Ann Thorac Surg 2011;91:1281-1283. doi:10.1016/j.athoracsur.2010.10.009
© 2011 The Society of Thoracic Surgeons
Case Reports
Mucosa-Associated Lymphoid Tissue Lymphoma of the Left Mainstem Bronchus
Takahiro Nakajima, MD, PhD,
Kazuhiro Yasufuku, MD, PhD,
Yasuo Sekine, MD, PhD,
Shigetoshi Yoshida, MD, PhD,
Ichiro Yoshino, MD, PhD*
Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
Accepted for publication October 1, 2010.
* Address correspondence to Dr Yoshino, Department of General Thoracic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, chuo-ku, Chiba, 260-8670 Japan (Email: iyoshino{at}faculty.chiba-u.jp).
 |
Abstract
|
|---|
Primary mucosa-associated lymphoid tissue (MALT) lymphoma of the large airway is extremely rare. We report a patient in whom we performed a sleeve resection of the left main bronchus without resection of lung parenchyma for MALT lymphoma. During restaging of the disease, tumor cells were detected in the bone marrow, and the patient subsequently underwent systemic chemotherapy with anti-CD20 antibody. The patient currently remains free of recurrence. Local resection of bronchial MALT lymphoma is very important to avoid airway difficulties. In addition, although MALT lymphoma of the bronchus appears to be localized, systemic spread of the disease must be considered and investigated.
|
Introduction
|
|---|
Mucosa-associated lymphoid tissue (MALT) lymphoma is a distinct subgroup of non-Hodgkin's lymphoma (NHL) that comprises more than two-thirds of all primary NHL of the lung [1]; however, it is extremely rare for MALT lymphoma to arise in the large airways [2]. Owing to its rarity, standard treatment protocols have not yet been optimized. In cases of central airway occurrence, local treatment, such as surgical resection, plays an important role to avoid airway obstruction. Although the prognosis of MALT lymphoma of the lung is known to be generally favorable [1], tracheobronchial NHL is usually accompanied by disseminated disease [2].
In this report, we present a patient with primary MALT lymphoma of the left main bronchus who was treated by sleeve resection of the left main bronchus, followed by systemic chemotherapy. We also review the clinical characteristics of MALT lymphoma in the large airways.
A 44-year-old woman was referred to our hospital for the treatment of an endobronchial tumor of the left main bronchus. She was completely asymptomatic, and the lesion was found by the anesthesiologist during an operation for a uterine leiomyoma. Chest computed tomography showed that the lesion was localized within the left main bronchus and the size of the lesion was measured as 12 mm (Fig 1A). Bronchoscopy showed narrowing of the left main bronchus by a protrusive lesion 3 rings from the entrance of the left main bronchus (Fig 1B). A transbronchial biopsy was attempted twice; however, a firm pathologic diagnosis beyond the suspicion of low-grade B-cell lymphoma could not be obtained from the specimen. Other lesions could not be detected during routine preoperative staging for thoracic malignancy.
We performed a sleeve resection of the left main bronchus without removing lung parenchyma. On entering the left thoracic cavity through a posterolateral thoracotomy on the fifth rib bed, the main trunk of left pulmonary artery was dissected and taped after detachment of the ductus arteriosus. The aortic arch and left subclavian artery were also dissected and taped after division of 2 intercostal vessels. The total length of the left main bronchus was then easily exposed. After 2-0 Prolene (Ethicon, Johnson & Johnson, Somerville, NJ) sutures were placed at the carina and at the left secondary carina for traction, the left main bronchus was resected under guidance by fiberoptic bronchoscopy, and an anastomosis was made in an end-to-end fashion with interrupted sutures with 4-0 polydioxanone suture (PDS; Ethicon).
The operation was successfully performed without complications (Fig 1C). The tumor consisted of infiltrated lymphoid cells (Fig 1D), and lymphoepithelial lesions were confirmed in the bronchial epithelium by immunohistochemistry for CAM5.2 (Fig 1E). CD79a, L26, CD3, and bcl-2 were positively stained, and ubiquitin carboxyl-terminal esterase L1 (UCHL-1), CD5, CD10, and cyclin D1 were negatively stained. Anti-
and 
light chain staining showed monoclonality for light chain (Fig 1F). These findings resulted in the diagnosis of MALT lymphoma of the left main bronchus. After this diagnosis, tumor cells were discovered in the bone marrow during restaging for the treatment of MALT lymphoma.
The patient received 4 cycles of chemotherapy with anti-CD20 antibody therapy and complete remission was achieved. She has since been stable, without disease recurrence, for 3 years after treatment.
|
Comment
|
|---|
MALT lymphoma is a rare type of extranodal marginal zone B-cell lymphoma that was first described in 1983 by Isaacson and Write [3]. Pulmonary NHLs are very rare tumors that comprise 1% of all lymphomas [1] and 3.6% of extranodal disease [2]. The clinical characteristics of MALT lymphoma of the lung are variable, and primary tracheal MALT lymphoma is extremely rare [2]. Because of its rarity, there is no consensus for the treatment of the disease, and surgical resection, radiotherapy, and chemotherapy are selected according to the clinical stage [1].
Although the prognosis of nongastrointestinal low-grade B-cell MALT lymphoma is believed to be more favorable than the same entity derived from other organs [1, 4], tracheobronchial NHL can present with disseminated disease [2]. Stage IV disease was present in 26% of patients with nongastric MALT lymphoma, and 32% patients had multifocal lesions at the time of diagnosis [5]. The efficacy of anti-CD20 monoclonal antibody therapy in pulmonary MALT lymphoma has been reported [6]. In the present patient, who was diagnosed as stage IV due to bone marrow spread, complete remission was achieved after she received chemotherapy with anti-CD20 antibody therapy.
The preoperative diagnosis of MALT lymphoma is difficult due to the morphologic similarity to reactive lymphocytes, and a high-quality specimen is required for histologic diagnosis by immunohistochemistry [4]. The presence of lymphoepithelial lesions is the key to the diagnosis of MALT lymphoma [4].
Local treatment by surgical intervention is important for large airway MALT lymphoma to avoid airway obstruction [7] and to obtain a definitive diagnosis. Complete resection of the tumor may also contribute to an improved prognosis [7]. Main bronchial sleeve resection with pulmonary preservation has been reported and showed favorable results [8]. This type of operation benefits patients in preservation of pulmonary function and quality of life; however, the bronchial anastomosis in the narrow surgical field can be difficult, especially in cases of the left side. The major complication of this operation is reported as postoperative stenosis of the airway; however, there were no bronchial stump complications in the present patient.
We performed a sleeve resection of the left main bronchus for MALT lymphoma, without removing lung parenchyma, to avoid the airway complications and also to obtain a definitive diagnosis. This aggressive approach led to the patient receiving a proper evaluation and treatment. Although the disease initially appeared to be localized, systemic disease was discovered after staging for lymphoma. Thus, when clinicians treat MALT lymphoma of the large airways, careful staging for systemic disease must be performed.
|
Acknowledgments
|
|---|
We thank Dr Yoko Takahashi and Prof Yukio Nakatani of the Department of Diagnostic Pathology, Chiba University for pathologic diagnosis. We are grateful to Dr Jonathan Yeung, Toronto General Hospital, for his review of this manuscript.
|
References
|
|---|
- Arnaoutakis K, Oo TH. Bronchus-associated lymphoid tissue lymphomas South Med J 2009;102:1229-1233.[Medline]
- Fidias P, Wright C, Harris NL, Urba W, Grossbard ML. Primary tracheal non-Hodgkin's lymphoma. A case report and review of the literature. Cancer 1996;77:2332-2338.[Medline]
- Isaacson P, Wright DH. Malignant lymphoma of mucosa-associated lymphoid tissue. A distinctive type of B-cell lymphoma. Cancer 1983;52:1410-1416.[Medline]
- Bacon CM, Du MQ, Dogan A. Mucosa-associated lymphoid tissue (MALT) lymphoma: a practical guide for pathologists J Clin Pathol 2007;60:361-372.[Abstract/Free Full Text]
- de Boer JP, Hiddink RF, Raderer M, et al. Dissemination patterns in non-gastric MALT lymphoma Haematologica 2008;93:201-206.[Abstract/Free Full Text]
- Czuczman MS, Grillo-López AJ, White CA, et al. Treatment of patients with low-grade B-cell lymphoma with the combination of chimeric anti-CD20 monoclonal antibody and CHOP chemotherapy J Clin Oncol 1999;17:268-276.[Abstract/Free Full Text]
- Okubo K, Miyamoto N, Komaki C. Primary mucosa-associated lymphoid tissue (MALT) lymphoma of the trachea: a case of surgical resection and long term survival Thorax 2005;60:82-83.[Abstract/Free Full Text]
- Cerfolio RJ, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Mainstem bronchial sleeve resection with pulmonary preservation Ann Thorac Surg 1996;61:1458-1462.[Abstract/Free Full Text]
Top
Abstract
Introduction
