B-cell lymphoma of bronchus-associated lymphoid tissue (BALT): CT features in 10 patients

A Case of Pulmonary MALToma Camouflaged Within Invasive Pulmonary Aspergillosis

A 59-year-old non-smoking male, with a known case of COPD (chronic obstructive pulmonary disease), treated pulmonary tuberculosis with Category 1 antitubercular drugs (six-month regimen) and was admitted with repeated bouts of moderate haemoptysis (~60 mL/day) for three days. The patient had a history of self-limiting occasional mild haemoptysis (~20 mL) over three years. An HRCT chest revealed a left upper lobe fibro-cavitary lesion with an intracavitary mass (air crescent sign), adjacent pleural thickening and fibrosis. Bronchoalveolar lavage (BAL) was positive for galactomannan and negative for Mycobacterium tuberculosis GeneXpert®. With the above clinical factors, host factors, and microbiological factors, the case was diagnosed as 'probable' invasive pulmonary aspergillosis and was treated with voriconazole. However, given relapsing haemoptysis despite adequate antifungal treatment, a left upper lobectomy was done. The resected left upper lobe specimen culture demonstrated Aspergillus fumigatus with histopathology confirming hyphae invading lung tissues confirming 'proven' invasive aspergillosis. Resected tissue also showed florid lymphoid tissue hyperplasia with Immunohistochemistry confirming the presence of a peculiar malignancy; MALT lymphoma/MALToma in the resected lobe. The association of a rare malignancy such as MALToma with invasive pulmonary aspergilloma (IPA) has been identified and reported for the first time. This could be because of a chronic inflammatory reaction elicited by the Aspergillus antigen. Long-standing fibro-cavitary disease and aspergillosis are partners in crime, augmenting the damages inflicted by one another. In such a scenario, early surgical intervention may be warranted if haemoptysis is moderate to severe or relapsing, following conservative medical management. Surgical resection may lead to the identification of unexpected diseases as in our case.

Pulmonary mucosa-associated lymphoid tissue lymphoma forming a reversed halo sign from ground-glass opacity

The reversed halo sign (RHS) has been associated with various pulmonary diseases. We report a rare case of pulmonary mucosa-associated lymphoid tissue lymphoma forming a RHS from a ground-glass opacity (GGO). A 73-year-old man was followed-up for the GGO on his computed tomography images, which gradually extended peripherally. During the fourth year of follow-up, the GGO significantly evolved into a well-demarcated, oval lesion, with interlobular and intralobular septal thickenings, and multiple air spaces were surrounded by a well-defined thin consolidative rim, called the RHS. A pathologic study of the specimen via transbronchoscopic biopsy revealed pulmonary mucosa-associated lymphoid tissue lymphoma.

Clinical Features and Survival Outcome of Early-Stage Primary Pulmonary MALT Lymphoma After Surgical Treatment

Background: We aimed to study the clinical features and survival outcomes of patients with early-stage primary pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma who underwent surgery.

Methods: This is a retrospective, single-center study including 32 patients with early-stage primary pulmonary MALT lymphoma. Univariate and multivariate Cox analyses were performed to select independent prognostic factors. The overall survival (OS) was analyzed by the Kaplan-Meier method and was compared with the log-rank test.

Results: Among the 32 patients included, there were 16 men (50.0%) and 16 women (50.0%). The average age was 59.2 years old. Ten patients had non-specific clinical symptoms including cough, expectoration, and chest pain, and four patients had B symptoms. CT images are not specific and can be shown as peripheral, central, solid, and ground glass but more peripheral (93.8%) and solid (75.0%). In prognostic analysis, univariate analysis showed that tumor stage and size were associated with relapse-free survival (RFS) and OS [hazard ratio (HR) = 1.105, 95% CI: 1.021–1.197, P = 0.011; HR = 1.211, 95% CI: 1.158–1.968, P = 0.003, respectively]. It seems to indicate that higher stage and larger size indicate a worse prognosis, but we could not find statistically significant predictors in multivariate analysis. Sublobectomy was performed in 21 (65.6) cases, lobectomy was performed in the other 11 (34.4) cases, both of them can achieve good prognosis (5-year RFS and OS are both 100%), and there is no significant difference between them.

Conclusions: The clinical manifestation of early-stage primary pulmonary MALT lymphoma is not significantly specific, and surgical resection is an effective treatment.

Pulmonary MALT Lymphoma has variable features on CT

Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma is the most common primary pulmonary lymphoma. There are limited studies on imaging features of pulmonary MALT lymphoma. We present the computed tomography (CT) manifestations of pulmonary MALT lymphoma and the correlation between CT manifestations and clinical characteristics. Patients (n = 53) with histologically confirmed pulmonary MALT lymphoma who underwent chest CT scanning were retrospectively analyzed. Evaluated findings included distribution of pulmonary lesions, morphological pattern of appearance, contrast enhancement features, size, presence of thoracic lymphadenopathy, and secondary associated features. Pulmonary MALT lymphoma was observed in multiple (79%) and bilateral (66%) disease with random distribution (≥70%) of pulmonary lesions. The most frequent morphological pattern was consolidation (n = 33, 62%), followed by nodule (n = 23, 43%) and mass (n = 11, 21%). Common associated features were air bronchograms and bronchiectasis, especially cystic bronchiectasis and angiogram sign. Asymptomatic patients had less consolidation and bronchiectasis than did symptomatic patients. Cystic bronchiectasis was only observed in the symptomatic group. In conclusion, pulmonary MALT lymphoma manifests as diverse patterns on CT scans. Consolidation combined with cystic bronchiectasis was a characteristic late sign, which may assist in differential diagnosis. High-resolution CT images and multiplanar reconstruction techniques are helpful for accurately determining imaging manifestations.

Multiple cystic lung lesions and autoimmune thrombocytopaenia developing after chemotherapy for pulmonary indolent B-cell lymphoma with plasmacytic differentiation

Among lung malignancies, primary pulmonary lymphoma is rare and many of them are indolent B-cell lymphomas. We describe a case of primary pulmonary indolent B-cell lymphoma with plasmacytic differentiation, which exacerbated with the manifestation of macroglobulinaemia and was successfully treated using chemotherapy. The patient subsequently developed pulmonary cysts and thrombocytopaenia due to autoimmune pathology and was successfully treated using prednisolone. This case suggests that in indolent B-cell lymphoma with plasmacytic differentiation, immunoglobulin M level should be carefully followed even if it is within the normal range at lymphoma onset. Additionally, new cystic pulmonary infiltrates that develop during the post-treatment follow-up of an indolent pulmonary B-cell lymphoma may indicate pulmonary lymphoma recurrence, but there is also a possibility of an immunological complication.

HRCT in primary pulmonary lymphoma: can CT imaging phenotypes differentiate histological subtypes between mucosa-associated lymphoid tissue (MALT) lymphoma and non-MALT lymphoma?

Background

Primary pulmonary lymphoma (PPL) mainly comprises mucosa-associated lymphoid tissue (MALT) lymphoma as well as other subtypes of lymphoma. Different phenotypes of PPL demonstrate various high-resolution computed tomography (HRCT) features. We aimed to evaluate the value of HRCT in the diagnosis and differential diagnosis of PPL, especially between MALT lymphoma and non-MALT lymphoma and the correlation between CT and pathological features.

Methods

We performed a retrospective analysis on 72 patients with PPL confirmed by pathology between 2007 and 2016. We compared the CT characteristics and correlation with pathological findings between MALT lymphoma and non-MALT lymphoma groups.

Results

All 72 patients with PPL were classified into two groups: low-grade MALT lymphoma (MALToma) (56/72) and high-grade non-MALT lymphoma (non-MALToma) (16/72). The latter group consisted of diffuse large B cell lymphoma (8/72), Hodgkin's lymphoma (3/72), T-cell lymphoma (4/72), and intravascular large B-cell lymphoma (1/72). A total of 168 lesions were analyzed, including 57 cases with multiple lesions and 15 cases with single lesion. The manifestation of four distribution patterns: nodular or mass-like involvement pattern, diffuse interstitial lung disease (DILD) pattern, pneumonia-like consolidative pattern and mixed pattern was not significantly different between MALToma and non-MALToma (all P>0.05). Signs of air bronchogram and CT angiogram occurred significantly more often in individuals with MALToma group than those with non-MALToma (75% vs. 25%, P=0.001; 64.3% vs. 12.5%, P<0.001; respectively). Conversely, the halo sign presented more often in non-MALToma than in MALToma patients (19% vs. 63.6%, P=0.02). In addition, the butterfly sign was only observed in four patients with MALToma.

Conclusions

HRCT imaging phenotypes were beneficial in the diagnosis of PPL. Solitary or multifocal nodules/masses and consolidation were the most common imaging patterns. The air bronchogram sign, CT angiogram sign, halo sign, and butterfly sign could be potential to help to differentiate MALToma from non-MALToma.

Pulmonary mucosa-associated lymphoid tissue lymphoma: 18F-FDG PET/CT and CT findings in 28 patients

OBJECTIVE

The aim of the study was to evaluate the CT and fluorine-18-fluorodeoxyglucose positron emission tomography/CT (¹⁸F-FDG PET/CT) imaging findings of lung mucosa associated lymphoid tissue (MALT) lymphoma.

METHODS

28 patients with histologically confirmed pulmonary MALT lymphoma who underwent a chest CT and ¹⁸F-FDG PET/CT for staging were retrospectively analysed. The CT images were evaluated to determine morphological pattern of appearance, laterality, localization, number, size, presence of thoracic lymphadenopaties and secondary/combined findings. PET images were analysed visually and semi-quantitatively by measuring the maximum standardized uptake value (SUVmax), lesion-to-liver SUVmax ratio and lesion-to-blood pool SUVmax ratio. The relationship between qualitative and semi-quantitative features at ¹⁸F-FDG PET/CT and CT findings were also analysed.

RESULTS

A total of 57 pulmonary lesions were identified by CT: 37 areas of consolidation, 4 masses, 12 nodules and 4 ground-glass opacities. Solitary and multiple lesions were detected in 10 and 18 patients, respectively; among patients with multiple lesions, 16 were bilateral and 2 unilateral. ¹⁸F-FDG PET/CT revealed increased ¹⁸F-FDG uptake in 47/57 lesions, in 26/28 patients. 18F-FDG avidity was significantly associated only with tumour size.

CONCLUSIONS

Pulmonary MALT lymphoma is ¹⁸F-FDG avid in most cases and ¹⁸F-FDG avidity is correlated with tumour size. Consolidation is the most frequent morphological pattern of disease presentation. Advances in knowledge: This study demonstrated that lung MALT lymphoma are ¹⁸F-FDG avid in most cases depending on tumour size. Single or multiple areas of consolidation are the most common pattern of presentation of lung MALT lymphoma at CT.

A Rare Case of Pulmonary Mucosa-Associated Lymphoid Tissue Lymphoma Transforming into Diffuse Large B-Cell Lymphoma

Mucosa-associated lymphoid tissue lymphoma (MALToma) is a low grade B-cell lymphoma that develops from the lungs, intestinal tract, salivary gland, and other organs and is included under extranodal marginal zone lymphoma. When a primary pulmonary MALToma develops from bronchus-associated lymphoid tissue (BALT), it is called BALT lymphoma (BALToma). The etiology of MALToma is not clear; however, an association between chronic inflammatory conditions and BALToma has been observed. Transformation of MALToma to high grade lymphoma is very rare. We experienced a case of MALToma that had developed from the lungs in a patient who was undergoing treatment for latent tuberculosis and rapidly transformed into high grade B-cell lymphoma.

An unusual presentation of gastric mucosa-associated lymphoid tissue (MALT)-type lymphoma

Mucosa-associated lymphoid tissue (MALT)-type lymphoma is a relatively rare disease; nevertheless, it is the third most common lymphoma type, accounting for 5–7% of all non-Hodgkin lymphomas. Case series and retrospective analysis published in the literature have suggested that extra gastrointestinal (GI) MALT-type lymphoma can occur simultaneously with MALT-type lymphoma involving the GI tract. We report the case of a healthy, 64-year-old Caucasian male who presented with progressive fatigue, non-productive cough, and worsening exertional shortness of breath for 3 months who was subsequently diagnosed with gastric extra-nodal marginal zone B-cell lymphoma or MALToma with simultaneous metastasis to the lung (bronchi) based on biopsy reports.

Pulmonary mucosa-associated lymphoid tissue lymphoma revisited

This general review sought to clarify the pathophysiological, diagnostic, prognostic, and therapeutic features of pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma.MALT lymphoma is the most common pulmonary B-cell lymphoma, which usually occurs in the context of acquired MALT. The disease is slow-growing with an asymptomatic chronic alveolar opacity visible on radiography. Diagnosis requires tissue samples that should be retrieved using minimally invasive techniques, such as bronchoscopy or computed tomography-guided biopsies. The pathophysiology includes cytogenetic abnormalities and autoimmune diseases, whereas an association with a chronic pulmonary infection is still suspected but not yet demonstrated. Disease prognosis is typically excellent and the current available treatments are discussed in this review, including the decision not to treat, surgery, and single- or double-agent chemotherapy.

Hematologic neoplasms: Interpreting lung findings in chest computed tomography

Lung disease is very common in patients with hematologic neoplasms and varies in function of the underlying disease and its treatment. Lung involvement is associated with high morbidity and mortality, so it requires early appropriate treatment. Chest computed tomography (CT) and the analysis of biologic specimens are the first line diagnostic tools in these patients, and sometimes invasive methods are necessary. Interpreting the images requires an analysis of the clinical context, which is often complex. Starting from the knowledge about the differential diagnosis of lung findings that radiologists acquire during training, this article aims to explain the key clinical and radiological aspects that make it possible to orient the diagnosis correctly and to understand the current role of CT in the treatment strategy for this group of patients.

Hematologic neoplasms: interpreting lung findings in chest computed tomography

La patología pulmonar en la historia de un paciente con neoplasia hematológica es muy frecuente y variable en función de la enfermedad de base y la terapia recibida. La morbimortalidad asociada es alta, por lo que requiere un tratamiento correcto y precoz. La tomografía computarizada (TC) torácica, junto con el análisis de muestras biológicas, son las herramientas de diagnóstico de primera línea empleadas en estos pacientes, y en determinados casos se requieren métodos invasivos. La interpretación de las imágenes exige el análisis de un contexto clínico en muchas ocasiones complejo. Partiendo del conocimiento que adquiere el radiólogo en su formación sobre el diagnóstico diferencial de los hallazgos pulmonares, el objetivo de este trabajo es explicar los aspectos clínicos y radiológicos claves que permiten orientar correctamente el diagnóstico y asimilar el papel actual de la TC en la estrategia terapéutica de este grupo de enfermos.

Primary pulmonary lymphoma: About five cases and literature review

Primary pulmonary lymphoma is a very rare neoplasm that represents only 3-4% of extranodal non-Hodgkin lymphoma (NHL), less than 1% of NHL and only 0.5-1% of primary pulmonary malignancies. Primary pulmonary NHL is most commonly represented by marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT lymphoma). The clinical characteristics, methods of treatment, and outcomes are not well-elucidated. We, therefore, reviewed the medical records of five Moroccan patients who were pathologically and clinically diagnosed as primary pulmonary lymphoma and treated in our institute of oncology.

The radiological spectrum of pulmonary lymphoproliferative disease

Pulmonary lymphoproliferative disorders (LPD) are characterised by abnormal proliferation of indigenous cell lines or infiltration of lung parenchyma by lymphoid cells. They encompass a wide spectrum of focal or diffuse abnormalities, which may be classified as reactive or neoplastic on the basis of cellular morphology and clonality. The spectrum of reactive disorders results primarily from antigenic stimulation of bronchial mucosa-associated lymphoid tissue (MALT) and comprises three main entities: follicular bronchiolitis, lymphoid interstitial pneumonia and (more rarely) nodular lymphoid hyperplasia. Primary parenchymal neoplasms are most commonly extranodal marginal zone lymphomas of MALT origin (MALT lymphomas), followed by diffuse large B-cell lymphomas (DLBCLs) and lymphomatoid granulomatosis (LYG). Secondary lymphomatous parenchymal neoplasms (both Hodgkin and non-Hodgkin lymphomas) are far more prevalent than primary neoplasms. Acquired immune deficiency syndrome (AIDS)-related lymphoma (ARL) and post-transplantation lymphoproliferative disorder (PTLD) may also primarily affect the lung parenchyma. Modern advances in treatments for AIDS and transplant medicine are associated with an increase in the incidence of LPD and have heightened the need to understand the range of imaging appearance of these diseases. The multidetector CT (MDCT) findings of LPD are heterogeneous, thereby reflecting the wide spectrum of clinical manifestations of these entities. Understanding the spectrum of LPD and the various imaging manifestations is crucial because the radiologist is often the first one to suggest the diagnosis and has a pivotal role in differentiating these diseases. The current concepts of LPD are discussed together with a demonstration of the breadth of MDCT patterns within this disease spectrum.

Pulmonary marginal zone lymphoma: a single centre experience and review of the SEER database

Pulmonary marginal zone lymphoma is a rare disease arising from bronchial-associated lymphoid tissue (BALT). There is limited information on clinical presentation, natural history and treatment of this type of lymphoma. We conducted a retrospective review of patients with biopsy-proven BALT lymphoma treated at our institution and patients from the surveillance epidemiology and end results (SEER) database. Twenty-one patients (median age 57) with disease stage IE (n = 10) and IV (n = 11), were treated at our institution. Initial management included observation (n = 4), surgery (n = 5), combination chemotherapy (n = 7), single-agent rituximab (n = 3) and radioimmunotherapy (n = 2). Complete remission was observed in 10, partial remission in 3, stable disease in 7, and disease progression in 1 patient. With a median follow-up of 20 months, Kaplan-Meier estimates for progression-free and overall survival (OS) at 80 months were 90% and 95%, respectively. We identified 326 patients (59% females and 41% males; median age 68 [30 to 85) with BALT lymphoma in the SEER database. Fifty-five per cent had stage IE, 10% stage IIE, 3% stage IIIE, and 22% stage IV disease. After a median follow-up of 35 months, median OS was 112 months, and disease-specific median survival was not reached. At 90 months, disease-specific survival was 85% (CI 77-92) with no significant differences in outcome between patients presenting with different stages. Our single institution experience and review of the SEER database, confirm the indolent features and favourable outcome of this rare disease.

Extranodal marginal zone lymphoma occurring along the trachea and central airway

Extranodal marginal zone lymphoma is a low-grade B cell lymphoma that presents with an indolent clinicopathologic nature. Although this tumor can occur in various sites, including the gastrointestinal tract and lungs, it develops and spreads extremely rarely along the trachea and central airway. We report a case of extranodal lymphoma of mucosa-associated lymphoid tissue with tracheobronchial involvement. An 83-year-old woman presented with a cough and dyspnea. Bronchoscopic evaluation confirmed diffuse, multiple nodular lesions in both the trachea and large bronchi, and she was diagnosed with an extranodal marginal zone lymphoma of the tracheobronchial tree. After systemic chemotherapy, she survived for more than 18 months.

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.

Bronchus-associated lymphoid tissue lymphomas: an update of a rare extranodal maltoma

Mucosa-associated lymphoid tissue (MALT) lymphomas were first described by Isaacson and Wright in 1983 in a small series of patients with low-grade B-cell gastrointestinal lymphomas. Although MALT lymphomas occur most frequently in the stomach, they have also been described in various non-gastrointestinal sites, such as the salivary gland, conjunctiva, thyroid, orbit, lung, breast, kidney, skin, liver, uterus, and prostate. The risk of a diagnostic dilemma is reduced by the favorable prognosis of this low-grade lymphoma and its tendency to remain localized to the primary site for a long time. On therapeutic grounds, in contrast to nodal lymphomas, low-grade MALT lymphomas also respond favorably to local treatments, such as surgery and/or local radiation therapy. The outcome and prognosis of low-grade MALT lymphomas are more favorable than those for other extranodal lymphomas. The purpose of this review is to point out the state of the art regarding bronchus-associated lymphoid tissues lymphomas in terms of etiology, pathogenesis, clinics, and therapeutics, including our single-center experience of 23 cases.

Marginal zone B-cell lymphoma of bronchus-associated lymphoid tissue: imaging findings in 21 patients

BACKGROUND

Few articles have been published on imaging findings of marginal zone B-cell lymphoma of bronchus-associated lymphoid tissue (BALT) of the lung. We present CT scan and 18F-fluorodeoxyglucose (FDG) PET scan findings of the disease.

METHODS

From March 1995 to February 2007, 21 pretreatment patients (male patients, 9; female patients, 12; age range, 35 to 76 years; mean [+/- SD] age, 54 +/- 10.4 years) were seen who had pathologic diagnoses of marginal zone B-cell lymphoma of BALT. After CT scans were reviewed searching for specific patterns and distribution of parenchymal lung lesions, patients were classified as having the following four different patterns: (1) single nodular or consolidative; (2) multiple nodular or areas of consolidation; (3) bronchiectasis and bronchiolitis; and (4) diffuse interstitial lung disease (DILD) patterns. In six patients, in whom PET/CT scanning was performed, the pattern and the extent of maximum standardized uptake values (mSUVs) of FDG uptake were described.

RESULTS

A single nodular or consolidative pattern was observed in 7 of 21 (33%) patients, multiple nodular or areas of consolidation were observed in 9 patients (43%), bronchiectasis and bronchiolitis were observed in 3 patients (14%), and DILD was observed in 2 patients (10%). On PET scans (n = 6), lesions showed heterogeneous FDG uptake in five patients and homogeneous uptake in one patient, with mSUVs ranging from 2.2 to 6.3 (mean mSUV, 4.2 +/- 1.48).

CONCLUSIONS

Marginal zone B-cell lymphomas of BALT manifest diverse patterns of lung abnormality on CT scans, but single or multiple nodules or areas of consolidation are the main patterns that occur in a majority (76%) of patients. Most lesions show heterogeneous but identifiable FDG uptake on PET scans.

Mucosa-associated lymphoid tissue lymphoma: molecular pathogenesis and clinicopathological significance

Mucosa-associated lymphoid tissue (MALT) lymphoma is a low-grade tumor closely associated with chronic inflammation such as that of Helicobacter pylori gastritis, Sjogren's syndrome, and Hashimoto's thyroiditis. Tumor regression by H. pylori eradication alone is well known in gastric MALT lymphoma, but some tumors occur in the absence of pre-existing chronic inflammation. The understanding of MALT lymphoma biology has significantly improved, and recurrent cytogenetic alterations have been detected. These include the trisomies 3 and 18, and the translocations t(11;18)(q21;q21), t(1;14)(p22;q32), t(14;18)(q32;q21), and t(3;14)(p14.1;q32). At least some of these alterations result in the constitutive activation of the nuclear factor (NF)-kappaB pathway, and may exert anti-apoptotic action. Apoptosis inhibitor 2-MALT lymphoma-associated translocation 1 (API12-MALT1) fusion, resulting from t(11;18)(q21;q21), is specific to, and is the most common in, MALT lymphomas, and its clinicopathological significance has been studied extensively. The focus of the present review is on the recent progress made in elucidating MALT lymphomagenesis and its clinicopathological impact, especially in terms of the effect of API2-MALT1 fusion on this unique tumor.

[Malt lung lymphoma]

MALT lung lymphoma is a low-grade primarily B-cell lymphoma. Most cases develop in a pain free patient presenting a chronic alveolar opacity. In this review, we describe the clinical radiological and pathological features as well as the diagnostic approach to this pathological entity. Prognosis is excellent. Therapeutic options are discussed.

Role of surgery in the treatment of primary pulmonary B-cell lymphoma

BACKGROUND

The purpose of this study was to define the role of surgery in the treatment of primary pulmonary lymphoma (PPL).

METHODS

We reviewed all patients presenting with a pathologic diagnosis of PPL in our institution during the past 20 years. We analyzed the outcome and determined the impact of complete versus incomplete surgical resection on survival.

RESULTS

The study included 17 patients with PPL confined to the pulmonary parenchyma. Pathologic diagnosis was low-grade B-cell PPL in 14 patients, high-grade B-cell PPL in 2, and lymphomatoid granulomatosis in 1. A complete resection was performed in 8 patients presenting with low-grade B-cell PPL and in 2 patients with high-grade B-cell PPL. The overall survival of patients presenting with low-grade B-cell PPL was 63% at 10 years; however, survival at 10 year tended to be better when a complete resection was performed (87.5% vs 25%, respectively; p = 0.08). Gender, bilateral disease, or adjuvant therapy did not affect survival. Both patients presenting with high-grade B-cell PPL are alive and free of disease 22 and 36 months after the surgery, respectively. The patient presenting with lymphomatoid granulomatosis is alive after 2 years of follow-up.

CONCLUSIONS

PPL is a rare disease that may be localized or diffuse in one or both lungs. Surgery should be the treatment of choice in the localized form of PPL if complete resection can be achieved. A complete resection is associated with an excellent long-term survival of almost 90%. If the lesions are diffuse or involve both lungs, medical therapy should then be the treatment of choice.

Extranodal marginal zone B-cell lymphoma of the lung in Sjögren's syndrome patients: Reappraisal of clinical, radiological, and pathology findings

BACKGROUND

Primary Sjögren's syndrome (pSs) is an autoimmune rheumatic disease that may express in a small number of patients a spectrum of lymphoproliferative diseases. The aim of this study was to describe clinical, imaging and pathology features of the extranodal marginal zone B-cell lymphoma (MZCL) of the lung of mucosa-associated lymphoid tissue (MALT) type in patients with pSs.

METHODS

All patients (N=10) with biopsy proven MZCL of the lung of MALT type diagnosed in a tertiary teaching hospital during the last 7 years were studied.

RESULTS

Seven patients had pSs. Almost all patients presented an indolent clinical course, contrasting strongly with the spectacular radiological findings in both chest roentgenograms and computed tomography. Pathology infiltration patterns observed were either nodular, peribronchial-perivascular, alveolar, or interstitial. Immunohistochemical study in all cases showed B cell phenotypes. Immunoglobulin light chain restriction was demonstrated in all patients. Monoclonal IgM(kappa) was evident in 5/7, IgM(lambda) in 1/7 and IgG (kappa) in 1/7 of patients.

CONCLUSIONS

Lung MZCL associated with pSs are characterized by an important dissociation between clinical expression and radiological pattern. Clinical presentation and imaging features are not specific. Therefore, histologic documentation is mandatory to ensure diagnosis. Various chemotherapeutic agents in combination with rituximab lead to partial or complete remission in the majority of patients.

Mucosa-associated lymphoid tissue lymphoma of the esophagus coexistent with bronchus-associated lymphoid tissue lymphoma of the lung

Non-Hodgkin's lymphoma very rarely involves the esophagus, occurring in less than 1% of patients with gastrointestinal lymphoma. A few cases of mucosa-associated lymphoid tissue (MALT) lymphoma of the esophagus have been reported in the English literature. To our knowledge, there has been no report of MALT lymphoma of the esophagus coexistent with bronchus-associated lymphoid tissue lymphoma (BALT) of the lung. This report details the radiological and clinical findings of this first concurrent case.

Diseases affecting the peribronchovascular interstitium: CT findings and pathologic correlation

Central bronchi and pulmonary arteries are surrounded and enveloped by a strong connective-tissue sheath termed the peribronchovascular interstitium, extending from the level of the pulmonary hila into the peripheral lung. Thickening of the peribronchovascular interstitium can be seen in a wide variety of diseases. The CT appearance can be smooth, nodular, or irregular depending on the underlying cause. Many of the diseases affecting the peribronchovascular interstitium are entities that show a predilection for lymphatic routes, such as sarcoidosis, pulmonary lymphangitic carcinomatosis, silicosis, and lymphoproliferative disorders. There are other entities that mainly affect the peribronchovascular interstitium without a predominant perilymphatic distribution, such as hydrostatic pulmonary edema, cryptogenic organizing pneumonia, Kaposi's sarcoma, interstitial pulmonary emphysema, and interstitial hemorrhage. Although there is an overlap in radiologic features, some CT findings are useful in differentiating among these entities. When CT shows mainly peribronchovascular abnormality, the differential diagnosis is considerably reduced, and it is generally possible to reach the correct diagnosis by considering the clinical context. We illustrate the CT findings and pathologic correlation for a number of different disorders that mainly affect the peribronchovascular interstitium.

Indeterminate solitary pulmonary nodules revealed at population-based CT screening of the lung: using first follow-up diagnostic CT to differentiate benign and malignant lesions

OBJECTIVE

We studied the role of the first follow-up diagnostic CT for differentiating benign and malignant lesions in indeterminate solitary pulmonary nodules revealed at CT screening for lung cancer in which a total of 13,786 CT examinations (46% in women and 54% in men; 46% were smokers; mean age, 62 years) were performed.

MATERIALS AND METHODS

We reviewed thin-section CT findings on the initial diagnostic CT (lesion size; percentages of ground-glass-opacity areas of lesion; and presence or absence of lobulation, spiculation, air bronchogram, cavity, satellite lesions, pleural tag, concave margins, polygonal shape, and peripheral subpleural lesion) in 80 pulmonary nodules (36 malignancies and 44 benign lesions) of 80 patients. We evaluated changes in size (regression, no change, or growth) on the first follow-up CT performed 42-120 days (mean, 93 days) after the initial CT.

RESULTS

The greatest accuracy (81%) with 89% sensitivity and 75% specificity for determining malignancy was attained with a combined criterion of growth of lesions or predominantly ground-glass-opacity lesions. Of all criteria that were specific to malignancy, the greatest sensitivity (50%) was achieved with a combination of growth or no change in size of lesions and predominantly ground-glass opacity and no concave margins. Of all criteria that were specific to benign lesions, the greatest sensitivity (45%) was attained with a combination of lesion regression or polygonal shape.

CONCLUSION

Follow-up CT findings were useful, and a combination of findings on initial CT and follow-up CT was optimal for differentiating benign and malignant pulmonary nodules.

Unsuspected primary pulmonary malignant lymphoma

A 70-year-old man referred for treatment of a left lower lung tumor was shown in chest computed tomography to have a homogeneous round tumor 45 mm in diameter with an enhanced thin wall in the lower lobe of the left lung. No specific finding was seen in material obtained by transbronchial and computed tomography (CT)-guided lung tissue biopsy, so the presumptive diagnosis was a lung abscess. Despite antibiotics administered for 2 weeks, radiography showed the tumor had grown, necessitating left lower lobectomy. The permanent section was diagnosed as diffuse large B-cell lymphoma. Because CT findings for the tumor suggested a lung abscess and the central part of the tumor consisted of fibrotic and necrotic tissue, we had difficulty establishing a final diagnosis. The literature showed primary pulmonary lymphomas yielded a variety of findings radiographically, making surgery paramount for ascertaining a final diagnosis.

Air-containing space in lung adenocarcinoma: high-resolution computed tomography findings

OBJECTIVE

To disclose imaging features of air-containing spaces other than air bronchograms in lung adenocarcinoma on high-resolution computed tomography (HRCT).

MATERIALS AND METHODS

We retrospectively reviewed HRCT scans of 42 consecutive patients with surgically proved lung adenocarcinoma correlating with pathologic specimens.

RESULTS

Air-containing spaces were seen in 17 (40%) of cases on HRCT. The air-containing spaces appeared as multiple air densities (16 cases [94%]) with variable shapes and had a relatively larger size than that of air bronchograms. Internal septi were often noted (11 cases [65%]).

CONCLUSION

Our results demonstrate that multiplicity, larger diameter, and internal septi are the features of air-containing spaces. These findings could be a key to the definitive diagnosis of lung adenocarcinoma, distinguishing it from the mimics such as organizing pneumonia, tuberculoma, or malignant lymphoma.

Unusual primary lung tumors: a radiologic-pathologic overview

Although the great majority of lung carcinomas are histologically characterized as adenocarcinoma, squamous cell carcinoma, large cell undifferentiated carcinoma, or small cell carcinoma, a variety of rare benign and malignant lung tumors may sporadically affect the lung. Several nonneoplastic tumorlike lesions are seen infrequently but are also part of the differential diagnosis for lung masses. Conventional radiographic findings, although of limited value in the diagnosis of these entities, should be examined carefully when lung tumors are suspected. Computed tomography (CT) is well suited for making a definitive diagnosis of some disease processes. CT helps determine the location and features of the lesions and depicts associated findings to help document the extent of disease. The differential diagnosis can be narrowed when there are typical CT features (eg, the presence of fat in lipoid pneumonia). Although unusual primary lung tumors are difficult to diagnose on the basis of imaging findings alone because such findings are nonspecific in the majority of cases, cross-sectional imaging can play an important role in the diagnostic work-up of these unusual tumors by delineating their extent and directing the radiologist or bronchoscopist to the appropriate biopsy site.

High-resolution CT of alveolar filling disorders

Airspace filling process is characterized on CT by the presence of one or more fairly homogeneous areas of consolidation with little or no volume loss. The consolidation may be segmental, subsegmental, lobular, or acinar (10 mm or less in diameter). Poorly defined centrilobular nodules may be associated. The margin of the consolidation usually is poorly defined except in the areas in which the consolidation abuts the pleura. Air-containing bronchi or bronchioles (CT air bronchograms or air bronchiolograms) are seen frequently. Many diseases can present with alveolar filling disorders. Because the HRCT findings overlap among various alveolar filling disorders, it may be impossible to make a definite diagnosis with HRCT findings alone. Integration of HRCT findings including disease pattern and distribution and time factors including evolution and resolution of the disease, however, may enable to narrow differential diagnosis of alveolar filling diseases. Furthermore, clinical and laboratory findings also may provide helpful clues to reach a reasonable diagnosis. The role of HRCT in alveolar filling disorders is not limited to diagnosis. HRCT also plays a useful role in determining the extent of disease and in identifying accompanying abnormalities, and complications of the primary disease.

Bronchus-associated lymphoid tissue (BALT) lymphoma of the lung showing mosaic pattern of inhomogeneous attenuation on thin-section CT: a case report

The authors present a case of histologically proven bronchus-associated lymphoid tissue (BALT) lymphoma of the lung in a patient with primary Sjögren's syndrome that manifested on thin-section CT scan as a mosaic pattern of inhomogeneous attenuation due to mixed small airway and infiltrative abnormalities