The patient was a 53-year-old Chinese male with no history of cancer in his immediate family. The patient underwent small intestinal stromal tumor surgery in June 2020 and was treated with oral imatinib after surgery. The patient complained that on April 30, 2021, he had cough and sputum, yellow purulent sputum, with fever, up to 38.8 C, accompanied by chest tightness, no obvious chest pain, and no hemoptysis. After 3 days of infusion in the clinic, he went to a local hospital for treatment. Chest CT showed cavity changes in the left lung, left pleural fluid, and nodules in both lungs. The hospital was given piperacillin + etimicin + levofloxacin anti-infective treatment for 12 days. The cough and sputum were better than before, but there was still fever, and bloodshot sputum appeared. For further diagnosis and treatment, he came to the respiratory department of our hospital on May 14, 2021. Physical examination: thick breath sounds in both lungs, and weak breath sounds in the left lung. Blood routine: C-reaction protein (CRP)158 mg/L, white blood cell (WBC)3.38x10^12/L, red blood cell (RBC)3.36x10^12/L, hemoglobin (HGB)99 g/L, lymphocyte (LYM)0.39x10^9/L, mononuclear cell (MONO)0.74x10^9/L. Hemoglobin A1C (HbA1c) Test: 7.9%. There is no special abnormality in liver and kidney function and electrolyte examination. General bacterial, fungal sputum examination, tuberculosis and other sputum pathogenic examinations were negative. Tumor markers AFP, CEA, CA199, and PSA, were all negative. Electronic bronchoscopy showed mucosal congestion and edema in the basal segment of the left lower lobe, the lumen was narrow, and lung lavage was performed. Chest CT examination was performed on May 16, 2021 ( Figures 1A-C ). On May 17, 2021, a lung biopsy was performed for pathological examination. Symptomatic treatment was given, and a thoracic surgery consultation was recommended to recommend surgery. On June 19, 2021, the left lower lung mass and left lower lung were resected under thoracoscopy, and the left upper lung nodule was wedge-shaped. The surgical specimens were sent for pathological examination. They were then sent to the Department of Pathology, Beijing Friendship Hospital, for genetic testing of T-cell clone analysis using BIOMED-2 PCR protocols. A CHOP chemotherapy regimen (ECOG score 0 points, body surface area 1.52 m2, cyclophosphamide 1.1 g1day, pyridoxine 70 mg1day, vinorelbine 40 mg1day, prednisone 100 mg1-5day) was given on August 23, September 16, October 7, October 27, November 18, December 7, 2021, at the Department of Hematology of our hospital, and the CT scan was repeated on October 27, showing that the patient's condition improved ( Figure 1D ). Radiation therapy was performed in the oncology department of our hospital from January 4 to January 29, 2022. The patient is still under follow-up.
Pathological diagnosis on left lung biopsy on May 17, 2021, showed lymphomatoid granulomatosis, tending to grade 3.
The macroscopic examination of the surgical specimen from June 19, 2021 ( Figure 2 ) revealed a 4x1.4x1 cm piece of lung tissue in the left upper lung and a 0.8x0.8x0.7 cm tumor seen in the lung tissue at a distance of 0.6 cm from the lung resection margin. There were many irregular tissues in the left lower lung, totaling 14x12x4 cm, of which a 9x8x4 cm gray-white, gray-yellow slightly hard area could be seen. Microscopic findings: lymphoid cells infiltrated the blood vessel wall in the tumor tissue, scattered B lymphocytes in the rich T lymphocytes background, T lymphocytes heteroplasia, mitotic figures were easy to see, and large necrosis was seen in the center of the tumor. Immunohistochemistry showed tumor tissue Vim(+), CD43, CD2, CD3, CD5, CD7, CD4, CD8 lymphocytes (+); CD56 scattered(+), TiA(+), GrB(+), CD20, CD79a and PAX5 scattered lymphocytes (+); CD10(-), bcl-6(-), Bcl-2(-), Mum(-), C-myc(-), CD21(-), CK23(-), CD30(-), CD15(-), CK(-), S-100(-), CD1a(-), langerin(-), CD68, CD163 histiocytes (+); and Ki-67 dysplastic T lymphocytes were approximately 60% (+). In situ hybridization: EBER focal, scattered (+). Pathological diagnosis: (left upper lung nodule) and (left lower lung) T lymphocytes heteroplasia, lymphoma cannot be excluded; genetic testing is recommended to exclude T-cell lymphoma. The 2 lymph nodes of Group 9 submitted for examination showed reactive hyperplasia.
Gene detection results: TCRbetavbeta+Jbeta2 and DB+Jbeta1/2 showed monoclonal rearrangement. Pathological diagnosis: pulmonary non-Hodgkin CD8-positive cytotoxic T-cell lymphoma with Epstein-Barr virus infection in some cells.