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 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.