Abstract Introduction Adrenal involvement in non-Hodgkin lymphoma (NHL) is rare and usually occurs in disseminated disease. Bilateral involvement, often leading to adrenal insufficiency, is typical. Unilateral adrenal disease is uncommon, especially when the first sign is peripheral lymphadenopathy. We present a case of secondary unilateral adrenal involvement by NHL, initially manifesting with cervical and axillary lymphadenopathy and preserved adrenal function. Clinical Case A 49-year-old male presented with a three-year history of painless swelling in the left cervical region and both axillae, accompanied by fatigue. Examination revealed non-tender, mobile axillary and cervical lymphadenopathy. Imaging showed mild hepatomegaly and borderline splenomegaly. There were no signs of adrenal insufficiency. Core biopsy of a left axillary lymph node revealed follicular NHL with a nodular pattern, positive for CD20, CD10, BCL2, CD79a, and BCL6. Laboratory tests excluded adrenal insufficiency and functional tumors, including pheochromocytoma. Morning cortisol (19.2 μg/dL), ACTH (42.4 pg/mL), sodium (137 mmol/L), and potassium (4.5 mmol/L) were normal. Plasma metanephrines were not elevated and overnight dexamethasone suppression test excluded autonomous cortisol secretion. Contrast CT showed a solid left adrenal mass (12 × 9 cm) without calcification or necrosis.The right adrenal was normal. Additional lymphadenopathy was present in axillary, cervical, and inguinal regions. PET-CT showed intense FDG uptake in all sites without other disease. CT-guided adrenal biopsy confirmed identical histology with a high-grade component. The patient received six cycles of Pola-R-CHP (polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin, prednisone). Adrenal function remained preserved,so glucocorticoid replacement was not needed. Follow-up PET-CT showed persistent FDG uptake in the left adrenal, with the mass reduced to 5.4 × 4.0 cm. Further management is under consideration. Conclusion This case describes secondary adrenal involvement in lymphoma with preserved hormonal function despite a large unilateral lesion. It underscores the importance of histological confirmation and grading to guide treatment. Hormonal assessment, particularly exclusion of pheochromocytoma, is crucial before adrenal biopsy. Early diagnosis and close follow-up are essential for optimal outcomes.Figure 1:Pet-CT of retroperitoneal region
Papanastasiou et al. (Thu,) studied this question.