A RARE PRESENTATION OF PRIMARY PULMONARY EXTRANODAL DIFFUSE LARGE B CELL LYMPHOMA

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Diffuse large B cell lymphoma (DLBL) is a common subtype of non-Hodgkin’s lymphoma (NHL) that usually presents with rapidly expanding lymphadenopathy. Here we present an unusual case of DLBL with a primary extra-nodal pulmonary presentation. CASE PRESENTATION: A 91-year-old female presented to her PMD for evaluation of a non-productive cough of several weeks’ duration. She had no prior history of pulmonary disease, was a never smoker, and was independent. She denied recent travel, pets, or known sick contacts and was up-to-date with pneumonia vaccinations. Complete blood counts and routine serum chemistries were unremarkable. She returned three months later with continued non-productive cough as well as generalized fatigue and intermittent chills. She was prescribed benzonatate and doxycycline for management of bronchitis. A CXR was ordered which showed a 4.5 cm right hilar opacity. CXR performed one year prior was unremarkable. She was referred for pulmonary consultation. CT chest showed a right upper lobe 4.8 x 5.9 cm mass, a left lower lobe 2.1 x 2.3 cm mass, right pleural thickening, and right cardiophrenic adenopathy measuring 2.0 x 1.2 cm. A navigational bronchoscopy with biopsy demonstrated a mass partially occluding right upper lobe bronchus and biopsy was consistent with DLBL. PET-CT revealed multiple areas of hypermetabolic activity in the abdomen, pelvis, and chest with multiple pulmonary masses, the most superior of which occluded the right upper lobe bronchus, as well as extensive pleural disease. She was started on a non-anthracycline chemotherapy regimen within two weeks of diagnosis. DISCUSSION: Primary NHL of the lung is rare, accounting for 0.4% of all malignant lymphomas. DLBL is an uncommon subtype within that group. Symptoms are non-specific, as are associated radiologic findings, making initial diagnosis difficult. Fine needle aspiration of DLBL usually obtains insufficient material to evaluate the architecture of the lymphoma for diagnosis. The majority of patients require invasive diagnostic biopsies to provide adequate tissue for evaluation. Several studies have shown that cell marker studies using bronchoalveolar lavage may be useful. Prompt initiation of treatment is necessary as DLBL of the lung has a worse prognosis than the more common MALT lymphoma of the lung. However, some studies report survival rates as high as 86% at three years for primary NHL of the lung. CONCLUSIONS: DLBL is a common NHL subtype that rarely manifests with primary pulmonary presentation masquerading as a primary lung malignancy. Given the non-specific clinical presentation, non-specific radiologic findings, and overall rarity, initial diagnosis is difficult, making prompt treatment a challenge. Further research is warranted to better diagnose and prognosticate primary DLBL of the lung. Reference #1: Teras, L. R., DeSantis, C. E., Cerhan, J. R., Morton, L. M., Jemal, A. and Flowers, C. R. (2016), 2016 US lymphoid malignancy statistics by World Health Organization subtypes. CA: A Cancer Journal for Clinicians, 66: 443-459. https://doi.org/10.3322/caac.21357 Reference #2: Kandori S, Kojima T, Nishiyama H. The updated points of TNM classification of urological cancers in the 8th edition of AJCC and UICC. Jpn J Clin Oncol. 2019; Reference #3: Kurtin PJ, Myers JL, Adlakha H, et al. Pathologic and clinical features of primary pulmonary extranodal marginal zone B-cell lymphoma of MALT type. Am J Surg Pathol. 2001;25(8):997-1008. DISCLOSURES: No relevant relationships by Joseph Berman, source=Web Response No relevant relationships by Miguel Conde, source=Web Response No relevant relationships by Kristin Fless, source=Web Response No relevant relationships by Vagram Ovnanian, source=Web Response No relevant relationships by Killol Patel, source=Web Response