Scientific Letter
Pleural Lymphoma Associated With Chronic Empyema
Linfoma pleural asociado a empiema crónico
Ana Cerezo-Hernández
, María Victoria García-Gallardo Sanz, Carmen Ainhoa Arroyo Domingo, Félix del Campo Matías
Corresponding author
Servicio de Neumología, Hospital Universitario Río Hortega, Valladolid, Spain
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elsevierViewall">TC de tórax con contraste, corte axial (izquierda) y coronales (centro y derecha:): masa pleural en pared medial y caudal de hemitórax izquierdo con infiltración pericárdica (flechas continuas) y gran colección en hemitórax izquierdo correspondiente con piotórax crónico (flechas discontinuas), produciendo en su conjunto desplazamiento mediastínico contralateral y compresión cardíaca.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Cerezo-Hernández, María Victoria García-Gallardo Sanz, Carmen Ainhoa Arroyo Domingo, Félix del Campo Matías" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Ana" "apellidos" => "Cerezo-Hernández" ] 1 => array:2 [ "nombre" => "María Victoria" "apellidos" => "García-Gallardo Sanz" ] 2 => array:2 [ "nombre" => "Carmen Ainhoa" "apellidos" => "Arroyo Domingo" ] 3 => array:2 [ "nombre" => "Félix" "apellidos" => "del Campo Matías" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => 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Note also the relationship of the feeding vessel (arrowheads) to the pulmonary artery pseudoaneurysm (PAP; arrow). (B) Three-dimensional coronal reconstruction clearly depicts the PAP (arrow) and feeding vessel (arrowheads). (C) Pulmonary angiography performed 1 week after CT shows oligemia in the right upper lobe, with no opacification of the feeding vessel or PAP. 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Chest X-ray revealed a significant increase in previous left pleural effusion with mediastinal shift, so thoracentesis was performed, which yielded cloudy pleural fluid, consistent with exudate, predominantly polynuclear, with low glucose, raised proteins, LDH and ADA, and normal CEA. Cytology was negative for malignant cells and culture was negative for bacteria and mycobacteria.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the patient's poor progress after evacuation of pleural fluid and findings suggestive of right heart failure, transthoracic echocardiography was performed, which revealed a hypoechogenic mass in the inferolateral wall of the left ventricle, with dilation of the left atrium, slight pericardial effusion, preserved LVEF, and dilated inferior vena cava without inspiratory collapse. Chest–abdomen computed tomography (CT) was performed, showing a soft tissue mass in the medial portion of the posterior chest wall, measuring 6×3<span class="elsevierStyleHsp" style=""></span>cm, with pericardial infiltration, mass effect, and associated small pericardial effusion. A significant increase in the pleural collection compared to previous studies was visualized, occupying practically the entire hemithorax, causing compressive atelectasis of the lung with contralateral mediastinal shift and cardiac compression (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A CT-guided biopsy of the mass was performed, which according to the pathology report was consistent with non-Hodgkin's diffuse large B-cell lymphoma, with a proliferation of 70%, no positivity for Epstein Barr virus (EBV) or c-myc, and no bone marrow infiltration. HIV, HBV, HCV and CMV serologies were negative. The patient's clinical situation worsened rapidly in a few weeks, so he was referred for palliative care and follow-up, and died 2 months after diagnosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Primary pleural lymphoma is an uncommon entity, accounting for approximately 7% of all lymphomas. It usually affects patients with HIV or chronic pyothorax (CP), and occurs only exceptionally in immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Although the incidence of CP is similar in both sexes, men are more susceptible to developing non-Hodgkin's lymphomas (NHL) than women (ratio of 5.2:1).</p><p id="par0030" class="elsevierStylePara elsevierViewall">Long-term inflammatory stimulation has been identified as an important etiological factor in the development of malignant lymphomas, and studies have reported longer periods between the onset of CP and the development of NHL (>20 years) in these patients compared to patients with autoimmune diseases or renal transplants (9.5 and 4 years, respectively). In fact, Aozasa et al. used the results of their study to differentiate and establish a characteristic clinico-pathological entity called pyothorax-associated lymphoma (PAL). This entity is defined as a B-cell NHL that develops in the pleural cavity of patients with CP of more than 20 years’ standing, in which an exclusive molecular profile has been determined, consisting of overexpression of interferon alpha-inducible protein 27 that plays a role in chronic inflammation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> EBV causes latent infection in PAL, with type III expression of EBV-related proteins in the tumor cells,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> a phenomenon not observed in our patient.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the most common symptom is chest pain, dyspnea may also develop in the presence of significant pleural effusion, as occurred in our case. Radiological signs include diffuse nodular pleural thickening, accompanied by pleural mass. A soft tissue mass in the pleura adjacent to the edge of a coexisting empyema cavity is suggestive of pyothorax-associated lymphoma.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Isolated pleural effusion may occasionally appear before the pleural mass develops.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Knowledge of the typical radiological findings and location assists in diagnosing this rare disease.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In line with the literature, in the months before diagnosis, our patient required repeated evacuating thoracentesis for recurrent empyema, and the pleural mass was only visualized subsequently, located (unusually) in the medial portion of the left posterior chest wall, extending to the pericardium.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For diagnosis, pleural biopsy should be obtained under ultrasound or CT-guidance or by video-assisted thoracoscopy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In histological terms, all cases of PAL are NHL, the most common being diffuse large B-cell type NHL, as found in our patient.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Aggressive surgical treatment with pleuropneumonectomy is highly effective in early-stage disease, but is therefore only possible in a very small number of patients.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Systemic chemotherapy based on CHOP combinations is required, but efficacy is variable. Radiation therapy is effective for local and primary control and for rescue therapy after chemotherapy. Prognosis is poor, with a 5-year survival rate of 20%–30%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Although this is an uncommon problem, a diagnosis of pleural lymphoma should be taken into account in the long-term follow-up of patients with chronic pleural infection, in order to avoid therapeutic delay.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cerezo-Hernández A, García-Gallardo Sanz MV, Arroyo Domingo CA, del Campo Matías F. Linfoma pleural asociado a empiema crónico. Arch Bronconeumol. 2018;54:400–401.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 988 "Ancho" => 3000 "Tamanyo" => 333132 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT with contrast medium, axial (left) and coronal slices (center and right): pleural mass in the medial portion of the anterior left chest wall with pericardial infiltration (solid arrows), and a large collection in the left hemithorax, corresponding with chronic pyothorax (dotted arrows), together causing contralateral mediastinal shift and cardiac compression.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lymphoma of the pleural cavity developing from long-standing pyothorax. 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Itami" 3 => "K. Miyakawa" 4 => "H. Fujimoto" 5 => "H. Ito" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2214/AJR.09.2603" "Revista" => array:6 [ "tituloSerie" => "AJR" "fecha" => "2010" "volumen" => "194" "paginaInicial" => "76" "paginaFinal" => "84" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20028908" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pyothorax-associated lymphoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Aozasa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Clin Exp Hematopathol" "fecha" => "2006" "volumen" => "46" "paginaInicial" => "5" "paginaFinal" => "10" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005400000007/v1_201807020412/S1579212918301551/v1_201807020412/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005400000007/v1_201807020412/S1579212918301551/v1_201807020412/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212918301551?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 2 | 15 |
| 2024 October | 51 | 26 | 77 |
| 2024 September | 61 | 20 | 81 |
| 2024 August | 76 | 40 | 116 |
| 2024 July | 42 | 22 | 64 |
| 2024 June | 70 | 27 | 97 |
| 2024 May | 78 | 28 | 106 |
| 2024 April | 53 | 35 | 88 |
| 2024 March | 45 | 21 | 66 |
| 2024 February | 32 | 23 | 55 |
| 2023 March | 15 | 3 | 18 |
| 2023 February | 88 | 27 | 115 |
| 2023 January | 52 | 29 | 81 |
| 2022 December | 70 | 39 | 109 |
| 2022 November | 70 | 30 | 100 |
| 2022 October | 85 | 46 | 131 |
| 2022 September | 44 | 34 | 78 |
| 2022 August | 75 | 53 | 128 |
| 2022 July | 66 | 40 | 106 |
| 2022 June | 59 | 43 | 102 |
| 2022 May | 70 | 42 | 112 |
| 2022 April | 87 | 44 | 131 |
| 2022 March | 70 | 42 | 112 |
| 2022 February | 82 | 33 | 115 |
| 2022 January | 102 | 40 | 142 |
| 2021 December | 69 | 51 | 120 |
| 2021 November | 78 | 42 | 120 |
| 2021 October | 87 | 48 | 135 |
| 2021 September | 89 | 47 | 136 |
| 2021 August | 67 | 43 | 110 |
| 2021 July | 51 | 28 | 79 |
| 2021 June | 77 | 46 | 123 |
| 2021 May | 72 | 48 | 120 |
| 2021 April | 204 | 77 | 281 |
| 2021 March | 105 | 23 | 128 |
| 2021 February | 45 | 28 | 73 |
| 2021 January | 61 | 10 | 71 |
| 2020 December | 58 | 19 | 77 |
| 2020 November | 56 | 26 | 82 |
| 2020 October | 39 | 33 | 72 |
| 2020 September | 42 | 17 | 59 |
| 2020 August | 39 | 14 | 53 |
| 2020 July | 37 | 24 | 61 |
| 2020 March | 29 | 5 | 34 |
| 2020 February | 32 | 14 | 46 |
| 2020 January | 58 | 21 | 79 |
| 2019 December | 43 | 19 | 62 |
| 2019 November | 38 | 24 | 62 |
| 2019 October | 37 | 16 | 53 |
| 2019 September | 42 | 5 | 47 |
| 2019 August | 32 | 19 | 51 |
| 2019 July | 30 | 18 | 48 |
| 2019 June | 24 | 12 | 36 |
| 2019 May | 37 | 15 | 52 |
| 2019 April | 34 | 28 | 62 |
| 2019 March | 43 | 22 | 65 |
| 2019 February | 20 | 21 | 41 |
| 2019 January | 27 | 17 | 44 |
| 2018 December | 2 | 3 | 5 |
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