Adrenal Biopsy Research Articles

Distinguishing between metastatic and benign adrenal masses in patients with extra-adrenal malignancies.

Background and ObjectivesThe adrenal gland is a common organ involved in metastasis. This study aimed to compare adrenal metastases (AMs) and adrenal benign masses (ABMs) of patients with extra-adrenal malignancies during the staging or follow-up.MethodsWe retrospectively collected data from 120 patients with AMs and 87 patients with ABMs. The clinical characteristics, imaging features, pathology, and treatment regimes were analyzed.ResultsThe most common types of extra-adrenal malignancies in patients with ABMs included thyroid, kidney, and gynecological cancers. On the other hand, lung and kidney cancers and lymphoma were the most frequent primary cancers of AMs. The age and incidence of symptoms were significantly higher in patients with AM. Radiological analysis showed that AMs tended to have larger tumor sizes and higher attenuation values than ABMs on pre-contrast computed tomography (CT). The diagnostic accuracy of positron emission tomography-CT for AM was 94.1%. An adrenal biopsy had a diagnostic accuracy of 92.5%. A multivariate logistic regression model demonstrated that the origins of extra-adrenal malignancies, the enhancement pattern, and attenuation values in pre-contrast CT were independent predictors of AMs. The sensitivity and specificity of this predictive model of combination was 92.5% and 74.1%, respectively.ConclusionsThe differential diagnosis between AMs and ABMs is extremely important. The combination of origin of first malignancy, enhancement pattern and CT value in non-enhanced phase is a valuable model for predicting AMs.

P186 Disseminated Histoplasmosis in an immunocompetent patient in a tertiary care center in North India

Poster session 2, September 22, 2022, 12:30 PM - 1:30 PM ObjectivesHistoplasmosis is a geographically restricted dimorphic fungi that causes disseminated infection in immune-competent as well as immunocompromised patients. Adrenal involvement is seen in disseminated disease but sometimes it may be the only site where then infection can be demonstrated. Early diagnosis and treatment are needed to save the patient from fatal adrenal insufficiency. We present a case of bilateral adrenal histoplasmosis in immunocompetent patient.MethodsA 63-year-old male presented to our hospital with a history of insidious onset of decreased appetite and unintentional weight loss for the last 6 months associated with generalized weakness. Patient had a history of mild to moderate intensity epigastric pain and discomfort which was intermittent in nature. Patient originally belongs to Azamgarh, Uttar Pradesh, but he was residing in Kolkata for the last 8 months.Patient had no history of fever, cough, hemoptysis, jaundice, chronic diarrhea, and steatorrhea. No history of orthostatic hypotension, salt craving, hyperpigmentation, headache, visual field disturbances, polyuria, behavioral changes, episodic headache, palpitation, diaphoresis, systemic hypertension with episodic all four-limb weakness. There was no history of abdominal striae, easy bruisability, difficulty in standing from squatting position. There was no history of tuberculosis among family members. On detailed history, it was revealed that he fed pigeons every day in the slum house where he lived in Kolkata.On the CECT abdomen it was found that there is an ill-defined hypodense enhancing lesion (72 × 52 × 77 mm) in right suprarenal region and bulky, necrosed 25 × 26 × 19 mm lesion in left suprarenal gland associated with multiple nonnecrotic paraaortic and aortic caval lymphadenopathy. He also received empirical anti-tubercular therapy for 15 days in the form of ethambutol and levofloxacin.ResultsIn all, 10% KOH wet mount of crushed smear of adrenal biopsy samples showed tissue debris and small narrow neck budding yeasts. Giemsa stain shows few small budding yeasts. Culture was put in SDA at 25°C and 37°C and incubated. On day 12, growth of colony in 25°C appears as white cottony growth with yellowish white reverse. On day 24, colony appears as buff brown with yellowish brown reverse. LPCB was done from the colony showing presence of characteristic tuberculate macroconidia (8–14) μm in diameter formed on short, hyaline, undifferentiated conidiophores and production of plenty round to pyriform microconidia (2–4 μm) in diameter, occurring on short branches and directly on the sides of the hyphae. Based on the direct microscopy and culture characteristics a diagnosis of Histoplasma capsulatum was given.ConclusionSystemic histoplasmosis is typically acquired through inhalation of microconidia or small hyphal elements in soil contaminated with bird and bat droppings leading to primary infection. This patient only manifested bilateral adrenal involvement with nonspecific symptoms.

Utility of rapid on-site evaluation in procurement of adrenal gland tissue biopsies.

While the number of adrenal biopsies has increased due to more "incidentalomas" were detected by widespread use of imaging studies, there have been very limited studies to evaluate the utility of rapid on-site evaluation (ROSE) in obtaining adequate core needle biopsy (CNB) tissue for diagnosis of adrenal lesions. We retrospectively reviewed all percutaneous adrenal CNB cases with available ROSE for a 12-year period in our institute in order to assess the usefulness of ROSE in adrenal CNB sampling. A total of 83 cases were identified in our database. The majority of cases (52/83, 63%) were diagnosed as metastatic malignancies with the lung being the most common primary site. Adrenal hyperplasia/adenoma was the most common primary adrenal lesion. The concordance between the ROSE interpretations and CNB final diagnoses is 80%. The interpretation errors accounted for majority (11/17, 65%) of the discordant cases. ROSE assessment during adrenal CNB procedures is a helpful tool for obtaining adequate diagnostic tissue. Pathologists should be familiar with adrenal cytology in order to reduce interpretation errors at ROSE.

Combined Heart Kidney Transplantation in a Previous Heart Transplant Recipient with Pheochromocytoma and Monoclonal Gammopathy of Uncertain Significance

Introduction Cancer survivors and patients with active malignancies are considered high risk for solid organ transplantation, as there is concern for recurrence and their concurrent co-morbidities. We present a case of combined kidney and repeat heart transplant (HT) for a patient with cardiac allograft vasculopathy (CAV) found to have pheochromocytoma and monoclonal gammopathy of unknown significance (MGUS) on pre-transplant evaluation. Case Report A 47-year-old male with a history of orthotopic HT 20 years prior due to viral myocarditis with post-transplant course complicated by CAV, chronic kidney disease stage 4 (presumed due to tacrolimus), MGUS, and atrial fibrillation presented with acute decompensated heart failure requiring inotropes. Echocardiogram revealed EF of 35%, global hypokinesis; RHC showed RA 19, RV 37/2, PA 38/17/25, PW 27, CI 1.6. LHC showed ISHLT CAV3: 70% mLAD lesion and diffuse 50-80% disease in distal LAD, Cx, and RCA. An IABP was placed and the patient was managed in the cardiac intensive care unit. Imaging revealed a right adrenal mass. He underwent an IR guided adrenal biopsy that demonstrated a pheochromocytoma, with biochemical markers of active tumor. The patient received a laparoscopic adrenalectomy and was listed for dual organ transplant. With worsening hemodynamics, he required peripheral VA-ECMO and received combined heart and renal transplant a month later. His post-operative course was complicated by RV dysfunction requiring central VA-ECMO, transplant pyelonephritis, and delayed renal allograft function requiring transient hemodialysis. Cardiac function recovered in 2 weeks post-transplant. Two and a half months post-transplant, a renal biopsy was performed for worsening acute kidney injury and demonstrated kappa light chain proximal tubulopathy. Given known MGUS, patient was diagnosed with monoclonal gammopathy of renal significance and started on started on Ixazomib-Cytoxan-Dexamethasone. He has shown improvement clinically and is now over one year post-transplant. Summary Combined heart kidney transplantation may be an option for selected patients with active malignancies like localized pheochromocytoma with MGUS. Long term follow up outcomes are unknown in this patient population. Cancer survivors and patients with active malignancies are considered high risk for solid organ transplantation, as there is concern for recurrence and their concurrent co-morbidities. We present a case of combined kidney and repeat heart transplant (HT) for a patient with cardiac allograft vasculopathy (CAV) found to have pheochromocytoma and monoclonal gammopathy of unknown significance (MGUS) on pre-transplant evaluation. A 47-year-old male with a history of orthotopic HT 20 years prior due to viral myocarditis with post-transplant course complicated by CAV, chronic kidney disease stage 4 (presumed due to tacrolimus), MGUS, and atrial fibrillation presented with acute decompensated heart failure requiring inotropes. Echocardiogram revealed EF of 35%, global hypokinesis; RHC showed RA 19, RV 37/2, PA 38/17/25, PW 27, CI 1.6. LHC showed ISHLT CAV3: 70% mLAD lesion and diffuse 50-80% disease in distal LAD, Cx, and RCA. An IABP was placed and the patient was managed in the cardiac intensive care unit. Imaging revealed a right adrenal mass. He underwent an IR guided adrenal biopsy that demonstrated a pheochromocytoma, with biochemical markers of active tumor. The patient received a laparoscopic adrenalectomy and was listed for dual organ transplant. With worsening hemodynamics, he required peripheral VA-ECMO and received combined heart and renal transplant a month later. His post-operative course was complicated by RV dysfunction requiring central VA-ECMO, transplant pyelonephritis, and delayed renal allograft function requiring transient hemodialysis. Cardiac function recovered in 2 weeks post-transplant. Two and a half months post-transplant, a renal biopsy was performed for worsening acute kidney injury and demonstrated kappa light chain proximal tubulopathy. Given known MGUS, patient was diagnosed with monoclonal gammopathy of renal significance and started on started on Ixazomib-Cytoxan-Dexamethasone. He has shown improvement clinically and is now over one year post-transplant. Combined heart kidney transplantation may be an option for selected patients with active malignancies like localized pheochromocytoma with MGUS. Long term follow up outcomes are unknown in this patient population.

Tissue miRNA Combinations for the Differential Diagnosis of Adrenocortical Carcinoma and Adenoma Established by Artificial Intelligence.

Simple SummaryThe histological differential diagnosis of adrenocortical adenoma and carcinoma is difficult and requires great expertise. MiRNAs were shown to be useful for the differential diagnosis of benign and malignant tumors of several organs, and several findings have suggested their utility in adrenocortical tumors as well. Here, we have selected tissue miRNAs based on the literature search, and used machine learning to identify novel clinically applicable miRNA combinations. Combinations with high sensitivity and specificity (both over 90%) have been identified that could be promising for clinical use. Besides being a useful adjunct to histological examination, these miRNA combinations could enable preoperative adrenal biopsy in patients with adrenal tumors suspicious for malignancy.The histological analysis of adrenal tumors is difficult and requires great expertise. Tissue microRNA (miRNA) expression is distinct between benign and malignant tumors of several organs and can be useful for diagnostic purposes. MiRNAs are stable and their expression can be reliably reproduced from archived formalin-fixed, paraffin-embedded (FFPE) tissue blocks. Our purpose was to assess the potential applicability of combinations of literature-based miRNAs as markers of adrenocortical malignancy. Archived FFPE tissue samples from 10 adrenocortical carcinoma (ACC), 10 adrenocortical adenoma (ACA) and 10 normal adrenal cortex samples were analyzed in a discovery cohort, while 21 ACC and 22 ACA patients were studied in a blind manner in the validation cohort. The expression of miRNA was determined by RT-qPCR. Machine learning and neural network-based methods were used to find the best performing miRNA combination models. To evaluate diagnostic applicability, ROC-analysis was performed. We have identified three miRNA combinations (hsa-miR-195 + hsa-miR-210 + hsa-miR-503; hsa-miR-210 + hsa-miR-375 + hsa-miR-503 and hsa-miR-210 + hsa-miR-483-5p + hsa-miR-503) as unexpectedly good predictors to determine adrenocortical malignancy with sensitivity and specificity both of over 90%. These miRNA panels can supplement the histological examination of removed tumors and could even be performed from small volume adrenal biopsy samples preoperatively.

Adrenal Histoplasmosis: An Uncommon Cause of Adrenal Crisis in an Immunocompetent Man

Abstract Background Histoplasmosis is a rare cause of primary adrenal insufficiency. Adrenal involvement is commonly encountered with disseminated disease in immunocompromised individuals though some have been reported in immunocompetent patients. Primary adrenal histoplasmosis where adrenals are the only organs with demonstrable disease is uncommon. Case Presentation A 33-year-old immunocompetent man presented with an adrenal crisis. Further evaluation of the underling etiology of primary adrenal insufficiency revealed bilateral adrenal enlargement that was confirmed to be histoplasmosis on adrenal biopsy. Conclusion The case highlights the importance of considering histoplasmosis as an underlying cause of primary adrenal insufficiency in patients from high endemic areas.

Bilateral adrenal masses due to tuberculosis: how to diagnose without extra-adrenal tuberculosis.

SummaryPrimary adrenal insufficiency is a rare disease and can masquerade as other conditions; therefore, it is sometimes incorrectly diagnosed. Herein, we reported the case of a 39-year-old Vietnamese male with primary adrenal insufficiency due to bilateral adrenal tuberculosis. The patient presented to the emergency room with acute adrenal crisis and a 3-day history of nausea, vomiting, epigastric pain, and diarrhoea with a background of 6 months of fatigue, weight loss, and anorexia. Abdominal CT revealed bilateral adrenal masses. Biochemically, unequivocal low morning plasma cortisol (<83 nmol/L) and high plasma adrenocorticotropic hormone levels were consistent with primary adrenal insufficiency. There was no evidence of malignancy or lymphoma. As the patient was from a tuberculosis-endemic area, extra-adrenal tuberculosis was excluded during the work up. A retroperitoneal laparoscopic left adrenalectomy was performed, and tuberculous adrenalitis was confirmed by the histopathological results. The patient was started on antituberculous therapy, in addition to glucocorticoid replacement. In conclusion, even without evidence of extra-adrenal tuberculosis, a diagnosis of bilateral adrenal tuberculosis is required. A histopathological examination has a significant role along with clinical judgement and hormonal workup in establishing a definitive diagnosis of adrenal tuberculosis without evidence of active extra-adrenal involvement.Learning pointsPrimary adrenal insufficiency can be misdiagnosed as other mimicking diseases, such as gastrointestinal illness, leading to diagnostic pitfalls.Adrenal insufficiency can be confirmed with significantly low morning plasma cortisol levels of <83 nmol/L without a dynamic short cosyntropin stimulation test.Tuberculous adrenalitis is an uncommon treatable condition; however, it remains an important cause of primary adrenal insufficiency, especially in developing countries. In the absence of extra-adrenal involvement, adrenal biopsy plays a key role in the diagnostic process. Alternatively, adrenalectomy for histopathological purposes should be considered if CT scan-guided fine needle aspiration is infeasible in cases of small adrenal masses.

Epstein-Barr Virus-Positive Adrenal Diffuse Large B-Cell Lymphoma after Treatment for Angioimmunoblastic T-Cell Lymphoma.

We report a case of EBV-positive B-cell lymphoma of the adrenal gland after treatment for angioimmunoblastic T-cell lymphoma (AITL)When patients present with signs and symptoms suggestive of relapse after AITL treatment, another biopsy should be performed for the accurate determination of whether these lesions indicate AITL relapse or new-onset of EBV-positive B-cell lymphoma.The involvement of extranodal sites may indicate a poor prognosis of EBV-positive B-cell lymphoma after AITL treatment.

Adrenal biopsy, as a diagnostic method, is associated with decreased overall survival in patients with T1/T2 adrenocortical carcinoma: A propensity score-matched analysis.

The standard diagnosis for adrenocortical carcinoma (ACC) is clinical diagnosis (CD) based on radiographic and biochemical studies. Biopsy diagnosis (BD) is seldom required for the suspicion of secondary malignancy. We aim to study the impact of BD in the context of underlying T1/T2 ACC on overall survival (OS) compared with CD. National Cancer Database (NCDB) for endocrine malignancies was utilized. Only patients with non-metastatic ACC, whose method of diagnosis and local disease extension were reported, and received a surgical adrenalectomy with curative intent were included. Patients were divided by disease stage into T1/T2, T3, and T4 groups. A propensity score match was applied to those with T1/T2 disease who received CD versus BD and the Kaplan-Meier method was used to compare OS. In total, 4000 patients with ACC were reported in the database, 1410 met selection criteria. Eight hundred and thirty patients had T1/T2, 365 had T3, and 162 had T4 ACC. Of patients with T1/T2 ACC, 742 (89.4%) received CD versus 88 (11.6%) with BD. A propensity score was calculated per a multivariable regression model with 79 patients matched from each group. Exact matching was applied for margin status and adjuvant therapies. Kaplan-Meier analysis showed a significant difference in median OS between CD versus BD patients in the matched data set (103.89 ± 15.65 vs. 54.93 ± 8.22 months; p = 0.001). In all comers, patients with T1/T2 ACC and BD had comparable median OS to that of patients with T3 ACC (52.21 ± 9.69 vs. 36.01 ± 3.33 months; p = 0.446). BD in T1/T2 ACC could be associated with disease upstaging and worse OS outcomes.

Cushing Syndrome Due to Pigmented Nodular Adrenal Hyperplasia in an Iranian Patient: A Case Report and Review of the Literature

Primary pigmented nodular adrenocortical disease (PPNAD) is a rare cause of Adrenocorticotropic hormone-independent Cushing syndrome. In this case, we present a case of PPNAD in 25 y/o women who presented with a 3 years history of weight gain, hirsutism, and abnormal menstruation. Our findings were suggestive of PPNAD in the pathological study of adrenal biopsy.

Bilateral Adrenal Adenomas Attributed to Extrapulmonary Mycobacterium Tuberculosis

Introduction: Adrenal infections are rare, with the Mycobacterium tuberculosis (MTB) being the most common causative agent in the developing world. MTB usually spreads to the adrenal glands hematogenously where it may be clinically manifested years after systemic infection. Here, we present a case of bilateral adrenal MTB infection associated with MTB peritonitis. Case Presentation: A 46-year-old male, from Ecuador, without significant medical history and no medical follow-up presented to the emergency room with a two-week history of abdominal pain, nausea, diarrhea, and significant weight loss. He denied fever, cough, or night sweats. No smoking, alcohol, or illicit drug use. He works as a construction worker without a history of sick contacts. Vital signs were stable, with abdominal distension and fluid shifting dullness on exam. Blood work revealed leucocyte count of 5.58K (4-11K), INR 1.2 (0.9–1.1), Sodium 132 mEq/L (136–145 mEq/L) with albumin 3.3 mg/dL (3.5–5.2 mg/dL), total bilirubin level, 1.3 mg/dL (0–1.2 mg/dL), and AST and alkaline phosphatase levels, 73 U/L (0–40 U/L) and 186 U/L (40–129 U/L) respectively. Computerized tomography (CT) of the abdomen showed large ascites, omental nodularity, calcified gall bladder, bilateral adrenal nodules, and multiple abdominal lymphadenopathies. Chest CT revealed right apical reticulonodular densities. A diagnostic paracentesis revealed an exudative effusion with serum ascites albumin gradient of 0.7, and negative acid fast bacilli (AFB) and adenosine deaminase enzyme. Ascitic cellular analysis was negative for malignant cells. AFB blood and sputum cultures were negative, though Quantiferon gold test was positive and a skin tuberculin test was 13x13mm. Tumor markers CA19-9, CEA, and alpha-fetoprotein came back negative. Additionally, serum aldosterone, plasma metanephrines, DHEA-S, AM Testosterone, ACTH, and morning cortisol levels were normal. The patient had a negative 1-mg dexamethasone suppression test. Positron emission tomography (PET) scan showed a hypermetabolic left adrenal mass (4.9x3.2 cm) and nodular peritoneum with no fluorodeoxyglucose (FDG) uptake in the enlarged abdominal lymph nodes. Peritoneal biopsy analysis revealed non-caseating granuloma positive for MTB. The adrenal biopsy was not performed given the extensive intra-abdominal disease. The patient was started on anti-MTB treatment (Isoniazid, rifampicin, pyrazinamide, and ethambutol) with significant clinical improvement and a slight decrease in the adrenal masses following abdominal imaging. Conclusion: Extrapulmonary MTB should be part of a differential diagnosis for bilateral adrenal masses. Adrenal glands could be infected by a variety of pathogenic microorganisms either by direct contact or hematogenous dissemination. A high index of suspicion is required for the diagnosis of MTB in patients with atypical presentation.

Bilateral Adrenal Incidentalomas, Uncommon Presentation and Very Rare Pathology

Background: Adrenal incidentaloma is an adrenal mass larger than 1cm accidentally discovered by radiological examination. The incidentalomas should be evaluated for malignancy and functionality. The prevalence of adrenal incidentaloma is 4–10%,1 and around 10–15% of incidentally discovered adrenal masses can be bilateral.2 We present a patient with bilateral adrenal masses due to primary adrenal lymphoma. Clinical Case: 74-year-old gentleman, with past medical history of type-2 Diabetes mellitus, hypertension, presented to our hospital with 2 months history of right-sided flank pain, 20 kg weight loss, loss of appetite and dizziness. Otherwise, no fever, night sweats, bleeding per rectum or urinary symptoms. On physical examination, vital signs were within normal, no remarkable findings other than tenderness over the right flank. Complete blood count and chemistry panel were within normal. Abdominal CT scan was done for evaluation of the abdominal pain which showed two large masses replacing the adrenal glands measure about 10cm in diameter with patchy areas of enhancement. Adrenal insufficiency was suspected based on the symptoms and the CT scan findings. Short syncatin test (high-dose test 250mcg) was done, which showed a cortisol baseline 152nmol/L, 30 minutes 168nmol/L, and 60 minutes 169nmol/L. This was suggestive of adrenal insufficiency, so he was started on hydrocortisone. Screening for pheochromocytoma was done as the patient developed uncontrolled BP readings prior to a scheduled adrenal biopsy. 24-hour urine metanephrines and normetanephrine were negative. CT-guided adrenal mass biopsy showed findings suggestive of large B-cell lymphoma. FDG PET-CT scan showed huge bilateral intense FDG uptake in the adrenal glands with no extra-abdominal manifestations noted. He was started on R-CHOP chemotherapy and after 4cycles, a PET scan showed a significant decrease in the size of previous adrenal masses. Conclusion: Bilateral adrenal incidentaloma should be evaluated the same as unilateral adrenal mass. Although adrenal involvement is common in non-Hodgkin lymphoma, primary adrenal lymphoma is extremely uncommon.

A Novel Diagnostic Model for Primary Adrenal Lymphoma.

ObjectivePrimary adrenal lymphoma (PAL) is easily misdiagnosed as other adrenal masses, such as adrenocortical carcinoma and pheochromocytoma, but patients with PAL benefit little from surgery. The diagnostic method for PAL thus far is limited to adrenal biopsy. In our study, we aimed to develop a quick and efficient diagnostic method for PAL.Methods and ResultsAt the same institution, 505 patients (between 2009 and 2019) and 171 patients (between 2019 and 2020) were separately included in the primary and validation studies. Univariate and multivariate analyses were conducted to evaluate clinical manifestations, laboratory findings, and radiological characteristics. Four determinants (age, bilateral masses, high-density lipoprotein cholesterol, and lactate dehydrogenase) were selected and further incorporated into a regression model to screen PAL. Accordingly, the nomogram was developed for clinical practice. In the primary study, the nomogram showed good discrimination, with an area under the receiver operating characteristic (ROC) curve (AUC) of 95.4% (95% CI, 90.6%–100.0%). Further validation study verified the efficacy of the nomogram, with an AUC of 99.0% (95% CI, 96.9%–100.00%) and 100.0% in all patients and patients with bilateral masses, respectively, and a sensitivity/specificity/positive predictive value (PPV)/negative predictive value (NPV) of 66.67%/99.40%/66.67%/99.40%, 66.67%/100%/100%/92.86%, 50%/99.20%/50%/99.20%, and 100%/100%/100%/100%, in all patients, patients with bilateral adrenal masses, patients with nonfunctional adrenal masses, and patients with positive catecholamine results, respectively. The validation study also revealed a diagnostic specificity of 99.35% and 100% for patients with a unilateral adrenal mass and functional PCC, respectively.ConclusionsThe presented nomogram is the first user-friendly diagnostic model for PAL that simplifies the complex diagnostic process into personalized numeric estimates. We deem that patients who score below 50 are less likely to have PAL. We suggest that clinicians should arrange adrenal biopsy and surgery for patients with nonfunctional tumors and overt catecholamine-secreting tumors, respectively, who receive a score of 50 points or higher to confirm the diagnosis as soon as possible.

AB082. SOH21AS180. A radiomic model to classify adrenal lesions on CT

Background: Medical imaging analysis has evolved to facilitate the development of AI-enhanced methods for high-throughput extraction of quantitative features that can potentially contribute to the diagnostic and treatment paradigm of adrenal pathology. Adrenal lesions can be classified as benign/malignant or originating in the cortex/medulla. Qualitative radiological features can contribute to diagnosis however histopathological assessment is required to definitively establish the type of lesion. There is a need for non-invasive diagnostic markers due to the impracticality of adrenal biopsy. The aim of this study was to develop and validate a radiomic classifier to non-invasively classify adrenal lesions on CT.

Bilateral Adrenal Lymphoma: A Diagnostic Challenge

Bilateral primary adrenal lymphoma is rare with no specific clinical or imaging features. We report herein the case of a 44-year-old man presenting with massive bilateral adrenal tumors associated with normal adrenal function. Computed tomography findings were nonspecific. Because pheochromocytoma was ruled out and the patient had a normal coagulation test, we performed an ultrasound-guided adrenal biopsy for diagnostic purposes. Pathology confirmed adrenal non-Hodgkin's lymphoma. By reporting our case, we aimed to propose a practical approach for this rare entity and to show that there are still situations in which biopsy is necessary to make a diagnosis.

Suspected Primary Adrenal Lymphoma (PAL) Associated With Hemophagocytic Lymphohistiocytosis (HLH).

Adrenal incidentalomas, masses noted on imaging performed for other purposes, are common, with 10% to 15% presenting as bilateral adrenal masses. These cases can be challenging as the differential diagnosis is broad, including metastatic disease, primary adrenal lymphoma (PAL), or infection, and often requiring a biopsy if initial biochemical workup is unrevealing. We present here a relevant case description, laboratory and radiologic imaging studies, and discussion of literature. A 62-year-old Korean woman presented with altered mental status and fevers. She was found to have bilateral adrenal incidentalomas and retained acupuncture needles. Adrenal workup did not show biochemical evidence of hormonal excess. Infectious workup was unrevealing, as was a metal/toxin workup due to retained acupuncture needles. Fevers and episodes of hypotension persisted which prevented the patient from obtaining an adrenal biopsy. Bone marrow biopsy was obtained for pancytopenia and revealed B-cell lymphoma with large cell morphology and few histiocytes with hemophagocytosis, raising concern for lymphoma-induced hemophagocytic lymphohistiocytosis (HLH). PAL associated with HLH was highly suspected in our patient, given the large (7 cm) bilateral adrenal masses and bone marrow biopsy findings of lymphoma. The patient was treated for diffuse large B-cell lymphoma, with clinical improvement. PAL is a rare but aggressive lymphoma with few reported cases. It should be considered in the differential for both unilateral and bilateral adrenal masses. An early diagnosis is crucial as the main treatment is chemotherapy rather than surgery and it confers a significant survival benefit.

THYMIC CANCER WITH ADRENAL METASTASIS: A RARE PRESENTATION

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thymic tumors are rare invasive neoplasms and account for 0.2% to 1.5% of all neoplasms. Among them, thymic carcinomas are the most aggressive variant that represents approximately0.06% of all malignancies. Lung involvement is very common whereas extra-thoracic metastasis is rare. We describe a case of thymic cancer with adrenal metastasis which is a very rare presentation. This case highlights the various presentations of such a rare tumor which can often be missed due to the paucity of knowledge of this malignancy due to low incidence. CASE PRESENTATION: A 40-year-old male arrived at the hospital with a chief complaint of dull aching chest pain and back pain for one month. He also endorsed weight loss, night sweats, and weakness. He denied smoking, travel, or remote history of TB. Initial vitals, physical examination, and labs were unremarkable. He had a chest Xray which showed an 8 cm lobulated anterior mediastinal mass. Chest tomography (CT) showed large anterior mediastinal mass 7 x13 cm, enlarged mediastinal lymph nodes, and bilateral adrenal masses. At this time our differentials included lymphoma, thymic cancer, metastatic testicular cancer, germ cell tumor, or infectious etiology. Scrotal ultrasound was not suggestive of testicular malignancy. Lactate Dehydrogenase was elevated at 800 concerning for germ cell tumor. Core needle biopsy of the mediastinal mass was suggestive of high-grade thymic carcinoma. An adrenal biopsy was positive for poorly differentiated thymic cancer. The diagnosis of metastatic thymic cancer was established. Oncology was consulted and chemotherapy with cisplatin, doxorubicin, and cyclophosphamide was initiated. Despite chemotherapy, his symptoms worsened and a repeat CT scan at 6 months showed enlargement of the primary tumor to 10x10 cm with infiltration of the sternum and anterior chest wall, enlargement of the bilateral adrenal metastasis, invasion into the right hepatic lobe, kidneys and retroperitoneal carcinomatosis. Due to the advanced nature and poor prognosis of the disease, the patient refused further chemotherapy and decided palliative care. DISCUSSION: Thymic epithelial tumors have an indolent clinical course and are often associated with vague symptoms. Paraneoplastic syndromes associated with thymic cancer include Myasthenia gravis and rarely pure red cell aplasia or hypogammaglobulinemia. Gold standard treatment for thymic neoplasms at any stage is surgical resection. In advanced cases, cisplatin-based chemotherapy is recommended. Pembrolizumab is an accepted option for refractory cancer. Every patient is given post-operative radiotherapy to reduce the chance of recurrence. CONCLUSIONS: 1) Though thymic cancers are uncommon, it must always be included in the differentials for a patient presenting with a mediastinal mass. 2) The prognosis of thymic carcinoma is generally poor and tumor stage is the most important prognostic indicator. Reference #1: Sharma, S. and L. Dawson, A Rare Tumor with a Very Rare Initial Presentation: Thymic Carcinoma as Bone Marrow Metastasis. Case Reports in Pathology, 2017. 2017: p. 6497376. Reference #2: Nishino M, Ashiku SK, Kocher ON, Thurer RL, Boiselle PM, Hatabu H. The thymus: a comprehensive review. RadioGraphics. 2006;26:335–348. Reference #3: A. Marx, J. K. C. Chan, J.-M. Coindre et al., "The 2015 World Health Organization Classification of tumors of the thymus: continuity and changes,” Journal of Thoracic Oncology, vol. 10, no. 10, pp. 1383–1395, 2015. DISCLOSURES: No relevant relationships by Alisha Grewal, source=Web Response No relevant relationships by Ricardo Herrera, source=Web Response No relevant relationships by Jonathan Munoz, source=Web Response No relevant relationships by Tarreq Noori, source=Web Response No relevant relationships by kinnari SHAH, source=Web Response

IS MARIJUANA SAFE? A CASE OF A NON-SMALL CELL LUNG CARCINOMA IN A SOLE MARIJUANA SMOKER

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Marijuana is the most commonly used illicit drug worldwide. Marijuana smoking shares almost the same carcinogens and irritants as tobacco smoking. Several case studies to date have documented premalignant changes in bronchial epithelium in marijuana smokers that lead to cancer. We present a case of a NSCLC in a patient who only smoked marijuana for 40 years. CASE PRESENTATION: A 67-year-old male with past medical history of hypertension and hyperlipidemia presents with a month history of cough, congestion and intermittent hemoptysis. He had been smoking marijuana joints for about 40 years but denied any tobacco smoking. Physical examination revealed prolonged expiratory breath sounds. CT chest with contrast showed spiculated left perihilar mass measuring 6.9 x 4.01 x 3.8 cm extending into the left upper lobe (LUL) causing mild narrowing. PET/CT scan showed hypermetabolic 6 cm LUL lung mass with SUV of 22. EBUS with a transbronchial biopsy of the LUL of the lung was positive for poorly differentiated adenocarcinoma. Lymph node and adrenal gland biopsies were negative for malignancy. Ultimate staging was cT3N0M0. Genomic testing showed no expression of PDL 1 and was negative for ROS 1 rearrangement. Patient was started on neoadjuvant chemotherapy with Alimta and Carboplatin for locally advanced disease. DISCUSSION: Around 3.9% of the global population age 15 to 64 years smokes marijuana. Marijuana smoke contains about 50% more benzopyrene and nearly 75% more benzanthracene than tobacco smoke, in addition to other carcinogens and co-carcinogens including phenols, vinyl chlorides, nitrosamines, and reactive oxygen species. Moreover, differences in the technique of smoking marijuana including deeper inhalation, lack of filter, much longer breath holding time and lower rod filtration result in a fourfold increase in deposition of the tar in the lung. Few experimental studies also suggested tetrahydrocannabinol (THC) promotes tumor growth by inhibiting antitumor immunity by a cannabinoid 2 receptor mediated pathway. In a chronic cannabis smoker, sputum cytomorphological analysis showed metaplastic cells, macrophages, pigmented macrophages and columnar cells. Endobronchial biopsies from habitual marijuana-only smokers reveal squamous cell metaplasia and cellular atypia which are precursors for malignancies. Immunohistology of bronchial tissue was also remarkable for overexpression of the nuclear proliferation antigen Ki-67, and of epidermal growth factor receptors. CONCLUSIONS: A definite association between lung cancer and smoking marijuana has been still limited by selection bias, small sample size and failure to adjust for tobacco smoking. Given the increased popularity of marijuana use in young adults and also for medicinal purposes, more prospective studies need to be performed to establish the association of marijuana with serious adverse events including lung Ca. Reference #1: Tashkin, D. P. (2013, June). Effects of marijuana smoking on the lung. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23802821/ Reference #2: Zhang, L. R., Morgenstern, H., Greenland, S., Chang, S.-C., Lazarus, P., Teare, M. D., … Hung, R. J. (2015, February 15). Cannabis smoking and lung cancer risk: Pooled analysis in the International Lung Cancer Consortium. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4262725/ Reference #3: Aldington, S., Harwood, M., Cox, B., Weatherall, M., Beckert, L., Hansell, A., … Cannabis and Respiratory Disease Research Group. (2008, February). Cannabis use and risk of lung cancer: a case-control study. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2516340/ DISCLOSURES: No relevant relationships by Santhosh Bayambe, source=Web Response no disclosure on file for Kristine Fless; No relevant relationships by Aditi Saha, source=Web Response No relevant relationships by Paarth Shah, source=Web Response No relevant relationships by Sohaib Tariq, source=Web Response

The role of percutaneous CT-guided biopsy of an adrenal lesion in patients with known or suspected lung cancer.

To determine the sensitivity, specificity, and complication rate of percutaneous adrenal biopsy in patients with known or suspected lung cancer. This study was approved by the Institutional Review Board at our institution as a retrospective analysis; therefore, the need for informed consent was waived. All percutaneous adrenal biopsies performed between April 1993 and May 2019 were reviewed. 357 of 582 biopsies were performed on 343 patients with known or suspected lung cancer (M:F 164:179; mean age 66years). The biopsy results were classified into malignant, benign, or non-diagnostic. The final diagnosis was established by pathology (biopsy and/or surgical resection) or imaging follow-up on CT for at least 12months following the biopsy. Patients with less than 12months follow-up were excluded (n = 44). Complications were recorded. The final diagnosis was metastatic lung cancer in 235 cases (77.8%), metastasis from an extrapulmonary primary in 2 cases (0.7%), pheochromocytoma in 2 cases (0.7%), and benign lesions in 63 cases (20.9%). Percutaneous adrenal gland biopsy had a sensitivity of 97% and specificity of 100% for lung cancer metastases. The non-diagnostic rate was 0.6%. Larger lesions were more likely to be malignant (p = 0.0000) and to be correctly classified as a lung metastasis (p = 0.025). The incidence of minor complications was 1.1%. There were no major complications. Over 20% of adrenal lesions in patients with known or suspected lung cancer were not related to lung cancer. Percutaneous adrenal gland biopsy is a safe procedure, with high sensitivity and specificity for lung cancer metastases.

SAT-172 FDG PET/CT in Benign vs. Malignant Adrenocortical Tumors

18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) is frequently used for evaluation of indeterminate adrenal nodules.The objective of this study was to evaluate the diagnostic performance of FDG PET/CT in distinguishing benign adrenocortical adenomas (ACA) from adrenocortical carcinoma (ACC).We identified 139 patients in our institution who completed both FDG PET/CT and adrenal biopsy or adrenalectomy from 2001 to 2019 using the institutional Electronic Medical Record Search Engine (EMERSE). Patients with adrenal pathology revealing non-adrenocortical tumors were excluded. The imaging characteristics of ACAs were compared with ACCs.Sixteen patients with ACAs and 50 patients with ACC were identified; of the latter, 30 were excluded, because FDG PET/CT imaging was completed after adrenalectomy. The average age of the ACC vs. ACA group was 48±14 and 52±17 years, respectively, with a gender composition of 35% and 25% men, respectively. All 20 patients with ACC had FDG avid lesions, defined by imaging report and increased ratio of adrenal tumor maximum standardized uptake value (SUVmax) to hepatic parenchymal average SUV (SUVmean) of greater than 2.5. Among those with ACAs, 11 had positive, 1 had mildly positive, 3 had indeterminate, and 1 had negative FDG PET/CT findings according to the report. Ratio of adrenal SUVmax to hepatic SUVmean was greater in ACC compared to ACA (13.5 versus 1.6, respectively, p = 0.13), but did not reach statistical significance, likely due to the small sample size and unavailability of SUV ratios for all lesions.Our study identified a large number of ACAs that were deemed FDG avid but without adrenal SUVmax to hepatic SUVmean ratio of greater than 2.5. Although the sensitivity, and therefore the negative predictive value, of FDG PET/CT scan is excellent for the diagnosis of ACC, our data does not allow for the calculation of specificity. This is due to the selection bias inherent in our patient population referred for evaluation of unusual adrenal masses, and the fact that ACAs with negative FDG PET/CT often do not undergo surgery or biopsy, and therefore pathology results are not available. Despite this limitation, our findings show that calculation of the ratio of adrenal SUVmax to hepatic SUVmean, rather than lesion SUVmax alone, helps for characterization of adrenal lesions as malignant vs. benign, and that a negative FDG PET/CT is valuable in excluding ACC.