原发性肺非霍奇金淋巴瘤三例影像学表现

目的　提高对原发性肺非霍奇金恶性淋巴瘤影像学表现的认识。方法　 3例经病理、临床证实的原发性肺非霍奇金恶性淋巴瘤 ,结合文献对其影像学 (胸部CT及X线片 )特征及病理进行分析讨论。结果　 3例患者均经CT导引肺穿刺切割肺活检获得标本并最终获得病理和免疫组织化学诊断 ,所有 3例在胸片和CT上存在着不同范围的肺实变 ,在所有实变病灶中见空气支气管征。其中 1例除了多个肺叶的实变外 ,在右下肺有一大小为 3.5cm× 3.0cm的肿块 ,在其它肺叶还有多个大小不等的结节 ,并且在肿块及部分结节中见空气支气管征。毛玻璃样改变或间质结构增厚所致的网格条索样改变在大多数肿块、结节和实变的边缘或其它部位存在。所有病灶中无坏死、空洞及钙化存在。无胸膜增厚及胸液。无明显的肺门及纵隔淋巴结肿大。结论　原发性肺非霍奇金恶性淋巴瘤影像学表现具有一定的特征 ,影像学表现有助于该疾病的诊断。经皮穿刺肺活检可有效的获得病理结果。     

伴胸部受累的淋巴瘤25例临床分析

目的 分析伴胸部受累的淋巴瘤的临床特点与诊断方法,以提高其诊断率.方法 回顾性分析2000-2007年北京大学第三医院确诊的有胸肺病变的淋巴瘤患者25例,收集患者确诊前的症状、体征、实验室检查结果、影像学资料、确诊方法和病理诊断.结果 25例患者中位年龄46岁,发热(13例)、6个月内体重减轻10%以上(11例)、咳嗽(10例)、气短(9例)、浅表淋巴结无痛性肿大(16例)是最常见的临床表现.72.7%的患者ESR增快;81%的患者血清乳酸脱氢酶(LDH)升高.25例患者中纵隔肺门淋巴结肿大者16例;影像学显示肺受累15例,包括斑片或实变表现、团块、多发结节、弥漫磨玻璃影、粟粒样病变;另外胸腔积液10例,心包积液4例,胸壁肿物2例;上述表现中有2种以上同时存在的患者18例.胸膜受累患者的胸腔积液外观呈黄色浑浊、血性或乳糜性,黏蛋白试验均阳性,比重1.031,白细胞6.72×10~9/L,淋巴细胞86%,中性粒细胞14%,蛋白31.4g/L,LDH 296 U/L,腺苷脱氨酶(ADA)67.4 U/L.外科手术活检确诊16例,其中浅表淋巴结活检确诊12例;超声或CT引导穿刺活检确诊5例;骨髓穿刺确诊1例;胸腔镜胸膜活检和纵隔镜纵隔肿物活检确诊各1例;经支气管镜黏膜活检确诊1例,而接受支气管镜气道黏膜活检和(或)经支气管肺活检(TBLB)确诊共8例.病理诊断除1例霍奇金淋巴瘤外,其余24例均为非霍奇金淋巴瘤.结论 伴胸部受累的淋巴瘤患者临床表现缺乏特异性,同时存在浅表或纵隔淋巴结肿大较为多见,血清学检查、胸腔积液性质和影像学检查亦有一定特点.浅表淋巴结手术活检是确诊淋巴瘤简便易行的方法;微创活检方法如超声或CT引导下浅表肿物、胸膜、肺、肝、脾、深部淋巴结活检及胸腔镜和纵隔镜胸膜、肺、纵隔病变活检亦具有较好的诊断价值,而经支气管镜获取气道黏膜和肺组织确诊率低.     

A case of CD56 positive T-cell lymphoma originating from mediastinal lymph nodes]

The patient, a 63-year-old man was admitted to our hospital with complaints of high-grade fever and left chest pain. The chest X-ray film taken on admission showed the presence of pleural effusion. The chest CT scan revealed left mediastinal enlargement. Examination of the pleural effusion showed a high concentration of adenosine deaminase (ADA) and the cytological examination showed no malignancy. We diagnosed pleuritis tuberculosa. His general condition worsened in spite of anti-tuberculosis therapy and soluble interleukin-2 receptor (sIL-2R) was elevated. The video-assisted thoracoscopic biopsy was negative. Soon after that the lymph nodes from the left supraclavicular region to the mediastinum became swollen. The diagnosis of peripheral T-cell lymphoma, unspecified (WHO classification) with CD56 expression, was established based on the results of lymph node biopsy and pleural effusion cytology. He was treated with cyclophosphamide/doxorubicin/vincristine/prednisolone (CHOP) chemotherapy. Since two courses of chemotherapy were not effective we changed to carboplatin/ifosfamide/ etoposide/dexamethasone (DeVIC) chemotherapy. His condition improved and a complete response was obtained. In conclusion, the presence of a high level of ADA in the pleural effusion and resistance to anti-tuberculosis therapy should suggest a malignant lymphoma.     

A case of multiple pleural cryptococcosis without pleural effusion

Pulmonary cryptococcosis is most likely to occur in immunocompromised patients. The radiological manifestations generally include pulmonary parenchymal lesions, namely, pulmonary nodules, cavitary lesions, and consolidation; thus, multiple pleural nodules are unusual presentation. Here, we report a woman who presented with multiple pleural cryptococcosis without pleural effusion. The patient had previously undergone surgery for stage II rectal cancer. In addition, she received 6 cycles of chemotherapy for follicular lymphoma. Computed tomography (CT) revealed multiple small nodules involving the pleura without pleural effusion, which suggested possible recurrence of rectal cancer or malignant lymphoma as pleural dissemination. Thoracoscopic examination was performed, and pleural cryptococcosis was diagnosed. Although pleural cryptococcosis without pleural effusion is extremely rare presentation, clinicians should consider it when an immunocompromised patient presents with multiple pleural nodules. Thoracoscopic exploration should be the best procedure for the definitive diagnosis of multiple pleural nodules.     

Pleural effusion in non-Hodgkin's lymphoma.

Intrathoracic non-Hodgkin's lymphoma (NHL) usually presents with roentgenographic evidence of mediastinal lymph node enlargement, pulmonary masses, pleural effusion, and a clinical picture of a systemic disease with lymphadenopathy. The presentation of NHL with pleural effusion as the major roentgenographic abnormality and no clinical peripheral lymphadenopathy or organomegaly is unusual. During a seven-year period, we encountered 19 patients with NHL in whom pleural effusion was the major roentgenographic and clinical finding. Pleural fluid cytologic results were diagnostic in only two patients. Closed pleural biopsy was positive in three. Eight of 11 patients had diagnostic immunophenotypic lymphocyte cell marker studies. Seven of nine patients had diagnostic thoracoscopy and one thoracotomy. The CT scan identified biopsy sites when pleural fluid and tissue studies were nondiagnostic. Lymphomatous tissue was obtained from the pleura in 17 of the 19 patients supporting the contention that pleural effusion in patients with NHL is usually due to pleural lymphoma rather than obstruction to mediastinal lymphatics.     

The clinical assessment of roentgenographically atypical pulmonary sarcoidosis

We studied 89 patients in whom the clinical diagnosis of sarcoidosis was supported by the findings on tissue biopsy. A chest roentgenogram in 14 of the patients showed one of the following atypical features: large pulmonary nodules, an alveolar parenchymal pattern or a pleural effusion.     

A case of pleural effusion in a patient with malignant lymphoma diagnosed by thoracoscopy with local anesthesia]

A 47-year-old woman was admitted for examination of massive right pleural effusion on chest radiography, together with chief complaints of dry cough and body weight loss. Exudative effusion was aspirated by thoracentesis, revealing many lymphocytes and a high level of adenosine deaminase. Thoracoscopy with local anesthesia was performed. Elevated white lesions and miliary nodules were observed, and these lesions were examined by thoracoscopic biopsy, leading to a diagnosis of malignant lymphoma. Treatment with chemotherapy (THP-COP) resulted in partial remission. Thoracoscopy with local anesthesia in cases of pleural effusion with malignant lymphoma can be a safe and useful procedure for diagnosis.     

Clinical examination of resected cases of lung cancer with pleural dissemination

Preoperative examination using chest computed tomography (CT) of cases with pleural dissemination and no pleural effusion revealed small disseminated nodules of the visceral pleura. However, chest CT could not exactly diagnose those of the parietal pleura. The indications of operation, especially pan-pleuropneumonectomy, for cases with pleural dissemination should be limited to the following cases; those in which no pleural effusion and no metastasis to the mediastinal lymphnodes has been clinically proved and in which it is not necessary to perform extensive combined resection other than pan-pleurectomy and partial resection of the diaphragm and/or pericardium. Well differentiated histological types of lung cancer are better indications for surgical treatment.     

Case of malignant lymphoma associated with rheumatoid arthritis]

A 72-year-old woman was admitted to our hospital with exacerbation of dyspnea. She had a history of rheumatoid arthritis (RA) for 26 years, and had been taking methotrexate and prednisolone. Chest radiograph and chest CT revealed marked mediastinal and right axillary lymph node swelling, interstitial shadows and bilateral pleural effusion. A biopsy of the right axillary lymph node for histopathological examination revealed diffuse large B cell lymphoma. The patient achieved complete remission, following 7 cycles of chemotherapy (R-EPOCH). As RA is associated with an increased risk of developing lymphoma, malignant lymphoma must be considered as a possible cause of the mediastinal swelling in a patient with RA.     

A case of malignant lymphoma diagnosed by thoracoscopy with local anesthesia]

A 67-year-old woman was hospitalized with right pleural effusion on chest radiography. Chest CT showed a thickened parietal pleura and pleural effusion in the right thorax. Cytological examination of pleural effusion showed atypical plasma cells. We performed thoracoscopy with local anesthesia for diagnosis and observed an about 5 x 5 cm seized red soft tumor on the parietal pleura. Pathological and immunohistochemical examination of the pleural tumor revealed that it was marginal zone B-cell malignant lymphoma. In this case, we could not reach a diagnosis only by cytological examination of the pleural effusion. Thoracoscopy with local anesthesia was safe and useful for diagnosis of malignant lymphoma with pleural effusion. Most cases of primary pleural malignant lymphoma have a history of chronic pyothorax. This case is thought to be a very rare case of primary pleural malignant lymphoma with no history of pyothorax.     

Propylthiouracil-induced lupus-like or vasculitis syndrome

ABSTRACT: A 27?year old female with Graves' disease presented with fever, exertional dyspnea and polyarthralgia. Erythema nodosum had occured three months earlier. The patient declared irregular use of propylthiouracil (PTU) for the last 8?months. Neutropenia and microscopic hematuria developed in the second week of admission. Chest X-ray showed inhomogenous pulmonary opacities, left pleural effusion and cardiomegaly. Computed tomography (CT) revealed multiple subpleural nodules, left pleural effusion, pericardial effusion, enlarged mediastinal and axillary lymph nodes. Bronchoalveolar lavage (BAL) cytology demonstrated hemosiderin laden macrophages. Histopathologic examination of the transbronchial biopsy specimen revealed a nonspecific inflammation. Serum was positive for ANA, P-ANCA, MPO-ANCA, PR3-ANCA and negative for anti-ds-DNA, C-ANCA, C3, C4 and anti-histone antibody. All symptoms resolved in two months after PTU withdrawal and starting steroid treatment. The same clinical manifestations recurred when the patient used PTU erronously one month after discharge.This is a case of PTU induced-autoimmune disease in whom the accurate distinction between drug-induced-lupus (DIL) and vasculitis was not possible due to the significant overlap of clinical and laboratory findings causing a significant diagnostic challenge for the chest physician.     

Pulmonary small lymphocytic lymphoma (mucosa-associated lymphoid tissue type) associated with pulmonary hyalinizing granuloma

A case of pulmonary hyalinizing granuloma (PHG) and concomitant low-grade, small lymphocytic lymphoma of the lung is presented. This is the first occurrence of pulmonary lymphoma in patients with PHG ever reported. The infiltrates around a left lower lobe nodule with left pleural effusion and thickening seen on chest CT were histologically proven to be lymphomatous infiltrates of the lung, pleura, and chest wall muscle. We believe that the lymphoma developed around the nodule and spread to the pleura and muscle in our patient. When infiltrates around the nodules, pleural effusion, or adenopathy are developed in a patient with proven PHG, close follow-up, biopsy, or careful cytology should be seriously considered to rule out a developing lymphoma.     

Malignant pleural mesothelioma caused by environmental exposure to asbestos in the Southeast of Turkey: CT findings in 117 patients

BACKGROUND AND OBJECTIVES: Malignant pleural mesothelioma (MPM) is reported to be common in the southeast of Turkey, as a result of environmental asbestos exposure. The aim of this study was to evaluate the computed tomography (CT) features of MPM in patients with a history of asbestos exposure. METHODS: The CT scans of 117 patients who had a diagnosis of MPM were retrospectively evaluated. Additionally, CT findings of histologic subtypes were compared. RESULTS: The most common CT findings included pleural effusion (n = 104, 89%), pleural thickening (n = 96, 82%), mediastinal pleural involvement (n = 77, 66%) and interlobar fissural involvement (n = 62, 53%). Histologic subtype analysis was performed in 89 patients; of these, epithelial, sarcomatous and mixed types were identified in 46, 23 and 20 patients, respectively. An analysis of CT findings demonstrated that the involvement of mediastinal pleural (91%), interlobar fissure (87%) and lung parenchyma (48%) was significantly more frequent in sarcomatous type, as compared to epithelial (61% and p < 0.01; 35 and 4%, p < 0.0001, respectively) and mixed types (65% and p < 0.05; 10% and p < 0.0001; 10% and p < 0.01, respectively). Furthermore, there was a significant correlation between pericardial involvement and chest wall involvement (r = 0.42, p < 0.05) in sarcomatous type. Similarly, lymphadenopathy and parenchymal involvement (r = 0.23, p < 0.02), pericardial and chest wall involvement (r = 0.25, p < 0.01), chest wall and interlobar fissural involvement (r = 0.25, p < 0.01) were significantly correlated, when CT findings of all histologic subtypes were combined. CONCLUSIONS: These results suggest that although CT findings of MPM vary, they may provide valuable clues to the diagnosis, at least in patients with a history of asbestos exposure. In addition, the presence of extensive lesions may suggest MPM of sarcomatous subtype.     

原发性肺隐球菌病12例临床分析

目的探讨免疫功能无异常的原发性肺隐球菌病患者cT征象及CT引导下经皮肺穿刺活检在诊断中的价值。方法回顾性分析浙江大学医学院附属邵逸夫医院经病理证实的12例原发性肺隐球菌病患者的临床资料。结果（1）12例患者的CT征象均为单肺叶发病,其中单发结节4例,局限性多发混杂的结节和（或）肿块和（或）肺实变8例,此外还可见支气管充气征／小泡征（9例）、空洞（2例）和“晕”征（4例）。（2）9例行CT引导下经皮肺穿刺活检,其中7例病理学确诊。（3）12例患者中7例行手术切除,术后2例行氟康唑治疗,余5例未用药,其中1例术后5个月发生隐球菌性脑膜炎;另5例用氟康唑治疗。结论免疫功能无异常者时有发生肺隐球菌病的可能;肺隐球菌病的临床症状与影像学表现明显不相称;大多数肺隐球菌病的CT主要征象为局限性多发混杂的结节和（或）肿块和（或）肺实变,如同时有支气管充气征／小泡征、晕征,则具有特征性;尽早采用CT引导下经皮穿刺活检将有助于该病的早期诊断;氟康唑治疗该病效果好,有助于预防严重并发症的发生。     

The overlap phenotype: the (missing) link between asthma and COPD

A 27?year old female with Graves’ disease presented with fever, exertional dyspnea and polyarthralgia. Erythema nodosum had occured three months earlier. The patient declared irregular use of propylthiouracil (PTU) for the last 8?months. Neutropenia and microscopic hematuria developed in the second week of admission. Chest X-ray showed inhomogenous pulmonary opacities, left pleural effusion and cardiomegaly. Computed tomography (CT) revealed multiple subpleural nodules, left pleural effusion, pericardial effusion, enlarged mediastinal and axillary lymph nodes. Bronchoalveolar lavage (BAL) cytology demonstrated hemosiderin laden macrophages. Histopathologic examination of the transbronchial biopsy specimen revealed a nonspecific inflammation. Serum was positive for ANA, P-ANCA, MPO-ANCA, PR3-ANCA and negative for anti-ds-DNA, C-ANCA, C3, C4 and anti-histone antibody. All symptoms resolved in two months after PTU withdrawal and starting steroid treatment. The same clinical manifestations recurred when the patient used PTU erronously one month after discharge. This is a case of PTU induced-autoimmune disease in whom the accurate distinction between drug-induced-lupus (DIL) and vasculitis was not possible due to the significant overlap of clinical and laboratory findings causing a significant diagnostic challenge for the chest physician.     

分子生物学假阳性致肺癌性淋巴管炎误诊为肺结核的临床诊治过程分析

2019年4月17日,武汉市肺科医院呼吸科收治1例69岁男性因外院结核分子生物学阳性诊断为肺结核的肺癌性淋巴管炎患者。该患者因“发现肺部阴影3个月,间断咳嗽2个月”入院。既往有结肠癌病史。胸部CT扫描显示双肺弥漫性沿支气管血管束分布结节伴磨玻璃影,伴小叶间隔增厚,双肺门及纵隔淋巴结肿大,双侧胸腔积液,在外院行肺泡灌洗液(BALF)GeneXpert MTB/RIF(简称“ GeneXpert”)检出MTB(极低)及TB-PCR检出MTB,诊断为肺结核,转诊至武汉市肺科医院。入院后完善结核相关检查,PPD皮肤试验阴性,γ干扰素释放试验阴性,胸部CT影像学特征不符合肺结核改变,临床怀疑BALF结核病病原分子生物学检测假阳性,建议患者复查BALF、GeneXpert及经气管镜超声引导针吸活检术(EBUS-TBNA),患者拒绝。给予诊断性胸腔穿刺,抽出胸腔积液20ml,送检显示,癌胚抗原(118.4μg/L)明显升高,提示恶性胸腔积液;最后行内科胸腔镜胸膜活检,提示转移性低分化腺癌,结合胸部CT表现,诊断为肺癌性淋巴管炎。患者后因病情恶化死亡。笔者认为,影像学表现为沿支气管血管束分布结节伴小叶间隔增厚及纵隔淋巴结肿大时需鉴别肺癌性淋巴管炎。影像学表现与肺结核不相符时,分子生物学阳性诊断肺结核需谨慎,以避免误诊误治。     

The surprising outcome of a giant primary mediastinal synovial sarcoma treated with neoadjuvant chemotherapy

There are only a few cases of primary mediastinal synovial sarcoma in the literature. Normally, they do not respond well to chemotherapy. In our case, a 30-year-old patient was admitted due to thoracic pain, dyspnea, orthopnea, cough, hoarseness and weight loss over a 3-month period as well as a dramatic worsening a week before the admission. A chest radiography showed a completely white left hemithorax and contralateral mediastinal shift; in addition, a chest tomography revealed a giant heterogeneous mediastinal mass, lung atelectasia and a small pleural effusion. The patient was submitted to Chamberlain procedure (biopsy) under local anesthesia and the diagnosis of a synovial sarcoma was obtained after immunohistochemical analysis. Due to his poor general condition, he received chemotherapy first, with a dramatic response, after what, the mass that had been reduced was removed surgically. After a 5-year- follow-up period there are no signs of disease recurrence.KEY WORDS : Sarcoma, synovial, chemotherapy, adjuvant, mediastinum, pleural effusion, thoracic surgery     

Case of malignant lymphoma arising from the posterior mediastinum, with pleural effusion]

We report a rare case of malignant lymphoma arising from the posterior mediastinum with bilateral pleural effusion. A 71-year-old man was admitted to our hospital for evaluation of a posterior mediastinal tumor and bilateral pleural effusion revealed on a chest CT scan. Because no tumor tissue could be obtained by fiberbronchoscopy, video-assisted thoracoscopic surgery was performed. The tumor sample was composed of large, atypical lymphocytes positive for CD20 on immunohistochemical analysis. A diagnosis of diffuse large B cell lymphoma was made from the typical histological features. The patient was treated with combination chemotherapy (CHOP) and rituximab and improved dramatically.     

Primary pleural non-Hodgkin's lymphoma without chronic pyothorax]

Most cases of primary pleural malignant lymphoma develop following chronic pyothorax. We report a case of primary pleural non-Hodgkin's lymphoma without chronic pyothorax. A 63-year-old woman was referred and admitted to our hospital with a right pleural effusion that was detected during a routine physical checkup. Her liver, spleen, and superficial lymph nodes were not palpable on physical examination. The massive right pleural effusion and a pleural mass were demonstrated on chest X-ray films and thoracic computed tomograms. Diffuse large B-cell non-Hodgkin's lymphoma was diagnosed by needle biopsy from the pleura, and the clinical stage was IE. Pleural effusion specimens contained no identifiable lymphoma cells, and examinations for Mycobacterium species were also negative. Human herpes virus 8 (HIV-8) DNA was detected in lymphocytes from the peripheral blood and pleural effusion. Epstein-Barr virus-encoded small RNAs and HHV-8 DNA were both negative in biopsied tissue from the pleural mass. Although a complete remission was achieved, the lymphoma relapsed about 8 months later. The patient is currently receiving salvage chemotherapy. Cases of primary pleural non-Hodgkin's lymphoma with massive pleural effusion that are not preceded by chronic pyothorax or Kaposi's sarcoma are very rare.     

Lymphoblastic lymphoma associated with subcutaneous nodules, intramuscular mass, pericardial effusion and peripheral lymphadenopathy

A 14-year-old boy was admitted to Department of Pediatrics at Mie University Hospital with a 12-day history of facial cervical edema associated with venous dilatation on the upper chest wall. On admission anterior mediastinal mass was found on chest X-ray film and computed tomography. A needle biopsy revealed non-Hodgkin's lymphoma, diffuse lymphoblastic type and he was staged as III. He was treated with High-risk lymphoma protocol and achieved complete remission. At relapse he developed various manifestations unusual for lymphoblastic lymphoma including peripheral lymphadenopathy, an intramuscular mass of the lt-lower leg, multiple subcutaneous nodules at anterior chest wall and upper abdomen, and pericardial effusion. No lymphomatous infiltration into bone marrow or central nervous system was observed throughout his clinical course. Immunological phenotype of lymphoma cells from pericardial effusion was quite compatible with that of common thymocytes. However cytogenetic analysis showed unique translocation: (2; 5) (q 33; q 35). Translocations with a break at 5 q 35 have been reported in peripheral T-cell lymphoma and malignant histiocytosis.