Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 39, Num. 4, 2002, pp. 154-156

Indian Journal of Cancer, Vol. 39, No. 4, (October - December 2002) , pp. 154-156

Renal Enlargement as Primary Presentation of Acute Lymphoblastic Leukaemia

Mona Basker, J. X. Scott, Benjamin Ross, Chellam Kirubakaran

Dept. of Child Health, Christian Medical College and Hospital, Vellore 632 004.

ABSTRACT

Renal enlargement in acute lymphoblastic leukaemia is well reported in literature from Western Countries. However there are very few reports from developing countries. Bilateral symmetrical enlargement of kidneys as a primary presentation of acute lymphoblastic leukaemia is rare. We report a child who had acute lymphoblastic leukaemia presenting with bilateral renal mass.

Key Words: Leukaemia, Renal Mass.

INTRODUCTION

There are several reports in the literature from western countries, about renal enlargement in acute lymphoblastic leukaemia (ALL).¹

Hann et al has reported renal enlargement in 24% of all diagnosed ALL patients.² In severe cases there is even marked bilateral and symmetrical enlargement of both kidneys. However clinical nephropathy and severe renal failure caused by leukaemic infiltration are unusual.^3,4 Extensive literature search showed very few reports from developing countries. We report a young boy who presented with bilateral renal mass, initially diagnosed as Wilm's tumour, but subsequently proven to be ALL.

CASE REPORT

This 4-year-old boy was referred from a peripheral hospital, to the Pediatric Hemato-oncology Clinic of Christian Medical College and Hospital, Vellore with a diagnosis of Wilm's tumor with distant metastasis. He had anorexia, swelling of right knee for five months and swelling in the right supraorbital region for one month.

He also had pain and swelling in the small Joints of the hand for one month. On examination, he had pallor. His Blood Pressure was 130170 mm Hg. Abdominal examination revealed liver enlargement of 4 cm and spleen of 2 cm below the costal margin. Both kidneys were palpable measuring approximately 10 x 10 cm. There was a tender diffuse swelling in the medial aspect of the lower end of the right thigh. There was periorbital swelling in the right eye.

His hemoglobin was 9.3 g/dl, total white blood cell count 13,100/cu. mm, with myelocytes 7%, metamyelocytes 3%, bandforms 9%, neutrophils 35%, eosinophils 2% and lymphocyte 44%. Platelet count was 89000/cu.mm. Serum creatinine was 0.6mg%. Serum electrolytes. liver function tests, prothrombin time, activated partial thromboplastin time, serum calcium, phosphorus, uric acid and bicarbonate were within normal limits. LDH was 6620 U/L. Urinalysis was normal. Ultrasound abdomen revealed bilateral renal enlargement, measuring 10 cm with increase in cortical echotexture. CT abdomen also revealed bilateral renal enlargement with multiple hypo dense lesions causing lobulations of the contour. Bone marrow aspirate was consistent with ALL- L2 of FAB. Immunophenotyping was consistent with precursor B Cell ALL. Trucut biopsy of the right renal mass was consistent with leukaemic infiltration of the renal medulla.

He was started on chemotherapy as per the ANZ-CCSG protocol. At completion of induction remission, child had complete resolution of swelling in the leg and supraorbital region. The renal masses were not palpable. His repeat ultrasonogram of abdomen showed definite decrease in the kidney size which measured 8cm bilaterally.

DISCUSSION

Reports from developed countries quote 67% renal involvement in ALL which are mostly microscopic infiltrates. Only 24% had palpable enlargement of kidneys.² There are no reports of bilateral renal involvement from developing countries. Leukemic infiltration is more common late in the course of the disease but can also occur at the time of original diagnosis of leukaemia as in our patient.^10,11 However clinical nephropathy and severe renal failure caused by leukaemic infiltrates are unusual.^3,4 Our patient, who also had bilateral renal enlargement, had normal renal functions. His uric acid level was also normal.

Various factors in leukamia singly or in combination lead to renal involvement. Direct effects of leukaemic infiltration were seen in one third of cases in a study reported by Kanna et al.⁷ DIC leading to renal failure was noted in one case of promyelocytic leukaemia. Infections by opportunistic organisms can also cause renal failure especially while being treated with anti-neoplastic drugs.⁷ Irradiation if given in the dose of 2300 rads can lead to renal damage.⁸

Uremia in acute lymphoblastic leukaemia can be due to hyperuricemia occurring due to rapid lysis of leukaemic tissue following chemotherapy⁵ and with hyperleukocytosis.⁶

In our patient, leukaemic infiltrates of renal tissue were documented by renal biopsy. Mcroscopically, leukaemic infiltration can be either diffuse or nodular in nature¹² but in children the diffuse pattern is more common.¹⁰ Infiltration is usually bilateral and symmetrical as reported in our patient. The infiltrates are reported to be mainly confined to the cortex with only minimal involvement of the medulla.¹⁰ In our patient however, the infiltrates were seen in the medulla.

Enlarged kidneys in ALL are thought to be an unfavourable prognostic sign.^10,13 Although the role of radiotherapy in the treatment of leukaemic infiltration of the kidney has been studied in the past¹⁴ currently, chemotherapy remains the basic treatment even with renal leukaemic infiltrates. Our patient also had complete resolution of renal masses clinically and definite reduction in the renal size and infiltration after the induction remission phase.

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