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CASE REPORT
Year : 2018  |  Volume : 17  |  Issue : 1  |  Page : 46-48

Unilateral primary adrenal lymphoma: Uncommon presentation of a rare disease evaluated using 18f-fluorodeoxyglucose positron emission tomography/computed tomography


1 Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication5-Jan-2018

Correspondence Address:
Bhagwant Rai Mittal
Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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DOI: 10.4103/1450-1147.222288

PMID: 29398965

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   Abstract 


Primary adrenal lymphoma (PAL) is a relatively rare disease entity with only fewer than 200 cases reported till date. PAL frequently presents with bilateral adrenal involvement and shows male preponderance. We here present a case of PAL in a 65-year-old female with a relatively uncommon unilateral adrenal involvement. The present case depicts that 18F-fluorodeoxyglucose positron emission tomography/computed tomography had decisive role in the treatment management of this patient suggesting its potential utility in the management of this rare disease.

Keywords: 18F-fluorodeoxyglucose positron emission tomography/computed tomography, diffuse large B-cell lymphoma, primary adrenal lymphoma, primary extranodal non-Hodgkin lymphoma


How to cite this article:
Radhakrishnan RK, Mittal BR, Reddy Gorla AK, Malhotra P, Bal A, Varma S. Unilateral primary adrenal lymphoma: Uncommon presentation of a rare disease evaluated using 18f-fluorodeoxyglucose positron emission tomography/computed tomography. World J Nucl Med 2018;17:46-8

How to cite this URL:
Radhakrishnan RK, Mittal BR, Reddy Gorla AK, Malhotra P, Bal A, Varma S. Unilateral primary adrenal lymphoma: Uncommon presentation of a rare disease evaluated using 18f-fluorodeoxyglucose positron emission tomography/computed tomography. World J Nucl Med [serial online] 2018 [cited 2020 Jan 28];17:46-8. Available from: http://www.wjnm.org/text.asp?2018/17/1/46/222288




   Introduction Top


Primary extranodal non-Hodgkin lymphomas (PE-NHL) have an incidence of ~25%–40%, varying with geography. Although no lone definition is universally accepted, the most wisely observed description defines it as the presentation of lymphoma at extranodal site with no/minor-associated nodal involvement, where bulk of the disease is situated at the extranodal site.[1],[2] Primary lymphomatous involvement of the adrenal glands (primary adrenal lymphoma [PAL]) is very rare and accounts for <1% of the PE-NHL cases. Most often PAL presents with bilateral involvement (~75% of the cases) of the adrenal glands as large masses and has a male preponderance.[3] 18F-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) is an established imaging modality which is widely used in initial staging, treatment response, and recurrence evaluation of lymphomas.[4] We here report a case of PAL with an uncommon presentation as a unilateral mass in an elderly female who was evaluated using 18F-FDG PET/CT during the disease management.


   Case Report Top


A 65-year-old female presented with pain and heaviness in the right flank for the past 2 months. Examination was unremarkable except for mild right hypochondrial tenderness. Evaluation with contrast-enhanced computed tomography revealed a large heterogeneously enhancing soft-tissue mass in the right suprarenal area. A whole-body 18F-FDG PET/CT was performed for further characterization, which revealed intense FDG uptake (maximum standardized uptake value [SUVmax] 20.0; ~9.8 cm × 7.0 cm × 7.8 cm) in the soft-tissue mass involving the right adrenal gland [Figure 1]a and [Figure 1]b. A few intensely FDG avid (SUVmax 16.7) enlarged retroperitoneal (largest measuring ~3.6 cm × 2.4 cm), and cervical lymph nodes are also noted [Figure 1]c. Unilateral presentation, intense FDG avidity, and associated lymphadenopathy suggested as possibility of adrenocortical carcinoma versus lymphomatous involvement. Fine needle aspiration cytology from the right adrenal gland mass revealed lymphomatous infiltration, and a core needle biopsy performed subsequently yielded a histopathological diagnosis of diffuse large B-cell lymphoma (DLBCL) through immunotyping [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. Bone marrow aspiration was negative for lymphomatous infiltration, and the patient was staged as Ann Arbor Stage IIIE. The patient then received four cycles of R-CHOP regimen, and interim 18F-FDG PET/CT revealed faint FDG avidity (SUVmax 2 vs. 20 previously) of the right adrenal mass lesion and resolution of FDG avidity of the retroperitoneal and cervical lymphadenopathy suggesting a favorable response to therapy [Figure 1]d, [Figure 2]e, [Figure 2]f. The patient then received two more cycles of R-CHOP. 18F-FDG PET/CT done at the end of six cycles revealed mild persistent FDG avidity in the right adrenal mass and appearance of renal lesions (SUVmax 18.3) and paracaval lymph nodes suggesting disease progression [Figure 1]g, [Figure 2]h, [Figure 2]i. Rapid cytopenia developed in the patient following chemotherapy, and the patient was changed to alternate chemotherapy regimen (R-ICE). Further deterioration in thrombocytopenia was noted in the patient after the first cycle, which lead to discontinuation of therapy and was followed by symptomatic treatment. Currently, the patient is clinically stable and started on oral chemotherapy regimen containing endoxan, etoposide, and procarbazine.
Figure 1: (a) Maximal intensity projection of the staging 18F-fluorodeoxyglucose positron emission tomography/computed tomography showing areas of intense abnormal tracer uptake in the right suprarenal location and along the midline; (b and c) Transaxial fused positron emission tomography/computed tomography images localized the intense tracer uptake to a large suprarenal mass and to a few enlarged retroperitoneal lymph nodes; (d-f) maximal intensity projection and fused positron emission tomography/computed tomography images of interim positron emission tomography/computed tomography (following four cycles of chemotherapy) showing significant resolution in size and fluorodeoxyglucose avidity of the right suprarenal mass and retroperitoneal lymph nodes. (g-i) End of treatment positron emission tomography/computed tomography images (after two more cycles of chemotherapy) revealing disease relapse in the form of a right renal lesion and a few retroperitoneal lymph nodes

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Figure 2: Photomicrographs showing (a) sheets of atypical lymphoid cells with large nuclei and moderate cytoplasm (H and E, ×400); (b) membrane positivity of tumor cells for CD20; (c) atypical lymphoid cells showing positivity for CD79a; (d) CD3 immunostaining highlighting reactive cells (b-d: Immunoperoxidase, ×400) confirming a diagnosis of diffuse large B-cell lymphoma

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   Discussion Top


Normally adrenal glands are devoid of lymphatic tissue and hence it is often believed that primary lymphomatous involvement originates in the setting of a precedent autoimmune adrenalitis.[5] There is paucity of literature evaluating large number of PAL, likely attributable to its rarity. In a recent didactic review of 187 cases by Rashidi and Fisher, the authors have systematically summarized the available cases of PAL in literature. They showed that PAL has a preferential bilateral involvement with DLBCL (~78% of the cases) as the most common histology. B-symptoms, abdominal pain, and fatigue were the most common symptoms at presentation. In their series, the authors also noted a high incidence of adrenal insufficiency (~61%), more commonly associated with bilateral adrenal gland involvement.[3]

Conventionally, PE-NHLs are claimed to demonstrate poorer prognosis as compared to nodal lymphomas with a higher relapse rate. Former cases of PAL treated with CHOP/CHOP-like regimens reported shorter survival rates. Kumar et al. in their study reported a mean overall survival of only 15.3 months (3.6 vs. 34 months in those with no response and that showed disease remission, respectively).[6] In a single largest study in 31 patients by Kim et al., the authors incorporated rituximab to the chemotherapy regimen. They reported higher survival rates as compared to the previously reported literature.[7]

DLBCL, an aggressive histological subtype, is usually highly metabolically active and being the most common of subtype noted in PAL, facilitates imaging with metabolic imaging using 18F-FDG PET/CT. The established role of 18F-FDG PET/CT in the management of metabolically active lymphomas permits its translation into evaluating of this rare entity.[4],[8] The present case depicts the utility of 18F-FDG PET/CT in assessment of disease response and also early detection of progression/relapse.

Furthermore, in the present case, several features including unilateral involvement, female gender, and the absence of several common associations were against an etiology of PAL. Thus, this case illustrates an uncommon presentation of PAL and suggests the need to consider it as a differential diagnosis during evaluation of adrenal masses.


   Conclusion Top


18F-FDG PET/CT is potential modality in the evaluation of patients with PAL for initial staging, response evaluation, and early detection of disease progression and thus can aid in therapeutic decision-making.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of intrest.



 
   References Top

1.
Chua SC, Rozalli FI, O'Connor SR. Imaging features of primary extranodal lymphomas. Clin Radiol 2009;64:574-88.  Back to cited text no. 1
    
2.
Krol AD, le Cessie S, Snijder S, Kluin-Nelemans JC, Kluin PM, Noordijk EM. Primary extranodal non-Hodgkin's lymphoma (NHL): The impact of alternative definitions tested in the Comprehensive Cancer Centre West population-based NHL registry. Ann Oncol 2003;14:131-9.  Back to cited text no. 2
[PUBMED]    
3.
Rashidi A, Fisher SI. Primary adrenal lymphoma: A systematic review. Ann Hematol 2013;92:1583-93.  Back to cited text no. 3
[PUBMED]    
4.
Tirumani SH, LaCasce AS, Jacene HA. Role of 2-deoxy-2-[18F]-fluoro-d-glucose-PET/computed tomography in lymphoma. PET Clin 2015;10:207-25.  Back to cited text no. 4
[PUBMED]    
5.
Zhang LJ, Yang GF, Shen W, Qi J. Imaging of primary adrenal lymphoma: Case report and literature review. Acta Radiol 2006;47:993-7.  Back to cited text no. 5
[PUBMED]    
6.
Kumar R, Xiu Y, Mavi A, El-Haddad G, Zhuang H, Alavi A. FDG-PET imaging in primary bilateral adrenal lymphoma: A case report and review of the literature. Clin Nucl Med 2005;30:222-30.  Back to cited text no. 6
[PUBMED]    
7.
Kim YR, Kim JS, Min YH, Hyunyoon D, Shin HJ, Mun YC, et al. 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). J Hematol Oncol 2012;5:49.  Back to cited text no. 7
[PUBMED]    
8.
Cronin CG, Swords R, Truong MT, Viswanathan C, Rohren E, Giles FJ, et al. Clinical utility of PET/CT in lymphoma. AJR Am J Roentgenol 2010;194:W91-103.  Back to cited text no. 8
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]


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