A 59-year-old, former smoker, man, presented at the Emergency Department with a sub-acute onset of increasing dyspnea and persistent dry cough. Previous medical history consisted of an occupational exposure to fine dusts and other toxic inhalants (ex pottery maker), and acute myocardial infarction previously treated with PTCA. No symptoms of collagen vascular/autoimmune disease were present.\nAt physical examination, digital clubbing was observed and inspiratory basal crackles were detected. Chest X-rays documented multiple bilateral pulmonary consolidations and a High-Resolution Computed Tomography (HRCT) confirmed the presence of bilateral multiple areas of consolidations with frequent air bronchograms, interlobular septal thickenings and ground-glass opacities (). Imaging was consistent with a crazy paving pattern.\nSputum examination was negative for pathogenic microbes, while pulmonary function tests revealed a moderate restrictive disease (VEMS 66,5%, FVC 61,1%, TLC 56,8%).\nThe post-operative course was unremarkable and the patient was discharged in 4th post-op day. At histology, the lung parenchyma showed nodular lesions characterized by an infiltration monomorphic small lymphocites and plasma-cells obliterating the alveolar spaces () associated with lymphoepithelial lesions (B). At immunohistochemistry, neoplastic lymphocytes show a B-cell clonal phenotype (CD20 immunohistochemistry, Hematoxylin counterstain, 20X (C)); moreover, stain for MIB1 shows a low proliferative index of the neoplastic infiltrate (MIB1 immunohistochemistry, Hematoxylin counterstain, 20X (D)) accounting for 3-5%. The final diagnosis of mucosa-associated lymphoid tissue-derived (MALT) lymphoma was finally made. The patient underwent chemotherapy with Rituximab and Bendamustine, with gradual and progressive improvement of the overall clinical scenario.
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.