Tumors in the tracheobronchial tree are rare and the vast majority of them are malignant tumors such as squamous cell carcinoma (1). A localized endobronchial mass is a far less common pattern of endobronchial Non-Hodgkin’s lymphoma (NHL) as compared to the diffuse distribution pattern (2). We report here on a case of endobronchial NHL that presented as a localized polypoid mass.
Case Report
An 82-year-old man was admitted due to 1-month his- tory of blood tinged sputum, dyspnea and cough. Night sweats, fevers, weight loss, fatigue and chest pain were not reported at the initial presentation. The patient had a medical history of hypertension that was diagnosed 6
months earlier and this was treated with antihyperten- sive drug. He is a smoker with a 30-pack-year history and had no familial history of lung disease or cancer.
The findings of the basic laboratory investigations such as a complete blood count and the blood chemistry tests were unremarkable.
A chest radiograph showed a left hilar mass accompa- nied by atelectasis of the left upper lobe (Fig. 1A). He underwent a CT scan of the chest (Asteion, Toshiba, Tokyo, Japan), which demonstrated an intraluminal polypoid protruding mass that measured 2 × 1 cm with homogeneous enhancement in the left upper lobe bronchus and nearly total collapse of the left upper lobe (Fig. 1B). The focal areas of ground-glass opacity with reticulation in the posterobasal segment of the left lower lobe were regarded as focal pneumonia. Slightly en- larged lymph nodes were present in the left upper para- tracheal, right lower paratracheal, paraaortic and subaortic areas and both the lower paratracheal and left hilar areas (Fig. 1C). Multifocal areas of centrilobular and paraseptal emphysema with bullae in both lungs were also noted.
Bronchoscopy revealed a fleshy polypoid mass ob-
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Non-Hodgkin’s Lymphoma Presenting as an Endobronchial Polypoid Mass: A Case Report1
Ji-Yeon Han, M.D., Ki-Nam Lee, M.D., Mee-Sook Roh, M.D.
2, Woo-Jung Kim, M.D.
1Department of Radiology, Dong-A University College of Medicine, Busan, Korea
2Department of Pathology, Dong-A University College of Medicine, Busan, Korea
Received July 22, 2010 ; Accepted October 26, 2010
Address reprint requests to : Ki-Nam Lee, M.D., Department of Radiology, Dong-A University College of Medicine, 3-1, Dongdaesin- dong, Seo-gu, Busan 602-715, Korea.
Tel. 82-51-240-5367 Fax. 82-51-253-4931 E-mail: [email protected]
Non-Hodgkin’s lymphoma seldom, if ever, involves the tracheobronchial tree, and it manifests as a diffuse infiltrating pattern with clinically apparent systemic lymphoma.
Endobronchial involvement presenting as an endobronchial polypoid mass is far rarer.
We report here on a case of diffuse large B-cell non-Hodgkin lymphoma that presented as an endobronchial polypopid mass obstructing the central bronchi and this led to lo- bar atelectasis.
Index words : Lymphoma
Non-Hodgkin
Bronchial Neoplasm
Tracheal Neoplasm
structing the left upper lobe bronchus (Fig. 1D).
Bronchoscopic biopsy was performed and histopatho- logical examination showed packed lymphocytes with pleomorphic hyperchromatic nuclei overlying the ciliat- ed pseudostratified columnar epithelium. The cells were CD-20-positive B cells that coexpressed bcl-2 and they showed immunoreactivity for Ki-67 antigen, which was consistent with a diffuse large B-cell non-Hodgkin’s lym- phoma (Fig. 1E).
On the additional staging investigations, PET/CT
showed uptake in the area of the endobronchial mass and regional lymphadenopathies (Fig. 1F). Otherwise, there was no other lymphomatous involvement in the extrathoracic area. The patient was started on 6 cycles of Rituximab with cyclophosphamide, adriamycin, vin- cristine and prednisone (CHOP) chemotherapy for 4 months, which led to complete resolution of the endo- bronchial mass. Follow up chest CT showed a decreased size of all the regional lymphadenopathies.
Discussion
Making the differential diagnosis of an endobronchial mass is difficult because tracheobronchial tumors are
Ji-Yeon Han, et al: Atypical Appearance of Endobronchial Non-Hodgkin’s Lymphoma
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A B
C D
Fig. 1. An 82-year-old man with endobronchial non-Hodgkin’s lymphoma.
A. A chest radiograph showed a left hilar mass (arrow) with obstructive pneumonia of the left upper lobe. Ill-defined increase opac- ity in the left upper lung zone is accompanied by elevation of the left hilum and the left sided juxtaphrenic peak.
B, C. The axial unenhanced (B) and enhanced (C) CT scans obtained at the carinal level show a 2 × 1 cm sized intraluminal pro- truding mass with homogeneous enhancement (arrow) in the left upper lobe bronchus, and this is accompanied by partial atelecta- sis of the left upper lobe and enlarged precarinal lymph nodes.
D. Bronchoscopy reveals a polypoid fleshy mass incompletely obstructing the left upper lobe bronchus (arrow).
rare and diverse in their etiologies. The CT findings of each endobronchial tumor are not specific for determin- ing the origin, yet the disease prevalence and the overall clinical history such as gender, a smoking history and systemic symptoms can help the differentiation. In this case, the patient’s old age, the long smoking history and the relatively short duration of dyspnea without any other systemic symptoms were clues for malignancy, which makes up the vast majority of endobronchial tu- mors. Further, a well enhancing polypoid mass with slightly enlarged lymph nodes raised the suspicion for lung cancer.
Endobronchial lymphoma is thought to be a rare man- ifestation of intrathoracic NHL (3). Intrathoracic NHL most frequently manifests as a mediastinal lym- phadenopathy followed by an intraparenchymal mass and pleural effusion (4). The combined data from 425 cases of tracheal tumor showed only a 0.23% preva- lence of NHL (5). Primary endobronchial involvement is far rarer according to strict criteria that exclude extra- pulmonary disease and adjacent mediastinal lym- phadenopathy (6, 7). Otherwise, some authors have con- sidered the patients with adjacent hilar or mediastinal lymphadenopathy as having a primary pulmonary lym- phoma in the absence of extrathoracic disease (8). This present case is also an extension of those arguments in that the tumor did not show any other extrapulmonary involvement except for mediastinal lymphadenopathy.
For the pathological correlation, two types of endo- bronchial NHL have been proposed. The first type is a
diffuse distribution of submucosal nodules throughout the bronchial tree in the presence of systemic lym- phoma. This is believed to the result of hematogenous or lymphatic spread along the bronchi. The second type is characterized by a localized endobronchial mass asso- ciated with regional lymph node enlargement and at- electasis. The atelectasis might be caused by direct tu- mor extension from the regional lymphadenopathy to the bronchi or retrograde lymph flow from a node ob- structed by tumor (3). Our case presented here is more likely to be classified into the second type as the endo- bronchial mass had close contact with the enlarged hilar lymph nodes and the patient clinically presented with atelectasis of the left upper lobe.
Radiologically it is impossible to distinguish between an endobronchial lymphoma and other tumors present- ing as an isolated mass within the airway. Yet minor ra- diologic manifestations can give some clues to differenti- ate endobronchial lymphoma from other tumors.
Squamous cell carcinoma is the most common primary lung tumor, and this may appear as a polypoid, focal sessile lesion or as irregular wall thickening that some- times distorts the adjacent bronchial wall. Adenoid cys- tic carcinoma tends to grow along the submucosal layer and it displays a circumferential infiltrative pattern.
Mucoepidermoid carcinoma in the tracheobronchial tree is a rare tumor that manifests with intraluminal nodules that occupy the bronchi and they adapt to the features of the airway. Secondary malignant tumors of kidney, colon, breast, melanoma and thyroid cancer
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E F
E. The microscopic photograph shows a diffuse proliferation of atypical lymphocytes with pleomorphic hyperchromatic nuclei overlying the ciliated pseudostratified columnar epithelium (H & E, ×200).
F. PET/CT shows a high metabolic rate in the endobronchial lesion, in both the interlobar and lobar lymph nodes and the lung parenchyma in the left lower lobe. The focal area of ground-glass opacity in the left lower lobe also reveals mild uptake.
may result in localized polypoid nodules (3), while ma- lignancy of the lung, larynx, esophagus and thyroid are more likely to invade directly (1). Hodgkin’s disease can also appear as a solitary mass involving the central air- ways in association with regional adenopathy (3).
Although its CT appearance is insufficient to differenti- ate it from other localized masses, the second type of en- dobronchial NHL has some common characteristics.
Solomonov et al. (8) reported that primary pulmonary NHL that presented as an endobronchial growth also showed lobar atelectasis; two patients had bi-lobar at- electasis and five had atelectasis associated with a medi- astinal mass invading the lobar bronchus. Sabanathan (9) found that the endobronchial lesions of NHL were more frequent in the main bronchi with varying degrees of lobar atelectasis in half of the cases. The additional findings were central opacity that represented mediasti- nal or hilar adenopathy, parenchymal infiltrates and pleural effusion (1, 8). Some authors have recently re- ported cases of an enhancing polypoid soft-tissue mass that obstructed the bronchi (6, 7, 10). Our case was a ho- mogeneously enhancing mass with preserved bronchial architecture and left upper lobe atelectasis, and the addi- tional findings were focal parenchymal infiltrates and regional lymphadenopathy.
In summary, endobronchial involvement is a rare manifestation of NHL, although NHL usually manifests with a diffuse infiltrating pattern (2). If NHL occurs as a localized mass, then it can be recognized as homoge-
neous soft tissue mass that causes atelectasis combined with regional mediastinal adenopathy, as our case demonstrated.
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