Radial Endobronchial Ultrasound to Diagnose a Case of Non-Hodgkin's Lymphoma in the Lung: A Case Report and Literature Review

Abstract

Non-Hodgkin's lymphomas (NHLs) are a heterogeneous group of lymphoproliferative malignancies that are very rarely seen in the lung. Although they generally have a favorable prognosis, the clinical symptoms and most efficient methods of diagnosis have not yet been clearly defined. This report highlights an interesting case wherein a 75-year-old male who presented with complaints of fever, cough, and generalized weakness for three weeks was diagnosed and treated as a case of pneumonia. He did not respond to conventional treatment with antibiotics and antipyretics. Hence, computed tomography of the thorax was done which showed consolidation in the right lower lobe along with a few enlarged right hilar nodes. To evaluate this unresolved pneumonia, he was further evaluated with a radial endobronchial ultrasound (EBUS) and biopsy, which helped in arriving at a diagnosis of NHL. This case illustrates the significance of advanced interventions such as radial EBUS to identify the exact etiology of the lesions. This is the first case to document the ultrasound images of NHL in the lung, obtained using a radial EBUS.

Keywords: lung malignancy; non-hodgkin’s lymphoma; non-resolving pneumonia; pulmonary lymphoma; radial endobronchial ultrasound (r-ebus).

Figure 1. (A) Chest X-ray showing consolidation in the right lower lobe (arrow). (B) High-resolution CT of the thorax demonstrating evidence of subpleural and peribronchial consolidation in the right lower lobe (arrow). (C) R-EBUS image demonstrating central hypoechoic mass with linear arcs and dots within the lesion (arrow), surrounded by a hyperechoic margin, thus confirming R-EBUS within the lesion.

CT: computed tomography; R-EBUS: radial endobronchial ultrasound

Figure 2. Endobronchial tissue fragments lined by ciliated columnar epithelium with underlying stroma consisting of monomorphic sheets of medium-to-large atypical lymphoid cells with round-to-oval vesicular nuclei with prominent nucleoli traversed by fibrovascular strands, atypical mitoses seen with no evidence necrosis. Staining agent used: hematoxylin and eosin (A). Atypical lymphoid cells which are diffusely positive for Immunohistochemistry marker CD20 (magnification ×40) (B).