoid neoplasms of the urinary tract and male genital organs are relatively rare, accounting for less than 5% of extranodal lymphomas. We present a rare case of mantle cell lymphoma infiltrating the ureter causing pelvi-ureteric junction obstruction on tissue diagnosis.
A 78-year-old Caucasian woman was referred to our department with right flank pain, pyrexia and features of a urinary tract infection. A nephrostogram revealed a grossly distended right pelvicalyceal system in a pelvi-ureteric junction obstruction pattern. She underwent an elective pyeloplasty after her acute management and the results of histological examination revealed mantle cell lymphoma.
We describe a rare presentation of mantle cell lymphoma as a pelvi-ureteric junction obstruction. To the best of our knowledge, there has not been any previously published report of the above finding. Our patient had a history of a previous lymphoma but the aim of this manuscript is to highlight a possible presentation rather than determining whether the mantle cell lymphoma was de novo or a transformation from her previous splenic lymphoma with villous lymphocytes.
Mantle cell lymphoma (MCL) is one of the several subtypes of non-Hodgkin’s lymphoma. MCL is the rarest of the subtypes, accounting for about 6% of all non-Hodgkin’s lymphoma cases in the United States and Europe. It is the result of a malignant transformation of a B lymphocyte in the outer edge of a lymph node follicle, called the mantle zone. Those cells can spread through the lymphatics and blood to other lymph nodes or tissues such as the bone marrow, liver and gastrointestinal tract. MCL has the worst prognosis among lymphomas, with a median survival of approximately three to four years [1, 2].
Lymphoid neoplasms of the urinary tract and male genital organs are relatively rare, accounting for less than 5% of extranodal lymphomas. We conducted a literature search of PubMed and MEDLINE using the keywords ‘ureter’, ‘mantle cell lymphoma’ and ‘lymphoma’. We found no reports of MCL involving the ureter.
We present a rare case of MCL infiltrating the ureter causing pelvi-ureteric junction obstruction (PUJO) on tissue diagnosis.
Day 5 (Discharge)
White blood cell count (×10 9 /L)
Neutrophils (×10 9 /L)
C-reactive protein (mg/L)
Over the next few days, our patient recovered quite well and was discharged from hospital after a five-day stay.
Our patient underwent an elective laparoscopic pyeloplasty two months after being discharged. The procedure included a cystoscopy, which revealed an inflamed bladder wall with normal ureteric orifices, and a right retrograde that showed a normal ureter with narrowing and a kink at the right pelvi-ureteric junction, with contrast spill into her pelvis - typical of a PUJO. The pyeloplasty was uneventful and her 6Fr stent was removed at flexible cystoscopy four weeks after the operation.
Our patient has now been referred back to the hematologist for further management of her MCL and is undergoing rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy treatment.
Lymphomas in the genitourinary tract are extremely rare, only a handful of small case series and isolated reports have been published describing their predominant sites and subtypes . To the best of our knowledge, lymphoma infiltrating the ureter has only been mentioned by Schniederjan and Osunkoya in their case series . MCL involving the ureter has not been described before.
MCL is a subtype of B-cell lymphoma, derived from CD5-positive antigen-naïve pregerminal center B-cells within the mantle zone that surrounds normal germinal center follicles. MCL cells generally over-express cyclin D1 due to a t(11:14) chromosomal translocation in the deoxyribonucleic acid (DNA). The cause is unknown and no inherited predisposition has been identified .
Ki-67 is an indicator of how fast cells mature: the lower the percentage, the lower the speed of maturity, and the more indolent the disease. In our scenario, our patient expressed less than 5% staining .
She had previously been diagnosed with SLVL, after which she had a splenectomy. Unfortunately, it was unclear how this diagnosis was made. She had been asymptomatic until her admission for pyonephrosis and follow-up scans after her splenectomy attributed her right hydronephrosis to a ‘congenital’ PUJO.
With good renal function demonstrated on her dimercaptosuccinic acid scan and her history of SLVL, one should be suspicious of attributing the finding to a congenital condition.
SLVL is a lymphoproliferative disorder characterized by the presence in the peripheral blood of atypical B-lymphocytes. Clinical features include massive splenomegaly and absence of peripheral lymphadenopathy. In our patient, an incidental finding of splenomegaly led to her having a splenectomy for SLVL .
In retrospect, we could argue that with good renal function on her previous imaging and with her history of SLVL, her right-sided hydronephrosis was secondary to the lymphoma process rather than to a congenital finding.
We describe a rare presentation of MCL as a PUJO. To the best of our knowledge, there has not been any previously published report of the above finding. Our patient had a history of a previous lymphoma but the aim of this manuscript was to highlight a possible presentation rather than determining whether the MCL was de novo or a transformation from her previous SLVL.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Our sincere thanks to Dr Jerry Grant, consultant pathologist, in providing assistance and images for the manuscript.
- Greer JP, Foerster J, Rodgers GM, Paraskevas F, Glader B, Arber DA, Means RT: Wintrobe’s Clinical Hematology. 2009, Philadelphia, PA: Lippincott Williams and Wilkins, 12
- Marcus R, Sweetenham JW, Williams ME: Lymphoma – Pathology, Diagnosis and Treatment. 2007, Cambridge: Cambridge University Press
- Lee HJ, Seo JW, Cho HS, Kang Y, Bae EJ, Lee DW, Jeon DH, Lee JS, Chang SH, Park DJ: Renal involvement of mantle cell lymphoma leading to end stage renal disease. Hemodial Int. 2012, 16 (1): 104-108.PubMed
- Schniederjan SD, Osunkoya AO: Lymphoid neoplasms of the urinary tract and male genital organs: a clinicopathological study of 40 cases. Mod Pathol. 2009, 22 (8): 1057-1065. 10.1038/modpathol.2009.65. Epub 2009 Apr 17View ArticlePubMed
- Huret JL: t(11;14)(q13;q32). Atlas Genet Cytogenet Oncol Haematol. 1998,http://AtlasGeneticsOncology.org/Anomalies/t1114ID2021.html,
- Hoster E, Dreyling M, Klapper W, Gisselbrecht C, van Hoof A, Kluin-Nelemans HC, Pfreundschuh M, Reiser M, Metzner B, Einsele H, Peter N, Jung W, Wörmann B, Ludwig WD, Dührsen U, Eimermacher H, Wandt H, Hasford J, Hiddemann W, Unterhalt M, German Low Grade Lymphoma Study Group (GLSG), European Mantle Cell Lymphoma Network: A new prognostic index (MIPI) for patients with advanced-stage mantle cell lymphoma. Blood. 2008, 111 (2): 558-565. 10.1182/blood-2007-06-095331.View ArticlePubMed
- Troussard X, Mossafa H: Splenic lymphoma with villous lymphocytes (SLVL). Atlas Genet Cytogenet Oncol Haematol. 2005,http://atlasgeneticsoncology.org/Anomalies/splenvillousID2063.html,
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.