Clinical diagnosis
Case 83
【Progress】
She was introduced to an expert department serving hematology and oncology for making an appropriate treatment strategy.
【Discussion】
Non Hodgkin lymphoma (NHL) which is 80-90 % of the malignant lympoma, involve pulmonary parenchyma with the incidence of 24%, while Hodgkin lymphoma which is 10 – 20 % of all malignant lymphoma is associated mediastinal lymphnode swelling with the incident of 38% (1, 2).
Interleukin-2 (IL-2) is produced by activated T-helper cells and functions survival, proliferation and differentiation of T cell. IL-2 has also a role of differentiation of naïve T cells into effector and memory T cells (3) (Although no relation with this case, Interleukin 6 which is secreted by T cell and monocytes, increases in Castleman disease. Lymphnodes in Castleman disease over-product IL6) (4). It is known that IL-2 level increases in malignant lymphoma. The mechanism responsible for the increase in IL-2 with malignant lymphoma has not yet been clarified (3). In our case, the level of interleukin-2 (IL-2) was extraordinary high, 12300 U/mL.
Malignant lymphoid proliferation of the lung include low-grade B cell lymphoma of mucosa-associated lymphoid tissue (MALT) which is once referred to pseudo-lymphoma, Hodgkin lymphoma and non-Hodgkin lymphoma (Table 1). Pulmonary lymphoma was categorized into primary pulmonary lymphoma and secondary one. Primary pulmonary lymphoma is rare, 0.3 % of all lung malignancies and less than 0.5% of all lymphomas (1, 2). Most cases of primary pulmonary lymphoma are of B-cell type. Primary pulmonary lymphoma is defined as lymphoid proliferation affecting one or both lungs with no evidence of mediastinal adenopathy and with no previous extrapulmonary involvement at the time of diagnosis or during the subsequent 3 months (1, 2).
Lung is a relatively frequent site of secondary involvement of lymphoma by hematogenous dissemination or by contiguous invasion from a hilar or mediastinal lymphonodes involvement. In our case, although hilar and mediastinal lymphnodes were not found, swollen pelvic lymphnodes were detected at the same time, implying the secondary pulmonary lymphoma probably via hematogenous route.
Radiologic findings of pulmonary lymphoma vary, with single or multiple, unilateral or bilateral lesions forming nodules or consolidation with diffuse ground-glass opacity (5, 6). Irrespective of primary lymphoma or secondary one, as the characteristic radiological finding, bronchus traverses the expansive nodule of lymphoma (2, 5, 6). In our case, chest CT showed marked infiltration with consolidation plus ground-glass opacity at both lower lobes which resemble interstitial pneumonia and expansively growing lesion with irregular margin which bronchus traverse the nodule.
【Summary】
We present an eighty six-year-old female with secondary pulmonary lymphoma whose laboratory test revealed LDH 232 U/L (100-200) and Interleukin 2 12300 U/mL (15-519). Chest CT showed consolidation & ground glass opacity and expansive mass with irregular margin that bronchus traverses. We should keep in mind that although radiologic chest findings of pulmonary lymphoma vary, mixed pattern of consolidation & ground glass opacification and expansive mass which bronchus traverses like air bronchogram sign are listed. IL-2 is produced by activated T-helper cells functions survival, proliferation and differentiation of naïve T cells into effector and memory T cells, and IL-2 increases in malignant lymphoma. Meanwhile, Interleukin 6 which is secreted by T cell and monocytes, and lymphnodes in Castleman disease.
【References】
1.Berkman N, Breuer R, Kramer MR, Polliack A. Pulmonary involvement in lymphoma. Leuk Lymphoma 1996;20:229–37 [PubMed]
2.Hare SS, et al. The radiological spectrum of pulmonary lymphoproliferative disease, Br J Radiol. 2012 Jul; 85(1015): 848–864.doi: 10.1259/bjr/16420165
3.Bachmann MF, et al. Interleukin 2: from immunostimulation to immunoregulation and back again. EMBO Rep. 2007 Dec; 8(12): 1142–1148. doi: 10.1038/sj.embor.7401099PMCID: PMC2267244
4.Burger R, et al. Interleukin-6 production in B-cell neoplasias and Castleman's disease: evidence for an additional paracrine loop. Ann Hematol. 1994 Jul;69(1):25-31.
5.Raman SP, Pipavath SN, Raghu G et-al. Imaging of thoracic lymphatic diseases. AJR Am J Roentgenol. 2009;193 (6): 1504-13. doi:10.2214/AJR.09.2532 - Pubmed citation
6.Lewis ER, Caskey CI, Fishman EK. Lymphoma of the lung: CT findings in 31 patients. AJR Am J Roentgenol. 1991;156 (4): 711-4. AJR Am J Roentgenol (abstract) - Pubmed citation
2017.12.6
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