Primary adrenal lymphoma presenting as Addison's disease. Case report and review of the literature

Cinematic rendering of primary adrenal lymphoma

Primary adrenal lymphoma (PAL) is a particularly rare subset of malignant adrenal neoplasms, accounting for ∼1% of all non-Hodgkin's lymphomas. Reported outcomes of PAL, though limited, are dismal, with a 12-month survival rate of ∼20%. PAL is treated with polychemotherapy and early tissue diagnosis to allow initiation of chemotherapy is associated with improved outcomes. Early and accurate radiological diagnosis of PAL is therefore essential in improving outcomes through informing decisions to biopsy and thereby facilitating timely initiation of chemotherapy. To date, however, imaging features of PAL have not been conclusively defined, and a range of divergent imaging appearances have been reported. Cinematic rendering (CR) is a 3D post-processing technique that simulates the propagation and interaction of photons as they pass through the imaged volume. This results in the generation of more photorealistic images that may allow for more comprehensive visualization, description and interpretation of anatomical structures. This manuscript presents the first characterization of the various CR appearances of PAL in the reported literature and provides commentary on the clinical opportunities afforded by CR in the workup of these heterogenous tumors.

Three-dimensional CT cinematic rendering of adrenal masses: Role in tumor analysis and management

The adrenal gland is home to an array of complex physiological and neoplastic disease processes. While dedicated adrenal computed tomography (CT) is the gold standard imaging modality for adrenal lesions, there exists significant overlap among imaging features of adrenal pathology. This can often make radiological diagnosis and subsequent determination of the optimal surgical approach challenging. Cinematic rendering (CR) is a novel CT post-processing technique that utilizes advanced light modeling to generate highly photorealistic anatomic visualization. This generates unique prospects in the evaluation of adrenal masses. As one of the first large tertiary care centers to incorporate CR into routine diagnostic workup, our preliminary experience with using CR has been positive, and we have found CR to be a valuable adjunct during surgical planning. Herein, we highlight the unique utility of CR techniques in the workup of adrenal lesions and provide commentary on the opportunities and obstacles associated with the application of this novel display method in this setting.

[A CASE OF PRIMARY ADRENAL LYMPHOMA SUSPECTED AS ADRENAL METASTATIC TUMOR FROM GASTROINTESTINAL STROMAL TUMOR]

We present a case of 75 year's old man for whom small bowel resection was performed for a small intestinal tumor diagnosed as a gastrointestinal stromal tumor (GIST) with KIT exon 11 mutation and intermediate Miettinen risk. Computed tomography (CT) 18 months after surgery showed a right adrenal mass measuring 20 mm in size. Imatinib therapy couldn't show the tumor shrinkage, and the adrenal mass increased up to 37 mm in size 3 months later. He was referred to our department for further examination and treatment. We diagnosed this adrenal tumor as imatinib resistant GIST or adrenal primary malignancy and performed retroperitoneal laparoscopic right adrenalectomy. The pathological diagnosis was diffuse large B-cell lymphoma (DLBCL) not GIST and PET-CT revealed systemic metastasis of DLBCL one month later after surgery. Six courses of R-CHOP therapy achieved a complete response.

Bilateral Adrenocortical Carcinoma Presenting as Acute Adrenal Insufficiency

The presentation of adrenocortical carcinoma (ACC) with bilateral adrenal masses and acute adrenal insufficiency is exceedingly rare and has only been seen in anecdotal case reports. Herein, we describe the case of a 50-year-old male who presented with a painful abdominal lump, loss of weight and appetite, several episodes of vomiting, and hypotension. Imaging studies were suggestive of bilateral adrenal masses and a lung mass. Hormonal work-up was suggestive of acute adrenal insufficiency, with the adrenal masses being non-secretory. An ultrasound-guided biopsy from one of the adrenal masses was suggestive of ACC, thus confirming the diagnosis as bilateral ACC with distant metastases. Bilateral adrenalectomy was planned for the patient, but unfortunately, he succumbed to his disease before the surgery.

Primary adrenal lymphoma with secondary central nervous system involvement: a case report and review of the literature

Approximately 10%-20% of all systemic lymphomas have central nervous system (CNS) involvement, which has been correlated to a worsened prognosis. It is well known that secondary involvement of the adrenal glands may occur in up to 25% of patients during the course of diffuse lymphoma. Primary adrenal lymphoma (PAL), however, is a different entity, and it is defined as the presence of adrenal lymphoma without evidence of either nodal involvement or leukemia. It has been shown that this occurrence is rarely accompanied by extranodal involvement, such as in the CNS. PAL exhibits a tendency for CNS relapse and this possibility should be examined even before symptoms are present. Herein we present a patient with PAL and secondary CNS involvement.

Clinicopathological analysis of primary adrenal diffuse large B-cell lymphoma: effectiveness of rituximab-containing chemotherapy including central nervous system prophylaxis

BACKGROUND

Primary adrenal lymphoma (PAL) is an extremely rare subtype of extranodal non-Hodgkin's lymphoma. Some researchers have reported some of the characteristics of PAL and its association with poor prognosis; however, the clinicopathological features of PAL remain to be elucidated.

METHODS

From 2008 to 2011 we experienced seven cases of PAL in our institutions. We retrospectively analyzed the clinical and pathological features of these patients.

RESULTS

The patients ranged in age from 50 to 85 years, with a median of 71 years. The overall male:female ratio was 6:1. All seven patients were diagnosed with diffuse large B-cell lymphoma (DLBCL) pathologically. Bilateral adrenal involvement was confirmed in five patients. The median largest tumor diameter at diagnosis was 58 mm. The Ki-67 index was generally high (>70%). All patients were treated with rituximab-containing chemotherapy, and central nervous system (CNS) prophylaxis was conducted for three patients. One patient with CNS involvement at the time of the diagnosis also received whole-brain radiation. The overall survival rate at two years was 57% (median follow-up; 24.8 months). It is noteworthy that the three patients who received a full course of the rituximab-containing regimen and CNS prophylaxis are currently alive without disease relapse, and that none of the seven patients died due to progression of lymphoma.

CONCLUSIONS

Primary adrenal DLBCL can be a clinically aggressive disease entity. Rituximab-containing chemotherapy combined with CNS prophylaxis could be a reasonable option for the treatment of PAL; however, analyses of more PAL cases are needed for the establishment of this strategy.

Clinicopathological analysis of primary adrenal diffuse large B-cell lymphoma: effectiveness of rituximab-containing chemotherapy including central nervous system prophylaxis

BACKGROUND

Primary adrenal lymphoma (PAL) is an extremely rare subtype of extranodal non-Hodgkin's lymphoma. Some researchers have reported some of the characteristics of PAL and its association with poor prognosis; however, the clinicopathological features of PAL remain to be elucidated.

METHODS

From 2008 to 2011 we experienced seven cases of PAL in our institutions. We retrospectively analyzed the clinical and pathological features of these patients.

RESULTS

The patients ranged in age from 50 to 85 years, with a median of 71 years. The overall male:female ratio was 6:1. All seven patients were diagnosed with diffuse large B-cell lymphoma (DLBCL) pathologically. Bilateral adrenal involvement was confirmed in five patients. The median largest tumor diameter at diagnosis was 58 mm. The Ki-67 index was generally high (>70%). All patients were treated with rituximab-containing chemotherapy, and central nervous system (CNS) prophylaxis was conducted for three patients. One patient with CNS involvement at the time of the diagnosis also received whole-brain radiation. The overall survival rate at two years was 57% (median follow-up; 24.8 months). It is noteworthy that the three patients who received a full course of the rituximab-containing regimen and CNS prophylaxis are currently alive without disease relapse, and that none of the seven patients died due to progression of lymphoma.

CONCLUSIONS

Primary adrenal DLBCL can be a clinically aggressive disease entity. Rituximab-containing chemotherapy combined with CNS prophylaxis could be a reasonable option for the treatment of PAL; however, analyses of more PAL cases are needed for the establishment of this strategy.

Radiology-pathology conference: primary adrenal lymphoma

We present a case of a 62-year-old man with a history of type II diabetes mellitus who presented to our emergency department with back pain and right upper quadrant abdominal pain associated with vomiting and weight loss. A computed tomographic scan of the abdomen and pelvis demonstrated a large adrenal mass, and subsequent biopsy showed primary adrenal lymphoma.

Adrenal Lymphoma: Case Report and Review of Literature

Adrenal lymphoma is a rare diagnosis in subject presenting with bilateral adrenal masses. Adrenal insufficiency is a common complication of this disease. Most cases of primary adrenal lymphoma (PAL) present with adrenal insufficiency and huge bilateral adrenal masses. These are very aggressive tumors with poor prognosis. We, hereby, report two subjects of adrenal lymphoma presenting with bilateral adrenal masses. First case is a 50 years old male presented with features of adrenal insufficiency like anorexia, weight loss, nausea, vomiting, and generalized hyperpigmentation. Routine investigations revealed hyponatremia, normal serum K; serum lactate dehydrogenase was moderately elevated. Primary adrenal insufficiency was confirmed by low basal and cosyntrophin stimulated cortisol. CT abdomen revealed huge bilateral heterogeneous enlargement of adrenal glands. Lymphoma was confirmed by histopathology and immunohistochemistry, diagnosis of PAL was made after further staging. He was treated with Rituximab-CHOP regimen. Second case, 50 years old lady presented with fever, anorexia, weight loss. She had generalized lymphadenopathy. On imaging found to have bilateral adrenal mass, and histopathology from lymph node, breast mass and adrenal mass was suggestive of non-Hodgkin's lymphoma.