Intrapulmonary Castleman's Disease Pretending to Be a Lung Cancer-Work Up of an Intrapulmonary Tumour

Pulmonary Manifestations of Plasma Cell Type Idiopathic Multicentric Castleman Disease: A Clinicopathological Study in Comparison with IgG4-Related Disease

Plasma cell type idiopathic multicentric Castleman disease (PC-iMCD) occasionally manifests as parenchymal lung disease. This study aimed to elucidate the detailed clinicopathological features of lung lesions in PC-iMCD and compare the findings with those in immunoglobulin (Ig) G4-related disease (IgG4-RD), the most difficult differential diagnosis of PC-iMCD. We analyzed the clinicopathological findings and immunohistochemical expression patterns of interleukin-6 (IL-6) and Igs in lung specimens from 16 patients with PC-iMCD and 7 patients with IgG4-RD. Histologically, pulmonary PC-iMCD could not be differentiated from IgG4-RD based on lesion distribution patterns, the number of lymphoid follicles and obliterative vasculitis, or fibrosis types. The eosinophil count was higher in the IgG4-RD group than in the PC-iMCD group (p = 0.004). The IgG4/IgG-positive cell ratio was significantly higher in the IgG4-RD group (p < 0.001). The IgA-positive cell count and IL-6 expression intensity were higher in the PC-iMCD group than in the IgG4-RD group (p < 0.001). Based on these findings, we proposed a new diagnostic approach to differentiate lung lesions of PC-iMCD and IgG4-RD. Our approach can be utilized to stratify patients with suspected lung-dominant PC-iMCD to identify candidates for strong immunosuppressive treatment, including IL-6 blockade, at an early stage.

[Clinical analysis of 30 cases of Castleman disease with different types of thoracic involvement]

目的

总结不同类型胸部受累Castleman病（CD）的临床、影像学、病理及诊治特征，以提高临床医师对CD的认识。

方法

回顾性分析广州医科大学附属第一医院自2009年6月至2019年5月收治入院的胸部受累CD患者30例，将其分为闭塞性细支气管炎（BO）组、不伴BO的单中心型Castleman病（UCD）组及不伴BO的多中心型Castleman病（MCD）组，分析其临床资料并总结其特征。

结果

30例患者中，5例（16.7%）纳入BO组，18例（60.0%）纳入不伴BO的UCD组，7例（23.3%）纳入不伴BO的MCD组。不伴BO的MCD组中位年龄明显大于BO组[（49.29±5.39）岁对（27.20±3.76）岁，P=0.005]和不伴BO的UCD组[（49.29±5.39）岁对（37.17±2.87）岁，P=0.034]。胸部症状在BO组（100%）和不伴BO的MCD组（71.4%）多见，而不伴BO的UCD组无胸部症状。贫血及IgG增高仅在不伴BO的MCD组出现（发生率均为57.1%），红细胞沉降率增快及低氧血症在BO组（发生率分别为40.0%和60.0%）及不伴BO的MCD组（发生率分别为57.1%和28.6%）均可出现。BO组患者的肺功能均表现为极重度混合性通气功能障碍。胸部CT所示肺实质受累率：BO组为100%；不伴BO的MCD组为57.1%，表现为双肺弥漫性病变；不伴BO的UCD组为11.1%，表现为孤立性肺结节。不伴BO的MCD组的淋巴结短径明显小于BO组[（1.83±0.51）cm对（4.73±1.63）cm，P=0.006]和不伴BO的UCD组[（1.83±0.51）cm对（3.62±0.26）cm，P=0.011]。BO组病理类型均为透明血管型（100%），不伴BO的UCD组88.9%为透明血管型，而不伴BO的MCD组以浆细胞型为主（57.1%）。BO组患者均出现口腔溃疡，在肿物切除术后予免疫调节剂治疗，溃疡症状缓解，但肺部症状仍进行性加重。不伴BO的UCD组主要治疗方式为胸腔镜下肿物切除，不伴BO的MCD组主要治疗方式为化疗、免疫调节剂、靶向治疗等。

结论

三组患者的年龄、临床症状、实验室检查、肺功能、影像学表现、病理类型、治疗及预后均有所不同，此分类能促进临床医师对本病的认识。

Clinicopathological comparison and therapeutic approach to Castleman disease-a case-based review

Castleman disease (CD) is a rare, B-cell lymphoproliferative disorder affecting lymph nodes and extranodal anatomical locations. Four types of clinical presentations can be distinguished after exclusion of mimics. The first division is into unicentric CD (UCD) and multicentric CD (MCD). MCD is classified further as HHV-8-negative (idiopathic), MCD associated with HHV-8 infection, and POEMS associated MCD. From the histological standpoint, UCD and MCD can be classified as hyaline-vascular (HV), plasma cell (PC), or mixed cellularity (MC) type, with a spectrum of histopathological manifestations. We present clinical and histopathological features and grading of 25 cases of CD classified according to CDCN histological criteria and according to this clinical algorithm, along with outcomes. Here we provide a fine-resolution description of the histological features of CD. We review and discuss the current diagnostic algorithm, grading system, and recently recommended treatment options. In the presented group of 25 patients with CD there were 14 women and 11 men in the age range 15-79 years. UCD was identified in 15 patients and it was most often located in mediastinum. MCD most frequently occurred as generalized lymphadenopathy. The most common type of CD was HV. All patients with UCD underwent complete surgical resection with a positive outcome. Patients with MCD had diagnostic partial surgical excision of the lesions, later followed by different types of treatment (corticosteroids, chemotherapy, radiotherapy, immunomodulatory agents) or 'watch and wait'. In four cases CD was associated with other malignancies (laryngeal cancer, small lymphocytic lymphoma, gallbladder cancer with hepatic metastases, primary squamous cell lung cancer). The accuracy of histopathological examination is essential and re-evaluation has to be performed in case of relapse or unexpected course of CD. Treatment tailored to fit the disease type and severity should follow the novel recommendations, including anti-IL-6 treatment in the case of MCD.

Tumor enucleation for Castleman's disease in the pulmonary hilum: a case report

Background

The development of Castleman’s disease in the pulmonary hilum is extremely rare. Although resection of only the lesion is sufficient because of its benign nature, lobectomy or more extensive procedures performed for the pulmonary hilar tumor have been reported.

Case presentation

The patient was a 15-year-old male with a tumor in the right pulmonary hilum. Endobronchial ultrasound-guided transbronchial needle aspiration was performed but no specific findings were obtained from the cytological and histological evaluation. 18F-fluorodeoxyglucose positron emission tomography showed moderate accumulation in the tumor, which suggested potential malignancy. Intraoperative frozen section diagnosis did not show any malignant findings. Thus, we performed only tumor enucleation without any lung resection. The pathological diagnosis was hyaline vascular type Castleman’s disease. No recurrence has been observed for seven years.

Conclusion

Because hyaline vascular type Castleman’s disease in solitary pulmonary hilar tumor is one of the benign diseases common in young people, intraoperative frozen section diagnosis is recommended to avoid unnecessary lung resection.