Bilateral adrenal enlargement is often the result of disseminated malignant disease, and this diagnosis is particularly likely to be considered in a patient with severe weight loss. We describe such a patient in whom bilateral adrenal masses, visualised by computed tomography (CT), were the result of disseminated histoplasmosis occurring at least 20 years after the original infection. Case historyA 74 year old woman had been unwell for three months with anorexia, nausea, upper abdominal pain, headache, low back pain, and 20 kg weight loss. She was born in Calcutta and at the age of 37 settled in London, remaining in Britain with the exception of a six month visit at the age of 54. She was lethargic, blood pressure was 100/60 mm Hg, and she had epigastric tenderness. Haematological concentrations were: blood urea 8-6 mmol/l (52 mg/100 ml), plasma creatinine 120 ,umol/l (14 mg/100 ml), sodium 129 mmol(mEq)/l, potassium 4-5 mmol(mEq)/l, albumin 27 g/l, and globulin 43 g/l. Alkaline phosphatase activity was 320 IU/l, aspartate transaminase activity 57 IU/l, haemoglobin concentration 17-2 g/dl, white cell count 3-9 x 10'/l (19% lymphocytes), and erythrocyte sedimentation rate <1 mm in first hour. The chest radiograph was normal and abdominal ultrasound showed an enlarged liver with increased echo pattern, compatible with metastases or cirrhosis. Ultrasound also detected a 5 cm retroperitoneal mass in the region of the splenic hilum, probably of pancreatic or lymph node origin. Endoscopy showed a hiatus hernia with oesophagitis; barium enema appearances were normal.Liver biopsy showed non-specific changes. One month after presentation she was confused and oedematous and her supine blood pressure was 80/60 mm Hg. Abdominal CT scan confirmed the hiatus hernia and showed fatty infiltration of the liver and large adrenal masses consistent with secondary deposits in both adrenal glands (fig 1). Blood urea concentration was 2-6 mmol/l (16 mg/100 ml), plasma sodium 132 mmol/l, potassium 2-7 mmol/l, albumin 19 g/l, globulin 46 g/l, and bilirubin 33 [tmol/l (1-9 mg/100 ml); serum enzyme activities were: alkaline phosphatase 741 IU/l, aspartate transaminase 76 IU/l, and y-glutamyltransferase 224 IU/I. Although random plasma cortisol concentrations were raised (770-810 nmol/l; 28-29 [ig/100 ml), progressive hypotension suggested adrenal failure and she was treated with parenteral dexamethasone, fludrocortisone, and saline. CT guided biopsy of an adrenal gland could not be performed because the blood pressure failed to improve and the prothrombin time was prolonged (ratio 1 5). Despite continued management of adrenal failure hypotension persisted and she died. At necropsy both adrenal glands were replaced by 4-5 cm diameter friable, yellow brown, partly necrotic masses resembling metastatic deposits. In addition, lung hilar nodes were enlarged and there were several rounded white areas 0-1-0-5 cm diameter in the renal parenchyma. Histologically there was little residual glandular tissue in the adrenals, which consisted of collect...

Introduction: We surveyed the Australian and New Zealand (ANZ) radiation oncology community to assess their perceptions, understanding and experience of the current role of proton beam therapy (PBT) and the existing referral process to access PBT overseas, ahead of the development of the first PBT centre in Australia. Methods: The survey was conducted between September and October 2019 using a 17-question instrument, which was distributed by email to all 632 radiation oncology fellows and trainees listed in the Royal Australian and New Zealand College of Radiologists database. Results: One hundred and one respondents completed the survey, with an overall response rate of 16%. Most respondents were based in Australia (93%), with the majority working in public centres only (59%); 51% were > 10 years post fellowship and 17% were trainees. Most respondents (76%) reported moderate or high levels of confidence in the role of PBT. Only 28% had previously referred a patient for PBT overseas, with the most common referral indication being chordoma. Of those who had not previously referred a patient, 48% were not convinced about the rationale of PBT over current therapies available locally, 33% were not aware of the referral process, and 24% had concerns about the timeliness of a decision for government-funded PBT abroad. Conclusion: This survey has demonstrated that, although there is reasonable confidence in the role of PBT among ANZ radiation oncologists, there are a number of important aspects of PBT awareness, education and access that need to be developed prior to commencement of PBT in Australia.

Background: Diffuse large B-cell lymphoma (DLBCL) represents the most common form of non-Hodgkin lymphoma and is characterized by an aggressive natural history. It often presents with rapid symptom development and disease progression. Most lymphomas are inherently radiosensitive, which allows for effective disease control from relatively low radiation doses. We report a case of a dramatic radiotherapy response in a necrotic diffuse large B-cell lymphoma mass in an elderly patient with early-stage diffuse large B-cell lymphoma, illustrating the potential for palliative radiotherapy to reduce disease burden in patients not fit for systemic therapy. There is no current consensus recommendation for radiotherapy treatment in this setting. Case presentation: A 97-year-old Caucasian woman presented to the emergency department of our institution with a painful, malodorous, necrotic right upper neck mass, which had progressed over a two-month period. Investigations confirmed stage 1A diffuse large B-cell lymphoma. Palliative radiotherapy was delivered to a dose of 25 Gray (Gy) in five fractions on alternate days over two consecutive weeks. After four months, the mass completely resolved with no residual symptoms. Conclusion: Dramatic responses resulting in durable local control and improvement in quality of life are achievable with palliative radiotherapy, owing to the radiosensitivity of diffuse large B-cell lymphoma.