Primary Adrenal Lymphoma

A 77 year-old Caucasian male complained about a 3-month history of progressive weakness, intermittent fevers and a 40 pound weight loss. He presented to the ED with abdominal pain, a hemoglobin level of 8.3 g/dl, MCV 95 fl. The patient had a negative gastrointestinal evaluation for blood loss sources completed a month before. LDH level was elevated at 669 U/L, beta-2 microglobulin at 4.3 mg/L, electrolytes, liver enzymes, thyroid studies and renal function tests read normal. Abdominal CT scan revealed a 10 x 10 x 9.5 cm mass on the right adrenal gland and a 10 x 7.6 x 7 cm mass on the left side. There was no adenopathy in the para-aortic or mesenteric area (Figure 1). CT guided biopsy showed CD45+ and CD20+ large cells with high nuclear:cytoplasma ratio, as well as scant cytoplasm consistent with diffuse large B-cell lymphoma (DLBCL). Due to a high apoptotic rate, further studies were done, MYC/IGH gene rearrangement was performed with negative results. Bone marrow biopsy did not show lymphomatous involvement. Staging PET-CT scan showed bilateral adrenal masses with a SUV as high as 27. There was no extra-adrenal uptake.