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Endobronchial Recurrence of Gastric Mucosa–associated Lymphoid Tissue Lymphoma

McCollum, Charles R. MD*; VanAsselberg, Chad B. MD*; Cook-Glen, Celeste L. MD; Bhagat, Rajesh MD*; Abraham, George E. III MD*

Journal of Bronchology & Interventional Pulmonology: October 2012 - Volume 19 - Issue 4 - p 338–339
doi: 10.1097/LBR.0b013e31826ca93e
Brief Reports
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Mucosa-associated lymphoid tissue (MALT) lymphoma is a diagnostic challenge when arising from bronchiolar submucosal tissue. The case herein describes a man with a lung mass and a remote history of gastric MALT lymphoma. After undergoing a bronchoscopic examination and tissue sampling, he was diagnosed with pulmonary recurrence of gastric MALT lymphoma. The diagnosis of MALT lymphoma in the lung can be challenging. Radiographic findings are typically nonspecific, and tissue biopsy by surgical means is often required. The diagnosis of bronchus-associated lymphoid tissue lymphoma has been previously demonstrated bronchoscopically when a needle aspiration is performed. This case supports the position that bronchoscopy with needle aspiration, and flow cytometry should be performed in all patients in whom pulmonary MALT lymphoma is suspected.

*Medical Service, G.V. (Sonny) Montgomery VA Medical Center, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center

Pathology and Medical Laboratory Service, G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS

Disclosure: There is no conflict of interest or other disclosures.

Reprints: George E. Abraham, III, MD, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS 39216 (e-mail: geabraham@umc.edu).

Received July 5, 2012

Accepted July 20, 2012

Mucosa-associated lymphoid tissue (MALT) lymphoma is an indolent non-Hodgkin B-cell lymphoma most often found in the gastric mucosa. The lymphoma cells infiltrate around reactive secondary follicles in a marginal zone distribution; hence, they are also labeled marginal zone lymphoma (MZL). When arising from lymphoid cells in the submucosal area of bronchioles, it is referred to as bronchus-associated lymphoid tissue (BALT) lymphoma. BALT is a diagnostic challenge, usually requiring either a thoracotomy or a video-assisted thoracoscopy for lung biopsy. The case herein describes a man with a remote history of gastric MALT lymphoma presenting with a lung mass, who on bronchoscopic evaluation was found to have a recurrence of MZL.

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CASE REPORT

A 65-year-old man with a history of hepatitis C, treated latent tuberculosis (TB), and gastric MALT lymphoma 10 years earlier status post chemotherapy was evaluated for a 7×5 cm right lower lobe mass on computed tomography. He reported a cough productive of yellowish sputum but was otherwise asymptomatic. His physical examination was unremarkable.

Bronchoscopy revealed abnormal mucosa in the posterior basal segment of the right lower lobe (Fig. 1). Bronchoalveolar lavage, transbronchial needle aspiration, and endobronchial biopsies were performed at this site. The biopsies and needle aspirate yielded similar results, small lymphoid cells within a background of chronic inflammation. Immunostainings revealed a large population of B lymphocytes (Fig. 2) with limited T lymphocytes. Flow cytometric analysis of the needle aspirate was indicative of a monoclonal process consistent with MZL. Histopathology from the lung lesion was compared with a gastric antrum biopsy from his prior MALT and was found to be consistent. A diagnosis of pulmonary recurrence of gastric MALT lymphoma was made.

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

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DISCUSSION

MALT lymphoma is a low-grade B-cell MZL and is subdivided on the basis of the involvement of node, extranodal tissue (MALT), or spleen. MALT lymphomas arise from lymphoid aggregates such as Peyer's patches or de novo from sites of chronic inflammation, often secondary to infection or autoimmune disease. The majority arises in the gastrointestinal mucosa, although they can arise in other locations including the lung,1 where it is often referred to as BALT lymphoma. Although chronic inflammation associated with Helicobacter pylori is the most frequent impetus for clonal proliferation in the gastric mucosa, BALT lymphoma has yet to be associated with any specific organism.2 It has been reported that the risk of non-Hodgkin lymphoma may increase in patients with a distant history of severe TB.3 However, the patient presented herein had only a prior positive purified protein derivative skin test and was treated for latent TB. Hepatitis C infection is also associated with various low-grade B-cell lymphomas,4 but it is unclear whether a relationship between hepatitis C and BALT lymphoma exists.

The diagnosis of MALT lymphoma of the lung can be difficult. Radiographic findings, most commonly, consolidation with air bronchograms,5 are nonspecific. In the past, evaluation of the tissue architecture through transbronchial or surgical lung biopsies has been necessary for BALT lymphoma diagnosis. However, in our patient, the bronchoscopic samples collected by transbronchial needle aspiration for cytology and flow cytometry helped clinch the diagnosis, highlighting the benefits of this diagnostic modality. The potential of transbronchoscopic needle aspiration for diagnosis of lymphoma, specifically BALT, has been alluded to in very limited pathologic studies.6 This case strengthens the contention that it should be part of the procedure in all bronchoscopies performed on individuals suspected to have these disease processes.

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CONCLUSIONS

MZL of the lung is a diagnostic challenge for which no one approach is best. Bronchoscopy with transbronchial needle aspiration sent for flow cytometry should be considered as a diagnostic modality in these patients, as it has significantly less morbidity compared with surgical options.

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REFERENCES

1. Cohen S, Petryk M, Varma M, et al. Non-Hodgkin’s lymphoma of mucosa-associated lymphoid tissue. Oncologist. 2006;11:1100–1117
2. Inagaki H. Mucosa-associated lymphoid tissue lymphoma: molecular pathogenesis and clinicopathological significance. Pathol Int. 2007;57:474–484
3. Askling J, Ekbom A. Risk of non-Hodgkin’s lymphoma following tuberculosis. Br J Cancer. 2001;84:113–115
4. Suarez F, Lortholary O, Hermine O, et al. Infection-associated lymphomas derived from marginal zone B cells: a model of antigen-driven lymphoproliferation. Blood. 2006;107:3034–3044
5. Knisely B, Mastey L, Mergo P, et al. Pulmonary mucosa-associated lymphoid tissue lymphoma: CT and pathologic findings. Am J Roentgenol. 1999;172:1321–1326
6. Ehya H, Patchefsky A. Bronchus-associated lymphoid tissue (BALT) lymphoma: diagnosis by fine needle aspiration cytology and flow cytometry: case report and review. Pathol Case Rev. 2003;8:267–274
Keywords:

bronchoscopy; mucosa-associated lymphoid tissue (MALT) lymphoma; transbronchial needle aspiration; flow cytometry

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