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.
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.