[New TNM classification of malignant lung tumours]

The staging system for lung tumours is now recommended for the classification of both non-small-cell and small-cell lung cancer as well as for carcinoid tumours of the lung. The T classifications have been redefined: T1 has been subclassified as T1a (≤ 2 cm in size) and T1b (> 2-3 cm in size). T2 has been subclassified as T2a (> 3-5 cm in size) and T2b (> 5-7 cm in size). T2 (> 7 cm in size) has been reclassified as T3. Multiple tumour nodules in the same lobe have been reclassified from T4 to T3. Multiple tumour nodules in the same lung but a different lobe have been reclassified from M1 to T4. No changes have been made in the N classification. The M classification has been redefined: M1 has been subdivided into M1a and M1b. Malignant pleural and pericardial effusions have been reclassified from T4 to M1a. Separate tumour nodules in the contralateral lung have been reclassified from T4 to M1a. M1b designates distant metastasis.

Esophageal sarcoidosis presenting as pseudodiverticulum

Sarcoidosis is a multisystem granulomatous disorder that may involve many organs. However, the involvement of the gastrointestinal tract is very rare. This report describes an unusual case of esophageal sarcoidosis presenting as a pseudodiverticulum and reviews the world literature. Our case is also characterized by unusual progression of the esophageal involvement despite stable disease in other organs involved. Myotomy improved the pharyngoesophageal stenosis with no recurrence to date. Physicians should be aware of this rare manifestation, which should be suspected in any sarcoidosis patient complaining about dysphagia.

[Bronchoalveolar lavage]

Bronchoalveolar lavage (BAL) has become an established method for the diagnosis of infectious and interstitial lung diseases. Using a bronchoscope material from the peripheral airways and alveolar spaces can be obtained. When standard protocols are followed the procedure is generally well tolerated and in combination with clinical tests allows a reliable diagnosis in many cases. Certain clinical entities, e.g. alveolar proteinosis and Langerhans cell histiocytosis can be diagnosed by BAL alone without resorting to invasive diagnostic tests. In other diseases, BAL allows to narrow the range of the differential diagnosis. However, biopsies can often still not be avoided completely. A combination of both methods together with the clinical findings represents a powerful tool for diagnosis and research into the pathologic alterations in inflammatory and fibroising lung diseases.

[Fever and nonspecific pulmonary lesions--a rare differential diagnosis]

HISTORY AND ADMISSION FINDINGS

A 70-year-old woman presented with rapidly increasing weakness, night sweats, progressive dyspnea and daily fever up to 39 C. 30 years before early stage breast cancer had successfully been treated by resection.

INVESTIGATIONS

Blood tests revealed moderate normocytic anemia and a considerable elevation of the serum level of lactate dehydrogenase (LDH). The differential blood count was normal. Chest radiography showed interstitial infiltrates. Computed tomography revealed reticular shadows and ground-glass opacities which on histological examination were attributed to intravascular lymphoma (IVL) of B cell lineage.

TREATMENT AND COURSE

Treatment with eight cycles of the R-CHOP 14 regimen (rituximab, cyclophophamide, doxorubicine, vincristine, prednisone; interval: 14 days) resulted in complete remission with rapid resolution of constitutional symptoms. 7 months later the IVL relapsed, again with fever and an elevation of the LDH level. Bone marrow biopsy revealed intravascular infiltration by lymphoma cells. Salvage treatment with six courses of a methotrexate-containing protocol led to a second complete remission.

CONCLUSION

Nonspecific constitutional symptoms, a large variety of potential clinical presentations and the infrequency of the disease render the ante mortem diagnosis of an intravascular lymphoma difficult. Treatment follows the same principles as in nodal aggressive non-Hodgkin's lymphomas.