Category: Adrenal Disorders

Type: e-Poster

Monitor: 33

33 - DIFFUSE LARGE B-CELL LYMPHOMA OF THE ADRENAL GLAND: RARE PRESENTATION WITH SUBCLINICAL CUSHING'S SYNDROME

Friday, Apr 26
11:30 AM – 12:00 PM

Objective : Report a rare case of adrenal lymphoma presenting with subclinical cushing’s syndrome. An adrenal incidentaloma is a mass greater than 1 cm in diameter serendipitously discovered by radiologic examination, most adrenal incidentalomas are nonfunctional, less than 15% secrete excess amounts of hormones. Subclinical cushing’s syndrome represent 6.4%. Lymphoma remains in the differential for bilateral adrenal masses, however usually present with adrenal insufficiency.


Methods :

We present a case of a 43-year-old female of Cuban origin who was evaluated for nausea and emesis after initiation of Helicobacter pylori treatment. Incidentally the patient was found to have bilateral adrenal masses on an abdominal ultrasound and MRI. On further inquiry, patient reported that she was first diagnosed with right adrenal nodule about 6 years prior to presentation. There was no hormonal evaluation completed at that time and she was told the findings were benign. At presentation, patient denied episodes of diaphoresis, elevated blood pressures, headaches, on exam not round face, central obesity, purple striae or supraclavicular fat pads were noted.


Results :

MRI of the abdomen showed, hypo-enhancing bilateral adrenal masses with necrotic areas, right adrenal mass measured 9.3cm x 6.0cm and left adrenal mass measured 11.4cm x 8.9cm. There was extensive retroperitoneal lymphadenopathy. On laboratory evaluation, during 1mg overnight Dexamethasone suppression test, next morning cortisol level were 2.7mg/dl (did not suppress) . Adrenocorticotropic (ACTH)Hormone level was low at 6 pg/ml. Patient had elevated 24-hour urine free cortisol levels at 113 mcg/24h (reference range 4-50 mcg/24h). DHEA-Sulfate was with normal range. Plasma Renin Activity and Plasma Aldosterone level were within normal range. The 24 hour urine collection of total and fractionated metanephrines was within normal range. Once pheochromocytoma was ruled out, the left adrenal mass was biopsied with pathology indicating large B-cell lymphoma with high grade features. Bone marrow biopsy showed hyper cellular marrow (80%) with trilineage hematopoiesis. 


 


 


 


 


 


Discussion : Patient was started on rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) . Currently, patient is awaiting post treatment scans and outpatient follow up with Oncology and Endocrinology.


Conclusion : Adrenal insufficiency is the most common hormonal abnormality associated with Lymphoma due to destruction of the glandular parenchyma. Here, we report a rare case of adrenal lymphoma presenting with Subclinical Cushing’s syndrome.

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Vindya Gunawardena

Endocrinology Fellow
University of South Florida
Tampa, Florida

Endocrinology fellow

Carlos Pla Fernandez

Endocrinology fellow
University of South Florida
Tampa, Florida

ENDO FELLOW

Marla Sevilla

Endocrinology faculty
University of South Florida

Endocrinology faculty

Joaquin Gomez-Daspet

Program director
University of South Florida

Program director