Primary bilateral adrenal lymphoma without adrenal insufficiency: a case report
Cavit Culha, Ziynet Alphan Uc, Esra Nur Ademoglu, Ahmet Yildirim, Dilek Dellal, Suheyla Gorar, Gonul Koc & Yalcin Aral
Although adrenal gland involvement may be seen in patients with diffuse (non-Hodgkin) lymphoma, primary adrenal lymphoma is quite rare and adrenal insufficiency accompanies the clinical picture in 2/3 of cases.
Case: A 70-year-old male patient presenting with anorexia and weight loss was referred to our clinic for bilateral adrenal masses, which were detected by abdominal computerized tomography (CT) as 5.2×5.2×2.7 cm in the right adrenal and 11×9×7 cm in the left adrenal. Plasma cortisol was normal (20 μg/dl) and suppressed with 1 mg of dexamethasone. Hypertension was not reported in the history and was not detected in the follow-up of the patient. ACTH (34 pg/ml), aldosterone, renin and 24-h urine catecholamine levels were normal. Bilateral adrenal masses were inactive. Initially, hemogram and peripheral blood smear were normal and sedimentation rate was 120 mm/h. In the second evaluation, hemoglobin was 8 g/dl, leukocyte 3500/mm3 (67.9% neutrophils, 15.9% lymphocytes and 13.9% monocytes) and platelet 591.000/mm3. Tuberculin skin test and chest tomography was normal. No adrenal insufficiency was detected clinically or in laboratory testing. The diagnosis of large diffuse large B-cell (non-Hodgkin) lymphoma was made by tru-cut biopsy of the left adrenal gland performed concomitantly with CT. The patient was referred to medical oncology department. CHOP regimen chemotherapy was begined. The symptoms and signs of the patient was reduced after the early phase of ongoing treatment.
Conclusion: The total number of reported cases with primary bilateral adrenal lymphoma in the literature so far is around 70. We should keep in mind that bilateral adrenal masses detected by imaging techniques may not always be metastases, but sometimes the primary malignancy itself, even if very rarely; and take into consideration that, as in our present case, there may be no accompanying adrenal insufficiency even if the bilateral adrenal masses are large.