A 59-year-old African American female with a history of type 2 diabetes mellitus (DM) and chronic gastroesophageal reflux disease (GERD) was evaluated in the pulmonology clinic with complaints of persistent dyspnea on exertion (DOE) and cough persistent for six months. She also cited intermittent, generalized abdominal pain and a twelve-pound weight loss in the previous four months. On further inquiry, she reported that she had undergone computed tomography (CT) scan of her chest six years earlier, which showed multiple bilateral nodules. Owing to her refusal, a transbronchial biopsy could not be performed, and her preliminary diagnosis of sarcoidosis was upheld. The patient was a lifelong non-smoker and denied a family history of lung diseases.\nOn clinical exam, the patient was hemodynamically stable with equal air entry bilaterally. Initial laboratory workup including complete blood count and complete metabolic picture were unremarkable. A repeat chest CT scan was obtained, which revealed nodular areas of consolidation in both lungs (). Due to her apprehensions against general anesthesia, a CT-guided right lung biopsy was performed, which disclosed a dense, monotonous population of centrocyte-like cells (). Immunohistochemistry stained positive for CD20, Bcl-2, and CD21 while in situ hybridization (FISH) showed kappa light-chain restriction, which confirmed the diagnosis of a marginal zone lymphoma (MZL) ().\nSubsequent staging investigations included negative bone marrow biopsy and an esophagogastroduodenoscopy (EGD). Gastric biopsies revealed an atypical B-cell lymphoid infiltrate consistent with an extra-nodal marginal zone lymphoma of MALT (). Additionally, Helicobacter pylori stool antigen and immunohistochemistry were negative. The gastric mucosa was involved by a monomorphous small cell lymphoid infiltrate with slightly irregular nuclear contours and moderate pale cytoplasm (centrocyte-like morphology) infiltrating the lamina propria with focal infiltration of the epithelial structures. Immunohistochemistry revealed positivity for CD 20 and a low proliferation index (Ki67).\nIn the ensuing week after staging, the patient was admitted to the inpatient setting with complaints of excessive abdominal pain, nausea, and vomiting. A CT scan of the abdomen and pelvis unveiled a hypo-dense 2.2 cm pancreatic neck. An endoscopic ultrasound (EUS) with biopsy established a new diagnosis of pancreatic ductal adenocarcinoma.\nMedical oncology was consulted for further management, and the patient was started on Gemcitabine and Abraxane, with an outpatient follow-up on a regular basis.
A 65-year-old man with a progressive lung GGN in the left upper lobe for six and a half years and no symptoms presented to our hospital. The patient had a past clinical diagnosis of tuberculosis in the right upper lobe, and the pGGN (14 × 13 mm) was found on 25 February 2013 (Fig. , A2). Right upper lung lesion was partly absorbed after anti-tuberculosis treatment for nine months. Unfortunately, the shadow on the right upper lobe increased and was found on repeated chest CT on 21 June 2015 (Fig. , B2), and was diagnosed as squamous cell carcinoma through CT-guided lung biopsy. The patient underwent right upper lobe resection and lymph node dissection on 20 July 2015. The post-operative diagnosis was moderately differentiated squamous cell carcinoma, T2aN0M0 Ib. No recurrence of lung cancer in whole body was confirmed based on the results of 11 repeated CT scans taken from 23 October 2015 to 4 December 2019, but the size of pGGN gradually increased and the density progressively became solid without any change after antibiotic treatment (Fig. ). This increased shadow was considered as adenocarcinoma without any positive finding by bronchoscope. Eventually, the ground-glass shadow on the left upper lobe was diagnosed as extranodal marginal zone lymphoma of the MALT by CT-guided needle biopsy on 13 December 2019 with pathological immunohistochemistry showing CD20 (+), CD3 cells (+), CD10 (−), bcl-6 (−), bcl-2 (+), CD21, CD23 cells (+), mum-1 (+), CK epithelial cells (+), Ki-67 5% (+), Pax-5 (+), CyclinD1 (−), sox-11 (−), and CD5 few (+) (Fig. ). After reviewing his medical history again, the patient underwent three gastroscopies due to intermittent abdominal pain and melaena from 6 June 2017 to 19 September 2018. Finally, he was diagnosed with MALT lymphoma with immune phenotype showing CD3 (−), CD5 (−), CD10 (−), Ki-67 (3% +), CD20 (+ + +), and CyclinD1 (−) (Fig. ; note: low-grade malignant). But, he had no further therapy and follow-up after anti-HP treatment for one month. The patient was diagnosed with coexisting lung squamous cell carcinoma combined with pulmonary MALT lymphoma and was transferred to the Department of Hematology in our hospital for further treatment after the pGGN was first discovered more than six years ago.