Bilateral primary adrenal non-Hodgkin's lymphoma and primary adrenocortical carcinoma--review of the literature preoperative differentiation of adrenal tumors

Development and validation of nomograms to predict survival of primary adrenal lymphoma: a population-based retrospective study

While it is known that accurate evaluation of overall survival (OS) and disease-specific survival (DSS) for patients with primary adrenal lymphoma (PAL) can affect their prognosis, no stable and effective prediction model exists. This study aimed to develop prediction models to evaluate survival. This study enrolled 5448 patients with adrenal masses from the SEER Program. The influencing factors were selected using the least absolute shrinkage and selection operator regression model (LASSO) and Fine and Gray model (FGM). In addition, nomograms were constructed. Receiver operating characteristic curves and bootstrap self-sampling methods were used to verify the discrimination and consistency of the nomograms. The independent influencing factors for PAL survival were selected by LASSO and FGM, and three models were built: the OS, DSS, and FGS (DSS analysis by FGM) model. The areas under the curve and decision curve analyses indicated that the models were valid. This study developed survival prediction models to predict OS and DSS of patients with PAL. The FGS model was more accurate than the DSS model in the short term. Above all, these models should offer benefits to patients with PAL in terms of the treatment modality choice and survival evaluation.

Histopathological Experience of Primary Adrenal Lymphoma From Two Tertiary Hospitals

INTRODUCTION

 Primary adrenal lymphoma (PAL) is a rare tumor. The aim of this study was to demonstrate the histopathological features of PAL at two tertiary hospitals.

MATERIALS AND METHODS

 All PALs diagnosed between January 2003 and February 2023 were retrieved. Pathology and immunohistochemistry slides were reviewed. Additional immunohistochemical markers were done in selected cases. Follow-up data were obtained.

RESULTS

 There were 7 cases of PAL. The age range of the patients was 52 to 73 years (median 64 years; mean 63.3 years). There were 4 males (57.1%) and 3 females (42.9%). The clinical manifestations included abdominal pain nausea, vomiting, and loss of weight. There were 4 cases of diffuse large B-cell lymphoma (DLBCL), 2 cases of high-grade B-cell lymphomas, and 1 case of follicular lymphoma. There were 5 cases that were unilateral and 2 cases that were bilateral, and both were high-grade B-cell lymphoma. During follow-up, the 1-year and 2-year overall survival rates were 50% and 33%, respectively.

CONCLUSION

 PAL is a disease of the elderly, and DLBCL is the most common pathological type. The prognosis is generally poor. Further reporting of PAL cases might help in understanding this disease and could lead to improvement in its management.

An unusual cause of adrenal insufficiency with elevation of 17-hydroxyprogesterone: case report

BACKGROUND

We present an intriguing case of primary adrenal lymphoma, with associated primary adrenal insufficiency (PAI), in a patient presenting a transitory partial 21-hydroxylase deficiency during the active phase of the adrenal disease.

CASE PRESENTATION

An 85-years old woman was referred because of worsening asthenia, lumbar pain, generalized myalgia and arthralgia. During investigations a computed tomography (CT) scan evidenced two large bilateral adrenal masses, highly suspicious for primary adrenal tumor. The hormonal assessment revealed very low levels of morning plasma cortisol and 24-h urinary cortisol, elevated ACTH levels with low plasma concentration of aldosterone, pointing to the diagnosis of PAI. After diagnosis of PAI our patient started glucocorticoid and mineralcorticoid replacement therapy with clinical benefit. In order to further characterize the adrenal lesions, adrenal biopsy, was performed. The histology revealed a high grade non-Hodgkin lymphoma with an immunophenotype consistent with intermediate aspects between diffuse large B-cell and Burkitt lymphoma, with a high proliferation index (KI-67 > 90%). The patient received chemotherapy with epirubicin, vincristine, cyclophosphamide, and rituximab, associated with methylprednisolone that resulted in a complete clinical and radiological remission within one year. After 2 years from the diagnosis and a total of 6 cycles of rituximab, the patient was in good clinical condition and was taking only the replacement therapy for PAI. The patient initially presented also a slight increase of 17-hydroxyprogesterone (17-OHP) for age that normalize after resolution of lymphoproliferative disease.

CONCLUSIONS

In the presence of bilateral adrenal disease and/or in the presence of signs and symptoms of PAI clinicians must exclude the presence of PAL. The evidence of elevated ACTH-stimulated 17-OHP levels also in patients with other adrenal masses, together with the detection of elevated basal 17-OHP levels in our patient make it more plausible, in our view, an effect of the lesion on the "healthy" adrenal tissue residue than a direct secretory activity by the adrenal tumor.

Adrenal Lymphoma: Case Reports and Mini-review

INTRODUCTION

Adrenal lymphoma is a rare condition which may occur in one of two forms; either as primary adrenal lymphoma (PAL), or secondary to a systemic lymphoma. Primary adrenal lymphoma is a very rare diagnosis and the most common histological pattern is diffuse large B-cell non‑Hodgkin lymphoma.

OBJECTIVES

In this study, we represent two examples of adrenal lymphoma, primary and secondary. In addition, we have included a mini-review of the literature regarding this rare presentation.

PATIENTS AND METHODS

We retrospectively reviewed all patients who were diagnosed with adrenal lymphoma in our hospital. We represent mainly the most two challenging cases where adrenal surgery was required to confirm the diagnosis. We have included a mini-review of the literature (PubMed data base: 1990 - 2020) on the clinical presentation and management of adrenal lymphoma cases.

RESULTS

Seventeen patients had adrenal lymphoma in our hospital; 16 of them had secondary involvement of the adrenal gland, while the last one had primary adrenal lymphoma. Patients with adrenal lymphoma mainly present with fever, lumbar pain, and/or symptoms of adrenal insufficiency. Primary adrenal lymphoma usually appears as heterogeneous complex large masses with low density on computerized tomography (CT) scan or magnetic resonance imaging (MRI); however, there is no pathognomonic features to diagnose PAL. The diagnosis is confirmed only with tissue biopsy. Chemotherapy is generally the standard treatment for lymphoma, while the role of surgery is limited.

CONCLUSIONS

The prognosis of these rare cases is generally poor with only about a third of patients achieving partial or complete remission following treatment.

sIL-2R: A Novel Diagnostic Biomarker for Primary Adrenal Lymphoma

CONTEXT

Primary adrenal lymphoma (PAL) is difficult to distinguish from other adrenal masses. Soluble interleukin-2 receptor (sIL-2R) is a diagnostic biomarker for nodal non-Hodgkin lymphoma, whose association with PAL is unknown.

OBJECTIVE

The aim of this study was to determine the diagnostic utility of serum sIL-2R for Patients with PAL.

DESIGN

Prospective cohort study.

SETTINGS AND PARTICIPANTS

A total of 118 patients with adrenal masses who were willing to be tested for levels of serum sIL-2R from a tertiary hospital between 2019 and 2021 were included.

MAIN OUTCOMES AND MEASURES

Serum sIL-2R and lactate dehydrogenase (LDH) levels.

RESULTS

Patients with PAL had significantly higher sIL-2R levels than those of patients with other adrenal masses with indetermined and benign computed tomography (CT) features (both Ps < 0.001). The LDH levels of patients with PAL were also significantly higher than those of patients with other adrenal masses with indeterminate and benign CT features (both Ps < 0.001). Good discrimination of patients with PAL from other patients (PAL vs other adrenal masses with indeterminate CT features/non-PAL) was achieved with an area under the receiver operating characteristic curve (AUC) of 0.984 (95% CI, 0.95-1)/0.992 (95% CI, 0.975-1.000) using the serum levels of sIL-2R and further improved (AUC = 0.998, 95% CI, 0.994-1.000; AUC = 0.999, 95% CI, 0.996-1.000) after adjusting by LDH category.

CONCLUSIONS

For the first time, we have identified that serum sIL-2R and LDH category-adjusted sIL-2R levels have good diagnostic performances for PAL.

Non-functioning adrenocortical carcinoma

Adrenocortical carcinoma (ACC) is a rare malignancy that arises from the adrenal cortex and can be classified as either non-functioning or functioning. A patient with non-functioning ACC may present no specific symptoms. Imaging analysis can provide some information to a clinician who suspects ACC, such as tumor size, density, washout, necrosis, hemorrhage, and calcification. Histopathology is used to confirm and determine the origin of the malignancy and can provide relevant prognostic information. Microscopic findings can be used to obtain information such as the Weiss score, resection surface features, Ki-67 proliferative index, and the degree of capsular and vascular invasion. Surgery can be curative for localized tumors, and adjuvant therapy using mitotane and cytotoxic chemotherapy is often employed for advanced-stage tumors. We describe a case report of a 32-year-old man with a non-functioning ACC that highlights the importance of radiological and pathological features in the diagnosis of ACC and their use as prognostic factors.

Primary Adrenal Lymphoma: Two Case Series From China

OBJECTIVE

Primary adrenal lymphoma (PAL) is a rare form of adrenal mass. We summarize our experience in its clinical presentation, biochemical indexes, radiological features, pathological information, therapy regimens, and outcomes.

METHODS

This was an institutional review board-approved retrospective review of medical records and surgical pathology specimens of patients with a diagnosis of PAL at the Chinese People's Liberation Army General Hospital and the First Affiliate Hospital of Xiamen University between July 2007 and July 2017.

RESULTS

Twenty-six patients were identified. The mean age at presentation was 60.84 ± 13.14 years with a male-to-female ratio of 2.25:1 (18:8). The most common presenting symptoms were loss of appetite (65%, 17/26), weight loss (62%, 16/26), abdominal pain (58%, 15/26), and fatigue (58%, 15/26). The levels of lactate dehydrogenase (75%, 15/20), β₂-microglobulin (100%, 10/10), C-reactive protein (82%, 14/17), and ferritin (88%, 7/8) and the erythrocyte sedimentation rate (83%, 10/12) were elevated. Bilateral involvement was seen in 21 of 26 patients (81%); 12 of 19 evaluated patients with bilateral lesions (63%) were confirmed to have adrenal insufficiency. On computed tomography (CT), the mean tumor diameter was 7.31 ± 3.35 cm and the median Hounsfield density was 37.0 HU (range: 31.0-45.0 HU); 67% (10/15) and 27% (4/15) of lesions presented with mild and moderate enhancement after injection of contrast medium. ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG PET)-CT revealed not only an adrenal tumor but also extra-adrenal lesions. Diffuse large B-cell lymphoma (DLBCL) was the most common phenotype (92%, 24/26). Ninety-two percent (24/26) of patients received chemotherapy while 8% (2/26) received unilateral adrenalectomy plus chemotherapy. The prognosis of PAL was poor, with a general survival time of 7.20 ± 5.18 months.

CONCLUSION

PAL is a rare disease. The clinical characteristics of PAL include loss of appetite and weight loss. Endocrine evaluation should be performed to determine whether patients have adrenal insufficiency, especially patients with bilateral lesions. FDG-PET appears to be more accurate than other imaging modalities in revealing extra-adrenal sites. Better therapy is required to improve the poor prognosis of PAL.

A Novel Diagnostic Model for Primary Adrenal Lymphoma

OBJECTIVE

Primary adrenal lymphoma (PAL) is easily misdiagnosed as other adrenal masses, such as adrenocortical carcinoma and pheochromocytoma, but patients with PAL benefit little from surgery. The diagnostic method for PAL thus far is limited to adrenal biopsy. In our study, we aimed to develop a quick and efficient diagnostic method for PAL.

METHODS AND RESULTS

At the same institution, 505 patients (between 2009 and 2019) and 171 patients (between 2019 and 2020) were separately included in the primary and validation studies. Univariate and multivariate analyses were conducted to evaluate clinical manifestations, laboratory findings, and radiological characteristics. Four determinants (age, bilateral masses, high-density lipoprotein cholesterol, and lactate dehydrogenase) were selected and further incorporated into a regression model to screen PAL. Accordingly, the nomogram was developed for clinical practice. In the primary study, the nomogram showed good discrimination, with an area under the receiver operating characteristic (ROC) curve (AUC) of 95.4% (95% CI, 90.6%-100.0%). Further validation study verified the efficacy of the nomogram, with an AUC of 99.0% (95% CI, 96.9%-100.00%) and 100.0% in all patients and patients with bilateral masses, respectively, and a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 66.67%/99.40%/66.67%/99.40%, 66.67%/100%/100%/92.86%, 50%/99.20%/50%/99.20%, and 100%/100%/100%/100%, in all patients, patients with bilateral adrenal masses, patients with nonfunctional adrenal masses, and patients with positive catecholamine results, respectively. The validation study also revealed a diagnostic specificity of 99.35% and 100% for patients with a unilateral adrenal mass and functional PCC, respectively.

CONCLUSIONS

The presented nomogram is the first user-friendly diagnostic model for PAL that simplifies the complex diagnostic process into personalized numeric estimates. We deem that patients who score below 50 are less likely to have PAL. We suggest that clinicians should arrange adrenal biopsy and surgery for patients with nonfunctional tumors and overt catecholamine-secreting tumors, respectively, who receive a score of 50 points or higher to confirm the diagnosis as soon as possible.

Clinical characteristics and outcomes of primary adrenal diffuse large B cell lymphoma in a large contemporary cohort: a SEER-based analysis

Primary adrenal lymphoma (PAL) is an extremely rare lymphoma, and the most common histologic type is diffuse large B cell lymphoma (DLBCL). Primary adrenal DLBCL has a quite poor prognosis, but the prognostic determinants are rarely reported. With the Surveillance, Epidemiology, and End Results (SEER) program, we collected the demographic, clinical, therapeutic information of patients with primary adrenal DLBCL from 1983 to 2015. The Kaplan-Meier method was used to obtain overall survival (OS) and cause-specific survival (CSS) curves. The prognostic values of OS and CSS were assessed using Cox proportional hazards regression model with univariate and multivariate analyses. A total of 136 patients were included in our cohort. Adrenal DLBCL predominantly affected male and the aged, and there was a high rate of unilateral adrenal origin. The patients were more likely to present advanced stage disease. The OS rates of the entire cohort of patients with adrenal DLBCL at 5 and 10 years were respectively 19.17% and 3.33%, and the similar results were shown in 5-year and 10-year CSS rates. Age more than 70 years old and bilateral were identified as independent prognostic factors that were correlated with both adverse OS and CSS, and patients with chemotherapy had a superior OS and CSS to the patients without any treatment.

Incidental lymphoma in lymph node dissection for carcinoma in the abdominopelvic cavity: a single-institution experience

Incidental detection of lymphoma in lymph node (LN) dissection for carcinoma is extremely rare. The occurrence and clinicopathological features of this rare condition have not been characterised. The medical records of 11,889 consecutive patients who underwent LN dissection for carcinoma in the abdominopelvic cavity were retrospectively reviewed. Among these patients, 11 had lymphomas detected in LN dissections and 7 had no previous history of lymphoma, representing an incidental detection rate of 0.06% (7/11889). The patients had a median age of 63 years (range, 48-69 years), and the male-to-female ratio was 1:2.5. The sites and histological types of the carcinoma were as follows: adenocarcinoma of the sigmoid colon (2 cases), endometrioid adenocarcinoma of the endometrium (2 cases), squamous carcinoma of the uterine cervix (1 case), adenocarcinoma of the stomach (1 case), and adenocarcinoma of the rectum (1 case). All incidental lymphoma cases (100%, 7/7) were low-grade B cell non-Hodgkin lymphoma (B-NHL), including 5 cases of follicular lymphoma (grades 1-2) and 2 cases of small lymphocytic lymphoma. The median follow-up interval was 39 months (5-65 months). All the patients were alive at the end of the follow-up period. Low-grade B-NHL can be incidentally detected during LN dissection for carcinoma in the abdominopelvic cavity. The subtype of incidental lymphoma is likely related to the epidemiology of lymphoma classes in the corresponding area. We should be aware of simultaneous occurrence of incidental lymphoma during lymphadenectomy for carcinoma.

Adrenal relapse of primary central nervous system diffuse large B-cell lymphoma: A case report

RATIONALE

Primary central nervous system lymphoma (PCNSL) is a rare form of non-Hodgkin lymphoma with a dismal outcome. Most patients relapse in intracranial sites and <5% of patients relapse in extracranial sites. Here, we present the first case of PCNSL with an adrenal relapse.

PATIENT CONCERNS

A 72-year-old woman, first presented 7 years ago with complaints of headache and dizziness.

DIAGNOSES

Enhanced magnetic resonance imaging revealed the mass within the splenium of the corpus callosum. On histological examination, there was a diffuse growth pattern of neoplastic cells in the brain biopsy. Immunohistochemistry and flow cytometric analysis demonstrated that the neoplastic cells were of B-cell lineage.

INTERVENTIONS

The patient underwent methotrexate-based chemotherapy and whole-brain radiotherapy after the initial diagnosis of primary central nervous system-large B-cell lymphoma (CNS-DLBCL).

OUTCOMES

After 4 years of clinical remission, the patient was diagnosed with endometrial cancer. Interestingly, a radiological study following the treatment of endometrial cancer demonstrated a right adrenal mass, which was suspicious for malignancy. Morphologic examination and immunohistochemistry studies confirmed the diagnosis of diffuse large B-cell lymphoma. A fluorescent in situ hybridization panel for lymphoma showed rearrangement of Immunoglobulin heavy chain (IGH) and B-cell lymphoma 6 (BCL6), respectively, suggesting fusion of BCL6/IGH. Immunoglobulin kappa analysis demonstrated a common origin for the brain and adrenal lesions, which led to the final diagnosis of an adrenal relapse of CNS-DLBCL.

LESSONS

PCNSL is a highly infiltrative neoplasm, particularly at relapse. To the best of our knowledge, this is the first case of CNS-DLBCL with adrenal relapse. Considering the poor outcome of CNS-DLBCL, molecular genetic studies should be done to identify a common origin for the primary and secondary lesion.

Imaging of F-18 FDG PET/CT and follow up of bilateral invasive adrenal diffuse large B cell lymphoma mimicking adrenocortical carcinoma

The incidence of malignant adrenal tumors, including primary adrenal lymphoma (PAL) and adrenocortical carcinoma (ACC), is rather low. Early differentiation between ACC and PAL is necessary because the therapeutic strategies for the two differ and the prognosis of each disease is poor. Unfortunately, there is no pathognomonic characteristic of PAL, so radiologists have difficulty in differentiating it from ACC. To our knowledge, there have been only two case reports on ACC that was evaluated and followed up using F-18 FDG PET/CT. The previously reported cases were simple, involving only the bilateral adrenal glands. Here, we report on a 52-year-old man diagnosed with PAL that radiologically mimicked ACC. He had findings of heterogeneous enhancement on CT, several adjacent lymphadenopathies with internal necrosis, and abutting hepatic and bilateral crural invasion. After pathological confirmation, we monitored his prognosis using F-18 FDG PET/CT after three cycles of rituximab-CHOP and again after six cycles of treatment.

The Clinical and Hormonal Characteristics of Primary Adrenal Lymphomas: The Necessity of Early Detection of Adrenal Insufficiency

Objective To analyze the clinical and endocrine characteristics of patients with primary adrenal lymphoma. Patients We retrospectively reviewed the cases of five patients with primary adrenal lymphoma who were treated in our hospital between April 2004 and March 2015. We investigated the characteristics of the clinical and pathological findings, treatment, prognosis and complications of adrenal insufficiency. Results Adrenal insufficiency, which was confirmed by the laboratory data at the initial presentation, was observed in two cases. One case was complicated by relative adrenal insufficiency during a course of chemotherapy. The plasma adrenaline and urinary adrenaline levels were decreased in four cases and three cases, respectively. Diffusion MRI was radiologically diagnostic. In all of the cases, the patients were pathologically diagnosed with diffuse large-B cell lymphoma and were treated with rituximab and CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone)-like chemotherapy. Two patients received central nervous system prophylaxis with high-dose methotrexate. Four of the patients survived and one patient died during the follow-up period. Conclusion The early detection of adrenal insufficiency and the administration of an appropriate dose of hydrocortisone are necessary during the course of chemotherapy as well as at the initial manifestation. The exclusion of adrenal dysfunction prior to invasive diagnostic procedures, such as CT-guided needle biopsy, is also critical.

A Rare Case of Primary Bilateral Adrenal Lymphoma

Lymphoma may involve the adrenal glands, but primary lymphoma is rare. Only a few cases have been reported in medical literature. Primary adrenal lymphoma is extremely rare, accounting for <1% of non-Hodgkin lymphomas. We here present a case of a middle-aged female who presented with persistent fever for three weeks. She also reported significant weight loss of more than 10 kgs over the duration of three months. Computed tomography of the thorax and abdomen and pelvis demonstrated bilateral adrenal masses. She underwent short Synacthen test which showed evidence of adrenal insufficiency. She underwent CT-guided adrenal gland biopsy. Histology of adrenal gland biopsy showed features consistent with diffuse large B-cell lymphoma. She was started on R-CHOP chemotherapy and had a good clinical response and remained in complete remission for five months after chemotherapy.

Bilateral primary adrenal diffuse large B cell lymphoma without adrenal insufficiency: A case report and review of the literature

Primary adrenal lymphoma (PAL) is an infrequent malignant tumor, occurring in the bilateral adrenal glands as a mass in the majority of cases. The current study presents a case of bilateral primary adrenal diffuse large B cell lymphoma in a 52-year-old female patient, who presented with abdominal pain in the left lumbar region for ~2 weeks. Abdominal ultrasound examination and computed tomography scanning revealed a mass of 132×119×101 mm on the left adrenal gland and a mass of 53×27 mm on the right adrenal gland. A percutaneous biopsy was performed and histopathological examination further confirmed this lesion as diffuse large B cell lymphoma. The present study highlights the importance of early diagnosis of PAL, and performs a literature review of the subject.

Adrenal lymphoma: presentation, management and prognosis

AIM

This study aimed to identify the clinical, radiological and prognostic features of primary adrenal lymphoma (PAL) in order to diagnose the disease more accurately.

MATERIALS AND METHODS

A retrospective multi-centre study was conducted on the clinical, biological and radiological features as well as the treatment and overall survival outcomes in PAL.

RESULTS

Between 1994 and 2014, 28 patients from five regions of eastern France were diagnosed with primary adrenal lymphoma. The revealing symptoms were a worsening general state (77%), weight loss (77%) and abdominal pain (42%). Biological features of PAL were almost omnipresent: increased LDH, β2 microglobulin, CRP or ferritinaemia levels. The PAL was bilateral in 20 cases (71%), adrenal insufficiency was searched for in 11 patients and found in eight (73%). CT scans showed masses of various sizes measuring up to 180 mm. On MRI, the lesions were hypointense in T1 and hyperintense in T2. When done, positron emission tomography with fluorodeoxyglucose (FDG-PET) showed locations not seen on the CT and revealed extra-adrenal locations in 70% of examinations. Adrenalectomy brought no benefit. The overall survival rate was poor (61.9% at 2 years) despite polychemotherapy.

CONCLUSION

The clinical presentation of PAL comprised major general symptoms. Adrenal insufficiency was very common in patients with bilateral involvement but was not systematically tested. PET was an efficient examination to visualize extra-adrenal locations. The preliminary results of MRI to distinguish between PAL and adrenocortical carcinoma should be confirmed. Further studies are needed to establish an optimal strategy for the management of these primary adrenal lymphomas.

Non-Hodgkin's lymphoma involving a femur bone and bilateral adrenal glands alone with adrenal insufficiency

Primary bone lymphoma and primary adrenal lymphoma are rare clinicopathological entities of non-Hodgkin's lymphoma (NHL). We present the first case of diffuse large B-cell lymphoma with the involvement of a single bone and both adrenal glands alone with adrenal insufficiency. As primary extranodal NHL may have other unusual extranodal lesions, which may present unexplained clinical findings, patients with primary extranodal NHL require careful systemic examination, even when lymphadenopathy is absent.

Acute adrenal insufficiency secondary to bilateral adrenal B-cell lymphoma: a case report and review of the literature

Primary adrenal lymphoma is an extremely rare entity which constitutes less than 1% of extranodal lymphomas. Most cases present with bilateral adrenal masses and without extraadrenal involvement, which can lead to symptoms of adrenal insufficiency. The prognosis is usually poor and chemotherapy is the first-line treatment option. We report here on a 78-year-old man admitted to our Internal Medicine Department because of constitutional symptoms and high fever spikes. He was diagnosed with adrenal insufficiency and a CT-scan revealed bilateral adrenal masses of about 6 cm in diameter. A percutaneous biopsy was performed and the histological exam was consistent with diffuse large B cell lymphoma. A review of the literature of this unusual entity was also carried out.

Primary adrenal lymphoma: three case reports and review of Japanese cases

Although primary adrenal lymphoma (PAL) is thought to be extremely rare, its prognosis is much worse than that of other extranodal malignant lymphomas. There are so far about 130 reported cases in the English literature, while 186 cases have been reported in the Japanese literature. Thus, the incidence of PAL in the Japanese population may be higher than in other races. The typical characteristics of PAL in Japanese patients are similar to those previously reported in Western literature: it predominantly occurs in male and elderly patients and involves bilateral involvement of the adrenal glands, which frequently leads to adrenal insufficiency. Here, we review three recent cases of PAL at our hospital, and analyze data from our institution regarding patients with PAL from 2002 to 2014. On biochemical analysis, median levels of sIL2R (5027.5 U/mL) and LDH (1111.46 U/L) were elevated in Japanese PAL patients compared to other adrenal tumors. It is critical that clinicians be familiar with the traits of PAL, especially for its differential diagnosis from adrenal large tumors.

Primary Adrenal Lymphoma Possibly Associated With Epstein-Barr Virus Reactivation Due to Immunosuppression Under Methotrexate Therapy

Primary adrenal lymphoproliferative disorder (LPD) is an extremely rare disease that is widely known to be associated with methotrexate (MTX) use in patients with rheumatoid arthritis (RA).A 70-year-old man was incidentally found to have a tumor at the dorsal part of the liver in a medical check-up. He had a history of RA treated with MTX. Abdominal ultrasonography demonstrated a low echoic mass (30 mm in diameter) at the dorsal part of the liver, located close to the inferior vena cava. Preoperative differential diagnoses included intrahepatic cholangiocarcinoma, adrenal tumor, and hepatic malignant lymphoma, but no definitive diagnosis was reached. On exploratory laparotomy, the tumor seemed to be derived from the right adrenal gland and adhered tightly to segment 7 of the liver. Therefore, right adrenectomy with partial resection of segment 7 of the liver was performed. Pathological findings revealed diffuse inflammatory cell infiltration with a population of small atypical lymphoid cells, with positive immunohistochemical evidence for Epstein-Barr virus (EBV). Final diagnosis was primary adrenal iatrogenic EBV-positive LPD, classified as "other iatrogenic immunodeficiency-associated LPDs: Hodgkin-like lesions."In this report, we described the possibility of the spontaneous healing of MTX-associated LPD (MTX-LPD) before treatment and the importance of doubting MTX-LPD and doing immunostaining to necrotic tissue. To our knowledge, this is the first reported case of MTX-related EBV-positive LPD, Hodgkin-like lesion, of the unilateral adrenal gland in patient with RA.

A case of primary adrenal diffuse large B-cell lymphoma in HIV

Primary adrenal diffuse large B-cell lymphoma in HIV is a very rare, highly aggressive extra-nodal lymphoma. There is only one previous case reported in the literature. Our patient presented with isolated bilateral adrenal masses with no lymphadenopathy or visceral involvement, which made the diagnosis challenging.

Bilateral primary adrenal non-Hodgkin's lymphoma without adrenal insufficiency

We are presenting a rare case of bilateral adrenal non-Hodgkin's lymphoma (NHL) that presented as a primary malignancy. An 83-year-old man presented with newly discovered bilateral adrenal incidentalomas, fatigue, and 30 pound weight loss. Of the 116 cases of primary adrenal NHL reported, over half have presented bilaterally and occur with adrenal insufficiency. Therefore, the finding of bilateral adrenal masses requires an urgent work-up of the functional status of the adrenal gland as well as a thorough analysis of the imaging characteristics seen on noncontrast computed tomography (CT) in order to maximize patient survival. Adrenal function testing was normal. Repeat CT imaging revealed rapidly growing lesions with high attenuations; both masses >10 HU. Histological examination of core biopsies discovered malignant lymphoma with no known past history of lymphoma. Our case coincides with the literature, which states that a mass with attenuation >10 HU in the adrenal glands has a high risk of malignancy.

PRIMARY ADRENAL LYMPHOMA: A SINGLE-CENTER EXPERIENCE

OBJECTIVE

To describe the clinical presentation, biochemistry, imaging features, and treatment outcome of patients with primary adrenal lymphoma (PAL) presenting to a single tertiary care center.

METHODS

We performed a retrospective analysis of case records of 7 patients diagnosed with PAL between January 2011 and May 2014 at our institution in Mumbai, India.

RESULTS

Median age of presentation in our series was 48 years (range, 41 to 60 years), with a male to female ratio of 6:1. Bilateral adrenal involvement was seen in 4 of 7 patients (58%). Adrenal insufficiency (AI) was seen in 3 of the 4 patients with bilateral involvement (75%). Computed tomography showed slight to moderate contrast enhancement of adrenal masses in 4 of 5 patients (80%). Diffuse, large, B-cell lymphoma (DLBCL) was the most common immunophenotype (85%). One patient died due to rapid disease progression even before starting chemotherapy. Six patients were treated with chemotherapy and/or external beam radiotherapy. After 1 year, 2 more patients had died, whereas 4 patients were in remission.

CONCLUSION

PAL should always be considered in differential diagnosis of bilateral adrenal mass with AI. DLBCL is the most common histologic subtype of PAL. Despite treatment, long-term prognosis of PAL remains poor.

Adrenal tumors with unexpected outcome: a review of the literature

The finding of an adrenal mass should induce a diagnostic work-up aimed at assessing autonomous hormone production and differentiating between benign and (potentially) malignant lesions. The common differential diagnosis in adrenal incidentaloma consists of (non-)functioning adenoma, pheochromocytoma, myelolipoma, metastasis, and primary carcinoma. There remains a category of lesions that are hormonally inactive and display nonspecific imaging characteristics. We provide a succinct literature review regarding pathologies from this category. Imaging and histological characteristics are discussed, as well as clinical management. In conclusion, an adrenal mass may present a diagnostic challenge. After exclusion of most common diagnoses, it can be difficult to differentiate between possible pathologies based on preoperative diagnostic tests. Surgical resection of possibly harmful tumors is indicated, for example, lesions with malignant potential or risk of spontaneous hemorrhage. Resection of an obviously benign lesion is not necessary, unless problems due to tumor size are expected.

Adrenal tumours: how to establish malignancy

Adrenal masses are commonly found in the course of abdominal investigations and present diagnostic challenges. The foremost issue is whether the mass is the cause of the symptoms being investigated. Additional important clinical questions are: (1) is the adrenal mass benign or malignant and (2) whether the adrenal mass is functional or non-functional? We present a case of a 48-year-old man with severe abdominal pain. Imaging revealed a very large adrenal mass. Differential diagnostic procedures were performed and a diagnosis of primary adrenal lymphoma, an extremely rare cause of adrenal malignancy, was made. He proceeded to chemotherapy with cyclical cyclophosphamide, doxorubicin, etoposide and prednisolone, in addition to rituximab. This case illustrates the importance of establishing the nature of adrenal masses, to rapidly facilitate appropriate treatment.

Primary adrenal lymphoma with paraneoplastic syndrome

Context:

The adrenal gland is a common site for neoplastic diseases and primary adrenal lymphoma (PAL) is a rare tumor with around 120 cases reported so far.

Case Report:

We present a rare case of 76-year-old male who presented with headache, confusion, inappropriate body movements and abdominal pain. Adrenal biopsy revealed PAL and he has had an excellent neurologic outcome to date with chemotherapy and involved field radiation.

Conclusion:

The majority of cases of PAL are B cell lymphomas with diffuse large cell in 70% of cases. Clinical symptoms are variable and patients may present with abdominal pain, fever, anorexia, weight loss, fatigue or symptoms of adrenal insufficiency. Therapeutic modalities for PAL include surgery, chemotherapy and radiotherapy and corticosteroid replacement. With this case report, we hope to raise awareness about this rare disease and to include lymphoma in the differential of adrenal masses.

Adrenal gland non-Hodgkin's lymphoma in a patient with pulmonary adenocarcinoma

Although primary neoplasms of adrenal gland are uncommon, adrenal metastases are frequently encountered in patients with malignancy, and lung is the most common primary tumour site. Among primary tumours of the adrenal gland non-Hodgkin's lymphoma (NHL) is a very rare entity. We describe a case of a 79-year-old man with a previous diagnosis of adenocarcinoma of the lung who presented after 2 years with a unilateral adrenal gland mass. A solitary metastasis from pulmonary carcinoma was suspected and a laparoscopic adrenalectomy was performed. Histological examination revealed a diffuse large B-cell NHL. The patient was treated with CHOP regimen plus rituximab and a total remission was achieved. After an 8-month follow-up the patient was free of disease. This is the first reported case of a rare non-synchronous tumoral combination involving lung and adrenal gland, emphasising at the incidental discovery of the NHL during a procedure performed for a pulmonary adenocarcinoma.

Complete remission of primary bilateral adrenal lymphoma achieved by Rituximab-CHOP chemotherapy

Primary adrenal lymphoma (PAL) is an exceedingly rare disease. Because of its rareness, uncertain etiology, variable duration of survival, unremarkable clinical presentations and unsatisfied therapeutic strategies, its treatment has always been unsatisfactory. Here we report a 50-year-old male patient with primary bilateral adrenal diffuse large B-cell lymphoma. He was treated with surgery followed by combined chemotherapy using R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone). He achieved complete remission after 3 cycles of chemotherapy. At present, he is considered free of tumor at 3 years after chemotherapy. Our case report demonstrates that patients with primary bilateral adrenal diffuse large B-cell lymphoma may achieve a good outcome using R-CHOP chemotherapy. To the best of our knowledge, our patient who achieved complete remission after R-CHOP chemotherapy has had the longest survival as published in the literature.

Unusual presentation of bilateral adrenocortical carcinoma mimicking adrenal metastasis

A 75-year-old female visited our hospital with bilateral adrenal masses that were detected incidentally during lumbar spine magnetic resonance imaging (MRI) for the evaluation of radiating flank pain. Consecutive computed tomography and MRI revealed bilateral adrenal masses with no evidence of lymph node enlargement or local invasion; 2[(18)F]fluoro-2-deoxyglucose (FDG)-positron emission tomography showed an intense FDG accumulation in both adrenal glands without abnormal FDG uptake in extra-adrenal regions. The laboratory test results were within normal ranges. We performed a bilateral adrenalectomy. The pathologic diagnosis of both adrenal masses was consistent with adrenocortical carcinoma. The patient recovered well with no complications.

Bilateral primary adrenal lymphoma accompanying hypertension

Primary adrenal lymphoma (PAL) accompanied by hypertension is extremely rare. We present a case of PAL with hypertension, whom was treated with bilateral adrenalectomy and a combination of the modified Appleby operation and chemotherapy. Computed tomography and biopsy is helpful to aid diagnosis.

Primary adrenal lymphoma: Differential involvement with varying adrenal function

Primary adrenal Non-Hodgkin's lymphoma is rare. The symptoms of the disease and response to treatment are variable depending on the type of lymphoma, tumor size, and presence of adrenal insufficiency. We report two cases of primary adrenal lymphoma who had varied presentations. One presenting with abdominal pain and weight loss was documented to have unilateral disease without any adrenal insufficiency and showed a good response to combination chemotherapy, while the second one had bilateral adrenal involvement with adrenal insufficiency and died after second chemotherapy. Functional adrenal involvement in lymphoma depends on the extent of involvement; patients with bilateral involvement almost always have adrenal insufficiency.

Primary bilateral adrenal diffuse large B-cell lymphoma demonstrating adrenal failure

Primary adrenal lymphoma (PAL) is extremely rare although involvement of malignant lymphoma into adrenals is common. We report a case of a 58-year-old man with bilateral PAL who demonstrated adrenal insufficiency. Primary large B-cell lymphoma was proven by a computed tomography-guided needle biopsy of the adrenal tumor. Although a complete remission was once achieved by combination chemotherapy plus rituximab, a recurrence occurred with brain metastasis leading to his death. We concluded that PAL should be considered as a possible cause of bilateral adrenal incidentalomas with progressive adrenal insufficiency.

Primary bilateral adrenal B-cell lymphoma associated with EBV and JCV infection

Primary lymphoma of the adrenal gland is a rare and highly aggressive disease, with only a few reports in the literature. The pathogenesis is unknown, but detection of Epstein Barr virus (EBV) genome sequences and gene expression in some cases of primary adrenal lymphomas suggested the virus might be a causative agent of the malignancy. While investigating the presence of genome sequences of oncogenic viruses in a large series of adrenal tumors, both EBV and JC polyomavirus (JCV) DNA sequences were detected in a diffuse large primary bilateral B-cell non-Hodgkin lymphoma of the adrenal gland, which was diagnosed only at postmortem examination in a 77 year-old woman with incidentally discovered adrenal masses and primary adrenal insufficiency. The presence of both EBV and JCV genome sequences suggests the relevance of EBV and JCV coinfection in the pathogenesis of this rare form of B-cell lymphoma.