肺黏膜相关淋巴组织淋巴瘤合并肺鳞癌一例并文献复习

Pulmonary mucosa-associated lymphoid tissue lymphoma concurrent with lung squamous cell carcinoma:a case report and literature review

目的探讨肺黏膜相关淋巴组织(mucosa-associated lymphoid tissue,MALT)淋巴瘤合并肺鳞状细胞癌的临床表现、影像学特征、病理特点及诊断治疗,提高对该病的认识。方法以“pulmonary mucosa-associated lymphoid tissue,squamous cell carcinoma”为检索词,在PubMed数据库进行检索,从1983年1月1日至2020年8月31日共检索到国外病例3例;在万方数据库以“肺黏膜相关淋巴组织淋巴瘤,肺鳞癌”为检索词,从1990年1月1日至2020年8月31日共检索到相关文献1篇;在中国知网数据库以“(肺)黏膜相关淋巴组织淋巴瘤,(肺)鳞癌”为检索词,未检索到相关病例报道。阅读文献入选4例及本文病例,共5例进行文献复习。结果患者男,64岁,因“胸闷、气促10 d,咳嗽、发热1 d”入院。胸部增强CT示右下肺门区可见软组织肿块影,相邻支气管局部阻塞,增强后局部轻度强化,双肺下叶见实变影,散在片状结节影,纵隔多发淋巴结肿大,右侧少量胸腔积液;支气管镜检查见右下基底段开口处菜花样新生物,约7 mm×8 mm;支气管镜活检示部分黏膜结构破坏,鳞状上皮层次消失,细胞核大深染,部分呈巢团状分布,伴不良角化和少量坏死、纤维组织反应;免疫组织化学染色示甲状腺转录因子-1(thyroid transcription factor-1,TTF-1)、NapsinA、程序性死亡配体-1(programmed cell death-Ligand 1,PD-L1)及p53均阴性,p40、细胞角蛋白(cytokeratin,CK)5/6及表皮生长因子受体(epidermal growth factor receptor,EGFR)均阳性,Ki-67阳性细胞约30%。右肺下叶穿刺活检示肺泡腔内充满巢状排列的淋巴样细胞,由小淋巴细胞、中心细胞样细胞及单核样细胞构成,偶见大细胞;免疫组织化学染色CD20+、CD79a+、平滑肌肌动蛋白(smooth muscle actin,SMA)血管及Bcl2均阳性,CD3散在阳性,Bcl6、CD10、细胞周期蛋白D1(CyclinD1)均阴性,Ki-67阳性细胞约3%。病理诊断:黏膜相关淋巴组织结外边缘区淋巴瘤(MALT淋巴瘤),肺鳞状细胞癌。结论肺MALT淋巴瘤合并肺鳞状细胞癌罕见,极易漏诊或误诊,胸部CT影像学可表现为单发或多发结节、团块影或实变影,常伴有病灶内空气支气管征、支气管扩张及病灶周围的磨玻璃密度影,肺门及纵隔淋巴结肿大,偶可见胸腔积液。肺组织活检是诊断的金标准。

Objective To explore the clinical manifestations,imaging features,pathological features,diagnosis and treatment of pulmonary mucosal-associated lymphoid tissue(MALT)lymphoma concurrent with lung squamous cell carcinoma,and to improve the understanding of this disease.Methods Using"Pulmonary mucosa-associated lymphoid tissue,squamous cell carcinoma"as the search term,from January 1,1983 to August 31,2020,a total of 3 cases were retrieved in the PubMed database.In the Wanfang database,using"Lung mucosa-associated lymphoid tissue,lung squamous cell carcinoma"as the search term,from January 1,1990 to August 31,2020,a total of 1 related document was retrieved.In the CNKI database,"(lung)mucosa-associated lymphoid tissue lymphoma,(lung)squamous cell carcinoma"was used as the search term,and no relevant case reports were retrieved.Results A 64-year-old man was admitted to the hospital because of chest tightness and shortness of breath for 10 days,cough and fever for one day.Enhanced CT of the chest showed a soft tissue mass shadow in the right lower hilar area,with obstruction of the adjacent bronchus,and local mild enhancement,suggesting of right lower lung cancer.In addition,the CT scan also showed consolidated shadows in the lower lobes of both lungs,scattered nodules,multiple lymphadenopathy in the mediastinum,and a small amount of pleural effusion on the right.Under bronchoscopy,a cauliflower-like neoplasm was seen at the opening of the lower right basal section,about 7 mm×8 mm,and biopsy showed that part of the mucosal structure was destroyed,with disappearance of the squamous epithelial layer,and the nuclei were large and deeply stained,and some were distributed in nests,with poor keratinization and a small amount of necrosis,and fibrous tissue reaction.Immunostaining revealed that the tumor was positive for p40,CK5/6 and EGFR and negative forTTF-1,NapsinA,PD-L1,p53,with about 30%Ki-67 positive cells.A puncture biopsy of the right lower lobe showed that the alveolar cavity was filled with nested lymphoid cells,consisting of small lymphocytes,central cell-like cells and monocyte-like cells,with occasionally large cells.Immunostaining revealed CD20+,CD79a+,scattered CD3+,Bcl2+,SMA vascular+,Bcl6-,CK-,CD10-,CyclinD1-,with about 3%Ki-67 positive cells.The histopathological examinations confirmed the diagnosis of mucosal-associated lymphoid tissue extranodal marginal zone lymphoma(MALT lymphoma),and lung squamous cell carcinoma.Conclusions Pulmonary mucosa-associated lymphoid tissue lymphoma complicated with lung squamous cell carcinoma is rare and easy to be missed and misdiagnosed.Chest CT imaging shows single or multiple nodules,mass shadows or consolidation,often accompanied by air-bronchial signs in the lesion,bronchiectasis,ground glass density around the lesion,hilar and mediastinal lymphadenopathy.Occasionally,pleural effusion can be seen.Lung biopsy is the gold standard for diagnosis.