Lung Cancer |

Primary Pulmonary T-Cell Lymphoma Presenting as Bilateral Interstitial Infiltrates FREE TO VIEW

Thomas Willson, MD; Tracy Sambo, MD; Jacques-Pierre Fontaine, MD; Mark Connolly, MD; Francis Podbielski, MD
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Saint Joseph Hospital, Chicago, IL

Chest. 2014;145(3_MeetingAbstracts):315A. doi:10.1378/chest.1836158
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SESSION TITLE: Cancer Case Report Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Primary pulmonary lymphomas are uncommon, and most frequently of B-cell lineage. Primary T-cell lymphoma of the lungs is a rare, aggressive entity with a poor prognosis and few reported cases. We describe a case in which the only presenting complaints were fatigue and persistent bilateral pulmonary infiltrates.

CASE PRESENTATION: The patient was a 57-year-old man with coronary artery and peripheral vascular disease, and diabetes who was followed for several months by his primary care physician for persistent lung infiltrates and chronic fatigue. Antibiotic therapy failed to resolve these infiltrates and endobronchial biopsy yielded equivocal results. The thoracic surgery service performed an open lung biopsy which revealed peripheral T-cell lymphoma, not otherwise specified (CD2+, CD3+, CD7+, CD8+, CD38+, CD45+; CD4-, CD5-, CD56-). Chemotherapy was initiated, but his response was poor. Later, he developed gastrointestinal bleeding with the same lymphoma being found on biopsy of a gastric ulcer. His disease continued to progress despite salvage chemotherapy and he expired approximately 10 months after the initial diagnosis.

DISCUSSION: Primary pulmonary lymphomas represent less than 1% of all lymphomas. Most are indolent and arise from a B-cell lineage; pulmonary T-cell lymphomas represent a rare, more aggressive subgroup. Patients with high-grade lesions tend to present with weight loss and other systemic complaints, while patients with low-grade lymphomas are frequently diagnosed after an exhaustive workup of an abnormal routine chest x-ray. Radiographic findings vary widely, but multiple pulmonary nodules and ill-defined alveolar masses with air-bronchograms are considered characteristic. The latter can also be seen with pneumonia and bronchioalverolar carcinomas while the former tend to be present in metastatic and granulomatous disease. Diffuse infiltrates, as found in our patient, are uncommon. Noninvasive diagnostic methods such as bronchoalveolar lavage (BAL) have an inconsistent yield. Bronchoscopic biopsy also plays a role in diagnosis, however, as in this patient, open biopsy is frequently required to definitively establish the diagnosis.

CONCLUSIONS: Although primary pulmonary T-cell lymphomas are rare they are highly aggressive and as such, delays in diagnosis can negatively impact patient survival. This diagnosis should be considered along with more common disease processes when a pulmonary infiltrate fails to resolve with standard therapy. Evaluation with noninvasive methods such as BAL and bronchoscopic biopsy should be rapidly followed by open or thoracoscopic biopsy when the diagnosis remains unclear.

Reference #1: Cordier JF, Chailleux E, Lauque D, Reynaud-Gaubert M, Dietemann-Molard A, Dalphin JC, Blanc-Jouvan F, Loire R. Primary pulmonary lymphomas: a clinical study of 70 cases in nonimmunocompromised patients. Chest. 1993 Jan; 103(1):201-8.

Reference #2: Bernabeu Mora R, Sanchez Nieto JM, Nieto Olivares A. Bilateral pulmonary nodules as a manifestation of primary pulmonary T-cell lymphoma. International Journal of Hematology. 2009 Sep; 90(2): 153-6.

Reference #3: Boon ES, Graal MB, van Noord JA. Primary extranodal non-Hodgkin’s lymphoma of the lung presenting with bilateral, patchy infiltrates dramatically improving after corticosteroid therapy. Chest. 1993 Oct; 104(4): 1292-3.

DISCLOSURE: The following authors have nothing to disclose: Thomas Willson, Tracy Sambo, Jacques-Pierre Fontaine, Mark Connolly, Francis Podbielski

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