ABSTRACT
In the staging of cancer patients, transient and spontaneously reversible bilateral adrenal hypertrophy may mimic a secondary localization of the disease. We discuss the case of an 82-year-old male patient with suspected testicular neoplasia in which abdominal CT examination reveals the onset of a bilateral macronodular adrenal enlargement, suggesting the diagnostic hypothesis of primary testicular neoplasia with secondary adrenal localization. The subsequent 18FDG-PET/CT study showed hyper-metabolism of the testicular mass, while the adrenal glands, surprisingly, did not show increased uptake of the radiotracer. After right orchifunicolectomy, primary testicular diffuse large B-cell lymphoma was diagnosed. The subsequent staging PET/CT study with iodine contrast medium, three months after the first CT examination, showed spontaneous complete regression of the adrenal hypertrophy without any use of drug therapy. The differential diagnosis of this finding considered the lack of hypermetabolism and the densitometric characteristics of the adrenal glands, the absence of possible pharmacological interactions throughout the time of the diagnostic procedures, and the available clinical-laboratory data. By excluding the main causes of adrenal hypertrophy, the most likely diagnostic hypothesis was transient adrenal hypertrophy due to stress induced by testicular lymphoma, meaning by stress a disturbance not only emotional but also an alteration of organic homeostasis. Our case suggests that the analysis of adrenal lesions appeared in cancer patients should take into account non-metastatic conditions that must be studied with a multimodal approach and with serial investigations.
ABSTRACT
The aim of this study was to assess the added diagnostic value of contrast-enhanced CT (CECT) as compared with unenhanced CT (UECT) in PET/CT staging and treatment response assessment of 18F-FDG-avid lymphomas. Methods: 170 PET/UECT scans followed by CECT scans were prospectively performed for staging (n = 85) and for treatment response assessment (n = 85) of 18F-FDG-avid lymphomas, during a single session using an integrated 64-slice PET/CT scanner. CECT and UECT images were evaluated separately by 2 radiologists, whereas PET images were evaluated by 2 nuclear physicians. Nodal and extranodal UECT and CECT findings were classified according to the Lugano criteria and were successively compared with PET/CT results, considered the gold standard. In the analyzed groups, the agreement rate with the disease status determined via PET was calculated separately for UECT and CECT using the McNemar test on paired data. The added value of the contrast medium was shown by the agreement between the PET and CECT results and the lack of agreement between UECT and PET. Results: CECT enabled the identification of additional extranodal lesions (hepatic, muscular, and gastric) in only 3 staging group cases (3.5%), indicating different stages as compared with UECT, whereas there was absolute agreement between CECT and UECT in terms of treatment response assessment. The added diagnostic value of CECT was lower than the established threshold for clinical relevance (15%). The McNemar test indicated no statistical significance in either group. The incidental findings detected by CECT but not UECT were important for clinical management but not sufficient to alter lymphoma treatment strategy. Conclusion: According to our results, it might be possible to exclude CECT examination of 18F-FDG-avid lymphoma from staging and treatment response assessment, with the consequent advantages of reducing radiation exposure and potential contrast-related risks.
