A 50-year-old female, smoker, with a past-history of a lymphocytic lymphoma in long last remission, presented with a tender large right lower neck mass, for which multiple fine needle aspiration cytology only disclosed necrotic material.
Chest CT revealed a peripheral lung nodule, in right upper lobe (Fig. 1A), with multiple pathologic mediastinal lymph nodes (Fig. 1B).
(A) Chest CT (axial plan (AP)): spiculated nodular densification of 30×20mm, with air bronchogram in the upper lobe of the right lung; (B) chest CT (axial plan (AP)): supraclavicular and mediastinal heterogeneous (partially necrotic) adenopathies; (C) endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): TBNA of thoracic lymph node in station 4R; (D) atypical morphology of TTF1+adenocarcinoma, on a background of lymphocytesC, 400×; (E) flow cytometry: pathological B lymphocytes marked in red, compatible with lymphocytic lymphoma.
The EBUS allowed the identification and transbronchial needle aspiration (TBNA) of thoracic lymph nodes in station 4L, 4R, 7 and 11R (Fig. 1C).
EBUS-TBNA in stations 4L, 4R, 7 and 11R was consistent with lymphocytic lymphoma confirmed by flow cytometry. However, in stations 4R and 11R lymph node infiltration, with metastatic TTF1+ lung adenocarcinoma, was also documented (Fig. 1D/E).
Although carcinoma of multiple primary origins has been associated with previous or concomitant lymphoma, lymph node metastasis of adenocarcinoma in lymphomatous lymph nodes is a rare situation. Chronic immune suppression caused by lymphoma and/or cytostatic treatment seems a plausible predisposing factor for multiple primary tumors.1,2
This case highlights the need for a complete diagnostic work-up to elucidate the various clinical hypotheses, particularly in a nearby pathologic and draining territory.
