An 86-year-old male with bilateral adrenal masses was diagnosed with primary adrenal lymphoma (PAL) via biopsy, demonstrating DLBCL with aggressive features requiring early intervention.
Primary adrenal lymphoma is a rare but important differential diagnosis for bilateral adrenal masses, requiring histopathological confirmation for appropriate management.
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Abstract Introduction Primary adrenal lymphoma (PAL) is a rare type of extranodal lymphoma, with diffuse large B-cell non-Hodgkin lymphoma (DLBCL) being the most common histological subtype. The disease typically presents in elderly males and is often associated with bilateral adrenal masses. Due to its rarity and nonspecific clinical manifestations, the diagnosis of PAL is often challenging and requires histopathological confirmation. We present a rare case of PAL in an elderly male with bilateral adrenal masses, emphasizing its consideration in the differential diagnosis for early detection. Clinical Case An 86-year-old male patient presented with complaints of abdominal pain and weight loss, persisting for one month. The patient was admitted to our department for further evaluation. His history included prostate cancer treated surgically 10 years earlier without metastasis. During the initial evaluation, his blood pressure was 110/70mmHg, there were no clinical findings suggestive of adrenal insufficiency. Laboratory tests revealed anemia, biochemistry demonstrated markedly elevated LDH, while liver-renal function tests were within normal limits. Hormonal evaluation showed a basal cortisol:10.9 µg/dL. Plasma metanephrine-normetanephrine levels were within normal ranges. After the 1 mg dexamethasone suppression test, cortisol was 1.2 µg/dL. Aldosterone-plasma renin activity was also within normal limits. Abdominal CT demonstrated lobulated-solid, heterogeneous masses occupying both adrenal regions, measuring 55×26mm on the right, 122×101mm on the left. PET/CT showed the lesions with marked pathological FDG uptake in both adrenal glands, no other pathological lesions were detected elsewhere within the imaging field. An ultrasound-guided adrenal tru-cut biopsy was performed. Histopathological examination revealed DLBCL, with staining positive for CD20, BCL2, BCL6, c-MYC. The patient was diagnosed as PAL and referred to the hematology department, treatment was initiated with the R-CHOP regimen. The patient developed sepsis in the first month of therapy and died in the intensive care unit. PAL is a rare and aggressive type of lymphoma with an unclear etiology. The disease is characterized by atypical clinical manifestations and nonspecific imaging findings, which often make diagnosis challenging for clinicians. Adrenal biopsy is indicated in cases where imaging cannot reliably distinguish benign from malignant lesions and when histopathological confirmation will directly impact therapeutic decision-making. Importantly, pheochromocytoma must always be excluded prior to biopsy. In patients without evidence of extra-adrenal metastases and in whom surgical resection of the adrenal lesion is a potential option, FDG-PET/CT is valuable to rule out occult metastases. Conclusion PAL is a rare but important consideration in the differential diagnosis of adrenal masses. Early diagnosis and a multidisciplinary approach are critical for optimizing patient outcomes.Figure 1:Bilateral adrenal masses on PET-CTPositron emission tomography–computed tomography (PET-CT) demonstrating heterogeneous lesions in both adrenal glands with marked pathological FDG uptake. Table 1:Laboratory findings of the patientBiochemical and hormonal parameters of the patient are presented
Bozkurt et al. (Thu,) reported a other. An 86-year-old male with bilateral adrenal masses was diagnosed with primary adrenal lymphoma (PAL) via biopsy, demonstrating DLBCL with aggressive features requiring early intervention.