INTRODUCTION: Extra-nodal marginal B-cell lymphoma of bronchial associated lymphoid tissue (BALT) is a rare entity accounting for less than 1% all lymphomas. It is characterized by an often indolent course, in patients that are often asymptomatic, and is found many times incidentally on chest radiography. In most cases BALT lymphoma is localized to one lung or involves bilateral lungs. Optimal management of this malignancy is not clearly defined.
CASE PRESENTATION: A fifty-nine year old black gentleman with PMH of renal insufficiency, diabetes, hypertension, severe PVOD, and a 100 pack-year smoking history was found to have an abnormal chest radiograph while undergoing a preoperative evaluation for a vascular procedure. The chest radiograph showed bilateral large lower lobe airspace opacities. In reviewing a chest radiograph from 3 years prior these opacities were present at that time. The abnormality had increased in size only slightly in the interval. Of note, the patient was lost to follow up after the initial abnormal CXR until this presentation. The patient experienced only mild respiratory complaints with dyspnea on exertion and occasional dry cough. There were no symptoms of hemoptysis, fever, chills, weight loss, or night sweats. He had no history of diagnosed autoimmune disease or family history of lung disease or cancer. On presentation, his vital signs were within normal limits, with an oxygen saturation of 95% on room air. Physical exam was significant for rales at the bilateral lung bases, no palpable lymph nodes were appreciated. CT scan of the chest revealed dense consolidation with air bronchograms of the several segments of bilateral lower lobes. No mediastinal lymphadenopathy was seen. The patient underwent bronchoscopy with transbronchial biopsy. Pathology showed extra-nodal marginal zone B cell lymphoma of bronchial associated lymphoid tissue (BALT). Further staging with PET-CT and bone marrow biopsy confirmed stage IV disease involving the subcarinal lymphnodes and bone marrow. Currently the patient is undergoing single agent treatment with rituximab with some decrease in size of the cancer. He remains relatively asymptomatic with ongoing occasional dry cough. He continues to report no B symptoms.
DISCUSSIONS: Extra-nodal marginal B cell Lymphoma of bronchial associated lymphoid tissue (BALT) is an extremely rare form of lymphoma. Case series have shown that the natural history of this malignancy is often times indolent. Up to one-third of patients are asymptomatic at presentation and most patients have disease localized to one lung or in some cases involving bilateral lungs. The 5 year survival in patients with this malignancy is reported to be >80%. We believe this case is interesting in that it is an example of the relatively indolent course of this rare malignancy. Our patient was lost to follow up for approximately three years, was relatively asymptomatic, and at subsequent presentation had involvement of the bone marrow. From review of reported cases, bone marrow involvement tends to be even more rare. As there is no clearly defined treatment regimen for this disease, he is undergoing treatment with rituximab with some response on follow up imaging.
CONCLUSION: BALT lymphoma is a rare, low grade lymphoma. Continued case reports and case series of this malignancy will add our knowledge of the natural history, presentation, and treatment of this infrequent disease.
DISCLOSURE: Rajeev Swarup, No Financial Disclosure Information; No Product/Research Disclosure Information