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Lymphoma masquerading as a recurrent brachial artery aneurysm
case report N. Fassiadis1 D. Ananos2 H. Zayed1 H. Rashid1 1
Department of Vascular Surgery, King’s College Hospital, London 2 Department of General Surgery, Belfast Cit ityy Ho Hosp spit ital al Correspond dence to: Mr Nicho olas la Fassiadis King’s Co olle l ge Hospital, Departm me of Vascular ment me Surg Su rger rg eryy, Denmark Hill, er London o SE5 9RS Tel: +44 4 (0)7968037711 Emaiil: n as nf [email protected] rg.u rg uk
LYMPHOMA MASQUERADING AS A RECURRENT BRACHIAL ARTERY ANEURYSM Malignant lymphoma inltrating the brachial artery in a renal transplant patient has not been documented previously. We report an angiodestructive B-cell lymphoma in a 64-year-old post-renal transplant recipient. Improved longevity post-transplantation has been associated with an increased incidence of cancer which means that we will be seeing such patients more frequently in the future. keywords: angiodestructive lymphoma, renal transplant, aneurysm Surgeon, 1 June 2008 182-83
Introduction There is a well-known relationship between renal transplantation and the subsequent development of lymphoma, which has been attributed to the longterm use of immunosuppressants.1 The overall rate of lymphoma is 33/10,000 person-years in transplant patients with the highest prevalence within the first 12 months post- transplant, after which the risk of lymphoma decreases.2 The development of abdominal aortic aneurysms in post-renal transplant recipients has also recently been documented with a prevalence of 1%.3 We describe a case of an angiodestructive B-cell lymphoma mimicking clinically and on imaging a thrombosed aneurysm arising in a 64-year-old patient, 21 years after cadaveric renal transplantation.
Case report A 64-year-old male patient presented in April 2004 with an acutely painful mass over his right antecubital fossa. He was known to our vascular department as he had a right brachial artery aneurysm, which was under surveillance and had required ligation in 1998 due to distal embolisation. His past medical history included Bartter’s syndrome, which lead to end stage renal failure requiring a right cadaveric renal transplant in 1983 at the age of 43. In March 2004 the patient developed a left iliofemoral deep vein thrombosis which extended into the inferior vena cava (IVC). At that time bilateral iliac artery aneurysms were detected (left 6.3cm, right 3.3cm). After insertion of an IVC filter, a bilateral iliac artery aneurysm repair was performed with an aorto-iliac-femoral bypass under temporary left axillary to right femoral artery bypass for protection of the transplanted kidney. The patient was also known to suff ffer from a right subclavian artery aneurysm, measuring 2.5cm, and an axillary artery aneurysm of 4.15cm. His regular post-renal transplant medication included azathio182 |
the royal colleges of surgeons of edinburgh and ireland
prine 75mg once daily, prednisolone 10mg once daily, cyclosporin A 50mg twice per day, atenolol 100mg once daily, aspirin 75mg once daily and phosphate supplementation. Physical examination confi firmed the presence of an antecubital mass which was tender and exhibited all signs of inflammation. fl A provisional diagnosis of an infected/thrombosed aneurysm was made which was confi firmed on duplex and MRI (Figure 1). An urgent right brachial aneurysmectomy was performed on the same day which appeared macroscopically to be a completely thrombosed aneurysm with extensive infl flammatory changes. The Th specimen was fully excised and sent for histological evaluation. The final histology report described a high grade, angiocentric and angiodestructive type of large cell lymphoma of B-cell phenotype probably representing post-transplantation lymphoproliferative disease in keeping with the clinical history of immunosuppresion following renal transplantation. The malignant lymphoid cells were strongly positive Th for Epstein–Barr virus. Unfortunately the patient went into multiorgan failure post-operatively triggered by Klebsiella pneumonia. Chest x-rays also showed evidence of pulmonary lymphoma infiltration. fi He finally passed away one month later whilst receiving treatment in the intensive therapy unit.
Discussion Angiocentric lymphomas are a heterogeneous group of haematolymphoid malignancies that share the histological characteristics of an angiocentric or perivascular growth pattern. They Th include a variety of T-cell lymphomas, B-cell lymphomas and natural killer cell derived lymphomas.4 The B-cell variation more frequently involves the lungs, skin and central nervous system.5 © 2008 Surgeon 6; 3: 182-3
Figure 1. MRI (coronal view) suggestive of infected/thrombosed brachial aneurysm or possibly a sarcoma as a radiological differential diagnosis Previous case reports have shown similar tumours being mistaken for infl flammatory processes.6,7 A true infection though might be superimposed in the presence of immunosuppression. We identifi fied previous reports associating post-renal transplant patients with aneurysms (ruptured intracranial aneurysm, dissection of the thoracic ascending aorta, dissection of the abdomianl aorta).8,9 All of the above were incidental findings and no histological examination was performed. There is only one other case in the literature describing a T-cell lyphoma infiltrating fi the abdominal aorta resulting in an aneurysm which was excised with subsequent histological evaluation of the aortic wall.10 To the best of our knowledge the present case report is the only one describing an angiocentric and angiodestructive lymphoma causing a brachial aneurysm in a post-renal transplantation patient.
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REFERENCES 1. Caillard S, Dharnidharka V, Agodoa L et al. Posttransplant lymphoproliferative disorders after renal transplantation in the United States in era of modern immunosuppression. Transplantation 2005; 80(9): 1233-43 2. Smith JM, Rudser K, Gillen D et al. Risk of Lymphoma after Renal Transplantation Varies with Time: An Analysis of the United States Renal Data System. Transplantation 2006; 81(2): 175-80 3. Favi E, Citterio F, Tondolo V et al. Abdominal aortic aneurysm in renal transplant recipients. Transplant Procc 2005; 37(6): 2488-90 4. Natkunam Y, Warnke RA. Angiocentric lymphomas (lymphomatous vasculitis). Semin Diagn Pathol 2001; 18(1): 67-77. Review.
© 2008 Surgeon 6; 3: 182-3
Ogata A. Central nervous system lymphomatoid granulomatosis. Rinsho Shinkeigaku 2002; 42(11): 1127-30 Laetsch B, Hofbauer G, Kempf W et al. Atypical poorly differentiated cutaneous T-cell lymphoma with an angiocentric growth pattern presenting histologically as vasculitis. Dermatology 2005; 210(4): 341-5 Jia H, Sun T. Extranodal NK/T-cell lymphoma mimicking cellulitis. Leuk Lymphoma 2004; 45(7): 1467-70 Beleva B, Stefanov G, Iakimov A et al. A case of malignant intestinal lymphoma following a successful kidney transplant. Khirurgiia (So oia) 1991; 44(4): 33-6 Fitzpatrick PM, Torres VE, Charboneau JW et al. Long-term outcome of renal transplantation in autosomal dominant polycystic kidney disease. Am J Kidney Dis 1990; 15(6): 535-43 Luo CY, Ko WC, Tsao CJ et al. Epstein-Barr virus-containing T-cell lymphoma and atherosclerotic abdominal aortic aneurysm in a young adult. Hum Patholl 1999; 30(9): 1114-7
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Department of Vascular Surgery, King’s College Hospital, London 2 Department of General Surgery, Belfast Cit ityy Ho Hosp spit ital al Correspond dence to: Mr Nicho olas la Fassiadis King’s Co olle l ge Hospital, Departm me of Vascular ment me Surg Su rger rg eryy, Denmark Hill, er London o SE5 9RS Tel: +44 4 (0)7968037711 Emaiil: n as nf [email protected] rg.u rg uk
LYMPHOMA MASQUERADING AS A RECURRENT BRACHIAL ARTERY ANEURYSM Malignant lymphoma inltrating the brachial artery in a renal transplant patient has not been documented previously. We report an angiodestructive B-cell lymphoma in a 64-year-old post-renal transplant recipient. Improved longevity post-transplantation has been associated with an increased incidence of cancer which means that we will be seeing such patients more frequently in the future. keywords: angiodestructive lymphoma, renal transplant, aneurysm Surgeon, 1 June 2008 182-83
Introduction There is a well-known relationship between renal transplantation and the subsequent development of lymphoma, which has been attributed to the longterm use of immunosuppressants.1 The overall rate of lymphoma is 33/10,000 person-years in transplant patients with the highest prevalence within the first 12 months post- transplant, after which the risk of lymphoma decreases.2 The development of abdominal aortic aneurysms in post-renal transplant recipients has also recently been documented with a prevalence of 1%.3 We describe a case of an angiodestructive B-cell lymphoma mimicking clinically and on imaging a thrombosed aneurysm arising in a 64-year-old patient, 21 years after cadaveric renal transplantation.
Case report A 64-year-old male patient presented in April 2004 with an acutely painful mass over his right antecubital fossa. He was known to our vascular department as he had a right brachial artery aneurysm, which was under surveillance and had required ligation in 1998 due to distal embolisation. His past medical history included Bartter’s syndrome, which lead to end stage renal failure requiring a right cadaveric renal transplant in 1983 at the age of 43. In March 2004 the patient developed a left iliofemoral deep vein thrombosis which extended into the inferior vena cava (IVC). At that time bilateral iliac artery aneurysms were detected (left 6.3cm, right 3.3cm). After insertion of an IVC filter, a bilateral iliac artery aneurysm repair was performed with an aorto-iliac-femoral bypass under temporary left axillary to right femoral artery bypass for protection of the transplanted kidney. The patient was also known to suff ffer from a right subclavian artery aneurysm, measuring 2.5cm, and an axillary artery aneurysm of 4.15cm. His regular post-renal transplant medication included azathio182 |
the royal colleges of surgeons of edinburgh and ireland
prine 75mg once daily, prednisolone 10mg once daily, cyclosporin A 50mg twice per day, atenolol 100mg once daily, aspirin 75mg once daily and phosphate supplementation. Physical examination confi firmed the presence of an antecubital mass which was tender and exhibited all signs of inflammation. fl A provisional diagnosis of an infected/thrombosed aneurysm was made which was confi firmed on duplex and MRI (Figure 1). An urgent right brachial aneurysmectomy was performed on the same day which appeared macroscopically to be a completely thrombosed aneurysm with extensive infl flammatory changes. The Th specimen was fully excised and sent for histological evaluation. The final histology report described a high grade, angiocentric and angiodestructive type of large cell lymphoma of B-cell phenotype probably representing post-transplantation lymphoproliferative disease in keeping with the clinical history of immunosuppresion following renal transplantation. The malignant lymphoid cells were strongly positive Th for Epstein–Barr virus. Unfortunately the patient went into multiorgan failure post-operatively triggered by Klebsiella pneumonia. Chest x-rays also showed evidence of pulmonary lymphoma infiltration. fi He finally passed away one month later whilst receiving treatment in the intensive therapy unit.
Discussion Angiocentric lymphomas are a heterogeneous group of haematolymphoid malignancies that share the histological characteristics of an angiocentric or perivascular growth pattern. They Th include a variety of T-cell lymphomas, B-cell lymphomas and natural killer cell derived lymphomas.4 The B-cell variation more frequently involves the lungs, skin and central nervous system.5 © 2008 Surgeon 6; 3: 182-3
Figure 1. MRI (coronal view) suggestive of infected/thrombosed brachial aneurysm or possibly a sarcoma as a radiological differential diagnosis Previous case reports have shown similar tumours being mistaken for infl flammatory processes.6,7 A true infection though might be superimposed in the presence of immunosuppression. We identifi fied previous reports associating post-renal transplant patients with aneurysms (ruptured intracranial aneurysm, dissection of the thoracic ascending aorta, dissection of the abdomianl aorta).8,9 All of the above were incidental findings and no histological examination was performed. There is only one other case in the literature describing a T-cell lyphoma infiltrating fi the abdominal aorta resulting in an aneurysm which was excised with subsequent histological evaluation of the aortic wall.10 To the best of our knowledge the present case report is the only one describing an angiocentric and angiodestructive lymphoma causing a brachial aneurysm in a post-renal transplantation patient.
5.
6.
7.
8.
9.
Copyright © 21 February 2007 10.
REFERENCES 1. Caillard S, Dharnidharka V, Agodoa L et al. Posttransplant lymphoproliferative disorders after renal transplantation in the United States in era of modern immunosuppression. Transplantation 2005; 80(9): 1233-43 2. Smith JM, Rudser K, Gillen D et al. Risk of Lymphoma after Renal Transplantation Varies with Time: An Analysis of the United States Renal Data System. Transplantation 2006; 81(2): 175-80 3. Favi E, Citterio F, Tondolo V et al. Abdominal aortic aneurysm in renal transplant recipients. Transplant Procc 2005; 37(6): 2488-90 4. Natkunam Y, Warnke RA. Angiocentric lymphomas (lymphomatous vasculitis). Semin Diagn Pathol 2001; 18(1): 67-77. Review.
© 2008 Surgeon 6; 3: 182-3
Ogata A. Central nervous system lymphomatoid granulomatosis. Rinsho Shinkeigaku 2002; 42(11): 1127-30 Laetsch B, Hofbauer G, Kempf W et al. Atypical poorly differentiated cutaneous T-cell lymphoma with an angiocentric growth pattern presenting histologically as vasculitis. Dermatology 2005; 210(4): 341-5 Jia H, Sun T. Extranodal NK/T-cell lymphoma mimicking cellulitis. Leuk Lymphoma 2004; 45(7): 1467-70 Beleva B, Stefanov G, Iakimov A et al. A case of malignant intestinal lymphoma following a successful kidney transplant. Khirurgiia (So oia) 1991; 44(4): 33-6 Fitzpatrick PM, Torres VE, Charboneau JW et al. Long-term outcome of renal transplantation in autosomal dominant polycystic kidney disease. Am J Kidney Dis 1990; 15(6): 535-43 Luo CY, Ko WC, Tsao CJ et al. Epstein-Barr virus-containing T-cell lymphoma and atherosclerotic abdominal aortic aneurysm in a young adult. Hum Patholl 1999; 30(9): 1114-7
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