Primary adrenal B cell lymphoma.

Abstract

A 57-year-old man presented with a 12-hour history of abdominal pain of sudden onset. The pain was localized to the right upper quadrant, and there were no relieving or aggravating factors. There was also no associated nausea or vomiting. Clinical examination revealed tenderness and voluntary guarding in the right upper quadrant, but no signs of rebound or peritonism. His only other symptom was night sweats which had been occurring for 2 years. There was no relevant past medical or family history. An ultrasound scan of the abdomen demonstrated a 7.5×6.6×4 cm mass, superior to and separate from the right kidney and separate from the right lobe of liver. The mass contained multiple internal echoes and had appearances consistent with an adrenal mass. The other abdominal organs including the contralateral adrenal gland appeared within normal limits. The ultrasound findings were confirmed on abdominal computed tomography (CT) scan and followed up by urine biochemistry, chest X-ray and routine blood tests, which were all normal. Protein electrophoresis showed a diffuse increase in γ-globulins (15 g/litre; range 4–7 g/litre). A CT-guided adrenal biopsy was performed which yielded a core of mostly necrotic tissue on which the differential diagnosis of malignant lymphoma or tuberculosis was raised. The patient proceeded to right adrenalectomy, which was uncomplicated. A spherical tumour mass 85×80×75 mm (weight 230 g), with a smooth capsule and some normal adrenal gland attached to one pole, was resected. Opening the tumour revealed mostly necrotic yellowish material containing flecks of calcification. Histological examination showed some viable tumour at the periphery of the mass destructively infiltrating residual normal adrenal gland. The neoplastic cells were arranged in solid sheets and possessed large vesicular nuclei and 1–2 nucleoli. There was a high mitotic and apoptotic rate. The neoplastic cells were immunoreactive for leucocyte common antigen and the B cell marker L26, and the appearances were thus of a diffuse high grade B cell lymphoma (Figures 1 and 2). Staging procedures including bone marrow trephine biopsy and CT scanning of the chest, abdomen and pelvis did not demonstrate any evidence of disease elsewhere. The patient received chemotherapy (cyclophosphamide, mitozantrone, vincristine and prednisolone) and has maintained a complete remission for 12 months.