Adreniform Shape of Nonadenom Surrenal Lesion : Lymphoma

Citation: Cuce F (2019) Adreniform Shape of Nonadenom Surrenal Lesion: Lymphoma. Int J Radiol Imaging Technol 5:043. doi.org/10.23937/2572-3235.1510043 Accepted: March 18, 2019: Published: March 20, 2019 Copyright: © 2019 Cuce F. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Non-Hodgkin lymphoma (NHL) frequently involves adrenal gland and to be usually bilateral.The computed tomography (CT) and magnetic resonance imaging (MRI) are the most important radiological imaging modalities with the majority of tumors having a hypoattenuating appearance and slight to moderate enhancement [1].In secondary adrenal lymphoma, the adrenals may appear normal, diffusely enlarge while maintaining a normal morphology, or demonstrate solitary or multiple masses [2].Extensive retroperitoneal disease may engulf the adrenal.Secondary lymphoma tends to be homogeneous in attenuation with low-level enhancement and slow washout on delayed images.Calcifications are rare in the absence of prior treatment [3].At MR imaging, primary and secondary lymphomas are hypointense to isointense on T1-weighted images and hyperintense on T2-weighted images when compared with liver [2].Mild to moderate enhancement is commonly seen [4].Given the highly cellular nature of lymphomatous masses, restricted diffusion is commonly seen [1].18F FDG PET is commonly performed for staging and treatment monitoring in lymphoma and may be helpful in evaluation of the adrenals [5].
The adrenal lymphoma could also infiltrate the gland which can be as an adreniform shape as in the post treatment image of this patient.Adreniform shape is caused by the infiltration of tumor cells and increasing were easily selectable in their own densities.There was marked diffusion restriction on diffusion weighted imaging but we could not distinguish the appearance of adrenal gland within the lesion on any MRI sequence unlike CT (Figure 2).The washout values on the delayed phase of CT favored nonadenoma lesion without no calcification, fat and cystic area.
Due to absolute (32%) and relative washout (13%) values of the lesion on CT, it was evaluated in the group of non-adenoma adrenal lesion.The biopsy resultant of lymph node with high activity on PET CT (Figure 3) was B-cell acute lymphoblastic lymphoma and the adrenal lesion was primarily considered to be lymphoma.During the medical treatment, the size of the adrenal lesion was markedly decreased and it could be seen as an adreniform shape (Figure 4).Adrenal insufficiency did not develop in follows-up.

Discussion
A variety of CT appearances of primary adrenal lymphomas have been reported.A recent review of the CT appearance described an approximately even distribution of homogeneous and heterogeneous patterns,   the gland size with maintaining the gland shape.This appearance has also been reported in benign processes as cortical hyperplasia of the gland, nontraumatic hematomas, metastatic disease, tuberculosis and fungal infections [6].
Secondary involvement of the adrenal gland with NHL has been reported in as many as 25% of the patients with NHL [7].In this case, we observed that the appearance of the lesion on CT may sometimes be a helpful clue in the differential diagnosis and may suggest the lymphoma as a priority.To avoid unnecessary surgery of adrenal lymphoma, in some cases, the appearance feature on CT may provide the presence of lymphoma at the top of your differential diagnosis list.

Figure 1 :
Figure 1: Portal phase images of CT in the sagittal (a) and axial (b) plan.Adrenal gland involvement of the lymphoma (white star) is presented while the gland with normal shape could be selected within the lesion (red arrow).

Figure 2 :
Figure 2: High-resolution, T2W sequence without fatsat in the axial plane.This sequence for anatomical orientation could not be revealed the gland within the lesion (red arrow).

Figure 3 :
Figure 3: a,b) Axial images of PET CT.The lymph node under the skin adjacent to right masseter muscle (red arrow) was observed to be hypermetabolic.

Figure 4 :
Figure 4: The image of follow-up CT after treatment.The soft tissue lesion of the lymphoma is significantly regressed and the enlargement of the gland with the maintenance of the adreniform shape was observed (red arrow).