Anatomic Pathology / FINE-NEEDLE ASPIRATION OF RENAL LYMPHOMA
`
`Renal Lymphoma
`
`The Diagnostic and Therapeutic Roles of Fine-Needle Aspiration
`
`Luan D. Truong, MD,1,2 Nancy Caraway, MD,3 Thu Ngo, MD,1,2 Rodolfo Laucirica, MD,1,2
`Ruth Katz, MD,3 and Ibrahim Ramzy, MD1,2
`
`Key Words: Renal lymphoma; FNA; Fine-needle aspiration; Cytology; Immunophenotyping; Posttransplant lymphoproliferative disorder
`
`A b s t r a c t
`This study focused on 19 patients with renal
`lymphoma (RL) from whom 20 initial (1 patient with
`fine-needle aspiration [FNA] specimens of masses in
`both kidneys) and 1 repeated FNA specimen were
`obtained. Of the 19 patients, 10 had secondary RL, 8
`primary RL, and 1 transplant RL. The FNA samples
`were studied by smears (all cases), tissues (11),
`phenotyping by immunostaining (13) or flow cytometry
`(4), and gene rearrangement (3). The final diagnoses
`included 1 T-cell lymphoma and 18 B-cell lymphomas.
`Of the 20 original specimens, 14 were reported as
`positive for lymphoma, 3 suggestive of lymphoma, 1
`positive for transitional cell carcinoma, and 2
`unsatisfactory. The follow-up specimen showed reactive
`changes. Tissue correlation, available in 11 cases,
`confirmed a positive cytodiagnosis (7), provided a final
`diagnosis in the cytologically inconclusive cases (3), or
`revised the misdiagnosis of transitional cell carcinoma
`from smears (1). The phenotyping elucidated the B vs T
`lineage of the lymphoma in all tested cases, confirmed
`the positive cytodiagnosis in 10 cases, confirmed the
`reactive cytodiagnosis in 1 case, and helped achieve a
`conclusive diagnosis in 2 cases suggestive of lymphoma.
`Gene rearrangement studies showed light chain
`restriction in the 2 tested cases. FNA has an essential
`role in treatment planning for RL. Although FNA usually
`is diagnostically conclusive, a high index of suspicion
`and awareness of atypical or misleading
`cytomorphologic features are important for a correct
`interpretation, especially for primary RL. Ancillary
`testing is essential for the diagnosis in problematic cases
`and lays the foundation for the differential diagnosis.
`
`Renal involvement by lymphoma is not unusual. Four
`types of renal lymphoma (RL) are known: secondary RL,
`defined as renal involvement during the course of systemic
`lymphoma1-3; primary RL, defined as lymphoma that mani-
`fests with renal abnormalities4; renal intravascular
`lymphomatosis, a rare condition characterized by lymphoma
`cells almost exclusively limited to the glomerular capil-
`laries5,6; and posttransplant lymphoma, which selectively
`involves the transplanted kidney.7 Each of these types of RL
`has distinctive clinicopathologic features and biologic
`behavior.
`It is accepted generally that a specific diagnosis is not
`essential for the initial management of a renal mass since the
`recommended procedure is total or, more recently, partial
`nephrectomy to achieve therapeutic and diagnostic goals.
`Treatment for RL veers from that rule, since RL, regardless
`of its type, in general, shows dramatic response to
`chemotherapy.8 A conclusive diagnosis of RL before plan-
`ning treatment may obviate unnecessary radical surgery.9
`Fine-needle aspiration (FNA) of the renal lesion can fulfill
`this goal.8 Yet, the literature on FNA diagnosis of RL is
`surprisingly scant.
`We herein report the clinical and cytologic features of 19
`RLs subjected to FNA, review the pertinent literature, and
`discuss the morphologic nuances and ancillary tests that lay
`the foundation for the differential diagnoses of RL.
`
`Materials and Methods
`
`Among a total of 395 renal FNAs performed at the
`Methodist Hospital or M.D. Anderson Cancer Center,
`Houston, TX, from 1988 to 1998, 21 were obtained from
`
`18 Am J Clin Pathol 2001;115:18-31
`
`© American Society of Clinical Pathologists
`
`NOVARTIS EXHIBIT 2028
`Breckenridge v. Novartis, IPR 2017-01592
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`

`renal lesions, which turned out to be lymphoma, in 19
`patients. These FNAs were the subject of the present study.
`Under visualization by sonography or computed tomog-
`raphy scan, the renal lesions were aspirated, using a 23- or
`25-gauge needle attached to a 20-mL syringe. Air-dried
`smears were stained with the rapid Romanowsky method for
`immediate evaluation of the specimen adequacy. Alcohol-
`fixed smears also were prepared and subjected to Papanico-
`laou stain. If lymphoid lesions were suspected by rapid
`Romanowsky–stained smears, additional passes were made
`and submitted in RPMI tissue culture fluid. This preparation
`subsequently was used for flow cytometry or to prepare cyto-
`centrifuged smears for immunostaining. Minute tissue frag-
`ments or intact tissue cores, obtained by FNA in several
`cases, were prepared as cell or tissue blocks and subjected to
`histologic examination.
`Phenotyping studies were done on many FNA samples
`by one of the following: (1) immunostaining the tissue
`sections (consecutive sections from cell or tissue blocks were
`submitted alternatively to routine histologic staining and
`immunostaining), (2) immunostaining of cytocentrifuged
`smears, or (3) flow cytometry. More than one method of
`immunophenotyping was used in some cases. For immuno-
`staining, a basic panel of antibodies specific for keratin,
`epithelial membrane antigen, leukocyte common antigen
`(LCA), CD20 (a B-lymphocyte marker), CD3 (a T-lympho-
`cyte marker), and lambda and kappa light chains was used in
`various combinations. Additional antibodies that may be
`helpful for lymphoma classification, including those specific
`for Ki-67 (a cell proliferation marker), CD5 (a marker for
`small B lymphocytes and lymphocytes from the mantle
`zone), and CD10 (a marker for follicular center cells), also
`were used in some cases. Cells immunopositive for each
`antibody were counted and expressed as the percentage of
`total number of cells in the cytocentrifuged smears. It is well
`documented that B lymphocytes express either lambda or
`kappa light chain on the cell membrane.9 Therefore, the aspi-
`rated B lymphocytes were classified as monoclonal if the
`ratio of one type of light chain–restricted B lymphocytes to
`the other was more than 6, polyclonal if this ratio was less
`than 3, and equivocal if this ratio was 3 to 6.
`For flow cytometry, the cell pellets were resuspended,
`washed, fixed in paraformaldehyde, and adjusted to no more
`than 10 × 106 cells per milliliter. Ten microliters of mouse T-
`or B-cell subset-specific monoclonal antibodies tagged with
`fluorescein isothiocyanate, phycoerythrin, or peridinin
`chlorophyll (Becton Dickinson, Franklin Lakes, NJ) were
`added to the cell suspensions before flow cytometric
`analysis. Results are reported as the percentage of positivity
`of the gated population.
`In 2 cases, frozen cell pellets were submitted to gene
`rearrangement study for T-cell receptor or light chain,
`
`Anatomic Pathology / ORIGINAL ARTICLE
`
`according to a previously published method,9 to confirm the
`monoclonal nature of the aspirated lymphoid cells.
`The cytologic features of each FNA specimen were
`tabulated and correlated with histologic and clinical findings.
`
`Results
`
`Final Diagnoses
`Of the19 patients with RL, 1 had 1 T-cell lymphoma and
`18 had B-cell lymphoma (large cell, 11; small cleaved, 3;
`small lymphocytic with plasmacytoid differentiation, 2;
`small lymphocytic, 1; and small noncleaved, 1).
`
`Clinical Findings
`Three groups were identified ❚ Table 1❚ : 1, secondary
`RL; 2, primary RL; and 3, RL involving a renal transplant.
`Group 1 included 10 cases (cases 1-10) in which lymphoma
`involving lymph nodes and, less frequently, other organs
`was diagnosed 1 to 92 months before the renal involvement.
`RL in this group was detected by computed tomography
`scans performed as a part of the routine follow-up study (7
`cases) or in response to clinical manifestations referable to a
`renal mass (3 cases). Group 2 included 8 cases (cases 11-18)
`in which RL was the initial manifestation of lymphoma. The
`clinical manifestations of these patients were heteroge-
`neous: 5 had with nonspecific features including weight
`loss, fever, malaise, abdominal mass, or flank pain; 1 had
`hematuria associated with bilateral renal masses and left
`pelvic filling defect, for which FNA was performed and
`misdiagnosed as transitional cell carcinoma (TCC),
`prompting a left-sided nephrectomy; the 2 remaining
`patients, 1 with AIDS, had acute renal failure. Group 3
`included a single case (case 19) in which RL of the trans-
`planted kidney initially manifested as progressive renal
`failure and pain of the graft that had been functioning well
`during the past 9 years.
`Staging workup after the diagnosis of RL showed that
`lymphoma of organs other than kidneys developed at or
`shortly after the diagnosis of RL in almost all patients (9/10)
`in group 1. In group 2, systemic involvement was docu-
`mented at or shortly after the diagnosis of RL in 7 patients;
`but in the remaining patient, the kidneys remained the only
`organ affected throughout the clinical course, and the patient
`was alive without disease at 52 weeks. The transplanted
`kidney was the only organ involved by lymphoma in the
`patient in group 3.
`Treatment for RL included chemotherapy alone (15
`cases), chemotherapy and radiation to the renal beds (1
`case), urinary stent alone for palliation of hydronephrosis (1
`case), and left-sided nephrectomy followed by chemotherapy
`
`© American Society of Clinical Pathologists
`
`Am J Clin Pathol 2001;115:18-31 19
`
`NOVARTIS EXHIBIT 2028
`Breckenridge v. Novartis, IPR 2017-01592
`Page 2 of 14
`
`

`

`Truong et al / FINE-NEEDLE ASPIRATION OF RENAL LYMPHOMA
`
`❚Table 1❚
`Renal Lymphoma: Clinical Features of 19 Cases
`
`Case No./Sex/ Age (y)
`
`Secondary lymphoma
`1/M/51
`2/F/77
`3/F/69
`4/M/75
`5/M/55
`6/M/66
`7/M/29
`8/F/76
`9/F/33
`10/M/63
`Primary lymphoma
`11/M/66
`12/M/71
`
`13/M/8
`14/M/50
`15/M/65
`16/F/75
`
`17/M/26
`18/M/36
`
`Time Interval
`(mo)*
`
`Clinical Manifestations
`
`Treatment for
`Renal Lymphoma
`
`Follow-up
`(mo)
`
`12
`36
`4
`92
`11
`96
`12
`1
`11
`4
`
`Routine follow-up CT scan
`Routine follow-up CT scan
`Routine follow-up CT scan
`Abdominal pain and fever
`Routine follow-up CT scan
`Routine follow-up CT scan
`Routine follow-up CT scan
`CT scan at initial staging workup
`Flank pain
`Flank pain
`
`At presentation
`At presentation
`
`At presentation
`At presentation
`At presentation
`At presentation
`
`At presentation
`At presentation
`
`Abdominal pain and mass, serum IgM spike
`Gross hematuria, left-sided pelvic filling defect
`(FNA misdiagnosed as transitional cell
`carcinoma)
`Abdominal pain, gross hematuria
`Abdominal pain, fatigue, malaise
`Fatigue, weakness, fever, profound weight loss
`Acute renal failure; workup showing lesions in
`kidneys, lungs, and bone and retroperitoneal
`lymphadenopathy
`AIDS, acute renal failure, weight loss
`Abdominal pain and fullness
`
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`
`Chemotherapy
`Left-sided nephrectomy
`followed by
`chemotherapy
`Chemotherapy
`Chemotherapy
`Chemotherapy
`Urinary stent
`
`DOD (57)
`DOD (36)
`DOD (3)
`DOD (12)
`DOD (94)
`AWD (5)
`DOD (14)
`AWD (19)
`DOD (10)
`AWD (12)
`
`DOD (14)
`AWD (26)
`
`DOD (4)
`DOD (10)
`AWD (5)
`DOD (1
`
`Chemotherapy
`Chemotherapy and
`radiation
`
`DOD (5)
`Alive without
`disease (52)
`
`Posttransplant lymphoma
`19/F/37
`
`At presentation
`
`Decreased renal function, tenderness and
`palpable mass of the renal transplant†
`
`Chemotherapy followed
`by nephrectomy
`
`Alive without
`disease (5)
`
`AWD, alive with disease; CT, computed tomography; DOD, died of disease (the renal tumor in many patients responded well to therapy but was followed by relapse in other
`organs); FNA, fine-needle aspiration.
`* The interval between the onset of lymphoma and the diagnosis of renal lymphoma.
`† The lymphoma developed in the transplanted kidney.
`
`(for the case initially misdiagnosed as TCC). The trans-
`planted kidney with lymphoma was treated by chemotherapy
`and subsequent graft nephrectomy performed in response to
`a lack of resolution of the mass in the graft, which showed
`total necrosis of the lymphoma against the background of
`acute rejection. The response to chemotherapy was excellent
`in all cases; in each the renal masses disappeared or became
`markedly smaller within 2 months of treatment. However, at
`1 to 92 weeks of follow-up, 12 patients died of disease and 5
`patients were alive with disease. Only 2 patients were alive
`without disease, and lymphoma was limited to the native
`kidney (case 18) and the transplanted kidney (case 19).
`
`Computed Tomography Scan Findings
`The RL from all 3 groups showed a similar spectrum of
`
`findings ❚ Table 2❚ , ❚ Image 1A❚ , ❚ Image 1B❚ , ❚ Image 1C❚❚Image 1D ❚ . Among the 18 cases of RL involving the native
`
`kidneys, bilateral or unilateral involvement was noted in 10
`(56%) and 8 (44%) cases, respectively. Among the 36
`kidneys, 8 (22%) appeared normal; 14 (39%) contained a
`single mass; 5 (14%), multiple masses; 3 (8%), predomi-
`nantly perirenal plaque with minimal renal involvement;
`and 6 (17%), massive renal enlargement without masses.
`
`Bilateral massive renal enlargement accounted for acute
`renal failure in 2 patients (cases 16 and 17). Perirenal or hilar
`extension was noted in 8 (22%) kidneys and obvious hilar
`adenopathy in at least 4 (11%) kidneys. The transplanted
`kidney with RL contained a 5.5-cm mass against a back-
`ground of diffuse renal enlargement.
`
`Gross Findings
`Only 2 nephrectomy specimens were available (Table
`2). One was a native kidney removed for a misdiagnosis of
`TCC, which displayed a 5-cm, unencapsulated, solid mass
`with a “fish-flesh” cut surface that occupied the lower pole,
`extended to the renal sinus, and compressed the renal pelvis.
`The other was a transplanted kidney, removed after
`chemotherapy, that displayed 1 unencapsulated 5.5-cm
`completely necrotic mass against the background of fibrotic
`renal parenchyma.
`
`FNA Findings and Tissue Correlation
`Twenty-one renal FNA samples were obtained (20 orig-
`inal specimens from 19 patients [both kidneys were aspirated
`in 1 patient] and a specimen from a repeated FNA in 1
`patient; Table 2). The 20 original FNA samples were reported
`
`20 Am J Clin Pathol 2001;115:18-31
`
`© American Society of Clinical Pathologists
`
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`

`❚Table 2❚
`Renal Lymphoma: The Morphologic Features of 21 Fine-Needle Aspiration Specimens in 19 Cases*
`
`Anatomic Pathology / ORIGINAL ARTICLE
`
`Case
`No.
`
`Computed Tomography
`or Gross Findings
`
`Cytology
`(Special Features)
`
`Positive (some
`lymphoid cell clusters)
`
`Positive (some
`tubular cells)
`
`Suggestive (many
`lymphoid cell clusters)
`Positive
`
`First FNA specimen:
`positive
`
`Second FNA specimen
`(6 mo after treatment):
`reactive
`Suggestive
`
`1
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`9
`
`Right kidney: 5-cm renal mass
`with hilar extension; left kidney:
`10-cm renal mass
`Right kidney: 4-cm renal mass;
`left kidney: normal
`
`Right kidney: normal; left kidney:
`6-cm renal mass
`Bilateral multinodular renal
`enlargement (16 cm) with
`extrarenal extension
`Right kidney: normal; left kidney:
`predominantly perirenal mass,
`with minimal renal involvement
`
`Right kidney: normal; left kidney
`diffuse renal enlargement with
`perirenal extension and hilar
`adenopathy
`Right kidney: 1-cm renal mass;
`left kidney: 3.5-cm renal mass
`Right kidney: 3-cm renal mass;
`left kidney: two 4-cm renal
`masses
`
`Right kidney: normal; left kidney:
`3-cm renal mass with hilar
`extension and hydronephrosis
`
`Tissue
`
`Tissue
`cores
`
`None
`
`None
`
`None
`
`None
`
`Immunostaining
`Results
`(Cell Type, %)
`
`ND
`
`B, 80; T, 20; kappa,
`65; lambda, 5;
`Ki-67, 3
`ND
`
`ND
`
`B, 90; T, 6; kappa,
`88; lambda, 15
`
`Flow
`Cytometry
`
`Final
`Diagnosis
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`Large B-cell
`lymphoma
`
`Small cleaved
`B-cell lymphoma
`
`Large B-cell
`lymphoma
`Small cleaved
`B-cell
`lymphoma
`Large B-cell
`lymphoma
`
`None
`
`B, 25; T, 80
`
`Polyclonal
`
`Reactive changes
`
`Cell
`block
`
`B, 60; T, 20; kappa,
`65; lambda, 5
`
`Positive (many
`lymphoid cell clusters)
`Positive
`
`None
`
`None
`
`ND
`
`B, 60; T, 20; kappa,
`10; lambda, 70
`
`Positive
`
`None
`
`ND
`
`ND
`
`ND
`
`Large B-cell
`lymphoma
`
`Large T-cell
`lymphoma
`Small B-cell
`lymphocytic
`lymphoma
`
`Large B-cell
`lymphoma†
`
`10
`
`Right kidney: 2-cm renal mass; left
`kidney: perirenal mass with
`minimal renal involvement
`
`Positive
`
`11
`
`Right kidney: multiple renal masses
`with perirenal extension; left
`kidney: diffuse renal enlargement
`with hilar adenopathy
`12A Left kidney: 5-cm pelvic mass and
`hydronephrosis
`
`12B Right kidney: 4-cm renal mass
`
`13
`
`14
`
`15
`
`16
`
`17
`
`18
`
`19
`
`Right kidney: 3-cm renal mass;
`left kidney: normal
`
`Right kidney: normal; left kidney:
`12-cm renal mass with necrosis,
`hilar adenopathy
`Right kidney: 1-cm renal mass and
`hilar soft tissue fullness;
`left kidney: perirenal plaque with
`a 2.5-cm renal mass
`Bilateral, diffuse renal enlargement
`(18 cm), hydronephrosis
`
`Bilateral, diffuse, renal enlargement
`
`Right kidney: normal; left kidney:
`multiple renal masses with
`extension to renal vein and hilum,
`hilar adenopathy, hydronephrosis
`Transplanted kidney: 5.5-cm renal
`mass with mild diffuse renal
`enlargement
`
`Positive (some lymphoid
`cell clusters, small and
`large lymphoid cells,
`some renal tubules)
`Positive (many cell clus-
`ters, many large round
`or spindle cells, mis-
`diagnosed as transi-
`tional cell carcinoma)
`Positive (FNA done after
`left-sided nephrectomy
`with features similar to
`those of FNA specimen
`from left kidney)
`Suggestive (some
`lymphoid cell clusters)
`
`Positive (some
`lymphoid cell clusters)
`
`Unsatisfactory
`
`Cell
`block
`
`None
`
`ND
`
`B, 80; T, 25; CD5, 20;
`Ki-67, 6; kappa, 10;
`lambda, 70
`
`Left-sided ND
`nephrec-
`tomy
`
`Cell
`block
`
`B, 60; T, 45; kappa,
`10; lambda, 86
`
`Tissue
`cores
`
`None
`
`B, 100; T, 0; Ki-67, 80;
`LCA positive, 100;
`kappa and lambda,
`poor stain
`B, 100; T, 0; kappa,
`50; lambda, 1
`
`Open
`biopsy
`
`ND
`
`Positive (many lymphoid
`cell clusters, many
`renal tubules and
`glomeruli)
`Positive (similar to case 16)
`
`Positive
`
`Tissue
`cores
`
`Tissue
`cores
`Tissue
`cores
`
`LCA positive; keratin
`negative; B, 100;
`T, 0
`
`Similar to case 16
`
`B, 60; T, 60; kappa,
`80; lambda, 5
`
`Unsatisfactory
`
`Tissue
`cores
`
`Keratin negative; LCA
`positive; B, 95; T, 5
`
`CD10, 50;
`CD5/CD9,
`3; kappa, 3;
`lambda, 93
`B, 99; T, 1;
`kappa, 95;
`lambda, 5;
`Ki-67, 80
`B, 65; T, 30;
`kappa, 2;
`lambda, 65
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`ND
`
`Small B-cell
`lymphoma with
`plasmacytoid
`features
`Small cleaved
`B-cell
`lymphoma
`
`Large B-cell
`lymphoma†
`
`Large B-cell
`lymphoma
`
`Small noncleaved
`B-cell
`lymphoma
`(Burkitt)
`Large B-cell
`lymphoma
`
`Small B-cell
`lymphoma with
`plasmacytoid
`features
`Large B-cell
`lymphoma
`
`Large B-cell
`lymphoma
`Large B-cell
`lymphoma
`
`Large B-cell
`lymphoma
`
`B, B lymphocytes; FNA, fine-needle aspiration; LCA, leukocyte common antigen; ND, not done; T, T lymphocytes.
`* Positive indicates abundant monomorphic lymphoid cells in discohesive, 1-dimensional sheets; suggestive, scanty monomorphic lymphoid cells in discohesive, 1-dimensional
`sheets; unsatisfactory, rare lymphoid or renal tubular cells; reactive, small and large lymphocytes, plasma cells, and necrotic cells; kappa, kappa light chain; and lambda, lambda
`light chain.
`† The diagnosis of lymphoma was confirmed by gene rearrangement.
`
`© American Society of Clinical Pathologists
`
`Am J Clin Pathol 2001;115:18-31 21
`
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`

`Truong et al / FINE-NEEDLE ASPIRATION OF RENAL LYMPHOMA
`
`A
`
`C
`
`*
`
`B
`
`D
`
`*
`
`❚ Image 1❚ Computed tomography scans of renal lymphoma. A, Bilateral renal masses (arrows), with massive retroperitoneal
`adenopathy (asterisk). B, Unilateral perirenal plaque (arrows), with minimal renal parenchymal involvement. C, Predominantly
`hilar involvement associated with hydronephrosis, requiring placement of a stent (arrow). D, An eccentric mass (asterisk) in a
`transplanted kidney noted against the background of diffuse enlargement.
`
`as unsatisfactory in 2, positive for lymphoma in 14, sugges-
`tive of lymphoma in 3, and positive for TCC in 1. Tissue
`correlation was available for 11 cases (cell blocks in 3 cases,
`tissue cores in 6, open biopsy in 1, and nephrectomy in 1).
`The 2 unsatisfactory FNA samples (1 primary RL and 1
`RL in a transplanted kidney) showed only rare tubular or
`lymphoid cells. In one of these cases (case 19), a corre-
`sponding tissue core also was obtained and was diagnostic.
`In the other case (case 15), subsequent open biopsy was
`performed.
`The 14 FNA samples positive for lymphoma (8
`secondary RLs and 6 primary RLs) yielded abundant
`lymphoid cells with at least 1 smear containing confluent
`
`cell sheets. These cells were isolated, noncohesive, and
`distributed evenly and uniformly. They displayed character-
`istic features of lymphoid cells including scant but preserved
`cytoplasm and round nuclei ❚Image 2A ❚ . The aspirated cells
`in 13 FNA samples were monomorphic, with a single and
`uniform population of lymphoid cells ❚ Image 2B❚ , whereas
`small and large lymphoid cells were seen in the remaining
`FNA specimen (Image 2B). Rare lymphoglandular bodies,
`which represent aggregations of lymphoid cell cytoplasm
`without nuclei, were seen in 4 cases (all were large cell
`lymphoma). Against the lymphoid background, cell aggre-
`gates reminiscent of epithelial cell clusters also were noted in
`8 FNA samples. The cytomorphologic features of the cells
`
`22 Am J Clin Pathol 2001;115:18-31
`
`© American Society of Clinical Pathologists
`
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`

`Anatomic Pathology / ORIGINAL ARTICLE
`
`A
`
`C
`
`B
`
`D
`
`❚ Image 2❚ Cytomorphologic features of renal lymphoma. A, Abundant lymphoid cells, which are noncohesive and distributed
`evenly and uniformly. Rare lymphoglandular bodies, which represent clusters of lymphoid cell nuclei without cytoplasm, are
`noted. The lymphoid cells display large nuclei, fine chromatin, and constant nuclei, suggestive of large cell lymphoma (Papanico-
`laou, ×3,364). B, A mixture of small and large lymphoid cells is noted (rapid Romanowsky, ×3,364). C, Cell aggregates reminis-
`cent of epithelial cell clusters sometimes are noted. The cytomorphologic features of the cells forming these clusters is,
`however, identical to that of those in the background, indicating their lymphoid nature (Papanicolaou, ×3,364). D, One fine-
`needle aspiration specimen shows aggregates of lymphoid cells with ample cytoplasm and spindle or cuboidal nuclei, highly
`reminiscent of epithelial cells (Papanicolaou, ×3,364). Image 2 continues on page 24.
`
`forming these clusters were, however, identical to that of
`those in the background, indicating their lymphoid nature
`❚ Image 2C❚ . These clusters were rare in general but were
`quite numerous in 2 FNA samples. One FNA specimen
`showed several lymphoid cells with ample cytoplasm and
`spindled or cuboidal nuclei, highly reminiscent of epithelial
`cells ❚ Image 2D❚ . Aside from lymphoid cells, rare tubular
`cells were noted in 2 FNA samples ❚ Image 2E❚ , whereas
`some glomeruli and abundant tubular cells, some of which
`
`were associated with lymphoid cells, were noted in another.
`The smears also displayed features that helped identify indi-
`vidual lymphoma types. These features included ample cyto-
`plasm, large nuclei with frequent nucleoli, and fine nuclear
`chromatin for the large cell type (Image 2A); scant cyto-
`plasm and small round nuclei with clumped and dense chro-
`matin for the small lymphocytic type ❚Image 2F ❚ ; scant cyto-
`plasm and an irregular or angulated nuclear contour for the
`small cleaved type ❚ Image 2G❚ ; and vacuolated cytoplasm
`
`© American Society of Clinical Pathologists
`
`Am J Clin Pathol 2001;115:18-31 23
`
`NOVARTIS EXHIBIT 2028
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`

`Truong et al / FINE-NEEDLE ASPIRATION OF RENAL LYMPHOMA
`
`E
`
`G
`
`F
`
`H
`
`(cont) E, A cluster of tubular cells against a background of scanty lymphoid cells (Papanicolaou, ×3,364). F, Well-differ-
`❚ Image 2❚
`entiated lymphocytic lymphoma characterized by small lymphocytes with scant cytoplasm and small round nuclei with clumped
`and dense chromatin (Papanicolaou, ×3,364). G, Small cleaved-cell lymphoma characterized by the presence of some lympho-
`cytes with scanty cytoplasm and irregular or angulated nuclear contour (Papanicolaou, ×3,364). H, Small noncleaved lymphoma
`cells with vacuolated cytoplasm and round nuclei with clump chromatin and absence of nucleoli (rapid Romanowsky, ×3,364).
`
`and round nuclei with clumped chromatin and absence of
`nucleoli for the small noncleaved type ❚ Image 2H❚ . Histo-
`logic correlation (tissue cores in 4 and cell blocks in 2 FNA
`samples) not only confirmed the diagnosis of lymphoma but
`also helped determine the lymphoma types.
`The 3 FNA samples reported as suggestive of
`lymphoma (2 secondary RLs and 1 primary RL) displayed
`scant lymphoid cells, but these cells were similar to those
`identified in the positive FNA samples ❚Image 3A ❚ . In 1 of
`these cases (case 2), although the smears were suggestive of
`lymphoma, the final diagnosis of RL was made clinically in
`view of the previous diagnosis of systemic large cell
`
`lymphoma. In the 2 remaining cases (6 and 13), the corre-
`sponding tissue cores or cell blocks provided the final diag-
`noses ❚Image 3B ❚ ❚
`Image 3C❚ .
`In the FNA samples originally diagnosed as TCC,
`although typical lymphoid cells were retrospectively identi-
`fied, the smears were dominated by “epithelioid” cell clus-
`ters and isolated spindle cells ❚Image 4A ❚ ❚Image 4B ❚ ❚Image
`4C❚ . Nephrectomy provided the correct diagnosis of primary
`RL ❚Image 4D ❚ ❚Image 4E ❚ .
`The single follow-up FNA (case 5), done 6 months after
`chemotherapy, showed mixed populations of lymphoid cells
`(small lymphocytes, large lymphocytes, and plasma cells)
`
`24 Am J Clin Pathol 2001;115:18-31
`
`© American Society of Clinical Pathologists
`
`NOVARTIS EXHIBIT 2028
`Breckenridge v. Novartis, IPR 2017-01592
`Page 7 of 14
`
`

`

`Anatomic Pathology / ORIGINAL ARTICLE
`
`..
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`❚ Image 3❚ A fine-needle aspiration specimen suggestive of
`renal lymphoma. A, Scant lymphoid cells are seen, but these
`cells have large nuclei (Papanicolaou, ×3,364). B, The corre-
`sponding tissue core shows lymphoid cells separated by
`abundant connective tissue stroma. This type of stroma may
`account for the poor cellularity of the fine-needle aspiration
`specimen (H&E, ×1,682). C, The lymphoid cells are
`immunophenotyped uniformly as B lymphocytes
`(immunoperoxidase, ×1,682).
`
`and necrotic cells. They were polyclonal by flow cytometry
`(see “Phenotyping Studies”), and were most probably of
`reactive nature rather than residual lymphoma.
`
`confirmed the positive cytodiagnosis in 10 cases, confirmed
`the reactive cytodiagnosis in 1 case, and helped achieve a
`conclusive diagnosis in 2 cases suggestive of lymphoma.
`
`Phenotyping Studies
`Phenotyping by immunostaining on cytocentrifuged
`smears or tissue sections was performed for 13 FNA samples
`and, in each case, showed a predominance of B cells (60%-
`100%) and light chain restriction ❚ Image 5❚
`(Table 2). In 2
`cases (12 and 18), abundant T cells (up to 60%) were found,
`but the smears were typical for large cell lymphoma, and the
`diagnosis of B-cell lymphoma was confirmed by an obvious
`light chain restriction. Flow cytometry, performed on 4 FNA
`samples, showed a monoclonal B-cell pattern in 3 original
`FNA samples (cases 8-10) and a polyclonal pattern in 1
`follow-up FNA specimen (case 5). The phenotyping eluci-
`dated the B vs T lineage of the lymphoma in all tested cases,
`
`Gene Rearrangement Studies
`These studies, performed in 2 FNA samples (cases 12A
`and 9), showed light chain restriction.
`
`Discussion
`
`Although FNA to diagnose RL is clinically essential and
`is performed rather frequently, the pertinent literature is
`surprisingly scant. We found only 4 reports on renal FNA, in
`which 1 to 8 cases of RL were mentioned briefly.10-13 The
`present study, we believe, represents the first comprehensive
`communication on the FNA diagnosis of RL.
`
`© American Society of Clinical Pathologists
`
`Am J Clin Pathol 2001;115:18-31 25
`
`NOVARTIS EXHIBIT 2028
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`Page 8 of 14
`
`

`

`Truong et al / FINE-NEEDLE ASPIRATION OF RENAL LYMPHOMA
`
`A
`
`C
`
`E
`
`B
`
`D
`
`❚ Image 4❚ A fine-needle aspiration specimen diagnosed
`initially as transitional cell carcinoma. A, The smears are
`dominated by “epithelioid” cell clusters (Papanicolaou,
`×1,682). B, The clusters are composed of cells with round or
`spindled nuclei and ample cytoplasm. Bare nuclei of tumor
`cells are noted (upper right) (Papanicolaou, ×3,364). C, The
`rapid Romanowsky stain shows the same features (rapid
`Romanowsky, ×3,364). D, The nephrectomy specimen
`displays confluent lymphoid cells that “crowd out” renal
`tubules (H&E, ×3,364). E, The lymphoid cells are
`immunophenotyped uniformly as B cells, whereas the
`remaining tubules are not stained (immunoperoxidase,
`×3,364).
`
`26 Am J Clin Pathol 2001;115:18-31
`
`© American Society of Clinical Pathologists
`
`NOVARTIS EXHIBIT 2028
`Breckenridge v. Novartis, IPR 2017-01592
`Page 9 of 14
`
`

`

`A
`
`B
`
`Anatomic Pathology / ORIGINAL ARTICLE
`
`❚ Image 5❚ Light chain immunophenotyping of cytocentrifuged preparations. A, The aspirated lymphoid cells are uniformly nega-
`tive for kappa light chain (immunoperoxidase, ×3,364). B, Most of these cells express lambda light chain (immunoperoxidase,
`×3,364).
`
`Clinical Settings for FNA of RL
`The present study highlights the clinical settings in
`which FNA is instrumental for the diagnosis of RL. In 10
`(53%) of 19 cases, FNA was performed to confirm renal
`involvement in patients with known lymphoma (secondary
`RL). The kidney often is affected during the course of
`systemic lymphoma, with an incidence between 34% and
`62% and 3% and 8% in autopsy and renal imaging studies,
`respectively.1-4 In the majority of cases, the typical renal
`imaging findings, in conjunction with a known history of
`lymphoma, warrant a conclusive diagnosis. However, renal
`masses in a patient with systemic lymphoma may represent
`lesions other than lymphoma such as infarct, infection,
`abscess, pyelonephritis, hydronephrosis, or even a renal cell
`carcinoma (RCC).4 Up to a 10-fold increase in the incidence
`of RCC has been noted in patients with systemic
`lymphoma.14 FNA is the best method to document RL
`unequivocally in this clinical setting. FNA to document
`secondary RL is a relatively common procedure; Gattuso et
`al10 noted that RL accounted for 29% of 28 cases of renal
`“metastases” diagnosed by FNA.
`FNA also is performed to document primary RL, as
`shown in 8 (42%) of the 19 present cases. Primary RL is
`defined as a lymphoma that manifests with signs and symp-
`toms related to the kidney.4,15-19 Morel et al1 identified 3
`primary lesions in a series of 48 RLs, and Dimopoulos et al19
`reported 6 primary RLs of 200 tumors initially thought to be
`RCCs. These observations and our own data indicate that
`primary RL is not as rare as previously assumed. Since
`primary RL, as in the case of secondary RL, usually responds
`dramatically to chemotherapy, the standard treatment for
`
`most renal neoplasms by nephrectomy is contraindicated.9,10
`A precise diagnosis is, therefore, essential before planning
`the treatment for primary RL and is best provided by FNA.
`The possibility of primary RL may be suggested by subtle
`clinical and/or renal imaging clues as seen in our cases, ie,
`acute renal failure associated with bilateral massive renal
`enlargement, multifocal and/or bilateral lesions, predomi-
`nantly perirenal plaques, extrarenal extension, and large hilar
`adenopathy. These features, which are unusual for other renal
`neoplasms including RCC, should prompt clinical considera-
`tion of primary RL and an FNA to prove it.
`Lymphoma may develop in a transplanted kidney and
`can be diagnosed by FNA, as demonstrated in 1 case (5%) in
`our study.20 Posttransplant lymphoproliferative disorder is
`defined as nodal or extranodal lymphoid proliferation that
`occurs after bone marrow or solid organ transplantation and
`displays a morphologic spectrum encompassing benign,
`borderline, and malignant lesions (lymphoma).8 The
`lymphoma may be polymorphic or monomorphic.8 The
`development of posttransplant lymphoproliferative disorder
`probably is related to therapeutic suppression of T-cell func-
`tion necessary for graft maintenance.8 The immunosuppres-
`sion facilitates infection of B lymphocytes by Epstein-Barr
`virus, an oncogenic virus that promotes B-cell proliferation.
`This proliferation is polyclonal (benign and reactive) at the
`onset but may switch to monoclonal (lymphoma) in response
`to factors thus far unknown. About 1% of renal transplant
`recipients develop posttransplant lymphoproliferat