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.
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.