The patient is a 63-year-old man with a past medical history of MALToma of the lung who presented with generalized weakness for the past one month associated with cough, fever, night sweats, and shortness of breath. The patient also had anorexia and weight loss of 15 pounds over one month. He denied a history of smoking. The patient was under treatment with isoniazid and pyridoxine for latent tuberculosis based on a positive skin tuberculin test.\nOn physical examination, his blood pressure was 110/59 mmHg, heart rate 118 beats per minute (bpm), respiratory rate 18/min, saturating 99% on room air with a temperature of 98.9oF. The patient was in no cardiopulmonary distress. A cardiovascular examination revealed no jugular venous distension, normal S1-S2, and no murmurs. On lung auscultation, the patient had rales at the left lung base.\nLaboratory data showed sodium 134 mEq/L, potassium 4.2 mEq/L, chloride 103 mEq/L, bicarbonate 25 mEq/L, blood urea nitrogen 17 mg/dl, creatinine 0.9 mg/dl, glucose 96 mg/dl, hemoglobin 6.6 g/dl, hematocrit 20.1%, white blood cell count 5.5 x 103/microliter, and platelets 128 x 103/microliter. The coagulation profile showed prothrombin time (PT) 17.2 sec, partial thromboplastin time (PTT) 44.3 sec, and international normalized ratio (INR) 1.38.\nChest X-ray (CXR) and computed tomography (CT) scan showed right middle lobe opacity (Figures -). Repeat imaging after six months showed multiple masses in the lung and an osteoblastic bone lesion involving the left ilium (Figures -). Esophagogastroduodenoscopy showed a normal gastro-esophageal junction with erythematous mucosa in the stomach. The gastric biopsy was normal.\nA lung biopsy done at initial presentation from the right middle lobe mass showed dense lymphoid infiltrate with proliferation of monocytoid B lymphocytes consistent with extranodal marginal zone lymphoma (BALToma/MALToma).\nA CT-guided core needle biopsy from the left posterior pelvic mass that was noted six months after the initial presentation showed high grade diffuse large B-cell lymphoma involving skeletal muscles. The pathology report showed diffuse proliferation of lymphocytes, which were positive for cluster of differentiation (CD) 20 and B-cell lymphoma (BCL)-2 by immunohistochemistry tests. He was started on chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) with subsequent complete clinical and radiologic remission (Figure ).
A previously healthy 19-year-old female of Asian ethnic origin, visited our hospital for an evaluation of abnormal chest CT findings on routine physical examination. On admission the patient was asymptomatic, without fever, cough, lymphadenopathy, night sweats or weight loss. As shown in , the patient had normal complete blood count. Additional tests revealed minimally elevated erythrocyte sedimentation rate. The antinuclear antibody test was negative. The levels of lactate dehydrogenase, β2 microglobulin and liver function tests were normal. The tests for tuberculosis, human immunodeficiency virus and other viruses, including hepatitis A, B and C, were all negative. The spleen and liver were of normal size and echogenicity. Spiral lung CT revealed bilateral multiple pulmonary consolidations, with the largest lesion sized ~4.5×4.5 cm (). Bone marrow aspiration was negative for lymphoma involvement. The patient underwent CT image-guided biopsy and the diagnosis of pMALToma was confirmed. The microscopic examination revealed lymphoepithelial lesions characterized by diffuse infiltration of the lung parenchyma by small lymphocytes, monocytoid cells and plasma cells (). Immunohistochemical staining demonstrated that the cells were positive for CD20 and B-cell lymphoma 2 protein, with 10% nuclear staining for Ki-67. According to the pathological findings, the patient was treated with 6 courses of chemotherapy with 2 mg vincristine, 4 mg/day chlorambucil plus 30 mg/day prednisolone for 7 days. After 2 cycles of chemotherapy, all the pulmonary lesions were significantly reduced in size (). Complete remission of the lung consolidations was observed following 6 cycles of treatment, as visualized by CT scan (). Fifteen months after the last course of chemotherapy, the patient was in good condition without any evidence of relapse. The patient remains in follow-up.