A case of B-cell lymphoma of Bronchus-Associated Lymphoid Tissue (BALTOMA) masquerading as an atypical interstitial pneumonia

H. Shaaban, A. Ko, J. Sensakovic, G. Guron
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Abstract

We describe a 60-year-old patient with symptoms of chest pain, chronic non-productive cough, generalised malaise and weight loss for four years. Bilateral interstitial infiltrates were observed radiologically. Bronchoscopy with bronchoalveolar lavage (BAL) came back positive for Mycobacterium Xenopi. She was treated with rifampin, ethambutol and azithromycin for 6 months but no clinical improvement. She became progressively dyspneic and subsequently had a Video-assisted thorascopic surgery (VATS) and histological examination of lung biopsy revealed replacement of normal lung parenchyma with diffuse infiltration of monotonous cells with scanty cytoplasma and little nuclear irregularity. In immunohistochemical examination it was detected that the LCA and B cell markers of the cells were stained positive for CD20 and CD79; whereas epithelial markers were stained negative for cytokeratin and EMA, and T cell markers were stained negative for CD3. The molecular path revealed Ig heavy chain gene clonal rearrangement consistent with neoplastic proliferation of the B-cell lineage. These features were compatible with the diagnosis of primary pulmonary BALT (bronchus-associated lymphoid tissue) lymphoma or BALTOMA. We recommend that BALTOMA should be included in the differential diagnosis of patients with slow-progressing nonspecific pulmonary symptoms and radiographic interstitial infiltrates. Biopsy under CT guidance or VATS provides sufficient tissue in peripheral lung lesions for immunologic studies to assist in diagnosis.
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支气管相关淋巴组织b细胞淋巴瘤(BALTOMA)伪装成非典型间质性肺炎一例
我们描述了一位60岁的患者,其症状为胸痛,慢性非生产性咳嗽,全身不适和体重减轻四年。影像学观察双侧间质浸润。支气管镜检查伴支气管肺泡灌洗(BAL)检出异种分枝杆菌阳性。给予利福平、乙胺丁醇、阿奇霉素治疗6个月,临床无改善。患者逐渐出现呼吸困难,随后进行了电视胸腔镜手术(VATS)和肺活检组织学检查,发现正常肺实质被弥漫性浸润的单一细胞所取代,细胞浆稀少,细胞核不规则。免疫组化检查发现细胞LCA和B细胞标记CD20和CD79阳性;上皮标记细胞角蛋白和EMA呈阴性,T细胞标记细胞CD3呈阴性。分子路径显示Ig重链基因克隆重排与b细胞谱系的肿瘤增殖一致。这些特征与原发性肺BALT(支气管相关淋巴组织)淋巴瘤或BALTOMA的诊断相符。我们建议将BALTOMA纳入进展缓慢的非特异性肺部症状和影像学间质浸润患者的鉴别诊断。CT引导下或VATS下的活检为免疫研究提供了足够的周围肺病变组织,以协助诊断。
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