An 83-year-old male with past medical history of mild Alzheimer's dementia, nonischemic cardiomyopathy, aortic regurgitation, and an ascending aortic aneurysm measured at 4.1 cm presented to the pulmonology clinic with an abnormal CT of the chest. He was seen by his PCP recently for follow-up of ascending aortic aneurysm and had a CT chest without contrast performed which showed 14.8 mm pleural-based nodular density in the posterior medial right upper lobe, irregular 20.5 mm right lower lobe nodule, and a 2 mm left upper lobe partially calcified nodule []. He had no respiratory or constitutional symptoms. He was a lifelong nonsmoker without any significant occupational exposures. [18F]Fluorodeoxyglucose-positron emission tomography with CT (18F –FDG PET/CT) was performed showing multiple 18F –FDG avid nodules in the right upper lobe, right lower lobe, and left upper lobe []. Initially thought to be inflammatory in nature, a 3-month follow-up CT chest was recommended; however, the patient opted for CT-guided transthoracic biopsy. Because the tissue sample was a core needle biopsy of a pleural-based nodule, it did not include any bronchial epithelium; therefore, the presence of lymphoepithelial lesions could not be evaluated. Immunohistochemical staining showed CD20 positive neoplastic B cells with CD3 positive small benign T cells. CD21 stain was also positive within the residual dendritic cell network, such that the marginal zones appeared to be expanded. These findings support a histopathologic diagnosis of low-grade B-cell NHL most consistent with marginal zone lymphoma []. The patient was referred to oncology for further management.
A 63-year-old man presents with a 4-year history of progressive exertional dyspnea and a recurrent productive cough producing white or yellowish sputum. He has a smoking history of 40 pack-years and stopped 4 months ago. He had been admitted to the local hospital many times and received a diagnosis of “COPD with lung abscess.” He was treated with antibiotics, which eased the symptoms. A chest CT showed emphysematous changes throughout and a solitary cavity in the left lower lobe (Fig. A and B). For the recurring symptom, he was referred to our hospital for the further diagnosis and treatment.\nVital signs were normal, and significant physical examination findings included the following: a barrel chest and the breathing sounds with widely dry rales in lung bilaterally. Significant laboratory findings on admission included the following: WBC count, 4.12 ×109/L (48.8% neutrophils and 40.5% lymphocytes); serum tumor makers: CA125 90.56U/mL (normal range <35U/mL), LTA 5.30ng/mL (normal range <3 ng/mL). Spirometry showed an FEV1 of 1.43L (54.3% predicted) and an FEV1/FVC of 61.4%. Arterial blood gas on room air showed a pH of 7.40, Pco2 of 48 mm Hg, and Po2 of 72 mm Hg. Renal function, electrolytes, and coagulation studies were within normal limits. The chest enhanced CT scan is shown in Figure C and D.\nThe patient was started on empiric antibiotic therapy with Ciprofloxacin for yellowish sputum and the cavity of the left lower lobe. Sputum culture showed Escherichia coli, and the antibiotics was not changed. The patient underwent fiberoptic bronchoscopy, which revealed no remarkable findings (data not shown). In spite of that, endobronchial biopsies of bronchus in the left lower lobe were obtained and histological examination showed a diffuse infiltrate of lymphocytes (Fig. A). Immunocytochemically, the lymphoid cells stained positive for CD20 (Fig. B) and Ig Κ (Fig. C), but negative for CD21, CD10, CD3, CD23, and CyclinD1 (data not shown). The positive rate of Ki67 was < 5% (Fig. D). Further, the PCR-based analysis showed IGH, IGΚ gene rearrangement (Fig. ). Afterward, the patient underwent abdominal CT scan, lymph node of neck color Doppler ultrasound, and bone marrow biopsy, which were negative. But he refused to take esophagogastroduodenoscopy, because he had received the exam which was also negative a few months ago in the local hospital. Finally, the patient was diagnosed COPD with pulmonary MZBL of MALT type and treated with CHOP (cyclophosphamide, adriamycin, vincristine, and prednisone) chemotherapy for twice and antibiotics. He is being followed-up for 1 year, with slight progress in pulmonary MZBL of MALT.