Primary pulmonary Hodgkin's disease

A Persistent Pulmonary Puzzle: Diagnosing Hodgkin Lymphoma in a Young Female With Chronic Respiratory Symptoms

Hodgkin lymphoma (HL), a lymphoid neoplasm characterized by the presence of Reed-Sternberg cells, often presents with painless lymphadenopathy and systemic symptoms. This case report details the diagnostic journey of a 27-year-old non-smoker female with chronic respiratory symptoms, including persistent cough, hemoptysis, and weight loss over two years. Despite multiple treatments for presumed infections and extensive diagnostic procedures, the correct diagnosis of HL was delayed due to atypical pulmonary manifestations, notably necrotizing pneumonia and multiple cavitary lung lesions. Ultimately, histopathology from a third bronchoscopy confirmed HL, highlighting the complexity of diagnosing HL with unusual presentations. Patients with cavitary lesions have a poor prognosis compared to others with typical pulmonary involvement, as cavitation in HL is likely caused by central ischemia necrosis due to the tumor's rapid growth. This case can be considered a primary pulmonary HL, a rare and hard-to-treat presentation since it does not respond well to radiotherapy. It emphasizes the challenge in diagnosing HL when it presents atypically, making it crucial to consider HL in differential diagnoses to avoid delayed diagnosis and improve patient outcomes.

Clinicopathological Characteristics of Primary Pulmonary Hodgkin Lymphoma (PPHL): Two Institutional Experiences with Comprehensive Literature Review of 115 PPHL Cases

Primary pulmonary Hodgkin lymphoma (PPHL) is an extremely rare condition. Its clinicopathological characteristics remain unclear because of the limited number of patients with PPHL. The aim of this study was to comprehensively analyze the clinicopathological characteristics of PPHL. We reviewed the electronic medical records and pathology slides of our 10 PPHL patients. The female-to-male ratio was 6:4, and the mean age was 41 years. Although three patients had no symptoms, seven had localized or generalized symptoms, including cough, sputum, chest discomfort/pain, and weight loss. Some cases had not been diagnosed as PPHL in the initial needle biopsy. Four patients underwent surgical resection. With chemotherapy, eight patients achieved complete remission. We also conducted a thorough literature review on 105 previously reported PPHL cases. Among a total of 115 PPHL cases, the most common subtype was nodular sclerosis (37.4%). More than half of the cases (55%) were clinically suspected as infectious pneumonia. Of 61 patients whose biopsies were available, 27 (44.3%) were diagnosed correctly as Hodgkin lymphoma, whereas the misdiagnoses included tuberculosis, Langerhans cell histiocytosis, solitary fibrous tumor, and adenocarcinoma. We demonstrated that PPHL represents a diagnostic challenge on small biopsies. Recognizing that this rare tumor can mimic infectious and inflammatory diseases as well as malignancies is important because the accurate diagnosis of PPHL is essential for adequate clinical management.

Diagnostic utility of transbronchial biopsy for Hodgkin's lymphoma: A case study

Lung lesions of Hodgkin's lymphoma (HL) are rare and difficult to diagnose by nonsurgical biopsy. We herein present the case of a 72-year-old Japanese male who presented with accumulation of lung infiltrates and masses bilaterally on the lungs for 3 years. Although transbronchial lung biopsy (TBB) and computed tomography-guided biopsy were conducted several times, his diagnosis remained inconclusive. On further deterioration of lung lesions, the patient was transferred to our hospital. Positron emission tomography revealed increased accumulation in the bilateral lungs and right supraclavicular lymph nodes. Surgical biopsy of the lymph node was performed. He was finally diagnosed with HL and underwent chemotherapy with doxorubicin, vinblastine, dacarbazine, and brentuximab vedotin. After chemotherapy, the lung lesion showed significant regression. A literature review indicated that the diagnostic success rate of TBB was low (18.5%) in cases of lung lesions in HL.

Nodular Sclerosing Hodgkin Lymphoma Combined with Disseminated Talaromyces marneffei Infection: A Case Report

Background

Talaromyces marneffei (TM) is the only temperature-biphasic pathogen among Penicillium spp. that causes talaromycosis marneffei (TSM). Clinical manifestations include fever, cough, expectoration, superficial and deep lymph node enlargement, hepatosplenomegaly, subcutaneous nodules, and bone and joint infections. Cases of TSM in Hodgkin lymphoma (HL) patients are uncommon. The clinical manifestations and imaging findings are similar in TSM and HL, which make it difficult for clinicians to distinguish between TSM and HL. Both diseases can present with symptoms, can involve the blood or the respiratory system and can include other symptoms. We report a rare case of HIV-negative nodular sclerosing Hodgkin lymphoma (NSHL) combined with T. marneffei infection to improve clinical knowledge.

Case Presentation

The patient was a 51-year-old man who presented with a 1-month history of cough, expectoration, intermittent fever in the afternoon and night, cervical lymph node enlargement, diabetes and previous lung surgery. He had markedly elevated serum inflammatory markers and moderate diffuse lung dysfunction. Chest computed tomography (CT) showed diffuse nodular lesions in both lungs with mediastinal lymph node enlargement. The patient did not respond to antibacterial and diagnostic antituberculosis therapy. After lymph node biopsy and lung culture, we obtained a definite diagnosis of NSLH with T. marneffei infection and administered antifungal therapy. His symptoms improved, and he was discharged for further treatment. Unfortunately, he died of Salmonella sepsis 7 months later.

Conclusion

It is rare for NSLH patients to be infected with T. marneffei. Both diseases can present with fever, lymphadenopathy, and hepatosplenomegaly and involve the blood and respiratory system or can cause other symptoms. Clinically, a misdiagnosis or missed diagnosis may occur. A multisite biopsy or culture should be performed to make a definitive diagnosis. Early antifungal therapy combined with standard chemotherapy can achieve satisfactory clinical efficacy.

A decade's experience of pediatric lung abscess and empyema at a community hospital

BACKGROUND

Discussions on the diagnostic and management of acquired pediatric lung pathology are usually published by large tertiary children's hospitals. It is likely that much of this pathology is actually seen and managed in nonacademic practices.

METHODS

A 10-year retrospective review of patients under 18-years of age, treated for lung abscesses or empyema was performed.

RESULTS

Nineteen empyema and four lung abscesses were included. Presenting symptoms, workup, and management are reviewed. A unique subset (n = 4) of atypical pulmonary pathology is described. A 14-year-old with a vaping history and a lung abscess misdiagnosed as an empyema. A 15-year-old with primary pulmonary Hodgkin's lymphoma presenting as a lung abscess and empyema. A 5-year-old with an empyema complicated by a bronchopleural fistula and a 21-year-old with autism and an acquired lung cyst.

CONCLUSION

Our dilemmas, experiences, and strategies in managing complex lung disease are generalized to community-based practice.

Primary pulmonary Hodgkin's lymphoma with pulmonary histoplasmosis

Primary pulmonary Hodgkins lymphoma is a rare and enigmatic neoplasm commonly seen in females. The aim of this case report is to emphasize that pulmonary lymphoma should be considered as a differential diagnosis in a young patient presenting with a lung mass and B symptoms. Extensive clinical details, imaging should be done to rule out the secondary involvement of lung by other lymphomas.

Computed tomography patterns of pulmonary and pleural involvement in lymphoma

Background

Pulmonary and pleural involvement is fairly common in patients with lymphoma, especially in the setting of progressive or recurrent disease. Pleuropulmonary involvement in lymphoma may occur as a single pattern or as a combination of multiple patterns which can often mimic unrelated pathologies.

Methods

Review of our institutional database from 01 Jan 2015 to 04 Oct 2017 revealed 90 patients with pulmonary and/or pleural lesions attributable to lymphoma. These lesions were classified into various categories, and the pattern of involvement was evaluated.

Results

Pulmonary involvement was seen in 17.6% of patients with Hodgkin lymphoma (HL) and in 10.5% of patients with non-Hodgkin lymphoma (NHL), whereas pleural involvement was seen in 6.5% of patients with NHL. Almost all the patients in our study had findings belonging to multiple categories. Pulmonary involvement in patients with HL was seen in the form of nodules (51.6%), masses (51.6%), and direct extension from a mediastinal/hilar mass (45.2%). Patients with NHL had pulmonary involvement in the form of nodules (42.4%), direct extension from a mediastinal/hilar mass (25.4%), pulmonary masses (18.6%), and interstitial pattern (2.4%). Pleural thickening (61.5%), masses (30.8%), and effusion (15.4%) were the three patterns of pleural involvement.

Conclusion

Nodules and masses were the two commonest patterns of pulmonary involvement in patients with HL, whereas nodules were the commonest pattern noted in patients with NHL. Pulmonary masses were seen more commonly in patients with HL than in those with NHL. Pleural involvement was seen exclusively in patients with NHL.

[Lung involvement in hematologic systemic diseases]

Pulmonary diseases can occur across the entire disease spectrum of malignant hematologic systemic diseases. Although infectious processes of the lungs are common in these immunosuppressed patient collectives, noninfectious causes account for up to half of the pulmonary manifestations found in hematologic malignancies. Besides the frequent infections including opportunistic pathogens, a broad differential diagnosis including drug-induced lung injury by cytostatic substances, cytokines, and innovative immunotherapeutic agents, rarer transfusion of blood products and intrathoracic manifestations of the hematologic malignancy itself, have to be kept in mind. Finally, vascular complications can also lead to pulmonary reactions. Early and consistent diagnostics and treatment of the bronchopulmonary, intrathoracic and vascular complications within the framwework of hematologic systemic diseases can be essential for the patient's prognosis.

Unusual case of primary pulmonary Hodgkin's lymphoma presenting with a continuous murmur

Systemic to pulmonary fistulas are an unusual entity, even more so in association with Hodgkin's lymphoma. We herein report a case of a 33-year-old woman that presented with an incidental lung lesion on a chest radiograph with an associated high-frequency continuous murmur over the lesion. The diagnosis of primary pulmonary Hodgkin's lymphoma, nodular sclerosis type, was obtained by a CT transthoracic biopsy. We achieved an excellent response after polychemotherapy with near-complete disappearance of the mass and a residual faint systolic murmur over the lesion.

Primary pulmonary lymphoproliferative neoplasms

Pulmonary lymphoproliferative neoplasms are rare lung tumors and account for <1% of all lung tumors. Among them, primary pulmonary lymphomas (PPL) constitute the majority, which include Non-Hodgkin's lymphoma (NHL) that comprise of mucosa-associated lymphoid tissue lymphoma, diffuse large B-cell lymphomas and other rare types of NHL and lymphomatoid granulomatosis. HL, which arises secondary to contiguous spread from the mediastinum, is the rarest type of PPL. Other entities described within the umbrella of pulmonary lymphoproliferative neoplasms include pleural lymphomas and posttransplant lymphoproliferative disorders (PTLD) - which occurs in the poststem cell and organ transplant patients. These neoplasms although rare, have a favorable prognosis, which does not depend on disease resectability. Moreover, with its nonspecific presentation, diagnosis is challenging, which often leads to delayed diagnosis or misdiagnosis in many cases. Therefore, knowledge of this entity is important for the practicing pulmonologist. This review article aims to describe the clinical presentation, diagnosis and management of primarily the entities within PPL, as well as pleural lymphomas and PTLD.

Multiloculated Cavitary Primary Pulmonary Hodgkin Lymphoma: Case Series

Primary pulmonary Hodgkin lymphoma (PPHL) is very rare and typically involves the superior portion of the lung. Pulmonary involvement is observed in 15-40% of Hodgkin lymphoma patients. Three such patients who presented with an unusual form of PPHL in radiological studies, i.e., multiloculated cavitary lesions, were admitted to our hospital. These lesions represent a new pathological and radiological feature of PPHL.

A Diagnostic Surprise: Primary Hodgkin's Lymphoma of the Lung

An 81-year-old male presented to the emergency room with a 3-month history of progressive shortness of breath, productive cough with white sputum, and generalized weakness with 10-pound weight loss in 2 months. On presentation, the patient was afebrile, with blood pressure of 93/55 mm Hg and oxy-hemoglobin saturation of 92% on 2 liters of oxygen via nasal cannula. Complete blood count with differential was significant for white count of 12 400/mL. Brain natriuretic peptide level was 454 ng/mL. Postero-anterior chest radiograph showed multiple round opacities in the lung fields. Computed tomography scan of the chest confirmed multiple round densities in both the lung fields along with mild mediastinal lymphadenopathy. Core needle biopsy was performed. Immunohistochemical stains were positive for CD30 and CD15 in a population of large atypical cells amid a background of CD3-positive nonneoplastic cells. These results were in support of the diagnosis of classical Hodgkin’s lymphoma of the lung with histological appearance confirming nodular sclerosis type. The patient was started on chemotherapy but was readmitted in 20 days for acute respiratory distress and suffered cardiac arrest and subsequently died. This case highlights the fact that although primary pulmonary Hodgkin’s lymphoma of the lung is a rare entity, it should be thought of as a differential while evaluating lung masses. In these cases, definite diagnosis can only be made by biopsy and histology. Early commencement of chemotherapy and regular follow-up with oncology is essential.

Primary Pulmonary Hodgkin's Lymphoma: A Rare Etiology of a Cavitary Lung Mass

Primary pulmonary Hodgkin's lymphoma (PPHL) is an uncommon disease. This entity is different from Hodgkin's lymphoma with parenchymal or nodal lung involvement. In this report, we highlight the case of a young female presenting with a six-month history of a productive cough and constitutional B symptoms. Imaging showed cavitary lesions in the right-upper and right-middle lobes. The initial comprehensive infectious workup was negative. Histopathology and immunochemistry confirmed the diagnosis of PPHL. PPHL is an uncommon etiology of cavitary lung lesions. Despite its diagnostic difficulties, awareness of such a disease is crucial, given its high rate of response to treatment, especially in the young population.

Advanced Lymphocyte-rich Classical Hodgkin Lymphoma Complicated with Fatal Hemophagocytic Syndrome

Lymphocyte-rich classical Hodgkin lymphoma (LRCHL) is a rare subtype of Hodgkin lymphoma with a favorable prognosis, and an aggressive clinical course of LRCHL is uncommon. A 55-year-old man suffering from swelling in the left neck was diagnosed with LRCHL with extranodal lesions in the lung and bone marrow. Initially, he received standard ABVD chemotherapy; however, disease progression, accompanied by hemophagocytic syndrome (HPS), occurred during the second course of ABVD. He received two subsequent courses of intensive chemotherapy containing high-dose steroids, cyclophosphamide, and etoposide. Nevertheless, this therapy was only temporarily effective, and he died of due to an aggressive disease progression accompanied by uncontrollable HPS and severe coagulopathy.

Primary pulmonary lymphoma mimicking a refractory lung abscess: A case report

The current study presents a case of primary pulmonary lymphoma (PPL) mimicking refractory lung abscess that was diagnosed at autopsy. An 80-year-old male with clinically inapparent aspiration presented with a large cavitated mass and pleural effusion. A lung abscess and empyema was diagnosed, therefore, antibiotics were administered and the pleural effusion was drained. Various examinations, including a biopsy, yielded no specific diagnosis. The lesion was considered inoperable due to the poor general condition of the patient. Subsequently, the mass that had been diagnosed as a refractory lung abscess became enlarged and a repeat biopsy resulted in a diagnosis of diffuse large B-cell lymphoma. The patient succumbed to sudden respiratory failure, and the final diagnosis of PPL was confirmed at autopsy. PPL is a rare disease that accounts for 0.45% of all pulmonary malignant tumors and is difficult to diagnose in inoperable cases. Therefore, patients with PPL who do not undergo surgery can be misdiagnosed and consequently treated inappropriately. PPL should therefore be considered in the differential diagnosis of a refractory lung abscess.

Diagnosis of primary pulmonary T- cell/histiocyte-rich large B cell lymphoma with tissue eosinophilia via clinicopathological observation and molecular assay

Background

Primary pulmonary lymphoma (PPL) is rare and easily misdiagnosed because of the lack of typical clinical features. It most commonly involves elderly patients aged between 60 and 70 years, and pathological diagnosis depends mainly on chest surgery rather than bronchial mucosal biopsy. Via percutaneous needle aspiration biopsy of the lung of a 33-year-old woman, which had distinct tissue eosinophilia, we diagnosed a rare case of rapidly growing large B cell lymphoma.

Methods

Bronchial mucosal biopsy and computed tomography–guided percutaneous needle aspiration biopsy were performed to determine the nature of the lesion, and we identified its immunophenotype using immunohistochemistry. We used BIOMED-2 gene rearrangement PCR to determine lymphocyte clonality; laser microdissection was used to confirm the clonality of suspicious malignant lymphocytes.

Results

Morphologically, the lesion was composed of a large number of eosinophilic cells and a few lymphoid cells. Immunohistochemical staining revealed a few CD1α-positive cells, but they were S-100–negative. The small lymphoid cells predominantly expressed CD3; the large lymphoid cells expressed CD20 and some scattered large lymphoid cells expressed Pax5. However, molecular studies confirmed clonal immunoglobulin heavy chain (IGH)-D gene rearrangement in Pax5–positive large B lymphocytes.

Conclusions

This is the first recorded case of T- cell/histiocyte-rich large B cell lymphoma with tissue eosinophilia of the lung. It highlights the unusual morphological features of PPL that might be mistaken for eosinophilic granuloma or parasitic infection. In addition, IGH and T cell receptor gene rearrangement play important roles in differentiating rare B cell lymphoma from lung space–occupying lesions with abundant eosinophils or T cell infiltration.

Virtual Slides

The virtual slide(s) for this article can be found here: http://med.motic.com/MoticGallery/Slides/AC5C9A6F-46EC-4C71-A448-1312F6900C65?user=2C69F0D6-A478-4A2B-ABF0-BB36763E8025

Primary pulmonary classical Hodgkin lymphoma: a case report

Primary pulmonary Hodgkin lymphoma (PPHL) is a rare entity. Most reported cases occurred before the availability of PET scan for accurate staging of the disease. We report a case of PPHL for which PET/CT scan was used and surgery was performed to confirm the diagnosis. A review of cases of PPHL since 1990 suggests that adjuvant chemotherapy and/or radiation therapy after surgical resection of the lung lesions achieve better disease control than surgical resection alone.

Primary pulmonary Hodgkin's lymphoma and a review of the literature since 2006

A 28-year-old woman of Laotian origin presented with dry cough, fevers, night sweats and weight loss over the preceding 6 weeks. Radiological investigations revealed large complex cavitary lesions in the middle and lower lobes of the right lung, with no mediastinal lymph node enlargement. Bronchoscopic investigations did not yield a diagnosis. CT-guided fine-needle aspiration raised the possibility of Langerhans cell histiocytosis. Open lung biopsy initially supported this, but eventually a microscopic and immunohistochemical diagnosis of Hodgkin's lymphoma was made. The final diagnosis was primary pulmonary Hodgkin's lymphoma. We present a new case as well as a literature review of reported cases published since 2006.

Giant thoracic mass: an unusual presentation of primary pulmonary Hodgkin's lymphoma

Primary pulmonary Hodgkin's lymphoma (PPHL) is rare. PPHL without peripheral lymphadenopathy or hepatosplenomegaly is exceptionally uncommon. We present a 61-year-old woman believed to have a solitary intrapulmonary fibrous tumour on a CT and a CT-guided biopsy, until surgical excision. Histopathology and immunohistochemistry of the excised mass confirmed PPHL. PPHL is a very rare differential diagnosis of large solitary intrapulmonary masses. A CT-guided biopsy is recommended, as it can be diagnostic, reserving excision for cases where the diagnosis remains in doubt.

Lymphoproliferative neoplasms of the lung: a review

CONTEXT

Diagnosis and classification of lymphomas are based on the morphologic, immunologic, and genetic features that the lesional cells share with their normal B and T lymphocyte counterparts. Primary pulmonary lymphomas account for 0.3% of primary lung neoplasms and less than 0.5% of all lymphomas.

OBJECTIVE

To describe and summarize the clinical and histopathologic features of the primary pulmonary lymphoma and secondary involvement of the lung by lymphoma.

DATA SOURCES

Peer-reviewed published literature and personal experience.

CONCLUSIONS

Diagnosis of clonal lymphoid proliferations in the lung has evolved owing to the greater utility of molecular and flow cytometric analysis of tissue. Further studies are needed to best define the clinical and prognostic features, as well as search for targeted therapy for these patients with rare neoplasms.

[Diagnostic difficulties caused by a pulmonary infiltrate]

Lung infiltration still causes differential diagnostic difficulties, which may delay the start of definitive treatment.

CASE REPORT

The examination of a 30-year-old man began due intermittent, remittent and permanent fever. Chest X-ray confirmed infiltration in the right upper lobe, which was accompanied by elevated CRP and physiological levels of procalcitonin. Most likely atypical pneumonia, tuberculosis, Wegener's granulomatosis or a malignant process was suspected. Throughout his examination infection could not be verified, repeated CT guided transthoracic needle biopsy suggested the possibility of a malignant process. Through surgical exploration the intraoperative histology was not informative; thus, the pneumonitis-remodelled right lung was removed due to the possibility of malignant transformation. Histological examination revealed lymphocyte rich classical Hodgkin lymphoma, which was found to be stage IV/B based on the 18FDG-PET/CT scan; therefore, eight cycles of ABVD (adriablastin, bleomycin, vinblastine, and dacarbazine) therapy was administered successfully. The patient is currently (for 30 months) in a complete metabolic remission.

CONCLUSION

Primary pulmonary Hodgkin lymphoma is a rare disease entity (in this case it might be the original process), in which the diagnosis is often difficult. 18FDG-PET/CT may be a useful early diagnostic tool investigating fever of unknown origin.

Primary pulmonary Hodgkin's lymphoma

A 21-year-old man presented to hospital with a two-month history of productive cough with no other symptoms. Radiology revealed a cavitating lesion in the left upper lobe for which a variety of diagnoses were considered. A biopsy revealed primary pulmonary Hodgkin's lymphoma. Primary pulmonary Hodgkin's lymphoma is an uncommon initial presentation; lung lesions usually occur later in the course of the disease. Following diagnosis, the patient began chemotherapy and full remission was achieved.

Primary pulmonary classical hodgkin lymphoma with two recurrences in the mediastinum : a case report

We report a case of primary pulmonary classical Hodgkin lymphoma (CHL) in a 58-year-old woman. Twelve years ago, the patient complained of slight fever and weight loss. A mass of about 5 cm in diameter was seen in the right lung on radiography and computed tomography (CT). Right total pneumonectomy and resection of mediastinal lymph nodes were performed. A pathological examination led to a strong suspicion of Hodgkin disease (HD) (now referred to as CHL), but a definite diagnosis could not be made at the time. Six years later, a chest CT showed a tumor around the ascending aorta, which was treated successfully by radiation therapy. Six years later, the chest CT revealed a tumor in the anterior mediastinum. CHL was diagnosed based on an immunohistochemical re-examination of lung specimens resected 12 years earlier and CT-guided fine needle tumor biopsy specimens of the second recurrent tumor in the anterior mediastinum were compatible with the recurrence of CHL. Therefore, we diagnosed this case as primary pulmonary CHL that later relapsed in the mediastinum. The tumor size was reduced by radiation therapy and the patient is currently under observation as an outpatient.

Cross-sectional evaluation of thoracic lymphoma

Thoracic lymphomas most frequently involve mediastinal lymph nodes in the anterior mediastinum and paratracheal areas. The lymphomas may also involve lung, thymus, pleura, pericardium, chest wall, and the breast and their radiologic manifestations are diverse. Lymphomas (mostly BALT lymphoma and large B-cell lymphoma) may arise primarily from the lung with various imaging features including single or multiple nodule(s) and area(s) of consolidation. CT is currently the most important imaging modality for the evaluation of thoracic lymphoma but FDG PET also plays a crucial role in the clinical management of these cases.

Diffuse cavitary lung lesions

An 11-year-old girl presented with a 2-month history of progressively worsening cough, daily fevers, and weight loss. A chest radiograph revealed multiple cystic cavitary lung lesions. An extensive infectious work-up was negative. Chest CT verified multiple cavitary lung lesions bilaterally, and [F-18]2-fluoro-2-deoxy-D-glucose ((18)F-FDG) positron emission tomography with CT (PET/CT) showed increased uptake in the lung lesions as well as regional lymph nodes. Subsequent biopsy of an involved lymph node confirmed classical Hodgkin lymphoma, nodular sclerosis type. This case represents an unusual presentation for a child with Hodgkin lymphoma and demonstrates a role for (18)F-FDG PET/CT in evaluating a child with cavitary lung lesions.

Primary endobronchial Hodgkin's disease

We report a case of primary pulmonary Hodgkin's disease presenting as an endobronchial mass. Tissue diagnosis was made by microscopic examination following open thoracotomy and excision biopsy of the mass. The patient responded well to the chemotherapy regimen.

Hodgkin lymphoma presenting as multiple cavitary pulmonary nodules with associated mediastinal adenopathy and neck mass

Hodgkin lymphoma involving the lung may present in a variety of radiographic and clinical patterns including solid or necrotizing lesions, with or without associated mediastinal adenopathy. Cavitary pulmonary lesions are exceedingly rare, occurring in less than 1% of cases, and are typically solitary. We report a case of an 18-year-old male presenting with multiple cavitating pulmonary nodules and a palpable mass in the neck. Imaging revealed associated mediastinal and cervical adenopathy. Biopsy of the neck mass and lung nodule initially revealed necrosis and granulomata, suggesting infection. Treatment for a presumed infectious etiology was without resolution. Subsequent open lung biopsy revealed marked granulomatous inflammation with diagnostic Reed-Sternberg cells. Hodgkin lymphoma should always be considered in the differential diagnosis of cavitary pulmonary lesions, especially those refractory to treatment.

Contribution of the 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography to the diagnosis of primary osseous Hodgkin lymphoma

Hodgkin lymphoma typically presents as a nodal lesion and infrequently involves extra nodal sites. Although cases of primary extra-nodal Hodgkin lymphoma have been reported previously, the reality of the primitive nature of the disease was difficult to authenticate with traditional high resolution imaging techniques, such as computed tomography or magnetic resonance imaging, because they cannot evaluate the spread of the disease throughout the whole body. We report here a case of primary osseous Hodgkin lymphoma, regarded as stage I extranodal IE thanks to the important contribution of a new imaging technique, the 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography/ computed tomography (18F-FDG-PET/CT). PET enables systemic Hodgkin lymphoma with secondary bone invasion to be distinguished from primitive osseous Hodgkin lymphoma. This technique is highly specific in demonstrating the isolated osseous localisation of the tumour and should be recommended in all patients with putative osseous lymphoma.

Primary pulmonary Hodgkin's lymphoma: a rare pitfall in transthoracic fine needle aspiration cytology

Primary pulmonary Hodgkin's lymphoma (PPHL) is extremely rare. At an extranodal location such as the lung this lymphoma is likely to be confused with the more commonly occurring carcinomas at this site. We report the fine needle aspiration cytology (FNAC) findings of a PPHL in a 36-year-old male with a view to discuss the pitfalls and clues to the accurate cytologic diagnosis. This patient presented with a large, heterogeneously enhancing mass involving the anterior segment of right upper lobe without any evidence of nodal involvement. A CT-guided transthoracic FNAC of this mass revealed large connective tissue fragments with entrapped voluminous cells amidst a polymorphous population of eosinophils, polymorphs, and lymphocytes. The large cells showed abundant often stripped off cytoplasm, an irregular nucleus with nucleolus and were initially diagnosed as non-small cell carcinoma of the lung. In view of the locally advanced stage, patient received a carboplatin and gemcite-based chemotherapy with complete response but postchemotherapy patient refused local surgery. Two years later, the patient developed enlarged nodes which were diagnosed as Hodgkin's lymphoma, and a review of prior lung tumor confirmed the diagnosis of PPHL. Hence the rare diagnosis of PPHL should be kept in mind when a cytopathologist observes large cells embedded in collagenous tissue fragments with dominant cell dispersal amidst an inflammatory infiltrate in an aspirate from a primary lung tumor.

Cross-sectional evaluation of thoracic lymphoma

In patients who have lymphoma, the presence and distribution of thoracic involvement is important in both tumor staging and treatment. Thoracic involvement in Hodgkin lymphoma (HL) is more common than in non-Hodgkin lymphoma (NHL). In HL, mediastinal lymphadenopathy with contiguous spread is a hallmark, and lung parenchymal involvement at the initial presentation is almost always associated with mediastinal lymphadenopathy. NHL is more heterogeneous and generally presents at a more advanced stage than HL. Most often, mediastinal involvement occurs as a disseminated or recurrent form of extrathoracic lymphoma. Bulky mediastinal disease with compression of adjacent structures can occur, particularly with high-grade subtypes of NHL and isolated lung disease without mediastinal lymphadenopathy can occur in contrast to HL.

Pulmonary lymphoma identified as a result of low-dose CT screening for lung cancer

PURPOSE

To describe the frequency and findings of pulmonary lymphoma in asymptomatic people undergoing computed tomographic (CT) screening for lung cancer.

METHODS

All lymphoma diagnoses resulting from CT screening of 31 567 at-risk subjects (median age, 61 years) were identified, and the CT images were reviewed to document the lesions as to number, location, density, shape, and margin. The presence of lymphadenopathy and pleural effusion was also documented.

RESULTS

Five patients with pulmonary lymphoma were identified. The lymphoma was a B-cell lymphoma in three, Hodgkin's lymphoma in one, and malignant lymphoma in one; it was primary in four and secondary in one. One patient had two lesions; the other four patients each had one lesion. Four of the six lesions were a mass, and two were a nodule. Four of the lesions had irregular margins. Air bronchograms were seen in three. Growth assessment was useful in leading to decisions for biopsy.

CONCLUSION

In a context of CT screening to detect lung cancer in asymptomatic volunteers, the diagnosis of pulmonary lymphoma was rare but, nevertheless, occurred in five (.016%) of 31 567 volunteers.

Hodgkin lymphoma presenting with exclusive or preponderant pulmonary involvement: a clinicopathologic study of 5 new cases

A review of the pathological features of Hodgkin lymphoma manifesting with exclusive or preponderant lung involvement is given for 5 patients. Three patients were men and 2 were women, with an age range 17 to 48 years (median, 42 years). They presented with nonspecific symptoms including dry cough, fever, or chest pain. Initial clinical assessment suggested a lung tumor. Pathological evaluation was carried out on lung biopsy, wedge resection, lobectomy, or pneumonectomy specimens. All the cases showed diagnostic Reed Sternberg cells within the proper background. Immunopositivity for CD15 and CD30 was documented as well. Nodular sclerosing and mixed cellularity were the documented subtypes. Additional histologic features were a pronounced nodular growth pattern with or without necrosis, a diffuse hypersensitivity pneumonia-like picture, or acute pneumonia-like changes. Our study confirms that the recognition of Hodgkin lymphoma in lung, although based on well-established morphologic criteria, may represent a source of interpretative problems because of the unusual clinical presentation as well as the peculiar histologic changes induced within the pulmonary microenvironment.

Primary pulmonary Hodgkin's disease and tuberculosis in an 11-year-old boy: case report and review of the literature

Tuberculosis (TB) has been described in association with different malignancies including Hodgkin's disease. However, the association with primary pulmonary Hodgkin's disease (PPHD) is hardly reported in literature and in teenage is quite exceptional. We report a case of an 11 years old boy in whom the diagnosis of tuberculosis preceded and delayed the diagnosis of PPHL.

Malignant and benign lymphoid lesions of the lung

Lymphoid lesions of the lung produce a complex of problems for the practicing pathologist. Although these lesions are eventually referred to hematopathologists, it is still the general surgical pathologist who first encounters them and confronts the problem of formulating an initial diagnosis. Over the last 20 years there has been a revolution in our knowledge of the classification and natural history of the pulmonary lesions, a plethora of information which warrants a thorough review. The purpose of this discussion is to report the clinical features and courses, pathologic features and, when known, etiologies or pathogenesis of the major "primary" pulmonary lymphoid lesions and present a brief approach to differential diagnosis. I will divide the lesions into malignant and benign, discussing each in turn.

[Radiological diagnostics of Hodgkin- and non-Hodgkin lymphomas of the thorax]

Malignant lymphomas belong to the most important malignant diseases in western countries with an increasing incidence of Non-Hodgkin lymphoma. The thorax is the location of primary manifestation especially in patients with Hodgkin's disease. Progression of disease and therapy associated complications are frequently located in the chest. Based on morphological imaging criteria the two types of lymphoma cannot be differentiated, helpful for differentiation is, however, the way of disease spread. Primary and secondary thoracic lymphoma represent a diagnostic challenge in radiology: the patterns are variable in radiography as well as in computed tomography and alter under therapy. Radiological studies, especially CT, are an integral part of the staging process. MRI is considered advantageous for chest wall disease. PET as functional imaging technique has its proven role for staging of high grade lymphomas, the combination of functional and morphological information provided by PET-CT will become the first diagnostic standard in the future.

Multiple cavitating pulmonary nodules and clubbing in a 12-year-old girl

We report on a 12-year-old girl with a prolonged history of cough and hemoptysis on three occasions. X-ray and computed tomography of the chest showed several cavitating lesions and mediastinal lymphadenopathy. Lung biopsy revealed nodular sclerosing Hodgkin's disease. Hodgkin's disease should be considered in the differential diagnosis of cavitating pulmonary lesions.

The solitary pulmonary nodule: a primer on differential diagnosis

Despite significant advances in noninvasive imaging techniques, management of the solitary pulmonary nodule (SPN) remains a challenge for chest physicians. Patients with SPNs are frequently asymptomatic, and the physical examination is seldom revealing. Accurate diagnosis is essential, because >50% of patients will require prompt disease-specific therapy. The complexity of the problem is best appreciated by reviewing the differential list, which includes nearly 80 distinct clinical entities. Consequently, a thorough understanding of the more common etiologies is necessary to adequately treat patients with SPNs.

Recurrent flu-like illness with migrating pulmonary infiltrates of unknown aetiology

Migrating pulmonary infiltrates present a difficult diagnostic and therapeutic challenge. We report on eight patients (mean age 51 years, range 32-78 years, with a prolonged history of migrating pulmonary infiltrates of unknown aetiology despite a very elaborate search for infectious causes, hypersensitivity pneumonitis or inhalation fever due to occupational or domestic exposure to fungi, or to other environmental causes, and for humoral or cellular immunological incompetence. These patients (one male, seven females) presented with recurrent episodes (mean 6, range 2-13) of a flu-like illness, often with cough, wheezing and pleuritic chest pain, but without systemic involvement. Previous medical histories were unremarkable. There was no relation with smoking habits, occupation, drug use or other possible exposures. Biochemical data were non-specific. There was no peripheral nor pulmonary eosinophilia; total IgE was normal, with negative RASTs and precipitins to a variety of antigens. Cultures and serological tests for bacteria, viruses, fungi, etc were non-contributory. Chest X-ray and computed tomography (CT) scan showed bilateral migratory pulmonary infiltrates, with a predilection for the middle and lower lung zones, often with a minor-to-moderate pleural effusion. Lung function tests were usually normal; at the most a slight decrease in diffusing capacity was noted in some patients. There was no or only a slight response to antimicrobials; systemic corticosteroids were not given. Further evolution was benign with patients being asymptomatic between the episodes. Despite elaborate investigations, the cause of these 'pneumonias' remains frustratingly unknown.

Extranodal Hodgkin disease: spectrum of disease

Extranodal lesions in Hodgkin disease may develop and spread to virtually any organ system, simulating other neoplastic or infectious diseases. It is important to determine whether extranodal involvement represents a primary manifestation or dissemination of systemic disease, which has a poorer prognosis. Computed tomography (CT) is the preferred modality, although ultrasonography and magnetic resonance (MR) imaging may also be helpful. CT is superior to conventional radiography in assessing chest disease, although MR imaging is more sensitive than CT in detecting chest wall involvement. CT is preferred for evaluating hepatic lymphoma and has proved particularly valuable in diagnosing gastric lymphoma and detecting renal or perirenal masses. CT and MR imaging are equally effective in detecting brain Hodgkin disease; however, the latter is superior in the detection of extracerebral tumor deposits in the subdural or epidural space. MR imaging is also preferred for evaluating meningeal and spinal cord involvement. Both MR imaging and CT allow excellent assessment of bone texture and accurate analysis of tumoral bone invasion, but MR imaging is superior in demonstrating bone marrow infiltration, and CT is superior in delineating the extent of cortical bone destruction. In the future, metabolic positron emission tomography may provide more information about extranodal lymphoma than do the current imaging modalities.

Primary anaplastic large cell lymphoma of the lung: a clinicopathologic study of five patients

Primary anaplastic large-cell lymphoma is a rare malignancy in the lung. Anaplastic large-cell lymphoma characteristically involves the lymph nodes or skin, with few reports from other sites. We studied the clinical and pathologic features of five cases of anaplastic large-cell lymphoma limited to the lungs. The patients were three women and two men aged 27 to 66 years (mean, 44.6 y) The tumors ranged in size from 1.1 to 5 cm. All patients were CD 30 (Ki-1) positive and CD 15 (LeuM-1) negative. Epithelial membrane antigen immunoreactivity was seen in two patients. Epstein-Barr virus was not detected by immunohistochemistry (four patients tested) or by polymerase chain reaction studies (three patients tested). The immunophenotypes were T cell (n = 3) and null (n = 2). Gene rearrangement studies supported the immunophenotypic findings. One patient who had underlying HIV infection died of infectious complications. One patient died at 6 months. Two patients developed recurrent disease and are alive after 42 and 51 months of follow-up. The remaining patient is alive at 8 years of follow-up without evidence of disease. ALCL can mimic metastatic or primary carcinoma and should be considered in the differential diagnosis of large cell neoplasms of the lung.