Solitary pulmonary mass in a patient with a history of lymphoma: a case report
© Yuan et al.; licensee BioMed Central Ltd. 2013
Received: 22 February 2013
Accepted: 25 March 2013
Published: 25 April 2013
With the progress made in treatments, the survival rate for patients with malignant lymphoma in the last 30 years has significantly improved. However, the risk of experiencing a second primary malignancy or other disease has increased significantly.
A 44-year-old Mongolian man with a large mass in his right lower abdomen was admitted to our hospital 15 years previously. The mass was removed, and confirmed via pathological examination to be a malignant B-cell lymphoma in the appendix and distal small bowel. Post-operative chemotherapy with standard cyclophosphamide, hydroxydaunomycin, vincristine (Oncovin®) and prednisolone regimen was given for six cycles. No obvious recurrence was detected over the following 12 years. Subsequently, a mass in the right lung was found on a regular X-ray follow-up; our patient did not report chills, fever or cough. Chest computed tomography and positron emission tomography scans confirmed the mass. A primary lung carcinoma was considered to be the most likely diagnosis. However, after an exploratory thoracotomy and right upper lobectomy was performed a pathological examination of tissue samples demonstrated a lung cryptococcal granuloma, with positive staining for periodic acid Schiff and periodic acid-silver metheramine.
Compared to the normal population, second primary malignancy (in particular leukaemia and lung cancer) in patients with malignant lymphoma during their long-term survival has been seen occasionally. However, other diagnoses should also be considered such as pulmonary cryptococcosis. Other than computed-tomography-guided needle biopsy, surgery for some patients is a much more appropriate choice, which could also help attain correct diagnosis and treatment.
With the progress made in treatments, in the last 30 years the survival rate for patients with malignant lymphoma has significantly improved. Use of the targeted drug rituximab in CD20(+) B-cell lymphoma has greatly increased the efficiency of treatment and five-year survival rate. However, compared to the normal population, the risk of suffering a second primary malignancy, in particular leukemia and lung cancer, has increased significantly in patients with malignant lymphoma during their long-term survival after treatment [1–3]. Usually, the first diagnosis in these patients with a mass found during regular follow-up is a tumor. However, on occasion this could be the wrong conclusion.
Diagnosis of pulmonary cryptococcosis usually depends on the etiology of infected tissue cultures or pathology findings. Surgery, percutaneous needle biopsy, bronchoscopy brushing or biopsy, bronchoalveolar lavage fluid culture, smear or culture of cerebrospinal fluid and lymph node biopsy are all effective methods for diagnosis. Combined with the results of PET and lung CT scans, our patient was suspected to have a second tumor: primary lung cancer. However, pathological examination verified the primary pulmonary cryptococcosis, caused by infection of Cryptococcus neoformans. Our patient denied an exposure history of bird secretions, dust and pollen. Previous studies have reported that T-cell-mediated immune dysfunction often occurs in patients with cancer after chemotherapy, who are susceptible to pulmonary cryptococcosis [4, 5]. We believe that surgery for such patients is a more appropriate choice, at least in some cases, which could also help attain correct diagnosis and treatment.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
This study was supported by Natural Science Foundation of China (Grant Number 81000945).
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