Fiberoptic bronchoscopy in patient with Hodgkin's and non-Hodgkin's lymphomas

Pulmonary Parenchymal Lymphoma Diagnosed by Bronchoscopic Cryoprobe Lung Biopsy

A 51-year-old man presented with progressively worsening lung infiltrates and respiratory failure. Extensive investigations including bronchoscopy with bronchoalveolar lavage and conventional transbronchial forceps biopsies failed to establish the diagnosis. After transfer to our institution, he underwent repeat bronchoscopy with transbronchial cryobiopsy, which provided large, high-quality biopsy specimens establishing the diagnosis of parenchymal diffuse large B-cell lymphoma.

Localisation bronchique révélatrice d’une maladie de Hodgkin

INTRODUCTION

Bronchial localisation of Hodgkins disease has been described only rarely and it is exceptional as the presenting feature. More frequently the clinical presentation is extrinsic bronchial compression.

OBSERVATION

Mr B.C., 34 years old, had a past history of cured alcoholism and abuse of cannabis and buprenorphine. In February 2001 he presented with generalised pruritus, weight loss of 8 kg in one year, a 1 cm node above the right clavicle, hypereosinophilia, and CT evidence of non-obstructive mediastinal adenopathy and interstitial lesions in the right lower lobe. Five months later he was admitted to hospital with a febrile illness. The right supraclavicular node had disappeared but there was gross mediastinal adenopathy, associated with a right perihilar soft tIssue mass encircling the upper, middle and lower lobe bronchi and multiple peripheral parenchymal nodules. Bronchoscopy revealed complete stenosis of the right upper lobe bronchus and bronchial histology confirmed Hodgkins disease.

CONCLUSIONS

Bronchoscopy is an effective investigation for the detection of endobronchial Hodgkins disease, often overlooked because parenchymal abnormalities are attributed to extrinsic compression. In order to determine the disease stage more precisely we advise immediate bronchoscopy when there is suspicion that Hodgkins disease may be the cause of clinical.

Pulmonary involvement in lymphoma

Intrathoracic involvement is common in both Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). The most common manifestation is mediastinal lymphadenopathy. In HD, nodal involvement is by contiguity and usually involves the superior mediastinum, while the findings in NHL are more variable. Pulmonary parenchymal disease occurs in 38% of HD and 24% of NHL. In untreated HD, parenchymal involvement is invariably associated with mediastinal lymphadenopathy and often with widespread disease. Three distinct radiological patterns of pulmonary lymphoma are recognised: nodular, bronchovascular-lymphangitic and pneumonic-alveolar. Rarely lymphoma may be endobronchial. Pleural effusion occurs in 16% of lymphoma patients and is usually associated with disease elsewhere. It is frequently caused by lymphatic obstruction but may be due to direct pleural involvement by tumour. Chylothorax may occur in NHL but is unusual in HD. Diagnosis of intrathoracic lymphoma is by transbronchial or transthoracic biopsy or by needle aspiration of tissue or pleural fluid. The addition of immunostaining improves the diagnostic yield in equivocal cases. Treatment and prognosis vary depending on cell-type, location and extent of disease.

Fiberoptic bronchoscopy in the evaluation of carcinoma metastatic to the lung

To determine the clinical presentation of patients with malignancies metastatic to the lung, the diagnostic utility of fiberoptic bronchoscopy (FB), and the primary site of malignancies metastasizing endobronchially, we retrospectively reviewed 1,853 FB records (1987 to 1991) and selected 111 cases for review. Cases were divided on the basis of FB findings into abnormal (44 patients) and normal (67 patients). Pulmonary symptoms (cough, hemoptysis, and chest pain) prompted referral significantly more often in the abnormal FB group (34/44) than in the normal FB group (24/67). The finding of atelectasis on chest radiograph occurred more frequently in patients with endobronchial abnormalities. The spectrum of extrapulmonary malignancies that metastasize endobronchially has changed during the AIDS epidemic. Our study shows the most frequent causes of endobronchial mass lesions were Kaposi's sarcoma and the lymphoma group (Hodgkin's disease, nonHodgkin's lymphoma, chronic lymphocytic leukemia) and the most common malignancies causing submucosal metastases were breast and the lymphoma group. In summary, the highest yield from FB can be expected in patients experiencing symptoms of cough or hemoptysis and/or having radiographic evidence of atelectasis. We propose a new mnemonic "KLAS" (Kaposi's sarcoma, Lymphoma, Adenocarcinoma, Sarcoma) to describe the malignancies most likely to metastasize endobronchially in the 1990s.

Detection of lymphomatous involvement of the lung by bronchoalveolar lavage. Application of immunophenotypic and gene rearrangement analysis

We report three cases of pulmonary involvement of non-Hodgkin's lymphoma in which immunophenotypic or gene rearrangement analysis of bronchoalveolar lavage (BAL) cells demonstrated monoclonality of T- or B-cell lineage. The first patient had T-cell lymphoma and developed pulmonary lesions. Surface marker analysis of the BAL cells revealed that CD8-positive lymphoid cells were dominant and Southern blot analysis of T-cell receptor gene detected gene rearrangement demonstrating monoclonality of T-cell lineage. The second patient presented with diffuse micronodular shadows on chest radiograph. Marked B-lymphocytosis in BAL fluid prompted us to analyze their clonality. The third was a case in which recurrence of primary pulmonary lymphoma was suspected. In the second and third case, the finding of marked increase in the number of CD 19-positive B lymphocytes with a single class of light chains proved a monoclonal population in BAL cells. With the review of other cases in our study and the relevant literature, we conclude that the clonal analysis of BAL cells is helpful in establishing the diagnosis of pulmonary involvement of T- or B-cell lymphoma.

Pulmonary lymphoproliferative disorders

Pulmonary lymphoproliferative disorders are a diverse group of conditions that primarily or secondarily involve the lungs. Modern diagnostic modalities, including immunologic and molecular genetics techniques, have contributed substantially to the continuously evolving understanding of these complex lesions. In this review, we classified pulmonary lymphoproliferative disorders into benign, intermediate or indeterminate, and malignant categories and described the clinical, radiographic, and pathologic features for the entire spectrum. Our emphasis is on the clinical findings and the role of tissue biopsy as well as ancillary techniques in diagnosis. Various treatments and expected responses are also discussed.

Pulmonary non-Hodgkin's lymphoma in AIDS

Whereas extralymphatic involvement is common in lymphomas associated with HIV infection, there have been few reports of pulmonary lymphoma. In 648 cases of AIDS reported in Colorado, 40 have had non-Hodgkin's lymphoma. Of these, four have had documented pulmonary involvement and are reported in detail. Clinical manifestations were nonspecific and included fever, weight loss, generalized lymphadenopathy, dyspnea, chest pain and cough. Chest roentgenograms revealed multiple nodules or interstitial infiltrates. Transbronchial biopsy failed to establish the diagnosis in all cases. Three of four patients died four to five months after appearance of pulmonary nodules; one patient with stage IE disease showed slow radiographic progression over 16 months following radiation and chemotherapy and died 18 months after appearance of pulmonary nodules. Pulmonary involvement with lymphoma should be considered in patients with HIV infection, especially if multiple nodules are seen on chest roentgenograms.

Pulmonary infiltrates--diagnostic problems in lymphoma

The use of invasive investigations in immunocompromised patients with pulmonary infiltrates is controversial. We report a series of 22 pulmonary lesions occurring in 19 patients with underlying Hodgkin's (7) and non-Hodgkin's (12) lymphoma in whom invasive investigations were performed. The principle techniques used were fibreoptic bronchoscopy, bronchoalveolar lavage and transbronchial lung biopsy. A specific diagnosis was made on 12 occasions (55%). Involvement of the lung with lymphoma (6) and cytotoxic drug induced pneumonitis (4) were the commonest diagnoses, infection being found on only one occasion. In 15 of these 22 procedures (68%) the information obtained made a positive contribution to patient management.

Cytologic diagnosis of pulmonary Hodgkin's disease via endobronchial brush preparation

A case is presented where a young man who was treated for Hodgkin's disease presented with a new pulmonary infiltrate. The infiltrate was diagnosed as recurrent Hodgkin's disease by means of endobronchial brush cytology via fiberoptic bronchoscopy.

Surgical management of lymphomas involving the chest

The efficacy of surgical judgments in the management of thoracic lymphoma was studied through review of 34 patients with primary mediastinal lymphomas, 30 patients who needed one or more thoracic operations after treatment of extrathoracic lymphomas, and 5 patients with primary lymphocytic infiltrates (PLI) of the lung. In all patients with primary lymphocytic infiltrates of the lung, thoracotomies were required in order to establish the correct diagnosis. Patients with primary mediastinal lymphoma required 74 surgical procedures (2.2 per patient) to establish the correct diagnosis. In retrospect, 40 operations were not beneficial. The procedures that provided diagnostic samples were 15 anterior mediastinotomies, 8 full thoracotomies, 3 median sternotomies, and 8 lesser procedures such as mediastinoscopy. Patients who needed thoracic procedures after treatment of extrathoracic lymphomas had 41 thoracic operations (1.37 per patient). Five operations were needed to manage complications of thoracic lymphoma or its therapy. To evaluate new radiographic findings, there were 35 operations (1.3 per patient) at a mean interval of 5.0 years following initial treatment; the findings were recurrent lymphoma in 62% and new lesions in 38% of patients. Among new lesions, there were 2 bronchogenic cancers; 9 enlarging mediastinal-pleural masses were not caused by lymphoma. The accurate diagnosis of thoracic lymphoma or new thoracic lesions in patients with lymphomas usually requires enough tissue for immunophenotyping. Providing adequate tissue samples and treating new lesions that are not lymphomas often require major thoracomediastinotomies for immunophenotyping.

Rapidly progressive fatal pulmonary infiltration by lymphoma

Two patients with diffuse lymphoma, one diffuse large cell and the other diffuse mixed, large and small cell, developed an illness characterised by a high swingeing fever and a pulmonary infiltrate. In both patients there was clinical evidence of chemotherapy-induced tumour response elsewhere at the time lung infiltrates progressed. Blood and sputum cultures, bronchial washings, and, in one case, trans-bronchial lung biopsy did not establish a diagnosis and there was progressive clinical deterioration. Post mortem examination showed widespread involvement of both lungs with lymphoma. The differential diagnosis of fever and pulmonary infiltrates in patients with diffuse lymphoma is discussed, in particular the possibility of this being due to rapidly progressive lymphoma.

Early involvement of the bronchi in patients with malignant lymphoma

Fibreoptic bronchoscopy in previously untreated patients with malignant lymphoma provided diagnostic information in 8 of 25 cases with radiological evidence of intrathoracic involvement. There was a marked difference in the pattern of endobronchial involvement between Hodgkin's Disease (HD) and Non Hodgkin's Lymphoma (NHL) which specifically infiltrated the bronchus-associated lymphoid tissue. Bronchoalveolar lavage was abnormal in only one patient with Hodgkin's Disease in whom the presence of many Sternberg-Reed cells suggested occult dissemination of otherwise localised disease.