Extrahepatic biliary obstruction
`
`617
`
`Renal lymphoma: an unusual cause of extrahepatic
`biliary obstruction
`
`Z Abbas, DA Johnston, FE Murray
`
`Summary
`This report describes a case of lymphoma
`arising in a kidney subjected to previous
`pyelolithotomy, lithotripsies and percuta(cid:173)
`neous nephrolithotomy. The tumour had
`invaded the pancreas and duodenum,
`in extrahepatic biliary and
`resulting
`gastric outlet obstructions. Fine-needle
`apiration cytology guided by computed
`tomography failed to suggest the diagnosis
`which was confirmed only on laparotomy
`and open biopsy. Drainage procedures
`were performed to relieve the obstruc(cid:173)
`tions. To our knowledge this is the first
`case report of renal lymphoma presenting
`with extrahepatic biliary obstruction.
`
`Keywords: non-Hodgkin's
`struction, lithotripsy
`
`lymphoma, biliary ob(cid:173)
`
`Extrahepatic biliary obstruction is an uncom(cid:173)
`mon feature of non-Hodgkin's lymphoma with
`reported incidences of 1.6% 1 to 5.5%. 2 Pa(cid:173)
`tients with non-Hodgkin's lymphoma who
`jaundice usually have
`develop obstructive
`either primary disease of the gastrointestinal
`tract or widespread disease with lymph node
`involvement along the biliary tree. We report
`an unusual case of renal lymphoma presenting
`with obstructive jaundice.
`
`Case report
`
`A 49-year-old man was admitted to hospital in
`January 1994 with a three-week history of
`obstructive jaundice associated with nausea
`and vomiting. He had previously undergone a
`panproctocolectomy with ileostomy, because
`of intractable ulcerative colitis in 1965 and a
`right pyelolithotomy for a staghorn calculus in
`1983. Recurrent right-sided calculi had been
`treated with lithotripsy in 1985 and again in
`1988. In 1990 right percutaneous nephro(cid:173)
`lithotomy was performed, despite which he
`had repeated attacks of right loin pain asso(cid:173)
`ciated with urinary tract infections.
`On examination, he was deeply jaundiced
`with scratch marks. The gallbladder was
`palpable. There were no palpable lymph nodes.
`Pertinent laboratory data included total bilir(cid:173)
`ubin 191 µmoll 1; alanine aminotransferase
`653 µl; alkaline phosphatase 564 µl; gamma(cid:173)
`glutamyl transferase 563 µl; albumin 40 g/1;
`creatinine 126 µmol/1; full blood count was
`normal. The urine was positive for bilirubin.
`Ultrasonography of the abdomen demon-
`
`strated a dilated biliary tree, enlarged gallblad(cid:173)
`der and a large mass arising from the right
`kidney. A computed tomography (CT) scan
`confirmed the ultrasound findings and demon(cid:173)
`strated the mass distorting the right kidney,
`displacing the inferior vena cava and head of
`pancreas anteriorly and extending into the
`right lobe of liver. Moreover there was a loss
`of definition between the mass and the aorta.
`Fine-needle aspiration cytology of the mass
`reported a large number of inflammatory cells
`including neutrophils, plasma cells, and lym(cid:173)
`phocytes. Endoscopic retrograde cholangio(cid:173)
`pancreatography was prevented by extrinsic
`compression at the junction of first and second
`part of duodenum, which hindered passage of
`the scope into the second part of duodenum.
`Laparotomy revealed a large unresectable
`renal mass which had infiltrated the head of
`pancreas and duodenum. The biliary and
`gastric outlet obstructions were managed by
`cholecystojejunostomy and gastrojejunostomy.
`Biopsy of the renal mass showed high grade T
`cell lymphoma of immunoblastic type. The
`patient was treated with cyclophosphamide,
`doxorubicin, vincristine and prednisolone
`(CHOP regimen). Parenteral nutrition was
`initiated. His liver function tests returned to
`almost normal and a repeat CT scan after three
`weeks showed a 50% reduction of the tumour
`size. He was given two more courses of CHOP
`but unfortunately there was no further reduc(cid:173)
`tion of tumour mass. Despite a change in
`chemotherapy to mitoxantrone and iphospha(cid:173)
`the patient died, six months after
`mide
`definitive diagnosis.
`
`Discussion
`
`We describe a patient who presented with
`obstructive jaundice which is a most unusual
`manifestation of non-Hodgkin's lymphoma. A
`Medline search on the subjects of lymphoma,
`cholestasis and extrahepatic bile duct obstruc(cid:173)
`tion revealed 29 reports of patients with
`gastrointestinal lymphomas or widespread dis(cid:173)
`ease at the time of presentation (table). We
`could not find any previous report of renal
`lymphoma causing obstructive jaundice.
`Our patient had a history of intractable
`ulcerative colitis for which panproctocolect(cid:173)
`omy had been performed in 1965. Extra(cid:173)
`intestinal lymphomas have been found to occur
`with increased frequency in patients with
`inflammatory bowel disease, 11 possibly as a
`result of primary immunological defects, im-
`
`Gastroenterology Unit,
`Department of Clinical
`Pharmacology,
`Ninewells Hospital
`and Medical School,
`Dundee DDl 9SY, UK
`Z Abbas
`DA Johnston
`FE Murray
`
`Correspondence to Dr Frank
`Murray
`
`Accepted 3 January 1996
`
`NOVARTIS EXHIBIT 2030
`Breckenridge v. Novartis, IPR 2017-01592
`Page 1 of 2
`
`

`

`618
`
`Abbas, Johnston, Murray
`
`Table Extrahepatic biliary obstruction by
`non-Hodgkin's lymphomas
`
`Hepatobiliary manifestations of
`lymphoma
`
`Site of lymphomatous involvement
`
`Patients
`(n)
`
`Rej
`
`Pancreas
`
`Small intestine
`
`Stomach
`Gastroduodenal
`Periampullary region
`Common bile duct
`
`Widespread disease with
`lymph nodes involvement
`
`7
`3
`3
`1
`1
`1
`1
`1
`1
`1
`1
`2
`2
`2
`2
`
`3
`2
`4
`5
`6
`7
`1
`7
`8
`1
`9
`1
`2
`5
`10
`
`• hepatic infiltration by lymphoma
`• hepatic granulomatous disease
`• fulminant hepatic failure
`• biliary tract obstruction
`
`Learningt,mmmary points
`
`• lymphoma causing biliary tract obstruction is
`unusual
`• lymphoma arising from the kidney causing
`such obstruction has not been previously
`described
`
`munosuppressive therapy or frequent exposure
`to X-rays. 12 Our patient did not have any
`residual inflammatory bowel disease but he
`had frequently been exposed to X-rays to
`investigate urinary tract infections associated
`with renal calculi. His right kidney was also
`diseased and damaged, and had been subjected
`to multiple manipulations for recurrent calculi.
`In addition, lithotripsy was performed twice.
`However, we could find no report of any
`association between lithotripsy and possible
`tumourogenesis, and any possible causative
`role of lithotripsy must remain purely spec(cid:173)
`ulative.
`Our patient had a high-grade lymphoma.
`These aggressive lymphomas respond to ag(cid:173)
`gressive treatment. Complete remission may
`
`be expected in 60- 80% of cases with intensive
`combination regimens and long-term disease
`from survival in 30- 50% cases. 13 Our patient
`was given CHOP regimen which has been
`shown to be better than new second and third
`generation regimens. 14 Unfortunately he had
`many poor prognostic factors including large
`tumour size and 'T' cell type. 15 Moreover,
`renal lymphomas carry a poor prognosis due to
`rapid spread, and survival for more than one
`year is rare. 16 Our patient survived only six
`months after diagnosis. He presented with
`extrahepatic biliary obstruction which may also
`be considered as a poor prognostic sign as all
`patients with non-Hodgkin's lymphoma who
`presented with obstructive jaundice had poor
`long term survival.
`
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`secondary to malignant lymphoma: a problem in multi(cid:173)
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`EnglJ Med 1993; 328: 1023-30.
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`NOVARTIS EXHIBIT 2030
`Breckenridge v. Novartis, IPR 2017-01592
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