Primary Pleural Lymphoma in an Immune-Competent Patient: A Diagnostic and Therapeutic Challenge

Abstract

Background: Primary pleural lymphoma is a rare disease posing diagnostic and therapeutic challenges. Case presentation: We present a 65-year-old woman with dyspnoea, cough, and asthenia, with no significant past medical history. Chest X-ray and computed tomography showed extensive right pleural effusion. Video-assisted thoracoscopy demonstrated multiple pleural nodules, while pleural fluid analysis revealed a lymphocytic exudate, and finally, a primary pleural lymphoma diagnosis was confirmed by immunohistochemistry analysis in pleural nodules biopsy. Discussion: In this regard, eight cycles of chemotherapy with cyclophosphamide, doxorubicin, vincristine, dexamethasone, and rituximab were indicated, and after one year of follow-up, complete clinical and radiological remission was observed. Conlusions: We conclude that video-assisted thoracoscopy with an appropriate histopathological examination remains the gold standard for diagnosis, while R-CHOP chemotherapy plus rituximab may represent a highly effective therapeutic choice.

Keywords: R-CHOP chemotherapy; immunohistochemistry; pleura; primary pleural lymphoma; video-assisted thoracoscopy.

Figure 1

Posteroanterior chest X-ray with a typical lung collapse image of pleural effusion. A dense, homogeneous opacity at the lower two-thirds of the right hemithorax obscures the ipsilateral cardiac and diaphragmatic borders.

Figure 2

Pleural echography. The observation of an anechoic image is consistent with a pleural effusion pattern.

Figure 3

Video-assisted thoracoscopy. Multiple, irregular, and white-coloured nodules in the middle (a) and infefior (b) parietal pleura.

Figure 4

Immunohistochemistry. Deparaffinised tissue sections were subjected to antigen retrieval and incubated with monoclonal and/or polyclonal antibody panels. A biotin-free visualisation technique was employed using a peroxidase–polymer complex and DAB as a chromogen. (a) LCA (Leukocyte common antigen) (+); (b) CD20 (+); (c) CK (Cytokeratin) (−); (d) KI67 (+).

Figure 5

Posteroanterior chest X-ray seven months after the chemotherapy completion. Chest X-ray at posteroanterior projection. Well-positioned, well-inspired, and well-penetrated. Heart size is within normal limits. Lung fields are clear with no evidence of infiltrates. Hilar regions are unremarkable, and no pleural effusion was noted.