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Challenging Diagnosis of Diffuse Large B-Cell Lymphoma of the Lung: A Case Report FREE TO VIEW

Kunal Patel, MD; Artur Shalonov, MD; Alan Fein, MD; Kelly Cervellione, MPH; Eduardo Andre*, MD
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Jamaica Hospital Medical Center, Jamaica, NY

Chest. 2012;142(4_MeetingAbstracts):982A. doi:10.1378/chest.1389395
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SESSION TYPE: Miscellaneous Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Diagnosis of diffuse large B-cell lymphoma (DLBCL) of the lung can be a challenging process due to low diagnostic yield on biopsy. Here we present a case of DLBCL with lung involvement and bony metastasis that illustrates the difficulty in diagnosing the disease.

CASE PRESENTATION: A 43-year-old Caucasian male presented with intermittent cough for one month associated with minimal, whitish expectoration that was occasionally blood-tinged. He reported night sweats and a 15-pound unintentional weight loss. He denied fever, exposure to sick contacts, recent travel and history of TB. On physical examination, he was afebrile; vital signs were normal. He had point tenderness at the T3 level and associated numbness of the lower extremities. The rest of exam and labs were unremarkable. Chest radiograph showed multiple, diffuse, bilateral lung densities. CT chest showed numerous bilateral lung masses with appearance consistent with lung metastasis and extensive mediastinal, axillary and supraclavicular lymphadenopathy (image 1). MRI of spine showed pathological compression fracture with early cord compression at T3. Patient was treated with intravenous corticosteroids and local radiation therapy to the spine. Patient had multiple biopsies including axillary lymph node biopsy, flexible bronchoscopy with transbronchial biopsy, CT-guided lung biopsy, and open lung biopsy for the multiple lung lesions. All biopsies were negative for malignancy with open lung biopsy showing multiple inflammatory fibrosing nodules, atypical pneumocyte hyperplasia and organizing pneumonia. Steroids were continued and significant improvement of symptoms and radiologic findings occurred (image 2). When steroids were tapered his symptoms recurred and the radiological findings worsened with reappearance of diffuse lesions, which were now cavitary and more diffuse. At this time, a PET/CT scan showed hyper-metabolic lesions of the lung along with intense signal coming from the stomach. Patient underwent an upper endoscopy with biopsy of ulcerating mass which was diagnosed as DLBCL. Patient received R-CHOP and all lesions responded to treatment.

DISCUSSION: DLBCL is the most common aggressive non-Hodgkin’s lymphoma in US. Extranodal disease is seen in 40% of the cases, most commonly in the gastrointestinal tract. Use of PET/CT, as in our case, may be useful in detecting other areas of involvement. Though steroid treatment is not curative, it may cause a dramatic decrease in lesions and mimic treatment response; discontinuation of steroids will cause recurrence of symptoms and, as in our case, may lead to further progression of disease.

CONCLUSIONS: As illustrated here, diagnostic yield of biopsy in DLBCL can be low, even when large specimens and lymph nodes are obtained through open-lung biopsy. Therefore, biopsy of extra-pulmonary disease may be required to make a diagnosis.

1) Friedberg JW. Diffuse large B-cell lymphoma. Hematol Oncol Clin North Am. 2008;22(5):941.

DISCLOSURE: The following authors have nothing to disclose: Kunal Patel, Artur Shalonov, Alan Fein, Kelly Cervellione, Eduardo Andre

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Jamaica Hospital Medical Center, Jamaica, NY




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