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Cytology was negative for malignant cells and culture was negative for bacteria and mycobacteria&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the patient&#39;s poor progress after evacuation of pleural fluid and findings suggestive of right heart failure&#44; transthoracic echocardiography was performed&#44; which revealed a hypoechogenic mass in the inferolateral wall of the left ventricle&#44; with dilation of the left atrium&#44; slight pericardial effusion&#44; preserved LVEF&#44; and dilated inferior vena cava without inspiratory collapse&#46; Chest&#8211;abdomen computed tomography &#40;CT&#41; was performed&#44; showing a soft tissue mass in the medial portion of the posterior chest wall&#44; measuring 6&#215;3<span class="elsevierStyleHsp" style=""></span>cm&#44; with pericardial infiltration&#44; mass effect&#44; and associated small pericardial effusion&#46; A significant increase in the pleural collection compared to previous studies was visualized&#44; occupying practically the entire hemithorax&#44; causing compressive atelectasis of the lung with contralateral mediastinal shift and cardiac compression &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A CT-guided biopsy of the mass was performed&#44; which according to the pathology report was consistent with non-Hodgkin&#39;s diffuse large B-cell lymphoma&#44; with a proliferation of 70&#37;&#44; no positivity for Epstein Barr virus &#40;EBV&#41; or c-myc&#44; and no bone marrow infiltration&#46; HIV&#44; HBV&#44; HCV and CMV serologies were negative&#46; The patient&#39;s clinical situation worsened rapidly in a few weeks&#44; so he was referred for palliative care and follow-up&#44; and died 2 months after diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Primary pleural lymphoma is an uncommon entity&#44; accounting for approximately 7&#37; of all lymphomas&#46; It usually affects patients with HIV or chronic pyothorax &#40;CP&#41;&#44; and occurs only exceptionally in immunocompetent patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Although the incidence of CP is similar in both sexes&#44; men are more susceptible to developing non-Hodgkin&#39;s lymphomas &#40;NHL&#41; than women &#40;ratio of 5&#46;2&#58;1&#41;&#46;</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&#44; and studies have reported longer periods between the onset of CP and the development of NHL &#40;&#62;20 years&#41; in these patients compared to patients with autoimmune diseases or renal transplants &#40;9&#46;5 and 4 years&#44; respectively&#41;&#46; In fact&#44; Aozasa et al&#46; used the results of their study to differentiate and establish a characteristic clinico-pathological entity called pyothorax-associated lymphoma &#40;PAL&#41;&#46; This entity is defined as a B-cell NHL that develops in the pleural cavity of patients with CP of more than 20 years&#8217; standing&#44; in which an exclusive molecular profile has been determined&#44; consisting of overexpression of interferon alpha-inducible protein 27 that plays a role in chronic inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> EBV causes latent infection in PAL&#44; with type III expression of EBV-related proteins in the tumor cells&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> a phenomenon not observed in our patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the most common symptom is chest pain&#44; dyspnea may also develop in the presence of significant pleural effusion&#44; as occurred in our case&#46; Radiological signs include diffuse nodular pleural thickening&#44; accompanied by pleural mass&#46; A soft tissue mass in the pleura adjacent to the edge of a coexisting empyema cavity is suggestive of pyothorax-associated lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Isolated pleural effusion may occasionally appear before the pleural mass develops&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In line with the literature&#44; in the months before diagnosis&#44; our patient required repeated evacuating thoracentesis for recurrent empyema&#44; and the pleural mass was only visualized subsequently&#44; located &#40;unusually&#41; in the medial portion of the left posterior chest wall&#44; extending to the pericardium&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For diagnosis&#44; pleural biopsy should be obtained under ultrasound or CT-guidance or by video-assisted thoracoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In histological terms&#44; all cases of PAL are NHL&#44; the most common being diffuse large B-cell type NHL&#44; as found in our patient&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Aggressive surgical treatment with pleuropneumonectomy is highly effective in early-stage disease&#44; but is therefore only possible in a very small number of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Systemic chemotherapy based on CHOP combinations is required&#44; but efficacy is variable&#46; Radiation therapy is effective for local and primary control and for rescue therapy after chemotherapy&#46; Prognosis is poor&#44; with a 5-year survival rate of 20&#37;&#8211;30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Although this is an uncommon problem&#44; a diagnosis of pleural lymphoma should be taken into account in the long-term follow-up of patients with chronic pleural infection&#44; in order to avoid therapeutic delay&#46;</p></span>"
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Scientific Letter
Pleural Lymphoma Associated With Chronic Empyema
Linfoma pleural asociado a empiema crónico
Ana Cerezo-Hernández
Corresponding author
anacerezo.barqueros@gmail.com

Corresponding author.
, María Victoria García-Gallardo Sanz, Carmen Ainhoa Arroyo Domingo, Félix del Campo Matías
Servicio de Neumología, Hospital Universitario Río Hortega, Valladolid, Spain
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        "titulo" => "Linfoma pleural asociado a empiema cr&#243;nico"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest CT with contrast medium&#44; axial &#40;left&#41; and coronal slices &#40;center and right&#41;&#58; pleural mass in the medial portion of the anterior left chest wall with pericardial infiltration &#40;solid arrows&#41;&#44; and a large collection in the left hemithorax&#44; corresponding with chronic pyothorax &#40;dotted arrows&#41;&#44; together causing contralateral mediastinal shift and cardiac compression&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We report the case of a 78-year-old man&#44; former smoker&#44; with a history of pulmonary tuberculosis treated with left therapeutic pneumothorax and chronic recurrent left empyema&#44; who presented with worsening of his general status in recent months&#44; with dyspnea&#44; weight loss&#44; asthenia&#44; generalized skin dryness&#44; symptoms of right heart failure&#44; and chronic hypercapnic respiratory failure&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Of note on clinical laboratory tests were anemia and mild liver enzyme changes&#46; Chest X-ray revealed a significant increase in previous left pleural effusion with mediastinal shift&#44; so thoracentesis was performed&#44; which yielded cloudy pleural fluid&#44; consistent with exudate&#44; predominantly polynuclear&#44; with low glucose&#44; raised proteins&#44; LDH and ADA&#44; and normal CEA&#46; Cytology was negative for malignant cells and culture was negative for bacteria and mycobacteria&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In view of the patient&#39;s poor progress after evacuation of pleural fluid and findings suggestive of right heart failure&#44; transthoracic echocardiography was performed&#44; which revealed a hypoechogenic mass in the inferolateral wall of the left ventricle&#44; with dilation of the left atrium&#44; slight pericardial effusion&#44; preserved LVEF&#44; and dilated inferior vena cava without inspiratory collapse&#46; Chest&#8211;abdomen computed tomography &#40;CT&#41; was performed&#44; showing a soft tissue mass in the medial portion of the posterior chest wall&#44; measuring 6&#215;3<span class="elsevierStyleHsp" style=""></span>cm&#44; with pericardial infiltration&#44; mass effect&#44; and associated small pericardial effusion&#46; A significant increase in the pleural collection compared to previous studies was visualized&#44; occupying practically the entire hemithorax&#44; causing compressive atelectasis of the lung with contralateral mediastinal shift and cardiac compression &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A CT-guided biopsy of the mass was performed&#44; which according to the pathology report was consistent with non-Hodgkin&#39;s diffuse large B-cell lymphoma&#44; with a proliferation of 70&#37;&#44; no positivity for Epstein Barr virus &#40;EBV&#41; or c-myc&#44; and no bone marrow infiltration&#46; HIV&#44; HBV&#44; HCV and CMV serologies were negative&#46; The patient&#39;s clinical situation worsened rapidly in a few weeks&#44; so he was referred for palliative care and follow-up&#44; and died 2 months after diagnosis&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Primary pleural lymphoma is an uncommon entity&#44; accounting for approximately 7&#37; of all lymphomas&#46; It usually affects patients with HIV or chronic pyothorax &#40;CP&#41;&#44; and occurs only exceptionally in immunocompetent patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Although the incidence of CP is similar in both sexes&#44; men are more susceptible to developing non-Hodgkin&#39;s lymphomas &#40;NHL&#41; than women &#40;ratio of 5&#46;2&#58;1&#41;&#46;</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&#44; and studies have reported longer periods between the onset of CP and the development of NHL &#40;&#62;20 years&#41; in these patients compared to patients with autoimmune diseases or renal transplants &#40;9&#46;5 and 4 years&#44; respectively&#41;&#46; In fact&#44; Aozasa et al&#46; used the results of their study to differentiate and establish a characteristic clinico-pathological entity called pyothorax-associated lymphoma &#40;PAL&#41;&#46; This entity is defined as a B-cell NHL that develops in the pleural cavity of patients with CP of more than 20 years&#8217; standing&#44; in which an exclusive molecular profile has been determined&#44; consisting of overexpression of interferon alpha-inducible protein 27 that plays a role in chronic inflammation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> EBV causes latent infection in PAL&#44; with type III expression of EBV-related proteins in the tumor cells&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> a phenomenon not observed in our patient&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the most common symptom is chest pain&#44; dyspnea may also develop in the presence of significant pleural effusion&#44; as occurred in our case&#46; Radiological signs include diffuse nodular pleural thickening&#44; accompanied by pleural mass&#46; A soft tissue mass in the pleura adjacent to the edge of a coexisting empyema cavity is suggestive of pyothorax-associated lymphoma&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Isolated pleural effusion may occasionally appear before the pleural mass develops&#46;<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&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> In line with the literature&#44; in the months before diagnosis&#44; our patient required repeated evacuating thoracentesis for recurrent empyema&#44; and the pleural mass was only visualized subsequently&#44; located &#40;unusually&#41; in the medial portion of the left posterior chest wall&#44; extending to the pericardium&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">For diagnosis&#44; pleural biopsy should be obtained under ultrasound or CT-guidance or by video-assisted thoracoscopy&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In histological terms&#44; all cases of PAL are NHL&#44; the most common being diffuse large B-cell type NHL&#44; as found in our patient&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Aggressive surgical treatment with pleuropneumonectomy is highly effective in early-stage disease&#44; but is therefore only possible in a very small number of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Systemic chemotherapy based on CHOP combinations is required&#44; but efficacy is variable&#46; Radiation therapy is effective for local and primary control and for rescue therapy after chemotherapy&#46; Prognosis is poor&#44; with a 5-year survival rate of 20&#37;&#8211;30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Although this is an uncommon problem&#44; a diagnosis of pleural lymphoma should be taken into account in the long-term follow-up of patients with chronic pleural infection&#44; in order to avoid therapeutic delay&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Cerezo-Hern&#225;ndez A&#44; Garc&#237;a-Gallardo Sanz MV&#44; Arroyo Domingo CA&#44; del Campo Mat&#237;as F&#46; Linfoma pleural asociado a empiema cr&#243;nico&#46; Arch Bronconeumol&#46; 2018&#59;54&#58;400&#8211;401&#46;</p>"
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ISSN: 15792129
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