Clinical Analysis of 50 Cases of Primary Pulmonary Lymphoma: A Retrospective Study and Literature Review

Surgical management of stage IE/IIE primary pulmonary lymphomas: a propensity score matching study

Background

Primary pulmonary lymphomas (PPLs) are rare malignancies that are frequently misdiagnosed due to their non-specific symptoms and ambiguous imaging findings. Although chemotherapy and radiation are typically the main treatment options, the role of surgery in managing PPLs remains uncertain. This study aimed to evaluate the impact of surgery on survival outcomes in patients with stage IE/IIE PPLs.

Methods

We analyzed 2,693 patients with stage IE/IIE PPLs using Cox regression and Kaplan-Meier analyses to assess overall survival (OS) and cancer-specific survival (CSS). Subgroup analyses were performed based on histological subtypes, including mucosa-associated lymphoid tissue (MALT) lymphoma, diffuse large B-cell lymphoma (DLBCL), other non-Hodgkin's lymphoma (NHL), and Hodgkin's lymphoma (HL). Additionally, we analyzed tumor stage and patient characteristics. Propensity score matching (PSM) was applied to reduce potential biases.

Results

Among the patients, 1,013 underwent surgery, while 1,680 did not. After PSM, surgery was associated with significantly improved OS [hazard ratio (HR) =0.75, 95% confidence interval (CI): 0.66-0.86, P<0.001] and CSS (HR =0.66, 95% CI: 0.54-0.81, P<0.001). Notably, surgery significantly improved OS and CSS in patients with stage IE (OS: HR =0.62, 95% CI: 0.46-0.84, P=0.002; CSS: HR =0.57, 95% CI: 0.39-0.84, P=0.005) and stage IIE (OS: HR =0.64, 95% CI: 0.41-0.99, P=0.046; CSS: HR =0.47, 95% CI: 0.27-0.85, P=0.01) DLBCL. However, surgery did not significantly affect OS (P=0.24) or CSS (P=0.83) in patients with HL, stage IE/IIE MALT lymphoma (stage IE: OS, P=0.11; CSS, P=0.34; stage IIE: OS, P=0.40; CSS, P=0.75), or stage IE/IIE other NHL (stage IE: OS, P=0.050; CSS, P=0.46; stage IIE: OS, P=0.22; CSS, P=0.11). Additionally, sublobectomy demonstrated outcomes comparable to lobectomy/pneumonectomy in terms of OS and CSS for both stage IE (OS: HR =0.81, 95% CI: 0.63-1.06, P=0.13; CSS: HR =0.91, 95% CI: 0.58-1.43, P=0.70) and stage IIE (OS: HR =0.66, 95% CI: 0.40-1.09, P=0.10; CSS: HR =0.58, 95% CI: 0.26-1.29, P=0.18) PPLs.

Conclusions

Surgery improves oncological outcomes for patients with stage IE/IIE DLBCL but does not provide survival benefits for MALT lymphoma, other NHL, or HL. Sublobectomy may be a viable surgical option when complete resection is achieved.

Mantle Cell Lymphoma Causing Recurrent Pleural Effusions: A Case Report

Mantle cell lymphoma (MCL) is a rare type of B cell non-Hodgkin's lymphoma. MCL is most commonly identified in the gastrointestinal tract. Yet, many other extranodal sites have been described in the literature, including the rare instances of the primary site being the pleura of the lung. We present a case with a 73-year-old female who presented with a three-month history of unintentional weight loss, nocturnal fever, and night sweats. She had recurrent left pleural effusions; however, thoracentesis and pleural fluid cytology were negative for malignancy. A definitive diagnosis was achieved after the patient underwent video-assisted thoracic surgery. MCL presenting as a pleural effusion is rarely reported in the literature.

Primary pulmonary lymphoma in Peru

Objective

To describe the clinical features, imaging, pathology and management of patients with primary pulmonary lymphoma (PPL).

Methodology

This is a case series study involving a retrospective analysis of 24 patients diagnosed with PPL between the years 2000-2019 at Instituto Nacional de Enfermedades Neoplásicas in Lima, Perú.

Results

73.9% of patients were male. Cough (78.3%) and weight loss (56.5%) were the most frequent clinical features. Dyspnoea and elevated values of DHL and B2 microglobulin were frequently altered in advanced stages. Diffuse large B cell lymphoma (DLBCL) represented 47.8% of the cases and the most common radiologic alterations were a mass (60%) and consolidation with air bronchogram (60%). The most utilised treatment was chemotherapy alone (60%). Three patients received only surgery. Median survival was 30 months. Five overall survival was 45%, and up to 60% in the case of mucosa-associated lymphoid tissue lymphoma.

Conclusion

PPL is infrequent. Clinical features are unspecific and the principal finding is a mass, nodule or consolidation with air bronchogram. Definitive diagnosis needs biopsy and immunohistochemistry. There is no standard treatment, it depends on histology type and stage.

Primary pulmonary diffuse large B-cell lymphoma presenting multiple nodules mimicking metastasis: A case report

Primary pulmonary diffuse large B-cell lymphoma is a rare entity. We describe a case of pulmonary lymphoma with multiple nodules mimicking metastases in a treated patient with rheumatoid arthritis. A 73-year-old man was diagnosed with rheumatoid arthritis at the age of 30. He was treated with leflunomide. He was followed up for a nontuberculous mycobacterial infection. He underwent percutaneous coronary intervention for acute myocardial infarction at the age of 70. In April 2022, routine follow-up revealed new-onset multiple nodules on chest computed tomography (CT). A position emission tomography/CT scan with 18F-fluorodeoxyglucose showed a low-high maximum standardized uptake value by multiple nodules. Pathologic examination of a video-assisted thoracic surgical biopsy revealed pulmonary diffuse large B-cell lymphoma. Systemic chemotherapy with rituximab, cyclophosphamide, vincristine, and prednisolone reduced and eliminated multiple nodules. Pulmonary lymphoma should be considered as a differential diagnosis in the case of multiple nodules on a chest CT.

Primary pulmonary extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type: a case report and literature review

Primary pulmonary mucosa-associated lymphoid tissue (MALT)-derived lymphoma is a low-grade B-cell non-Hodgkin's lymphoma. It is rare with unclear clinical and imaging findings, requiring biopsy or surgery for diagnosis. Here, we provide a new case to learn the symptoms, diagnosis and treatment of primary pulmonary MALT lymphoma. The patient was a 51-year-old male. During the annual physical examination in 2019, a shadow in the lower lobe of the right lung was accidentally found in his chest computed tomography image. In 2020, the size and density of the shadows increased, which was suspected to be lung adenocarcinoma. The patient underwent video-assisted thoracoscopic surgery and segmental resection. Pathological examination showed residual germinal centers around the tumor cells, and many inflammatory cells had diffusely infiltrated, mainly monocyte-like B cells. Immunohistochemical analysis showed that CD3, CD20, Bcl-2, CD43, CK-pan and CD23 were positive, while BCL-6, CD5, CD10, c-myc and cyclin D1 were negative. The patient was diagnosed with MALT extranodal marginal zone B-cell lymphoma. The patient did not receive chemotherapy or radiotherapy after the operation but was still under close observation. Primary pulmonary MALT develops slowly and tends to be inert and spontaneous. Due to the lack of specific clinical symptoms and imaging findings, it can easily be misdiagnosed as tuberculosis, lung cancer, or infection. Thoracoscopic resection may be a good choice for the diagnosis and treatment.

Case report: Simultaneous occurrence of primary pulmonary lymphoma and opportunistic infections in a patient with chronic myeloid leukemia

Background

The occurrence of primary pulmonary lymphoma (PPL) as a secondary malignancy in patients diagnosed with chronic myeloid leukemia (CML) is extremely rare. As the clinical manifestations are atypical, most patients with PPL tend to be misdiagnosed with pneumonia. When the radiographic features of PPL and pulmonary infection overlap, clinicians can be confused about the diagnosis. Here, we report the first case of coexistence of PPL and opportunistic infections in a patient with CML in chronic phase (CML-CP).

Case presentation

A 55-year-old woman presented with three weeks of hemorrhage of the oral mucosa at the Department of Hematology. After undergoing various examinations, she was diagnosed with CML-CP and was started on imatinib (400 mg/daily). Due to sudden respiratory distress, the patient was admitted to the respiratory intensive care unit 11 months later. Chest computed tomography (CT) revealed ground-glass opacities, patchy shadows, and multiple nodules in both lungs and enlarged mediastinal lymph nodes. The combination of biapenem and voriconazole antibiotic treatments was effective. The patient’s respiratory distress was relieved, but there was intermittent coughing. In the following time, the patient developed a fever, and the imaging findings indicated progression of the disease in both lungs. Bronchoalveolar lavage (BAL) identified pathogens of multiple opportunistic infections. The coexistence of lymphomatoid granulomatosis (LYG) was not confirmed in this patient until a second CT-guided biopsy was performed. Ultimately, the patient underwent chemotherapy in time and is currently alive today.

Conclusions

When the patient’s recurrent respiratory symptoms and imaging findings do not coincide, secondary tumors should be considered in addition to infection as a diagnosis. In these cases, multiple pathological tissue biopsies should be performed.

Role of 18F-FDG PET/CT in patients affected by pulmonary primary lymphoma

Background

Primary pulmonary lymphoma (PPL) is defined as clonal abnormal hyperplasia of lung parenchyma or bronchial lymphoid tissue originating from bronchial mucosal tissue. However, PPL is rare, which accounts for approximately 3-4% of extraneurotic lymphomas and 0.5-1% of all primary tumors in the lung. Owing to the lack of any typical clinical symptoms and radiological features, it is challenging to accurately diagnose PPL, which affects its clinical management and prognosis. Considering this, herein, we aim to raise awareness of this disease and help physicians understand the role of 18F-FDG PET/CT in the diagnosis of PPL.

Method

A retrospective analysis was performed on the clinical and 18F-FDG PET/CT imaging data of 19 patients diagnosed with PPL by biopsy pathology at our hospital from April 2014 to December 2021.

Results

Of the 19 PPL patients, 15 patients showed clinical symptoms with the most common being fever and cough. In addition, there were 4 cases that had no clinical symptoms, and all of them were MALT lymphoma. In fact, 16 patients were misdiagnosed as lobar pneumonia, lung cancer, tuberculosis, and diffuse interstitial inflammation, representing a misdiagnosis rate of 84.2%. Also, 73.7% were MALT lymphomas, representing the most common pathological pattern, along with 3 DLBCL and 2 T-cell lymphomas. With reguard to CT signs, the air-bronchial sign was found to be the most common, followed by the halo sign and the collapsed leaf sign. On the basis of the predominant radiologic features, lesions were categorized as pneumonic consolidation, nodular/mass type, diffuse interstitial type, and mixed type. The average SUVmax of lesions was 7.23 ± 4.75, the ratio of SUVmax (lesion/liver) was 3.46 ± 2.25, and the ratio of SUVmax (lesion/mediastinal blood pool) was found to be 5.25 ± 3.27. Of interest, the different pathological types of PPL showed different values of 18F-FDG uptake. The 18F-FDG uptake of DLCBL was the most prominent with a SUVmax of 15.33 ± 6.30 and was higher than that of MALT lymphoma with a SUVmax of 5.74 ± 2.65. There appeared similarity in 18F-FDG uptake between MALT lymphoma and T-cell lymphoma. For the SUVmax of lesion, we found statistical significance between MALT lymphoma and DLCBL (P value<0.001). In addition, we also found statistical significance (P value < 0.05) in SUVmax of lesions between pneumonic consolidation type and nodal/mass type, I stage, and other stages.

Conclusions

On 18F-FDG PET/CT images, certain features of PPL morphology and metabolism can be identified that may contribute to a better understanding of this disease. In addition, 18F-FDG PET/CT whole-body imaging has the potential to refine the staging of PPL. Most importantly, functional 18F-FDG PET/CT imaging can readily reflect tumor cell activity, thus allowing for the selection of an optimal biopsy site.