Muhammad Ihsan ul haq Shahid

Jinnah Hospital Lahore, Pakistan

Title: Bilateral Adrenal Diffuse Large B-Cell Lymphoma Masquerading as Metastatic Disease: The Diagnostic Role of EUS-Guided Fine-Needle Biopsy

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Biography

Muhammad Ihsan ul Haq Shahid is an Internist and Gastroenterologist with qualifications of MBBS and FCPS Medicine and has been a Fellow of Gastroenterology since January 2024. He is currently working as a Fellow of Gastroenterology at Jinnah Hospital, Lahore, Pakistan. His clinical interests include advanced and interventional gastroenterology, particularly endoscopic ultrasound and other minimally invasive diagnostic and therapeutic procedures. He also has a strong interest in clinical research and academic medicine. He believes that gastroenterologists have an increasingly important role in the multidisciplinary management of gastrointestinal and abdominal malignancies, particularly where endoscopic interventions can provide definitive tissue diagnosis. His experience with this rare case of bilateral adrenal DLBCL diagnosed through EUS-guided fine-needle biopsy has further reinforced his interest in the diagnostic potential of EUS in uncommon abdominal malignancies.

Abstract

Background: Bilateral adrenal masses pose a challenging diagnostic dilemma, with metastatic malignancy, primary adrenal neoplasms, granulomatous disease, and lymphoma among the important differentials. Primary adrenal lymphoma is rare, with diffuse large B-cell lymphoma (DLBCL) being the predominant histological subtype. Tissue diagnosis is essential when cross-sectional imaging cannot establish the underlying etiology.

Case Presentation: A 70-year-old normotensive, non-diabetic man presented with one month of unintentional weight loss, anorexia, abdominal bloating and generalized abdominal discomfort. Contrast-enhanced computed tomography revealed relatively symmetrical bilateral adrenal masses measuring 56 × 28 × 55 mm on the right and 61 × 30 × 54 mm on the left, initially raising suspicion of bilateral adrenal metastases or primary adrenal malignancy. Extensive evaluation, including CT of the neck and chest and colonoscopy, failed to identify an extra-adrenal primary malignancy. Biochemical evaluation excluded pheochromocytoma. Endoscopic ultrasound demonstrated a 6.75 × 2.38 cm right adrenal mass. EUS-guided fine-needle biopsy using a 22-gauge core needle with three passes provided adequate tissue for histopathological and immunohistochemical assessment. Histology demonstrated sheets of large atypical lymphoid cells with frequent mitoses. Immunohistochemistry showed strong diffuse CD20 and PAX-5 positivity with negative CD3, confirming DLBCL. The patient was referred to oncology and received rituximab-based chemotherapy, initially R-CVP followed by R-CHOP.

Conclusion: Bilateral adrenal DLBCL can closely mimic metastatic disease radiologically. When extensive evaluation fails to identify an extra-adrenal primary, EUS-guided tissue acquisition offers a minimally invasive route to definitive histological diagnosis and immunophenotypic characterization. This case highlights the important and expanding role of therapeutic gastroenterology and EUS in the multidisciplinary diagnosis of rare intra-abdominal malignancies.

Keywords: Bilateral adrenal mass; diffuse large B-cell lymphoma; primary adrenal lymphoma; EUS-FNB; endoscopic ultrasound; adrenal biopsy; tissue diagnosis; gastrointestinal endoscopy