An 83-year-old male with past medical history of mild Alzheimer's dementia, nonischemic cardiomyopathy, aortic regurgitation, and an ascending aortic aneurysm measured at 4.1 cm presented to the pulmonology clinic with an abnormal CT of the chest. He was seen by his PCP recently for follow-up of ascending aortic aneurysm and had a CT chest without contrast performed which showed 14.8 mm pleural-based nodular density in the posterior medial right upper lobe, irregular 20.5 mm right lower lobe nodule, and a 2 mm left upper lobe partially calcified nodule []. He had no respiratory or constitutional symptoms. He was a lifelong nonsmoker without any significant occupational exposures. [18F]Fluorodeoxyglucose-positron emission tomography with CT (18F –FDG PET/CT) was performed showing multiple 18F –FDG avid nodules in the right upper lobe, right lower lobe, and left upper lobe []. Initially thought to be inflammatory in nature, a 3-month follow-up CT chest was recommended; however, the patient opted for CT-guided transthoracic biopsy. Because the tissue sample was a core needle biopsy of a pleural-based nodule, it did not include any bronchial epithelium; therefore, the presence of lymphoepithelial lesions could not be evaluated. Immunohistochemical staining showed CD20 positive neoplastic B cells with CD3 positive small benign T cells. CD21 stain was also positive within the residual dendritic cell network, such that the marginal zones appeared to be expanded. These findings support a histopathologic diagnosis of low-grade B-cell NHL most consistent with marginal zone lymphoma []. The patient was referred to oncology for further management.
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.