A case of primary adrenal diffuse large B-cell lymphoma achieving complete remission with rituximab-CHOP chemotherapy

Bilateral primary adrenal diffuse large B cell lymphoma: A rare presentation

Primary lymphoma of the adrenal gland is an uncommon origin of adrenal tumors; it must be explicitly invoked anytime bilateral adrenal affections are revealed. We report a case of bilateral primary adrenal diffuse large B cell lymphoma and perform a review of the literature. Our patient was a 55-year-old man who presented night sweats and a feeling of cardiac palpitations all evolving in a context of deterioration of his general condition. An ultrasound study was requested reporting a bilateral mass corresponding to the adrenal region. A thoraco-abdominopelvic CT scan was requested and revealed bilateral homogenous, polylobed, adrenal masses, discreetly enhanced after injection of contrast product. These masses were associated with multiple retroperitoneal, para-aortic, and celio-mesenteric adenopathies. Anatomopathologic examination of the percutaneous CT-guided biopsy specimen of the adrenal tumor revealed the presence of diffuse large B cell lymphoma grade IIIB according to the Ann Arbor system. Primary adrenal lymphoma PAL on its own is an extremely rare disease entity and less than 100 cases have been reported in the last 40 years. A large proportion of PAL case reports showed that this disease usually has no excretory endocrine function and the symptoms are due to the pressure effect of the mass, whereas adrenal insufficiency usually exists. Our patient presented symptoms of indrenal insufficiency which seems to be the reason for the early diagnosis. Primary bilateral adrenal lymphoma is very rare entity that should be kept in mind whenever bilateral adrenal masses are assessed in the CT scan images.

Primary adrenal diffuse large B-cell lymphoma with normal adrenal cortex function: A case report

BACKGROUND

Diffuse large B-cell lymphoma, which accounts for about approximately 30% to 40% of non-Hodgkin's lymphomas, is the most common type and is a class of aggressive B-cell lymphomas. However, diffuse large B-cell lymphomas primary to the adrenal gland are rare.

CASE SUMMARY

A 73-year-old man was admitted with abdominal pain and fatigue. After admission, enhanced adrenal computed tomography indicated irregular masses on both adrenal glands, with the larger one on the left side, approximately 8.0 cm × 4.3 cm in size. The boundary was irregular, and surrounding tissues were compressed. No obvious enhancement was observed in the arterial phase. Resection of the left adrenal gland was performed. Pathological diagnosis revealed diffuse large B-cell lymphoma. After surgery, the patient received R-CHOP immunochemotherapy. During the fourth immunochemotherapy, patient condition deteriorated, and he eventually died of respiratory failure.

CONCLUSION

R-CHOP is the conventional immunochemotherapy for primary adrenal diffuse large B-cell lymphoma. Surgery is mainly used to diagnose the disease. Hence, the ideal treatment plan remains to be confirmed.

Primary bilateral non-Hodgkin's lymphoma of the adrenal gland

Primary bilateral non-Hodgkin's lymphoma (NHL) of the adrenal gland is very rare. Herein, we report the case of a high-grade lymphoma of both adrenal glands that was found in a 38-year-old patient. The patient was admitted because of an ultrasound which demonstrated large bilateral adrenal masses. The computed tomography scan-guided biopsy of both adrenal glands suggested the diagnosis of bilateral adrenal NHL. Primary bilateral adrenal NHL should be considered as the differential diagnosis of adrenal masses, especially if they are bilateral and well defined with rapid growth in imaging. Early diagnosis and treatment might dramatically affect the clinical outcome.

Primary adrenal diffuse large B cell lymphoma: a clinicopathological and molecular study from China

Primary adrenal lymphoma is a rare entity that, in most cases, is derived from B cells. The most commonly seen primary adrenal lymphoma is diffuse large B cell lymphoma (DLBCL). To better understand the clinicopathological and molecular features of these tumors, we studied 14 Chinese patients with DLBCL who initially presented with an adrenal tumor. The clinicopathological features of the 14 primary adrenal DLBCL cases were retrospectively reviewed using immunohistochemistry, immunoglobulin gene rearrangement analysis, evaluation of Epstein-Barr virus status, and fluorescence in situ hybridization. Patient age ranged from 43 to 69 years, with a mean age of 58 years. The patients most commonly presented with abdominal pain and adrenal mass. Ten patients exhibited bilateral adrenal masses, and four had unilateral adrenal masses (three left, one right). Thirteen of 14 DLBCLs were DLBCL not otherwise specified, and one was an intravascular large B cell lymphoma. According to the algorithm of Hans et al. (Blood 103:275-282, 2004), 13 and 1 cases were classified as the non-germinal center B-cell-like subtype and the germinal center B-cell-like subtype, respectively. The Ki-67 index ranged from 35 to 80%. Epstein-Barr virus-encoded RNA was detected by in situ hybridization in 6 of the 12 available cases. Two patients showed BCL-6 rearrangements. The follow-up period ranged from 1 to 87 months. During the follow-up period, four patients died of the disease, five were alive with the disease, four were alive without disease, and one was lost during the follow-up period. In summary, most primary adrenal lymphomas are non-germinal-center B-cell-like subtype DLBCLs, which have high proliferative activity and a poor prognosis.

High 18F-fluorodeoxyglucose uptake in primary bilateral adrenal diffuse large B-cell lymphomas with nongerminal center B-cell phenotype: A case report

RATIONALE

Bilateral adrenal diffuse large B-cell lymphoma, nongerminal center B-cell phenotype (non-GCB DLBCL), is an uncommon malignancy that exhibits rapid development. Fluorine-18-fluorodeoxyglucose position emission tomography/computed tomography (CT) is extremely sensitive in distinguishing highly malignant tumors from benign tumors.

PATIENT CONCERNS

We report a case of non-GCB DLBCL showing significantly high uptake of 18F-FDG on PET/CT examination.

DIAGNOSES

Histopathological and immunohistochemical examination further confirmed that the bilateral adrenal masses were non-GCB DLBCL.

INTERVENTIONS

The maximal standardized uptake value (SUVmax) of the adrenal lesion was 17.2. Abnormal 18F-FDG uptake was observed in a retroperitoneal lymph node, the SUVmax of which was 14.2.

OUTCOMES

He was administered CHOP chemotherapy without rituximab due to high costs.His therapeutic effect and survival time could not be tracked due to patient privacy.

LESSONS

non-GCB DLBCL is a rare malignancy.18F-FDG PET/CT examination can distinguish benign from malignant adrenal lesions based on increased FDG uptake. It is a noninvasive method to diagnose malignant adrenal tumors.

Extranodal diffuse large B-cell lymphomas: A retrospective case series and review of the literature

Non-Hodgkin lymphomas commonly show extranodal involvement (25-30%) but primary diffuse large B-cell lymphomas (DLBCL) with extranodal localization represent clinically and molecularly distinct entities. The present study involved retrospective analysis of case records of 4 patients who were diagnosed with extranodal DLBCL between 2010 and 2016 at the Medical Oncology and Hematology Departments of the Ioannina University Hospital, Greece. Median age of presentation was 69 years (range 60-77 years). There were 2 males and 2 females. The sites of DLBCL involvement included adrenal gland, mandible, cervix uteri, and ileum. Two patients had B symptoms while none had bone marrow involvement. After staging workup, all the patients fell into IE stage. The treatment approach included chemotherapy combined with rituximab (R), whereas one patient received additionally irradiation therapy. Post-treatment positron emission tomography-computed tomography scan was performed in 3 patients. In terms of the outcome, 3 patients are alive in complete response, whereas one was lost in follow-up. Further prospective data analyses are required so as to better elucidate the biology and course of extranodal DLBCL.

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.

Primary Adrenal Lymphoma Presenting with Adrenal Failure: A Case Report and Review of the Literature

INTRODUCTION

Primary adrenal lymphoma is rare, with a few cases reported in the literature. Most often it manifests as bilateral adrenal lesions and adrenal insufficiency is a common complication.

CASE PRESENTATION

A 53-year-old male was referred with abdominal discomfort and darkening of the skin since 1 month prior to admission. His workups detected large bilateral adrenal masses. The patient was admitted due to hypotension, and was diagnosed with adrenal insufficiency. Laboratory studies showed high erythrocyte sedimentation rate (ESR), lactate dehydrogenase (LDH), and adrenocorticotropin levels. There was no other organ involvement and computed tomography (CT)-guided percutaneous biopsy of the adrenal gland revealed B-cell type of non-Hodgkin lymphoma. Replacement therapy with glucocorticoid and mineralocorticoid was initiated with remission of symptoms. After 3 months of chemotherapy his condition improved, but the patient worsened thereafter and died 2 months later.

CONCLUSIONS

However, this case reminded the importance of considering primary adrenal lymphoma in the differential diagnosis of bilateral adrenal masses, especially if the patient presents with adrenal insufficiency.

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.

Primary Non Hodgkin's Lymphoma of Left Adrenal Gland - A Rare Presentation

Primary adrenal lymphoma is rare and constitutes for 3% of extranodal lymphoma cases. Approximately 70% of patients present with bilateral disease and have adrenal insufficiency. Prognosis of primary adrenal lymphoma (PAL) is poor, most of patient die within one year of diagnosis. Moreover, there are no standard treatment protocols on such cases. Patients are generally treated with regimens similar to other nonhodgkin lymphoma which includes surgery, combination chemotherapy and or radiotherapy. We are presenting a successfully treated case of primary diffuse large B cell non Hodgkin lymphoma of adrenal gland in a 57-year-old patient. The patient had unilateral adrenal involvement (left adrenal gland), without adrenal insufficiency and normal Serum lactate dehyrogenase level. The patient was treated with left adrenalectomy followed by combination chemotherapy. Two years after diagnosis and treatment the patient is disease free on clinical and imaging studies.

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.

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.

Bilateral primary adrenal lymphoma presenting with adrenal insufficiency

Lymphoma may occasionally involve the adrenal glands, but primary adrenal lymphoma (PAL) is very rare and only few cases have been reported. We present a case of a 60-year-old, otherwise healthy, woman, with bilateral PAL presenting with adrenal insufficiency. The patient responded initially upon administration of large doses of intravenously hydrocortisone with total remission of symptoms. An abdominal computerized tomography scan demonstrated bilateral adrenal lesions but did not demonstrate any other pathology. Since metastatic malignant disease was suspected a positron-emission-tomography scan was performed only showing significant uptake in the adrenal glands. Endocrine evaluation did not reveal abnormal function of any hormonal system and the patient was scheduled for bilateral adrenalectomy. However the clinical condition deteriorated rapidly and the patient was readmitted to hospital before surgery was performed. A new computerized tomography scan showed rapid progression of disease with further enlargement of the adrenal masses and both pulmonary and hepatic metastasis. Needle biopsy was performed but the patient refused further treatment and died before a diagnosis was obtained. The immuneohistochemical diagnosis was large B-cell lymphoma. This case should remind clinicians that PAL may be a cause of bilateral adrenal incidentaloma especially if the patient presents with adrenal insufficiency.

Prognostic factors in primary diffuse large B-cell lymphoma of adrenal gland treated with rituximab-CHOP chemotherapy from the Consortium for Improving Survival of Lymphoma (CISL)

BACKGROUND

The objective of this study was to identify prognostic factors for survival in patients with primary diffuse large B-cell lymphoma (DLBCL) of the adrenal gland.

METHODS

Thirty one patients diagnosed with primary adrenal DLBCL from 14 Korean institutions and treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) were analyzed.

RESULTS

Complete remission (CR) and overall response rate after R-CHOP chemotherapy were 54.8% and 87.0%. The 2-year estimates of overall survival (OS) and progression-free survival (PFS) were 68.3% and 51.1%. In patients achieving CR, significant prolongations of OS (P = 0.029) and PFS (P = 0.005) were observed. Ann Arbor stage had no influence on OS. There was no significant difference in OS between patients with unilateral involvement of adrenal gland and those with bilateral involvement. When staging was modified to include bilateral adrenal involvement as one extranodal site, early stage (I or II) significantly correlated with longer OS (P = 0.021) and PFS (P <0.001).

CONCLUSIONS

Contrary to prior reports, our data suggests that outcomes of primary adrenal DLBCL are encouraging using a regimen of R-CHOP, and that achieving CR after R-CHOP is predictive of survival. Likewise, our modified staging system may have prognostic value.

A case of primary ovarian lymphoma with autoimmune hemolytic anemia achieving complete response with Rituximab-based combination chemotherapy

Ovarian involvement as primary or secondary lymphomatous process is extremely uncommon. In most cases, the diagnosis is usually not suspected initially and is confirmed only after detailed histopathological evaluation. We report a patient with primary ovarian diffuse large B-cell lymphoma (DLBCL) and associated auto-immune hemolytic anemia (AIHA) who achieved complete remission after treatment with Rituximab-cyclophosphamide-doxorubicin-vincristine and prednisolone (R-CHOP) chemotherapy. This patient was a 50 year old female, who presented with fever, abdominal pain, vomiting, weight loss and anemia. Computed tomography scan of the abdomen and pelvis revealed a large left ovarian mass with bilateral hydronephrosis. We performed exploratory laparotomy and partial resection of the mass was done due to the adhesions. Histopathology confirmed the diagnosis of DLBCL. After six R-CHOP chemotherapy cycles, patient achieved complete response with correction of anemia. To our knowledge, this may be the first case report till date of primary ovarian DLBCL with AIHA treated with R-CHOP chemotherapy who achieved complete remission in terms of primary disease as well as hemolytic anemia.

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.

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.

Primary bilateral adrenal lymphoma revealed by hemophagocytic syndrome

Primary adrenal lymphoma is rare. It is often bilateral and in most of the cases of B-cell type. The clinical features are various and not specific. We report a case of a 69-year-old woman who had a diffuse large B-cell lymphoma associated with hemophagocytic syndrome. The abdominal imaging reveals the existence of bilateral adrenal hypertrophy. A CT scan-guided biopsy concluded to a diffuse large B-cell lymphoma CD 20-positive associated EBV. The treatment consisted on "CHOP like" chemotherapy associated with rituximab. Primary adrenal lymphoma has a poor prognosis, even more poorly if associated with hemophagocytic syndrome.

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma

BACKGROUND

Rarely, a patient presents to a surgeon for evaluation of an adrenal incidentaloma where the final pathology is primary malignancy. For primary adrenal lymphoma, fewer than 100 cases have been reported in the literature.

CASE REPORT

We report a case of unilateral primary adrenal aggressive B cell lymphoma discovered incidentally in a 41-year-old female. Preoperative testing demonstrated the 6-cm mass to be biochemically silent. Subsequently, the patient underwent a laparoscopic adrenalectomy. Following pathologic diagnosis of B cell lymphoma, a metastatic workup was negative, and she underwent treatment with systemic chemotherapy. She is currently disease free 6 months postoperatively.

CONCLUSION

Primary adrenal lymphoma should be considered in patients with unilateral adrenal incidentaloma. We believe that adherence to guidelines of resection of incidentalomas allowed for early surgical intervention and possible cure.

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.