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Endobronchial Nodules: A Rare Manifestation of Non-Hodgkin’s Lymphoma
Pulmonary Manifestations of Systemic Disease SESSION TITLE: Fellow Case Report Slide: Pulmonary Manifestations of Systemic Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 23, 2016 at 10:45 AM - 12:00 PM
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Endobronchial Nodules: A Rare Manifestation of Non-Hodgkin’s Lymphoma Gurminder Dhillon MD*; and Andrew Zane MD MCW, Milwaukee, WI INTRODUCTION: Lymphoma may involve the lung. Pulmonary manifestations of lymphoma typically involve the lung parenchyma. Endobronchial disease is rarely seen. We present a case of non-Hodgkin’s lymphoma, follicular subtype, with diffuse pulmonary parenchyma and endobronchial involvement. CASE PRESENTATION: A 63-year-old Caucasian female with a history of mycobacterium avium-intracellulare (MAI) infection who is 2 years status post 18 months of usual treatment is referred to the pulmonary department for progressive dyspnea and abnormal chest CT findings. Within the past year, she was diagnosed with follicular lymphoma after an abnormal routine mammogram followed by lymph node excision and bone marrow biopsy. Due to the absence of bulky disease, treatment was not initiated and she was followed by routine surveillance. CT chest for evaluation of her dyspnea was significant for bilateral diffuse nodular parenchymal opacities, endobronchial nodularity with associated bronchial narrowing, and absence of mediastinal lymphadenopathy. Because of these findings with the lack of systemic involvement, lymphoma was thought to be less likely and bronchoscopic evaluation was pursued. Bronchoscopy showed numerous scattered endobronchial polypoid nodules with near complete obstruction of the right upper lobe junction. Microbiological studies on bronchoalveolar lavage specimen were negative, including fungal and mycobacterial cultures. Endobronchial biopsy was positive for follicular lymphoma, consistent with the patient’s known history. The patient was initiated on RCHOP chemotherapy with plans for follow up bronchoscopy to document resolution. DISCUSSION: Lymphoma with endobronchial involvement is rare. Recognition is crucial given its capacity to obstruct the airways. What makes our case more intriguing is the extent of pulmonary parenchyma and tracheobronchial tree disease with absence of mediastinal lymph node involvement. Anecdotal cases show implementation of chemotherapy typically leads to a robust therapeutic response with near resolution of endobronchial lesions. CONCLUSIONS: The pulmonary manifestations of lymphoma can mimic other disease entities and lead to life-threatening complications secondary to endobronchial obstruction. Given its tendency for near resolution with institution of chemotherapy, keeping a wide differential is important when approaching patients with endobronchial lesions. Reference #1: Mcrae, W.m., C.s. Wong, and G.m. Jeffery. Endobronchial Non-Hodgkin’s Lymphoma. Respiratory Medicine 92.7 (1998): 975-77. Web. DISCLOSURE: The following authors have nothing to disclose: Gurminder Dhillon, Andrew Zane No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1171
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
1064A
[
150#4S CHEST OCTOBER 2016
]
PULMONARY MANIFESTATIONS OF SYSTEMIC DISEASE
Endobronchial Nodules: A Rare Manifestation of Non-Hodgkin’s Lymphoma Gurminder Dhillon MD*; and Andrew Zane MD MCW, Milwaukee, WI INTRODUCTION: Lymphoma may involve the lung. Pulmonary manifestations of lymphoma typically involve the lung parenchyma. Endobronchial disease is rarely seen. We present a case of non-Hodgkin’s lymphoma, follicular subtype, with diffuse pulmonary parenchyma and endobronchial involvement. CASE PRESENTATION: A 63-year-old Caucasian female with a history of mycobacterium avium-intracellulare (MAI) infection who is 2 years status post 18 months of usual treatment is referred to the pulmonary department for progressive dyspnea and abnormal chest CT findings. Within the past year, she was diagnosed with follicular lymphoma after an abnormal routine mammogram followed by lymph node excision and bone marrow biopsy. Due to the absence of bulky disease, treatment was not initiated and she was followed by routine surveillance. CT chest for evaluation of her dyspnea was significant for bilateral diffuse nodular parenchymal opacities, endobronchial nodularity with associated bronchial narrowing, and absence of mediastinal lymphadenopathy. Because of these findings with the lack of systemic involvement, lymphoma was thought to be less likely and bronchoscopic evaluation was pursued. Bronchoscopy showed numerous scattered endobronchial polypoid nodules with near complete obstruction of the right upper lobe junction. Microbiological studies on bronchoalveolar lavage specimen were negative, including fungal and mycobacterial cultures. Endobronchial biopsy was positive for follicular lymphoma, consistent with the patient’s known history. The patient was initiated on RCHOP chemotherapy with plans for follow up bronchoscopy to document resolution. DISCUSSION: Lymphoma with endobronchial involvement is rare. Recognition is crucial given its capacity to obstruct the airways. What makes our case more intriguing is the extent of pulmonary parenchyma and tracheobronchial tree disease with absence of mediastinal lymph node involvement. Anecdotal cases show implementation of chemotherapy typically leads to a robust therapeutic response with near resolution of endobronchial lesions. CONCLUSIONS: The pulmonary manifestations of lymphoma can mimic other disease entities and lead to life-threatening complications secondary to endobronchial obstruction. Given its tendency for near resolution with institution of chemotherapy, keeping a wide differential is important when approaching patients with endobronchial lesions. Reference #1: Mcrae, W.m., C.s. Wong, and G.m. Jeffery. Endobronchial Non-Hodgkin’s Lymphoma. Respiratory Medicine 92.7 (1998): 975-77. Web. DISCLOSURE: The following authors have nothing to disclose: Gurminder Dhillon, Andrew Zane No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.1171
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
1064A
[
150#4S CHEST OCTOBER 2016
]