Introduction: Primary testicular lymphoma is very rare and constitutes about 2% of all extra nodal lymphomas, mostly in men above the age of 60. Bilateral adrenal masses could be due to metastatic disease, congenital adrenal hyperplasia, bilateral macro-nodular hyperplasia, adrenal adenomas, lymphomas, infiltrative diseases, amyloidosis and infections like tuberculosis. Metastasis occurs most commonly from lung, bowel, breast and pancreatic cancer. Metastasis from lymphomas is far less common. We report a case of primary testicular lymphoma with bilateral adrenal metastases.
Case report: A 71 year old man presented with right sided testicular swelling and underwent a right radical orchidectomy. Histology showed diffuse large cell B cell lymphoma. A subsequent staging CT scan revealed bilateral adrenal masses with no significant lymphadenopathy. There was marked FDG uptake in both adrenals on PET-CT, in keeping with FDG avid disease. His 24-hour urinary cortisol was 31 nmol (normal range 100379 nmol). Plasma metanephrines were within normal range. He complained of excessive tiredness and ongoing weight loss, and had clinical evidence of orthostatic hypotension. His serum electrolytes were within normal range but a short synacthen test confirmed adrenal insufficiency with a baseline cortisol of 142 nmol/l and 141 nmol/l at 30 min. His symptoms markedly improved on hydrocortisone replacement. He underwent a CT guided biopsy of the right adrenal gland which confirmed diffuse large B cell lymphoma on histology, likely metastatic from his previous testicular lymphoma. He was then followed up by the haematologist for chemotherapy and radiotherapy.
Conclusion: Patient with bilateral adrenal masses, especially in the context of underlying malignant disease should be investigated for hormone excess and deficiency before any further intervention is undertaken. Biochemical investigation to rule out adrenal insufficiency is recommended to prevent adrenal crisis during invasive or operative interventions.