INTRODUCTION: Endobronchial involvement of Hodgkin lymphoma is rare and typically has been described on initial presentation. We describe a patient with relapsing Hodgkin lymphoma who, during evaluation for concomitant infection prior to initiation of salvage chemotherapy, was found to have endobronchial Hodgkin lymphoma.
CASE PRESENTATION: A 35 year old African American man with history of relapsing Hodgkin lymphoma Stage IIIb, nodular sclerosing subtype, and complaints of dry cough with low grade fevers, presented for bronchoscopic evaluation to rule out concomitant infection prior to initiation of salvage chemotherapy. The patient was originally diagnosed one year prior, and had undergone two chemotherapeutic regimens (six cycles of adriamycin, bleomycin, vinblastin, dacarbazine and three cycles of ifosfamide, carboplatin, etoposide) without clinical remission. His second regimen was complicated by neutropenia requiring granulocyte colony stimulating factor, with his last dose 3 months prior. After completion of the third cycle of his second regimen, positron emission tomography and computed tomography (CT) scan revealed diffuse lymphadenopathy that had not improved. Lymph node biopsy via mediastinoscopy confirmed recurrence of Hodgkin lymphoma. CT also revealed new extensive parenchymal ground glass opacities and subcentimeter nodules that were concerning for concomitant infection given complaints of dry cough and low grade fevers. Bronchoscopy was performed for evaluation of infection versus parenchymal involvement of lymphoma. Examination of the trachea and mainstem bronchi revealed several raised endobronchial lesions that were friable with biopsy. Pathology from the endobronchial biopsies revealed Reed-Sternberg cells, staining positive for CD30, fascin, and CD15, consistent with residual or recurrent Hodgkin lymphoma. Microbiological data was negative and patient was started on gemcitabine, vinorelbine, and doxorubicin with the eventual plan for stem cell transplant. The patient’s cough improved and fever resolved with initiation of chemotherapy.
DISCUSSION: Hodgkin lymphoma often involves the mediastinal and hilar lymph nodes of newly diagnosed patients. Pulmonary involvement is less common and may involve lymph nodes, lung parenchyma, and the tracheobronchial tree. Based on autopsy data, 40% of Hodgkin patients have mediastinal involvement, 14 to 38% have local lung infiltration, and up to 14% can have endobronchial manifestations. Discovery of antemortem endobronchial involvement is much less frequent, approximately 1.9% among newly diagnosed patients. This discrepancy may imply development of endobronchial disease following initial diagnosis or screening bias as, bronchoscopy is not routinely performed unless respiratory symptoms or a bulky mediastinum is noted on initial presentation. Intrathoracic disease does not always produce respiratory symptoms in adults due to the relatively soft lymph nodes compared to the cartilaginous skeleton of the trachea and proximal bronchi. The pathogenesis of endobronchial Hodgkin lymphoma is unclear. Mucosa-associated lymphoid tissue (MALT) or other sources including adjacent nodal spread or hematogenous spread are presumed mechanisms. Depending on the morphology of the lesion, obstructive pathophysiology may be present. Whether for initial identification of Hodgkin lymphoma or confirming recurrence, a definitive diagnosis should be obtained in order to rule out primary lung cancer, specifically small cell carcinoma. If a diagnostic specimen cannot be obtained from bronchoscopy or from lymph nodes, more invasive procedures should be utilized. For patients with critical airway obstruction, interventional bronchoscopic intervention using laser therapy, photodynamic therapy, or mechanical stent placement should be considered via rigid bronchoscopy.
CONCLUSIONS: Hodgkin lymphoma rarely manifests as endobronchial disease, especially on initial presentation; however, a clinician must be aware of this possibility once an endobronchial lesion is discovered. A specific diagnosis must be made for the purposes of staging and appropriate treatment, including possible surgical intervention.
Reference #1 Bahram Kiani, Cynthia M. Magro and Patrick Ross, Jr. Endobronchial presentation of Hodgkin lymphoma: a review of the literature. Ann Thoracic Surg 2003; 76:967-972
DISCLOSURE: The following authors have nothing to disclose: Thomas Martin, Cynthia Callahan, Paru Patrawalla, Laura Evans
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