An Unusual Presentation of Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma as Diffuse Pulmonary Infiltrates with Spontaneous Regression

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.

Surgery and chemotherapy cannot improve the survival of patients with early-stage mucosa-associated lymphoid tissue derived primary pulmonary lymphoma

Background

To date, there is no treatment consensus on mucosa-associated lymphoid tissue (MALT) derived primary pulmonary lymphoma (PPL).

Methods

We identified patients with early-stage MALT-type PPL from the National Cancer Institute’s Surveillance, Epidemiology, and End Results program database. The patients were divided into four groups according to treatment modalities: None of surgery or chemotherapy (None) group, Surgery alone group, Chemotherapy alone (Chemo alone) group, and Surgery plus chemotherapy (Surgery + chemo) group. Overall survival (OS) and cancer-specific survival (CSS) were study endpoints. We performed Cox regression analyses, propensity score-matched analyses (PSM) and Kaplan-Meier (KM) survival curves to compare the survival among different groups.

Results

A total of 953 patients were included in our analysis with 302, 403, 175, and 73 cases in the None, Surgery alone, Chemo alone, and Surgery + chemo groups, respectively. In this cohort, the estimated 3-year, 5-year and 10-year OS rates were 86.95%, 78.91%, and 55.89%, respectively. Meanwhile, the estimated 3-year, 5-year and 10-year CSS rates were 96.71%, 93.73%, and 86.84%, respectively. Multivariate Cox regression analyses demonstrated that increasing age, tumors located in the lower lobe, and stage II were significant predictors of poorer OS while increasing age and tumors located in the bilateral lungs were associated with lower CSS. After PSM analyses, the KM survival curves showed no significant differences in OS or CSS among the four groups.

Conclusion

Early-stage MALT-type PPL is indolent in nature. Neither surgery, chemotherapy nor a combination of surgery and chemotherapy can improve OS and CSS, suggesting that “watch and wait” may be a reasonable alternative.

Primary pulmonary lymphoma manifesting as diffuse ground glass opacities: a case report and literature review

Primary pulmonary lymphoma is a rare clinical neoplasm, and its atypical manifestation frequently leads to misdiagnosis. Here, we have reported a rare case of a 55-year-old man who presented with cough, dizziness, and fatigue. His chest computed tomography (CT) revealed diffuse ground glass pulmonary opacities. Bronchoscope lavage demonstrated lymphocyte predominance, while transbronchial biopsy indicated chronic inflammation. The administration of a broad-spectrum antibiotic regime supplemented with a high dosage of methylprednisolone was ineffective in improving the general condition of the patient, and the diffuse ground glass pulmonary opacities continued to worsen. CT-guided percutaneous lung biopsy confirmed the diagnosis of primary pulmonary lymphoma-diffuse large B-cell (PPL-DLBCL) without extrapulmonary involvement. The patient's general condition improved with the systemic chemotherapy of CHOP. In the context of a systemic review of relevant literature, pulmonary lymphoma should be considered in the differential diagnosis of diffuse ground glass pulmonary opacities, and bronchoscopy is recommended for pathological diagnosis. Moreover, CT-guided percutaneous lung biopsy should also be adopted whenever necessary.

Abscopal Regressions of Lymphoma After Involved-Site Radiation Therapy Confirmed by Positron Emission Tomography

PURPOSE

Patients with abscopal regressions of lymphoma after palliative involved-site radiation therapy (ISRT), detected on sequential ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET), were identified by audit. A retrospective analysis was subsequently conducted to estimate the frequency of abscopal regression in follicular lymphoma (FL).

METHODS AND MATERIALS

Potential cases were identified at multidisciplinary lymphoma meetings and fulfilled these criteria: (1) palliative ISRT given for histologically confirmed lymphoma, (2) >2 lesions visualized on FDG-PET, (3) >1 unirradiated lesion(s) outside ISRT volume, (4) no systemic therapy delivered <2 months before radiation therapy or between radiation therapy and response assessment, (5) complete metabolic response (CMR) in ≥1 unirradiated lesions detected on serial FDG-PET/CT. All ISRT patients with FL treated in 2016 to 2018 were systematically reviewed.

RESULTS

Seven cases of abscopal regression were identified, including 4 patients with FL. In all cases, a CMR was apparent both within the ISRT volume and in ≥1 unirradiated lesions. One patient each was identified with mantle cell lymphoma (4 Gy in 2 fractions), Hodgkin lymphoma (20 Gy in 3 fractions, then 30 Gy in 15 fractions to the same volume), and Richter transformation of chronic lymphatic leukemia (30 Gy in 10 fractions). The 4 patients with FL received either 4 Gy in 2 fractions (n = 3) or 4 Gy followed 8 months later by 30 Gy in 15 fractions (n = 1). From 2016 to 2018, 29 courses of ISRT were prescribed for multifocal FL, after which 4 of 29 (13.8%) abscopal responses were detected, including in 4 of 9 (44.4%) patients with serial PET scans. Two patients, with relapsed disease after initial abscopal responses, experienced durable CMRs with immunotherapies.

CONCLUSIONS

In 4 of 7 cases, PET-detected abscopal regression of lymphoma occurred after 4 Gy, in 2 of 7 cases after repeated ISRT to the same volume, and in 2 of 7 was associated with subsequent complete response to immunotherapy, consistent with an immune basis for the abscopal effect. Abscopal regressions in FL appear to be more common than previously suspected.

Retrospective Analysis of 9 Cases of Primary Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma and Literature Review

Background

Primary pulmonary mucosa-associated lymphoma tissue lymphoma is rare and is often misdiagnosed because of its diverse and nonspecific clinical features. The aim of this study was to raise awareness among clinicians and to share our experience of treating and managing such patients.

Material/Methods

This retrospective study was conducted between 1 January 2009 and 31 October 2017 at the First Affiliated Hospital of Guangxi Medical University. All cases were confirmed via pathology and immunohistochemistry. In addition, we reviewed all relevant literature.

Results

Altogether, 21 patients (7 female, 14 male) with a median age of 54 (range, 19–84) years were diagnosed with primary pulmonary mucosa-associated lymphoma. Expiratory dyspnea, repeated cough and expectoration, and weight loss were the most common symptoms. Pulmonary lesions were found via physical examination in 10 patients who had no obvious symptoms. Chest computed tomography showed nodules, pulmonary consolidation, bronchial bronchogram, ground-glass opacity, and mediastinal lymph node enlargement. Some patients were misdiagnosed with tuberculosis and pneumonia, while others were initially diagnosed with cancer. Tumor pathology and immunocytochemistry indicated primary pulmonary mucosa-associated lymphoma tissue lymphoma. Six patients underwent chemotherapy, 5 underwent surgery, 4 underwent surgery and chemotherapy, 3 were only observed, and 3 refused treatment.

Conclusions

The development of primary pulmonary mucosa-associated lymphoid tissue lymphoma is slow and insidious. Having no specific clinical symptoms and imaging findings, it is easily misdiagnosed. Final diagnosis is made via pathologic evaluation and immunohistochemistry. Surgery and chemotherapy are the primary treatment modalities and yield a good prognosis.

Pulmonary Mucosa-associated Lymphoid Tissue Lymphoma with Spontaneous Regression after Computed Tomography-guided Needle Biopsy: A Case Report and Summary of 8 Reported Cases

A 72-year-old woman was admitted to our hospital with a solitary right lung nodule. She had no symptoms and no abnormal physical findings except for bladder cancer. Tumor markers were mildly elevated but no other abnormal laboratory data were found. The nodule was diagnosed to be pulmonary mucosa-associated lymphoid tissue lymphoma on computed tomography-guided needle biopsy. Thereafter, she first underwent surgery for bladder cancer. The lung nodule was found to have slightly increased at three months and then disappeared at 15 months after the biopsy. The notable clinical course of this rare disease suggests the effectiveness of a non-interventional treatment strategy.