A 35-year-old woman was found to have a few shadows with GGOs on chest CT in 2012. She was monitored and a shadow in right S10 was found to increase in size, which suggested lung adenocarcinoma. The patient was referred to our hospital for further evaluation. The patient had a history of bronchial asthma. The shadow in right S10 had increased to 14 × 8 mm by 2015 (Fig. ). Other shadows also appeared (Fig. ). After preoperative CT-guided marking, the patient underwent video-assisted thoracoscopic surgery with a right wedge resection of the lower lobe that included the largest nodule in S10 and other nodules. Her postoperative course was uneventful.\nGrossly, the surgical specimen contained pale, somewhat yellow lesions (Fig. ). Histopathological examination of the right S10 lesion and other nodules revealed small- or medium-sized lymphocyte-like cells that were located in the alveolar interseptal spaces. The alveolar walls remained intact (Fig. , ). Immunohistochemical staining showed that tumor cells were positive for CD20 (1:400 dilution; DAKO, Carpinteria, CA, USA, Fig. ), CD79a (1:200 dilution; DAKO, Carpinteria, CA, USA), and BCL2 (1:50 dilution; DAKO, Carpinteria, CA, USA, Fig. ) expression and negative for CD10 (1:50 dilution; Novocastra, Newcastle upon Tyne, UK), cyclin D1 (1:75 dilution; DAKO, Carpinteria, CA, USA) and CD30 (1:40 dilution; DAKO, Carpinteria, CA, USA). The lesions were diagnosed as extranodal marginal zone B-cell lymphoma of MALT. The patient has remained well during 12 months of follow up after surgery. Although she did not receive chemotherapy because the MALT lymphoma lesions have been stable without progression, the patient is kept under close observation because of potential progression of the disease.
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.