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Erythropoietin Secreting Tumor or Renal Lymphoma? Our Case of the Month May 2014

Case Of the Month

Erythropoietin Secreting Tumor or Renal Lymphoma? Our Case of the Month May 2014

A 7-year-old FS Beagle was presented for vomiting, lethargy, and anorexia. Blood chemistry showed a high creatinine, hypercalcemia (not ionized), hypoalbuminemia, and hyperglobulinemia. CBC showed polycythemia with a hematocrit of 65%.

A 7-year-old FS Beagle was presented for vomiting, lethargy, and anorexia. Blood chemistry showed a high creatinine, hypercalcemia (not ionized), hypoalbuminemia, and hyperglobulinemia. CBC showed polycythemia with a hematocrit of 65%.

DX

Renal Lymphoma

Outcome

Ultrasound-guided FNA revealed renal lymphoma The patient was somewhat stable on CCNU and prednisone therapy months after diagnosis of renal lymphoma.

Erythropoietin levels were not taken in this patient however EPO hypersecretion was suspected given the clinical presentation.

Comments

 
 

So how is it that polycythemia was present in this case of renal lymphoma?

See what Dr. Remo Lobetti (http://sonopath.com/about/specialists/remo-lobetti-bvsc-mmedvet-phd-decvim) pulled up from his library to explain it out.

Based on the paper: Durno AS, Webb JA, Gauthier MJ, Bienzle D. Polycythemia and inappropriate erythropoietin concentrations in two dogs with renal T-cell lymphoma. J Am Anim Hosp Assoc. 2011;47:122-128. Two dogs presented with suspected renal disease and polycythemia. Abdominal ultrasound examinations performed on both dogs revealed coalescing masses causing bilateral renomegaly. Serum erythropoietin (EPO) concentrations were physiologically inappropriate. Postmortem examinations revealed renal T-cell lymphoma in both dogs. One of the two dogs also had involvement of the liver and mesentery. EPO-immunohistochemistry on tissue samples demonstrated positive staining in tumor cells and occasional normal renal cells. This report illustrates that paraneoplastic EPO production may induce polycythemia. The pattern of EPO-immunohistochemistry staining suggested that the mechanism of production was due to tumor production of EPO and local hypoxia-induced EPO production from compression of normal renal cells and vasculature.

 

Clinical Differential Diagnosis

Renal, chronic kidney disease, pyelonephritis, neoplasia. Hypercalcemia, neoplasia, granulomatous desease, hyperparathyroidism, renal disease. Polycythemia, vera, secondary (pulmonary disease, erythropoietin producing tumor).

Sampling

US-guided FNA revealed renal lymphoma.

Sonographic Differential Diagnosis

Renal neoplasia. Given the polycythemia suspect erythropoietin secreting tumor. Renal lymphoma or other round cell neoplasia possible.

Image Interpretation

The right kidney in this patient presented a mixed, hypoechoic mass that measured 10.4 x 8.08 cm with hyperechoic surrounding fat. The right kidney was completely infiltrated with a separate mass that measured 4 x 2.69 cm. Pyelectasia was noted in the right kidney and measured 1.08 cm. The right kidney measured 10.28 cm. Complete disruption of the corticomedullary junction and renal pelvis was noted. The left kidney was also enlarged with mild degenerative changes and pyelectasia that measured 0.5 x 1.5 cm. The left kidney measured 5.11 cm.

UA Specific Gravity Range

1.018

Patient Information

Gender : Female, Spayed
Species : Canine

History

  • Anorexia
  • Lethargy
  • Vomiting

Images

image_1_ginger_bevilacqua_renal_eythropoitein_tumorimage_2_ginger_bevilacqua_renal_eythropoitein_tumor_2

Blood Chemistry

  • Albumin, Low
  • Calcium, High
  • Creatinine, High
  • Globulin, High

CBC

  • Hematocrit, High