Hodgkin lymphoma (HL), first described in 1832 by Thomas Hodgkin, is an aggressive malignancy arising from B cells within germinal centers and histologically characterized by the presence of Hodgkin and Reed–Sternberg cells [3, 4]. The majority of patients with HL present with nodal involvement; however, there have been reported cases of extranodal disease including within the lungs, liver, gastrointestinal tract, bones, and thyroid [5, 6]. Pulmonary involvement with this malignancy is relatively common, occurring in 15–40% of cases and involving direct parenchymal invasion of hilar disease [7]. Primary pulmonary Hodgkin lymphoma (PPHL) is extremely rare with approximately 100 cases since 1927. The nodular sclerosis type is most frequently observed, occurring in 60–70% of cases, and it predominantly affects young women [8,9,10].
PPHL has various radiographic findings such as solitary or multiple nodules, consolidations, and ground glass opacities, and often involves the upper lobes [11, 12]. Kern et al. described four cases that shared the following features: (1) typical histologic features of HL, (2) disease restricted to the lung or with minimal hilar lymph node involvement, and (3) adequate clinical and/or pathologic exclusion of disease at other sites [13]. A cavitary pulmonary lesion is an uncommon presentation of PPHL [14,15,16,17], with our case one of few reported in the literature.
Cavitary pulmonary lesions present with a broad differential diagnosis including life-threatening infections from bacterial, tubercular, and fungal pathogens, malignancies, granulomatous diseases, inflammatory disorders, and inhalational conditions. Given the wide variety of causes for these lesions, obtaining a tissue biopsy via an invasive procedure is paramount, which may include bronchoscopy and transbronchial biopsy, image-guided percutaneous needle biopsy, or video-assisted thoracoscopy surgery (VATS). All these procedures involve risk of aerosolization of microscopic particles from the respiratory tract of the patient.
In the beginning of the COVID-19 pandemic in the USA, non-emergent surgeries and procedures were halted in our institution as the risk for infection with the SARS-CoV-2 virus transmitted through respiratory droplets from aerosol-generating procedures, and disease within exposed health care workers, were believed to be high. Eventually expert opinion guidelines were published addressing bronchoscopy in patients with suspected malignancy in need of urgent tissue diagnosis. While timely performance was advised, provider discretion and consideration of indication, severity of COVID-19 infection, and timing of symptom resolution were emphasized [18]. Delaying bronchoscopy until 2 weeks had elapsed from a negative COVID-19 test was also recommended [19].
Radiologic societal guidelines stated that any potentially aerosol-generating procedure should be done in a negative pressure room with all involved personnel donning appropriate personal protective equipment (PPE) [20]. Additional preprocedural factors to consider included local infection and death rates, PPE obtainability, and negative pressure room and ventilator availability.
Given the seriousness and rapid progression of disease in our patient, timely biopsy for diagnosis was imperative. The risk of viral aerosolization posed by bronchoscopy was deemed excessive. A CT-guided percutaneous needle biopsy was pursued, but could not be safely performed as our interventional suite was not under negative pressure and a high concern existed for viral aerosolization from periprocedural patient coughing. After discussion with radiology and anesthesiology, the patient was electively intubated and sedated in a negative pressure room, and transferred to and from the interventional suite on mechanical ventilation utilizing a closed circuit with appropriate high-efficiency filters to prevent viral aerosolization during the biopsy. This multidisciplinary strategy prevented a delay in diagnosis at our facility, which had the necessary resources to safely perform such a procedure on a patient actively infected with SARS-COV-2.
All patients hospitalized with COVID-19 at our institution early in the pandemic were considered high risk for thrombosis on the basis of reported hypercoagulability [21] and placed on prophylactic dosing of low molecular weight heparin or subcutaneous heparin. Given his compounded risk for thrombosis from suspected malignancy prior to his tissue biopsy, our patient continued prophylactic subcutaneous low molecular weight heparin for the entirety of his hospitalization and did not develop thrombotic or hemorrhagic complications.
Timing of treatment in oncology patients infected with SARS-COV-2 was problematic early in the COVID-19 pandemic. Patients with cancer who had recently been treated with chemotherapy, immunotherapy, radiotherapy, and surgery were reported as having increased risk for severe events complicating COVID-19 infection, including need for intensive care and mechanical ventilation, and death [22,23,24]. Guidance for clinicians was limited on when to initiate or resume therapy in previously infected patients. Proposed approaches included delaying chemotherapy until the patient was considered clear of infection by World Health Organization and Center for Disease criteria [25], and assessing the chronicity and aggressiveness of the malignancy to determine the timing of therapy [26]. A lower-risk and slower-growing malignancy, such as a chronic hematologic malignancy, could have treatment delayed for up to 3 months, while higher-grade and more aggressive cancers should not.
Following discussion with medical oncology, our patient was observed for nearly 3 weeks with no change in his clinical condition to suggest development of complications from COVID-19. As his PPHL was aggressive, he started treatment with combined chemotherapy and immunotherapy, and suffered no ill effects. Importantly, apart from fever that resolved as an inpatient, and an intermittent cough, he had no clinical signs of serious infection from SARS-CoV-2 (that is, hypoxia) or radiographic evidence of viral pneumonia. The factors involved in deciding when to begin his HL regimen included his limited disease from COVID-19, adequate time allowed to clear his infection, and his high risk of progression if therapy was further delayed.
