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 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.