Waxing and Waning Nodules: A Rare Diagnosis of Pulmonary Malt Lymphoma
Recommended Citation
Nakdali R, Bradley P. Waxing and Waning Nodules: A Rare Diagnosis of Pulmonary Malt Lymphoma. Am J Respir Crit Care Med 2025; 211:A6999.
Document Type
Conference Proceeding
Publication Date
5-20-2025
Publication Title
Am J Respir Crit Care Med
Abstract
Introduction: Mucosa-associated lymphoid tissue (MALT) lymphoma is a rare type of non-Hodgkin's lymphoma that can involve extranodal sites, including the lungs. Primary pulmonary MALT lymphoma is an uncommon diagnosis, presenting incidentally or with nonspecific symptoms. We present a patient with long-standing pulmonary nodules and several inconclusive biopsies, ultimately diagnosed with pulmonary MALT lymphoma. Case: A 60-year-old man, with a 70-pack year smoking history, was incidentally found to have bilateral noncalcified pulmonary nodules, measuring up to 2.4cm, on routine lung cancer screening seven years prior to presentation to our clinic. The nodules were followed by annual computed tomography (CT) scans with waxing and waning size of the nodules. At the onset, he underwent two lung biopsies, however pathology was inconclusive with reactive changes, fibrous stroma and scattered chronic inflammatory cells. He deferred surgical biopsy due to concern for risks of surgery, which led to ongoing CT surveillance without definitive diagnosis. Imaging in 2024 demonstrated progression of the pulmonary nodules, with the largest nodule in the right upper lobe now measuring 5.5 x 3.7 cm, along with new nodules in both lungs. The patient remained asymptomatic, denying cough, hemoptysis, fever, chills, shortness of breath, and chest pain. A positron emission tomography (PET) scan revealed a hypermetabolic right upper lobe mass measuring 5.5 x 3.7 cm, with multiple foci of mild hypermetabolic satellites variable in size along with a hypermetabolic 1.7cm x 2.4cm pleural based pulmonary nodule in the left lower lobe, suggestive of malignancy. There was no evidence of metastatic disease. The patient underwent a bronchoscopic biopsy of the right upper lobe nodule. Pathology revealed a diagnosis of low-grade B-cell lymphoma, specifically extranodal marginal zone lymphoma of MALT type. Discussion: This case highlights the evasive nature of pulmonary MALT lymphoma on imaging. In this case, our patient had bilateral pulmonary nodules that fluctuated in size over seven years and biopsies yielded two inconclusive results. A high index of suspicion led to the patient being reevaluated and eventual diagnosis. MALT lymphoma is the most common type of primary pulmonary lymphoma, which constitutes only 1% of all pulmonary malignancies. It is often indolent and can be asymptomatic, with a variety of findings on CT as described by numerous papers. Treatment options include surveillance, surgical intervention, chemotherapy, or immunotherapy, depending on the extent and progression of disease.
Volume
211
First Page
A6999
