PMC5537377_01
An enhances CTscan of the two right sided renal transplants. The patient had an extensive transplant history with both a (A) Right Iliac Transplant and a (B) Right Retroperitoneal Transplant. Her last transplantation was in 2002 when she received a left sided iliac transplant after a prior left iliac transplant nephrectomy. Both the right sided allografts were non-functional at the time of transplantation in 2002.
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The patient also had 2 right non-functioning cadaveric kidneys remaining in her right iliac fossa and retroperitoneum (Fig. 1).
A contrast enhanced CT scan of the patient's abdomen at the time of presentation. The mass was found to measure 13 x 13 x 19 cm on the right side of the abdomen. (A) Lower Retroperitoneal Mass: There is demonstrated involvement of a failed right-sided iliac kidney allograft. This appears grossly expanded and distorted. There are cystic regions within the mass that are most likely related to necrosis. (B) Mid Retroperitoneal Mass: The mass is causing soft tissue abnormalities within the retroperitoneum at the level of the duodenum and appears to involve the right retroperitoneal renal allograft. (C) Upper Retroperitoneal Mass: The liver is homogenous in appearance, with mild intra- and extrahepatic biliary duct dilation. There is mass effect on the pancreas with prominence of the pancreatic duct. Native right kidney is present, atrophic and does not appear to be involved by the mass.
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A contrast enhanced CT scan revealed a large right sided lower abdominal mass which crossed the midline, and was associated with paracaval lymphadenopathy (Fig. 2).
A non- enhanced serial CT scan of the patient's abdomen after 4 cycles of rituxumab. Marked improvement in the appearance of the abdomen had occurred since the previous examination (see Fig. 2). (A): Lower Retroperitoneal Mass: An atrophic transplanted kidney is again identified. There is residual soft mass in the right retroperitoneum that is significantly smaller than at the time of presentation. The left-sided iliac fossa renal transplant appears to be functioning well. (B): Mid Retroperitoneal Mass: Bifurcated vessels are apparent within the mid portion of the retroperitoneal mass involving the retroperitoneal transplanted kidney above the right iliac transplanted kidney. Soft- tissue abnormalities appear to be significantly improved, with no obvious apparent lymphadenopathy. (C): Upper Retroperitoneal Mass: The liver demonstrates diffuse increased attenuation consistent with increased iron deposition, reflecting possible hemosiderosis. The native kidney is displaced by the retroperitoneal mass involving the retroperitoneal placed renal allograft.
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After 4 cycles of therapy the patient underwent a follow-up CT scan of the abdomen and pelvis revealing marked improvement with significant regression of the mass which now measured 8.1 x 7.1 cm in maximum AP and transverse dimensions (Fig. 3).
A contrast enhanced CT of the patient's abdomen after completing an 8 cycle course of ritixumab. Marked improvement in the appearance of the abdomen has occurred since initial presentation (see Fig. 2) but with ongoing, persistent residual tumor. (A): Lower Retroperitoneal Mass: The previously failed right iliac renal allograft is present along with the functioning normal left iliac allograft. The size of the right iliac allograft is smaller than previous scan done at the time of presentation (see Fig. 2). (B): Mid Retroperitoneal Mass: The right retroperitoneal allograft is slightly smaller in size measuring 7.0 x 7.0 x 10.0 cm with persistent psoas mass and paracaval lymphadenopathy. (C): Upper Retroperitoneal Mass: Right retroperitonal allograft with decreased mass effect on the adjacent abdominal organs is observed.
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After 4 more cycles of ritixumab the patient underwent another repeat CT scan of the chest, abdomen and pelvis (Fig. 4).
A non-enhanced CT scan of the patient's abdomen post resection. The right retroperitoneal masses have been cleared along with the psoas mass and paracaval lymphadenopathy. The patient has remained disease free with good renal allograft function since being treated with ritixumab, surgery and then CHOP chemotherapy.
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There were a few additional solid lesions at the medial aspect of these transplant kidneys, which had also markedly regressed, representing residual disease in enlarged lymph nodes (Fig. 5).