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Originally published as JCO Early Release 10.1200/JCO.2008.18.4325 on September 8 2008 © 2008 American Society of Clinical Oncology.
Anaplastic Large-Cell Lymphoma Presenting As an Endobronchial Polypoid Tumor
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital; China Medical University, Taichung, Taiwan
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
China Medical University, Taichung, Taiwan
Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
Department of Pathology, China Medical University Hospital, Taichung, Taiwan
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Tungs’ Taichung MetroHarbor Hospital, Taichung, Taiwan A 17-year-old previously healthy male student had chronic dry cough and low-grade fever for 6 weeks. Body weight loss of about 10 kg was also noted in the last 4 months. There were multiple palpable lymph nodes with tenderness over the bilateral sides of the neck and supraclavicular areas noted when the patient consulted at our pediatric clinic. He was then referred to the chest medicine clinic for his refractory cough and progressive dyspnea on exertion. Right middle lobe and left lower lobe atelectasis was seen on chest x-ray. Chest computed tomography revealed a polypoid lesion in the trachea and soft tissue lesions occluding the left main bronchus and right bronchial intermediates (Figs 1A, 1B, 2A, and 2B; arrows). Endotracheal and endobronchial tuberculosis was the initial impression, so the patient was admitted for isolation and treated with isoniazid, rifampin, ethambutol, and pyrazinamide for high risk of transmission. However, serial sputum acid-fast stain showed negative findings. Flexible bronchoscopy demonstrated polypoid lesions in the distal trachea, left main bronchus, and right bronchus intermedius (Figs 3A and 3B). Broncho-alveolar lavage fluid acid–fast stain also showed no pathogens, but cytology examination revealed suspicious malignancy. Bronchoscopic electrocautery tumor dissection was then performed to resolve his dyspnea. Biopsy confirmed a CD30+ anaplastic large-cell lymphoma (ALCL; Fig 4). Positron emission tomography and whole body computed tomography for staging exhibited tumor metastasis in both sides of the necks, left supraclavicular regions, sternum, mediastinum, left lower lung, spine, celiac region, para-aortic region, pelvis, iliac bones with bony destruction, and right buttock region. Bone marrow study did not show any malignant cells. The patient then received chemotherapy with cyclophosphamide, adrimycin, vincristine, and prednisolone, and the lymphoma responded well. The collapsed lung and dyspnea also resolved. He was subsequently discharged and continued receiving further chemotherapy.
Malignant lymphoma arising from endobronchial lesions is extremely rare and more often in Hodgkin's disease than in non-Hodgkin's lymphoma (NHL).1-3 Primary pulmonary NHL comprise less than 1% of all NHL cases, 3.6% of extranodal lymphomas, and only 0.5% to 1% of primary pulmonary malignancies.4 Endobronchial lymphoma is classified into two types. Type I includes diffuse submucosal infiltrates spreading from the systemic lymphoma via the hematogenous or lymphatic system. Type II includes airway involvement by a localized mass due to a direct spread of the lymphoma from adjacent lymph nodes or arising de novo from bronchus-associated lymphoid tissue. Type II lesions are always associated with signs of airway obstruction, such as coughing or wheezing, as in our patient.4 ALCL comprises 2% to 7% of NHL, and the most common morphology of endobronchial ALCL is polypoid lesion with airway obstruction.5 As compared with endobronchial tuberculosis, the lesion can be classified into four stages: exudative, ulcerative, cicatrative, and broncho-glandular lesions.6 Because of the extreme rarity of endobronchial lymphoma and high incidence of pulmonary tuberculosis in Taiwan, physicians may inadvertently delay diagnosis. Primary lymphoma arising from the bronchus is usually a chemotherapy-sensitive tumor, and it is necessary to add primary lymphoma to the differential diagnoses of endobronchial polypoid masses. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
NOTES published online ahead of print at www.jco.org on September 8, 2008 REFERENCES 1. Kaira K, Ishizuka T, Tanaka H, et al: B-Cell Non-Hodgkin lymphoma presenting as an endobronchial polypoid mass. J Thorac Oncol 3:530-531, 2008[Medline] 2. Berkman N, Breuer R, Kramer MR, et al: Pulmonary involvement in lymphoma. Leuk Lymphoma 20:229-237, 1996[Medline] 3. Ferraro P, Trastek VF, Adlakha H, et al: Primary non-Hodgkin's lymphoma of the lung. Ann Thorac Surg 69:993-997, 2000 4. Solomonov A, Zuckerman T, Goralnik L, et al: Non-Hodgkin's lymphoma presenting as an endobronchial tumor: Report of eight cases and literature review. Am Journal of Hematol 83:416-419, 2008[CrossRef] 5. Kim DH, Ko YH, Lee MH: Anaplastic large cell lymphoma presenting as an endobronchial polypoid mass. Respiration 65:156-158, 1998[CrossRef][Medline] 6. Kim YH, Kim HT, Lee KS, et al: Serial fiberoptic bronchoscopic observations of endobronchial tuberculosis before and early after antituberculosis chemotherapy. Chest 103:673-677, 1993[CrossRef][Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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