Concurrent Lymphoma and Transitional Cell Carcinoma?

Joseph A. Sparano, MD

Disclosures

August 07, 2001

Question

A 52-year-old male was diagnosed with bulky right-sided mediastinal diffuse large-cell lymphoma. The right hilar mass envelopes the upper, middle, and lower lobe bronchi; it extends to the subcarina and envelopes the right pulmonary artery and superior vena cava below the azygous. There are multiple nodules at the right upper lobes, with the largest measuring 3x5 cm. Biopsied specimens were all from the hilar mass. A 5x5-cm transitional cell carcinoma of the right renal pelvis was also found.

The patient is ambulatory and at home, has exertional dyspnea with occasional blood-tinged sputum, and has lost 15 lb in the last 2 months. He has occasional hematuria, an elevated LDH, and a creatinine of 1.6.

Which tumor should be treated first? What is the best treatment for each?

Response from Joseph A. Sparano, MD

This is a difficult case that poses several diagnostic/therapeutic dilemmas. It is conceivable that both the lymphoma and the transitional cell carcinoma are potentially curable. However, the presence of the multiple right upper lobe nodules accompanied by hemoptysis is somewhat unusual for lymphoma, raising the question as to whether these are metastatic lesions from the transitional cancer or perhaps even a third primary cancer in the lung.

Given the symptomatology attributed to the lymphoma and the rapidly responding nature of this disease, it would be reasonable to initiate treatment of the lymphoma with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) immediately. If this is a B-cell lymphoma, the addition of rituximab would also seem reasonable given the results of the recent Groupe d'Etudes des Lymphomes de l'Adulte (GELA) study,[1] although one would need to proceed with caution because of the risk of a pulmonary reaction associated with rituximab.

If the right upper lobe lung nodules disappear after treatment with CHOP, it would suggest that they are a result of the lymphoma. Of course, a biopsy confirming this prior to treatment would be desirable.

After the lymphoma is under control, a right nephrectomy may be necessary to treat the transitional cell carcinoma of the right renal pelvis. If hematuria becomes problematic, the patient might benefit from embolization of the right kidney if feasible.

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