Bilateral Adrenal Masses in a Patient in Remission From Acute Myelomonocytic Leukemia

Abstract

CLINICAL PRESENTATION A 51-year-old man presented in the outpatient department with a 1-month history of persistent low-grade fever. He was diagnosed with acute myelomonocytic leukemia 4 years before and was treated with induction therapy of standard-dose cytarabine with daunorubicin, followed by consolidation therapy with cytarabine. Until this time, he had been in complete remission. Workup on admission revealed no pathogen detected in blood or sputum cultures. The early morning serum cortisol was 15.89 mg/dL, and urine vanillylmandelic acid level was normal. The bone marrow aspiration revealed normal cellularity and no residual blasts. The coronal computed tomography (CT) scan of abdomen and pelvis demonstrated bilateral adrenal masses, 10.8 cm in diameter on the right side (Figure 1A, black arrow) and 10.0 cm in diameter on the left side (Figure 1A, arrowhead). Celiac trunk nodal involvement was also found (Figure 1A, white arrow). 18Fluorine-fluorodeoxyglucose (18F-FDG) positron emission tomography/CT imaging showed “H” appearance of intense 18F-FDG uptake at bilateral adrenal glands (the maximum value of standardized uptake value [SUVmax] up to 30) and an ill-defined FDG-avid tumor (about 4.5 cm, SUVmax from 18.3 to 20.9) between bilateral lesions (Figure 1B). The core biopsy of the right adrenal mass disclosed features of diffuse large B-cell lymphoma, and he was treated with rituximab plus cyclophosphamide, liposomal doxorubicin, vincristine, and prednisone (R-CLOP). Follow-up CT scan obtained 3 months later showed nearly complete resolution of bilateral adrenal mass. Although secondary involvement of the adrenal gland occurs in up to 25% of patients with non-Hodgkin’s lymphoma, its clinical manifestation is usually ambiguous. Positron emission tomography/CT has potential advantages over traditional radiological examinations for diagnosis, staging of disease and detecting recurrences of malignancies. In this case, the “H” appearance of significantly higher 18F-FDG uptake helped to differentiate secondary adrenal involvement from a primary adrenal malignancy.