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February 1985, Volume 35, Issue 2

Case Reports

Non Hodgkin Lymphoma Detected by Renal Flow Study-A Case Report

Mahfooz Akhtar  ( Atomic Energy Medical Centre, Mayo Hospital, Lahore. )
Maqbool Shahid  ( Atomic Energy Medical Centre, Mayo Hospital, Lahore. )

Abstract

A patient having a tumour in the right para-aortic region (proved to be a non-Hodgkin Lymphoma on biopsy) was for the first time detected by a non-invasive, isotope study with TC99m MMSA for renal blood flow. The lesion was outlined due to displacement of aorta and involvement of the upper pole of the right kidney as seen 15 seconds after the I.V. injection of MMSA (JPMA 35:51, 1985).

Introduction

The technique of taking sequential pictures over the kidneys after giving an intravenous injection of pertechnetate was first used in 1.966 to find out the state of renal blood flow in the transplanted kidney1. The technique has the advantage of giving more or less similar information noninvasively as obtained by aortography which is an invasive technique and is also contraindicted in cases of renal function impairment. Later on the pertechnetate was substituted for Tc99m -Glucoheptonate which gives the same information as pertechnetate about the transit through the renal tissue and at the same time gives a static image of the kidney at the conclusion of the study2.
This technique was later on used for detecting extent of renal injuries3 and differen­tiating between vascular and avascular focal defect in the kidney4.
At the Atomic Energy Medical Centre, Mayo Hospital, we have used Tc99m-Monomer. captosuccinic acid (MMSA) both for the renal flow study and renal imaging.5 The advantage is that both these tests are performed by a single injection of radiopharmaceutical. MMSA is excreted by the kidney tubules and is an ideal substance for renal imaging. The patient is positioned under the Gamma Camera in prone position with a pillow under his abdomen and the detector focused to view both the kidneys and the area around. After an injection of Tc99m MMSA (5 mci) immediate sequential pictures are taken at the intervals of 5 seconds for one minute obtaining 12 frames, and a static picture is taken after about 15 minutes to complete the study.

Case Report

A 25 years old lady was admitted in the hospital with a history of pain in the right lumber region. The pain gradually became severe and sometimes the symptoms of acute intestinal obstruction would appear. On clinical examination the only positive finding was some tenderness in the right lumbar region right iliat fossa and epigastrium. No mass was palpable. The leucocyte count was 9000. H=-1 2.56 G% X-Ray lumbar spine was normal intravenous pyelogram showed normal excretion on both the sides (Fig. 1).


The patient was referred to the Atomic Energy Medical Centre, Mayo Hospital for radioisotope studies. The routine renogram with I131 Hippuran showed no significant abnormality except that the secretory and excretory phase on the right side were slightly delayed but were still within the normal limits (Fig.2).

A colour scan done with Hg197 Neohydrin revealed a crescenteric focal defect on the medial border of the upper pole of the right kidney. Both the kidneys were otherwise normal in site, size, shape and function (Fig. 3).


A sequential dynamic scintigraph was then done on the Gamma Camera after an injection of 5 mci of Tc99m MMSA. Five seconds pictures were taken for one minute. The 15-20 seconds post injection frame revealed the displacement of abdominal aorta to the left side in the region just above the kidneys. The upper pole of the right kidney showed an avascular area involving most of its medial part. The area between the displaced aorta and “nibbed” upper part of the right kidney clearly indicated the presence of a space-occupying lesion as there was much less background radioactivity as compared to the contralateral region on the left side (Fig. 4).

Laparatomy was performed which revealed an infiltrating growth arising in the right lumbar region, involving upper pole of the right kidney, porta hepatis, lesser omentum and was crossing the midline over to the left side. The bistopathology showed a non-Hodgkin diffuse, mixed cell lymphoma.

Discussion

The most important point to be stressed in the report is, the non-invasiveness of the technique like most of the other isotope procedures.

References

1. Rosenthal, L. Radionucide angiography as a method for detecting relative difference in renal flow. J. Canad.Ass. RadioL, 1968; 19 8.
2. Rosenthal, L. Radiotechnetium renogr7 hy in Renovascular Hypertention, Radionuclid adies of Germitoimmunary. New York, Grune and Stratton, 1974.
3. Mordecai, et al. Traumatic Injuries of the Renal Vasculature and Parenchyme. Radionuclide studies of the Germitoirninunary system. New York Grune and Stratton, 1974.
4. Jose, 0. Marales. Space occupying Lesions of the Kidney. Radionuclide studies of the Germitoimmunary system. New York, Grune and Stratton, 1974.
5. Faiz-ur-Rehman, et al. Technetium-99m-Sn-Mono mercaptosuccinic Acid (MMSA)A potential Radiopharmaceutical for Renal Studies. J. Nucl. Med., 1982; 23 72.

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