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 Adrenal lymph oma

Adrenal Lymphoma

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Adrenal Lymphoma

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  • 5/20/2018 Adrenal Lymphoma

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    Adrenal lymphoma

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    KG, 32/M, 2012090710

    Referred as a case of

    bilateral adrenal

    masses with c/o-

    Right upper abdominal

    No history of-

    Headache

    Sweating

    Palpitations

    Visual blackouts

    2

    pain- 2 months, vague,

    no shifting or migration

    High grade fever- 2 days

    Maximum BP recorded-140/100 mm Hg

    Tremors

    Weakness

    Graveluria

    Neck swelling

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    Family History

    70 yrs

    Cause?

    Young age

    Cause ?

    3

    Accidental

    death

    70 yrs

    Heart attack

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    Examination

    No neurocutaneous markers

    P/R- 80/min, regular in rhythm

    BP-

    4

    Supine- 140/90 mm Hg

    Standing- 130/84 mm Hg

    Neck- Single mobile LN in left level 2 Abdomen- NAD

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    USG abdomen

    Bilateral large adrenal

    masses-

    Left-

    11.4 x 10.0 x 9.3 cm

    5

    Predominantly

    hypoechoic

    Right-

    11.6 x 8.6 x 7.4 cm

    Predominantly

    hypoechoic

    Kidneys normal

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    Biochemical evaluation elsewhere

    Hormone Value Normal range

    24-hr urinary metanephrine 6.93 g/day 53-341

    24-hr urinary metanephrine 4.01 g/gm creatinine 27-155

    24-hr urinary normetanephrine 1530.84 g/day 88-444

    24-hr urinary normetanephrine 885.13 g/gm creatinine 46-256

    6

    - r ur nary reat n ne . mg

    24-hr urinary VMA 140.61 ng/dl 1.8-6.7

    24-hr urinary VMA 30.98 mg/gm creatinine 1.6-4.2

    S. Cortisol 83.0 ng/ml 30-150

    Potassium 4.2 mmol/L 3.5-5.4

    S. ACTH 64.4 pg/ml 7.9-66.1

    24-hr urinary Cortisol 30.4 g/day 28.5-213.7

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    Chest X-ray

    7

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    CECT abdomen

    8

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    CECT abdomen

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    CECT abdomen

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    CT-Angio

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    MRI abdomen

    12

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    Treatment elsewhere

    Diagnosis made as bilateral adrenal

    Pheochromocytoma

    Patient was given -blockers that were

    13

    -

    blockers

    Was planned for surgery elsewhere but

    Surgeons refused; said it was inoperable

    mass

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    Differential Diagnosis

    Bilateral adrenal masses-

    ?Pheochromocytoma

    ?? Lymphoma

    14

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    Course @ SGPGI

    Due to confusion in diagnosis, plan was to workup again

    Fever persisted despite antimalarials, antibiotics

    Decreased oral intake with increasing pain

    15

    a omen

    Plan- FNAC from neck LN

    Repeat 24-hour urinary fractionated metanephrines Hematology, Biochemistry, cultures, serology,

    malarial parasite (PBS)

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    Investigations @ SGPGI

    FNAC neck LN- Predominance of large

    atypical lymphoid cells, possibility of

    lymphoproliferative disorder

    16

    - , , -

    for bacterial growth

    Peripheral smear- negative for malarial

    parasite

    HIV, Widal- non reactive

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    Investigations @ SGPGI

    Hormone Value Normal range

    24-hr urinary metanephrine 26.43 g/day

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    Repeat CECT abdomen

    Right- 11x10x8 cm

    Left- 11x10.5x6 cm

    Few necrotic areas

    No calcification/ hge

    18

    Encasement of celiac,

    splenic and renal arteries

    and veins and a focal

    segment of aorta

    Bilateral pleural effusion

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    Histopathology from Adrenal gland

    Lymphoblastic lymphoma

    Bone marrow infiltration absent

    19

    +ve- -ve- LCA, CD3 - CD20, TdT

    Ki-67- 70-80%

    Immunohistochemistry

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    Further course

    Given chemotherapy first cycle- CHOP

    Partial improvement in symptoms

    Fever subsided

    20

    Intake improved

    Patient discharged in stable condition after

    one week of chemotherapy

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    Course @ home

    Patient developed fever, vomiting and

    dizziness after 10 days

    Admitted at local hospital for supportive

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    Further course

    Patient developed fever and cough with

    anemia

    Admitted in shock

    22

    - , - , progress ve y

    rising (502, 166), viral markers negative

    LDH increased to 4,602 U/L

    Patients condition did not improved and

    succumbed 13 days after admission

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    THANK YOU

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