Synchronic Diagnosis of Non-Hodgkin Lymphoma and Lung Adenocarcinoma via EBUS-guided TBNA.

Abstract

To the Editor: Synchronous lymphoma and lung cancer is uncommon. Reported cases were diagnosed by surgical specimens from the lungs and/or lymph nodes. This is the first reported case of a synchronic diagnosis of Mantle cell lymphoma and lung adenocarcinoma made by endobronchial ultrasound guidance transbronchial needle aspiration (EBUS-TBNA) sampling and cytology processing. A 61-year-old man, former smoker, asymptomatic, recently diagnosed Mantle cell lymphoma (not on treatment) presented for evaluation of an incidentally found lung nodule. Positron emission tomography-computed tomography imaging showed a 2.8×3 cm speculated lung nodule in the right upper lobe suggestive of a primary lung cancer, as well as a 1.8 cm lower right paratracheal lymph node. Both were fluorodeoxyglucose (FDG) avid with standardized uptake value maximum of 14.7 and 15.1, respectively (Fig. 1). Patient underwent bronchoscopy with EBUS-TBNA for staging with the specimens sent for cytology and flow cytometry evaluation. The cytology specimen taken from the lower right paratracheal lymph node was positive for both metastatic adenocarcinoma and Mantle cell B cell non-Hodgkin lymphoma (NHL) (Fig. 2). The patient received treatment for both primary tumors.FIGURE 1: PET-CT scan (transverse section) showing FDG uptake in lung nodule and lower right paratracheal lymph node. FDG indicates fluorodeoxyglucose; PET-CT, positron emission tomography-computed tomography.FIGURE 2: Adenocarcinoma CK7 positive cells and B lymphocyte CK20 positive cells on same cytology specimen.Mantle cell lymphoma is one type of mature B cell NHL constituting about 7% of adult NHL in the United States and Europe1 and has a median survival of 9 years. Most patients have advanced stage disease by the time they are diagnosed (70%). Although around 75% of patients initially present with lymphadenopathy. Lung adenocarcinoma is the most common form of lung cancers consisting 40% of all lung cancers in the United States. Most cases of adenocarcinoma are strongly associated with smoking, usually peripherally located originating from the “goblet cells” which are the mucus producing glands of the lung with a high tendency for early metastasis. Previous case reports have shown synchronous primary tumors (lymphoma and carcinoma) originating at the lungs, requiring surgical biopsies to clarify diagnosis. Examples are synchronous pulmonary adenocarcinoma and mucosa-associated lymphoid tissue seen in the same specimen diagnosed after superior lobectomy2; and a case of synchronous lung adenocarcinoma and pleural mucosa-associated lymphoid tissue3 diagnosed after surgical bullectomy and pleurectomy. Fine needle aspiration technique (either transthoracic or EBUS-guided TBNA), includes the use of 19 to 23-G needle. These samples can be processed as histologic or cytologic specimens, as well as for evaluation by flow cytometry. Studies proved that morphology alone is not enough for accurate diagnosis of NHL as different types may have similar morphology yet different cells of origin emphasizing the importance of combined cytology and flow cytometry as the mainstay for diagnosis with a sensitivity ranging 75% to 99% and a specificity ranging 87% to 100%.4 EBUS-TBNA sampling has a sensitivity of 84% to 88% in the diagnosis of lymphoma.5 As opposed to the conventional method of sampling for the diagnosis of NHL usually performed by surgical resection of tissue specimen via excisional biopsy, our case is the first reported case with EBUS-TBNA (as per our knowledge) illustrating the diagnosis of both metastatic adenocarcinoma from a primary lung cancer and mantle cell lymphoma from the same lymph node specimen processed by cytology only. Synchronic diagnosis of lung adenocarcinoma and Mantel cell lymphoma (NHL) can be made with EBUS-TBNA sampling and cytology processing. George Samuel, MD* Michael Simoff, MD*† Said Chaabaan, MD*† Javier Diaz-Mendoza, MD*†*Henry Ford Hospital†Wayne State University School of Medicine Detroit, MI