INTRODUCTION: Bronchial-associated lymphoid tissue (BALT) lymphoma is a rare entity that usually accounts for 1% of all lymphomas 2. BALT lymphoma comprises two-thirds of all primary lung Non-Hodgkin’s Lymphoma, however, endobronchial lesions involving the trachea are uncommon1.
CASE PRESENTATION: This is a 91 year-old female who was referred to our institution after work-up at an outside hospital for shortness of breath, audible wheezing and hypoxia revealed a persistent soft-tissue density in the distal trachea with 2-dimensional size of 1.5X1.7 cm, with a tissue bulk of around 3.6 cm, extending distally into the right mainstem bronchus and bronchus intermedius. This was initially found on a CT-scan of the chest performed few months prior and was suspected to be a mucus plug and since the patient clinically improved on steroids and bronchodilators, it was not pursued further at that time. At our institution, she underwent a rigid and flexible bronchoscopy, which revealed a distal tracheal tumor with near complete occlusion of the distal trachea and a crescent shape opening towards the left mainstem bronchus. The lesion was found to be broad-based, globular in appearance, arising from the right lateral tracheal wall without any identifiable compromise of the right mainstem bronchus which was visualized after advancing the bronchoscope behind the lesion. The frozen section of the biopsy sent to pathology was suspicious for lymphoma. Mechanical tumor debridement was performed using flexible biopsy forceps as it was difficult to core out the lesion with the rigid barrel and complete airway patency was re-established. Final pathology revealed Low-grade B-cell lymphoma consistent with lymphoplasmacytic type. Immunostains were positive for B-cell antigens CD20 and CD79a. Background T-cells were positive for CD3, CD5 and CD43. Flow cytometry revealed 73% of the lymphocyte population to be B-cell with antigen positivity for CD19, CD20, HLA-DR and CD38. No other sites of lymphoma were identified. The post-operative course was complicated with a right pneumothorax which resolved with chest tube drainage and pneumomediastinum which resolved with conservative management. Her symptoms improved and the patient was discharged home with plans for outpatient oncology evaluation.
DISCUSSION: BALT lymphomas are rare and indolent tumors. The primary lesions involving the trachea are even more infrequent form of the NHL (Non-Hodgkin Lymphoma) of the lungs 1,2. These frequently are low-grade B-cell lymphoma and resemble closely to mucosa-associated lymphoid tissue 1. Chronic antigenic stimulation prompted by recurrent infection or auto-immune process may lead to aggregation of lymphoids evloving into BALT lymphoma 3. These lesions have been conventionally treated with radiation, chemotherapy and surgery with resection and/or reconstruction of the trachea 1.
CONCLUSIONS: Isolated endobronchial lymphoma is a rare entity but should be considered as a differential for endobronchial tumors. In patients, where other treatment modalities cannot be performed due to risks of potential complications, endoscopic tumor debulking might be an alternative option.
Reference #1 Primary tracheal non-Hodgkin's lymphoma. A case report and review of the literature. Fidias P, Wright C, Harris NL, Urba W, Grossbard ML Cancer. 1996 Jun 1;77(11):2332-8
Reference #2 Bronchial-associated lymphoid tissue lymphoma: a clinical study of a rare disease. Ahmed S, Kussick SJ, Siddiqui AK, Bhuiya TA, Khan A, Sarewitz S, Steinberg H, Sison CP, Rai KR. European Journal of Cancer. 2004 Jun;40(9):1320-6
Reference #3 A patient with endobronchial BALT lymphoma successfully treated with radiotherapy. Hashemi SM, Heitbrink MA, Jiwa M, Boersma WG. Respiratory Medicine. 2007 Oct;101(10):2227-9
DISCLOSURE: The following authors have nothing to disclose: Ali Ashraf, Ilan Yavitz, Antonio DeGorordo Arzamendi, Samaan Rafeq, Armin Ernst
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