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      Diffuse large B cell lymphoma with bilateral adrenal and hypothalamic involvement: A case report and literature review

      case-report

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          Abstract

          BACKGROUND

          Non-Hodgkin’s lymphoma (NHL) can involve extralymphatic organs, resulting in diverse clinical manifestations, especially if the endocrine organs are affected. This type of involvement can often be difficult to detect accurately. Until now, no patients with NHL and concomitant bilateral adrenal and hypothalamic involvement have been reported. The purpose of this article is to discuss the diagnosis and treatment of lymphoma with bilateral adrenal gland and hypothalamic involvement so as to help physicians avoid misdiagnosis and missed diagnosis.

          CASE SUMMARY

          We describe a case of a 52-years-old male patient with bilateral adrenal masses, who presented with a fever of unknown origin on admission. Subsequently, hypopituitarism of the anterior pituitary followed by posterior pituitary developed. 18fluorine-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) showed lesions with a high metabolism in both adrenal glands, hypothalamus, left supraclavicular lymph nodes, and other organs. The etiological diagnosis was determined based on a left supraclavicular lymph node biopsy. The patient, who eventually present with panhypopituitarism, was finally diagnosed with diffuse large B cell lymphoma with bilateral adrenal gland and hypothalamic involvement. After immunochemotherapy, glucocorticoids administration and desmopressin acetate replacement therapy, the symptoms of fever and panhypopituitarism improved, and all the lesions reduced in size.

          CONCLUSION

          This report demonstrates that, although synchronous involvement of two endocrine organs is rare in NHL, extra caution should be taken when dysfunction occurs in multiple endocrine organs.

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          Most cited references28

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          Clinical practice. The incidentally discovered adrenal mass.

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            Tumors metastatic to the pituitary gland: case report and literature review.

            Tumors metastatic to the pituitary gland are an unusual complication of systemic cancer typically seen in elderly patients with diffuse malignant disease. Breast and lung are the commonest sites of the primary tumor, whereas diabetes insipidus is the most frequent symptom at presentation. Their rarity and usually indolent course, as well as the lack of specific clinical and radiological features, impede their differentiation from other more common sellar area lesions, particularly when history of malignancy is absent. Management of these patients may also be very difficult because the prognosis depends on the course of the primary neoplasm. A 68-yr-old man, with no history of malignancy, presented with recent onset of hypopituitarism, mild diabetes insipidus, headaches, left oculomotor nerve palsy, and progressive bilateral deterioration of visual acuity and visual fields. Magnetic resonance imaging revealed a large sellar mass compressing the optic chiasm and invading the left cavernous sinus, whereas a prolactin elevation at 438.6 ng/ml (19.73 nmol/liter) was noted. Decompression of the sellar region was attempted, and pathology disclosed a metastatic hepatocellular carcinoma. On postoperative investigation, primary liver tumor was identified and confirmed by biopsy. The patient improved transiently but died 3 months after diagnosis because of deterioration of the liver disease. The relevant literature is reviewed in light of this unusual case, illustrating the problems in the diagnosis and management of patients with metastasis to the pituitary.
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              Approach to the patient with an adrenal incidentaloma.

              K. Nieman (2010)
              Unsuspected adrenal masses, or incidentalomas, are increasingly found with the widespread use of thoracic and abdominal imaging. These masses may be hormonally active or nonfunctional and malignant or benign. Clinicians must determine the nature of the mass to decide what treatment, if any, is needed. Measurement of precontrast Hounsfield units (HU) and contrast washout on computed tomography scan provide useful diagnostic information. All patients should undergo biochemical testing for pheochromocytoma, either with plasma or urinary catecholamine measurements. This is particularly important before surgical resection, which is routinely recommended for masses larger than 4 cm in diameter without a clear-cut diagnosis and for others with hormonal secretion or ominous imaging characteristics. Hypertensive patients should undergo biochemical testing for hyperaldosteronism. Patients with features consistent with Cushing's syndrome, such as glucose intolerance, weight gain, and unexplained osteopenia, should be evaluated for cortisol excess. Here, the dexamethasone suppression test and late-night salivary cortisol may be preferred over measurement of urine cortisol. The ability of surgical resection to reverse features of mild hypercortisolism is not well established. For masses that appear to be benign ( 50%), small (<3 cm), and completely nonfunctioning, imaging and biochemical reevaluation (pheochromocytoma and hypercortisolism only) at 1-2 yr (or more) is appropriate. For more indeterminate lesions, repeat evaluation for growth after 3-12 months is useful, with subsequent testing intervals based on the rate of growth.
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                Author and article information

                Contributors
                Journal
                World J Clin Cases
                WJCC
                World Journal of Clinical Cases
                Baishideng Publishing Group Inc
                2307-8960
                6 December 2019
                6 December 2019
                : 7
                : 23
                : 4075-4083
                Affiliations
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China. cycon_ck@ 123456yeah.net
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
                Department of Hematology, Chinese PLA General Hospital, Beijing 100853, China
                Author notes

                Author contributions: Chen K made substantial contributions to conception and design of the case report; An P analyzed the data and drafted the manuscript; Chen YL and Jin XY made substantial contributions to acquisition of data; Yang GQ, Dou JT, and Wang QS made critical revisions related to important intellectual content of the manuscript; Wang XL made substantial contributions to interpretation of data; Mu YM provided advice for this report; and all authors have approved the final version to be published.

                Corresponding author: Kang Chen, MD, PhD, Assistant Professor, Department of Endocrinology, Chinese People’s Liberation Army General Hospital, 28 Fuxing Road, Beijing 100853, China. cycon_ck@ 123456yeah.net

                Telephone: +86-18801217670 Fax: +86-10-66937711

                Article
                jWJCC.v7.i23.pg4075
                10.12998/wjcc.v7.i23.4075
                6906562
                31832411
                69a4b4e4-95a5-40a9-8cb3-5d5bc8257e25
                ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

                This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

                History
                : 7 September 2019
                : 22 October 2019
                : 14 November 2019
                Categories
                Case Report

                non-hodgkin’s lymphoma,bilateral adrenal glands,hypothalamus,panhypopituitarism,case report

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