Tuberc Respir Dis.  2015 Oct;78(4):390-395. 10.4046/trd.2015.78.4.390.

Endobronchial ALK-Positive Anaplastic Large Cell Lymphoma Presenting Massive Hemoptysis

• Kim HK
• Kim BH
• Kim SA
• Shin JK
• Song JH
• Kwon AY
• Kim JH
• Kim EK
• Lee JH
• Kim GI
• Jeong HC

• KMID: 2320713
• DOI: http://doi.org/10.4046/trd.2015.78.4.390

Abstract

Primary anaplastic large cell lymphoma (ALCL) of the lung is highly aggressive and quite rare. We report here a case of anaplastic lymphoma kinase-positive endobronchial ALCL, that was initially thought to be primary lung cancer. A 68-year-old woman presented with hemoptysis, dyspnea, and upper respiratory symptoms persisting since 1 month. The hemoptysis and and bronchial obstruction lead to respiratory failure, prompting emergency radiotherapy and steroid treatment based on the probable diagnosis of lung cancer, although a biopsy did not confirm malignancy. Following treatment, her symptoms resolved completely. Chest computed tomography scan performed 8 months later showed increased and enlarged intra-abdominal lymph nodes, suggesting lymphoma. At that time, a lymph node biopsy was recommended, but the patient refused and was lost to follow up. Sixteen months later, the patient revisited the emergency department, complaining of persistent abdominal pain since several months. A laparoscopic intra-abdominal lymph node biopsy confirmed a diagnosis of ALCL.

Keyword

Large Cell Lymphoma; Respiratory Failure; Hemoptysis

MeSH Terms

Abdominal Pain
Aged
Biopsy
Diagnosis
Dyspnea
Emergencies
Emergency Service, Hospital
Female
Hemoptysis*
Humans
Lost to Follow-Up
Lung
Lung Neoplasms
Lymph Nodes
Lymphoma
Lymphoma, Large-Cell, Anaplastic*
Radiotherapy
Respiratory Insufficiency
Thorax

Figure

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  Figure 1 An initial chest X-ray (A) and chest computed tomography (B) revealed obstruction of the left main bronchus with obstructive collapse with air trapping in the left lung, which suggested lung cancer with obstructive collapse. Chest X-ray (C) and chest CT (D), taken on the 12th day after radiotherapy and steroid administration, revealed a markedly decreased mass and disappearance of obstruction in the left main bronchus.

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  Figure 2 Bronchoscopy showed total obstruction of the left main bronchus (A, arrow indicates the mass located at proximal left main bronchus extending carina). Bronchoscopy done after radiotherapy showed no evidence of bleeding and resolved obstruction (B, arrow indicates the remnant of mass).

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  Figure 3 The biopsy performed on her first hospitalization showed only ulceration and granulation tissue (A, H&E stain, ×100). Laparoscopic biopsy from intra-abdominal lymph nodes shows anaplastic large cell lymphoma cells having marked pleomorphism (B, H&E stain, ×400). Immunohistochemical stain reveals positivity for anaplastic lymphoma kinase (C, ×400), epithelial membrane angiten (D, ×400), and CD30 (E, ×400).

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  Figure 4 Abdomen-pelvis computed tomography (A) revealed extensive intra-abdominal lymph node metastasis and biliary obstruction by markedly increased size of portocaval and hepatoduodenal ligament, which showed as hypermetabolic lesions in positron emission tomography (B).

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