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Solitary Pulmonary Nodule in an Immunosuppressed Patient With Non-Hodgkin Lymphoma: An Unusual Situation FREE TO VIEW

Gilmar Zonzin, MD; Vitório Puntel, PhD; Silvio Guerra; Vinicius Agostinho; Mariana Silva; Priscila Virgens; Marina Faria
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Pneumology, Centro Universitário de Volta Redonda, Volta Redonda, Rio de Janeiro, Brazil

Chest. 2014;146(4_MeetingAbstracts):635A. doi:10.1378/chest.1993045
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SESSION TITLE: Cancer Global Case Reports

SESSION TYPE: Global Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The carcinoid tumor is a rare neoplasm of enterochromaffin cells. Its main location is in the intestine, more often in the appendix. Carcinoid tumors may or may not produce the carcinoid syndrome, characterized by various clinical symptoms such as tachycardia, flushing and paraesthesia, all related to serotonin secretion by the tumor. We report a case of a patient in use of adjuvant chemotherapy after diagnosis of non-Hodgkin's lymphoma that presented in exam chest ray routine circumscribed pulmonary nodule. After long follow-up, it was opted for surgical resection of the lesion, being diagnosed carcinoid tumor of the lung.

CASE PRESENTATION: MAF, female, 68 years old, housewife, resident in the interior of Rio de Janeiro, Brazil. Was presented for the first time to our service with clinical cough, yellowish scanty expectoration and low fever of 37.8°. She was treated with prednisone 30 mg daily, omeprazole, acyclovir , sulfametozaxol-trimethoprim and ondansetron. Reported a previous diagnosis, received eighteen months prior this consultation, of non-Hodgkin's lymphoma, obtained through biopsy of inguinal lymph node. Chest radiography showed pulmonary nodule with soft tissue density of 1.8 cm in diameter, without calcification and well delimited in the left lower lobe that was first identified three years prior. This lesion had been accompanied by another service of pneumology and oncology in a conservative way. Was treated for the infection with a more enlarged approach, using amoxicillin-clavulonate and clarithromycin, because of her underlying disease and continuous use of systemic corticosteroids. Complete regression of symptoms occurred with absolute improvement. The nodulation remained present in later radiographys. Requested chest CT which showed lobulated nodule with well-defined borders in the medial basal segment of the left lower lobe, near the thoracic aortic wall, measuring 2.0 cm, with intense enhancement after contrast infusion. The examination of inflammatory tests after treatment of the infection were in low titles: CRP of 6mm and ESR of 10mm. Normal conventional lung function test. In this moment, the oncology service decided, in relation to the treatment of the lymphoma, the addition of rituximab to the treatment regimen. It was made screening for infectious diseases with no data suggesting underlying disease. Despite nonreactive Mantoux test, as the same was held on corticosteroids use, it was requested bronchoscopy. Collected material, with results of direct examination and culture negative for tuberculosis and fungi, as well as negative oncotic cytology. In regards of epidemiological risks, the absence of etiological definition and risks inherent in the use of rituximab, it was decided to introduce prophylactic isoniazid for prevention of possible masked TB. In the monitoring of the non-Hodgkin lymphoma, PET scan was requested to re-estage, which revealed absence of signs of disease activity. On the other hand, the previously identified lung injury exhibited growth, evidenced by increasing its dimensions in relation to previous studies. Because of this, she was referred to thoracic surgery. Due to difficult surgical access, it was decided to approach the nodule via videothorascoscopy, being perfomed a lung segmentectomy. Retrieved tissue containing a nodule of 3 cm in diameter, which was diagnosed after examination as typical carcinoid tumor. The surgery was uneventful and the patient is currently asymptomatic on follow -up.

DISCUSSION: Despite the carcinoid tumor usually require large surgical excision, segmentectomy was performed due to the limitations of the patient and the peculiar location of the lesion. As histopathological study revealed that the surgical margins were free of lesions and PET-scan showed no metabolic activity in other sites, we considered the segmentectomy a proper treatment of the condition founded.

CONCLUSIONS: The involvement of more than one different type of neoplasm sequentially is uncommon. There are no reports in the literature that non-Hodgkin lymphoma may predispose carcinoid tumor and vice versa. In elderly, frail or patients with comorbidities, segmentectomy can assume similar healing criteria of the lobectomy.

Reference #1: SAVIVA, E. V.; DESCOURT, R. Focus on treatment of lung carcinoid tumor. Onco Targets Ther. 2013

Reference #2: TRAVIS, W.D. Advances in neuroendocrine lung tumors. Oxford Journals Medicine. Annals of Oncology 2010

Reference #3: REKHTMAN, N. Neuroendocrine Tumors of the Lung - An Update. Arch Pathol Lab Med. 2010

DISCLOSURE: The following authors have nothing to disclose: Gilmar Zonzin, Vitório Puntel, Silvio Guerra, Vinicius Agostinho, Mariana Silva, Priscila Virgens, Marina Faria

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