AJR 2001; 177:336
© American Roentgen Ray Society
Radiologic-Pathologic Conferences of the
Massachusetts General
Hospital |
Posttransplantation Non-Hodgkin's Lymphoma of the Adrenal Gland
Mark E. Mullins1,
Steven Chao1,
Henry Dong2 and
Priscilla J. Slanetz1
1
Department of Radiology, Massachusetts General Hospital, Founders House,
Boston, MA 02114.
2
Department of Pathology, Massachusetts General Hospital, Boston, MA
02114.
Received December 4, 2000;
accepted after revision January 24, 2001.
From the weekly radiologic-pathologic correlation conferences conducted by
Theresa C. McLoud.
Address correspondence to M. E. Mullins.
Introduction
A 59-year-old man presented with vague epigastric pain 8 years after
undergoing orthotopic heart transplantation. Physical examination was
unremarkable. Laboratory data revealed elevated levels of creatinine and serum
glucose and proteinuria. Unenhanced CT revealed a right adrenal mass
(Fig. 1A) approximately 2
x 1 cm, with a density of 37 H, which was a new finding compared with a
previous CT examination. The mass measured 78 H with contrast-enhanced
abdominopelvic CT and 80 H on 10-min delayed images. Numerous new small lymph
nodes were also noted in the subcarinal, peripancreatic, and retroperitoneal
lymph node chains. A right laparoscopic adrenalectomy was performed.
Histopathology revealed intermediate grade monoclonal non-Hodgkin's lymphoma,
consistent with a monomorphous posttransplantation lymphoproliferative
disorder in an allograft recipient (Fig.
1B). Immunoperoxidase stains confirmed a B-cell lineage and
Epstein-Barr virus-encoded RNA expression
(Fig. 1C). The final
clinicopathologic diagnosis was posttransplantation non-Hodgkin's lymphoma of
the adrenal gland.
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Fig. 1A. —59-year-old man, who presented 8 years after heart
transplantation, with right adrenal mass pathologically proven to be B-cell
lymphoma. Contrast-enhanced CT image shows round right adrenal mass
(arrow) measuring 78 H in attenuation.
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Fig. 1B. —59-year-old man, who presented 8 years after heart
transplantation, with right adrenal mass pathologically proven to be B-cell
lymphoma. High-resolution photomicrograph of pathology specimen shows diffuse
proliferation of large, atypical lymphocytes with irregular nuclear contours,
frequently prominent nucleoli, and high mitotic rate. (H and E,
x200)
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Fig. 1C. —59-year-old man, who presented 8 years after heart
transplantation, with right adrenal mass pathologically proven to be B-cell
lymphoma. High-resolution photomicrograph of pathology specimen shows many
tumor cells express Epstein-Barr virus-encoded RNA detected by in situ
hybridization as darkly stained nuclei. (Immunoperoxidase, x200)
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Posttransplantation lymphoproliferative disorder is a devastating
complication of immunosuppression. Two to six percent of patients develop
posttransplantation lymphoproliferative disorder after cardiac
transplantation; for these patients, it is the third leading cause of death
beyond the perioperative period
[1]. Incidence is highest
during the first year after transplantation. The spectrum of posttransplantion
lymphoproliferative disorders can range from lymphoid hyperplasia to
non-Hodgkin's lymphoma. Non-Hodgkin's lymphoma usually presents as a solitary
enlarging mass at a nodal or extranodal site. The most common sites of
involvement are the lymph node chains, the gastrointestinal system, and the
thorax. Involvement of the adrenal glands occurs in fewer than 5% of
cases.
Imaging characteristics of an adrenal mass can be helpful in
differentiating benign from malignant processes. Unenhanced CT attenuation of
less than 0 H predicts benignity, whereas unenhanced CT attenuation of greater
than 20 H predicts a malignant cause
[2]. Lower CT density is
believed to be related to fat content, a typically benign finding associated
with adrenal adenoma, whereas a higher CT density would be less likely to
indicate a large component of fat and thus less likely to represent an adrenal
adenoma. When contrast-enhanced CT images obtained after a 5- to 15-min delay
are compared with the initial scan, benign adrenal adenomas have been found to
exhibit an earlier, more pronounced washout of contrast material than
nonadenomas [3]. MR imaging can
also be used to differentiate benign from malignant lesions by calculation of
the chemical-shift ratio, a measure of signal intensity loss between in- and
opposed-phase images [4].
Although radiologic imaging can play a critical role in differentiating
benign from malignant adrenal masses, the diagnosis of posttransplantation
lymphoproliferative disorder remains histologic. Distinguishing
posttransplantion lymphoproliferative disorder from classic non-Hodgkin's
lymphoma is crucial because the clinical course and treatment are markedly
different. Posttransplantation non-Hodgkin's lymphoma is strongly associated
with the Epstein-Barr virus. Pathogenesis is believed to result from
suppression of T-cell function, leading to proliferation of B cells driven by
the Epstein-Barr virus [1].
A trial of weaning patients from immunotherapy is the leading therapy.
Surgical resection or limited irradiation can also be considered if the lesion
is anatomically localized. Experimental antiviral therapies with
interferon-
-2b and anti-B-cell monoclonal antibodies are also being
considered. Chemotherapy may be attempted for posttransplantation
lymphoproliferative disorder refractory to reduction of immunosuppression
[1]. Incidence of
posttransplantation lymphoproliferative disorder will likely continue to climb
with the availability of increasingly effective immunosuppresive agents.
References
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Swinnen LJ. Diagnosis and treatment of transplant-related lymphoma.
Ann Oncol
2000;11[suppl 1]:45
-48
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McNicholas MM, Lee MJ, Mayo-Smith WW, Hahn PF, Boland GW, Mueller
PR. An imaging algorithm for the differential diagnosis of adrenal adenomas
and metastases. AJR
1995;165:1453
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Korobkin M, Brodeur FJ, Francis IR, Quint LE, Dunnick NR, Londy F.
CT time-attenuation washout curves of adrenal adenomas and nonadenomas.
AJR
1998;170:747
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Korobkin M, Giordano TJ, Brodeur FJ, et al. Adrenal adenomas:
relationship between histologic lipid and CT and MR findings.
Radiology
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Introduction
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