대한흉부영상의학회 Weekly Chest Cases

Case No : 1241 Date 2021-08-02

Courtesy of Yoon Yeong Choi, KyungHee Lee / Inha University Hospital
Age/Sex 65 / M
Chief Complaintchest wall pain and mass (2months ago). history of right decortication (4 years and 6months ago).

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Diagnosis With Brief Discussion

Diagnosis: Pyothorax Associated Lymphoma (PAL)
Radiologic Findings: Fig 1: Chest PA shows soft tissue swelling in the right lower thorax and right lower pleural effusion with multiple calcifications and pleural thickening with calcification in the left mid thorax.
Fig. 2-3 (CT scans 4years and 6months ago): CT scans show loculated right lower pleural fluid with diffuse pleural thickening and passive lung atelectasis. There is also nodular pleural thickening with calcifications in the right diaphragmatic pleura and left lower posterior pleura,
Fig. 4-6: CT scans show infiltrative lesion with diaphragmatic extension. It shows fluid-like low attenuation and thick peripheral enhancement involving pleural space and chest wall.
Brief Review: Partial excision of chest wall mass was performed and the pathology revealed chronic empyema associated high-grade lymphoma with extensive (95%) infarction (EBV-positive diffuse large B cell lymphoma.

Malignant neoplasm is a rare complication of chronic empyema and is likely to occur after more than 5years of chronic empyema. Malignant lymphoma is the most common malignant cell type associated with chronic empyema. Most pyothorax-associated lymphoma (PAL) are non-Hodgkin’s lymphoma with diffuse large B cell type.
The diagnosis of PAL is difficult in most cases because the tumor frequently shows extensive necrosis or cystic degeneration that simulates the exacerbation of empyema or empyema necessitans.
Extensive tumor necrosis may be related to the fact that most PALs are high-grade. To differentiate malignancy from empyema necessitans, it is important to examine the shape of a mass with soft-tissue attenuation, particularly concerning the irregular wall thickness and the existence of projections in the cavity. Another helpful CT finding for differential diagnosis is bony destruction.
References: Kim YK, Lee SW, Choi HY, Im SA, Won TH, Han WS, A case of pyothorax-associated lymphoma simulating empyema necessitatis, Clinical Imaging 27(203) 162-165
Ueda T, Andreas C, Itami J, Miyakawa K, Fujimoto H, Ito H, Roos JE, Pyothorax-Associated Lymphoma : Imaging Findings AJR 2010;194:76-84
Please refer to: Case 1052 Case 1020 Case 938 Case 874 Case 522 Case 460
Keywords

No. of Applicants : 96

▶ Correct Answer : 32/96, 33.3%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Korea University Guro Hospital , Korea (South) SEOKYOUNG LEE
- Showa General Hospital , Japan MASAFUMI KAIUME
- Mayo Clinic , United States AKITOSHI INOUE
- , United Kingdom SAMSON KADE
- CHCB , France LE GUEN RAPHAEL
- NIMS, HYDERABAD , India BHASKAR K
- , Italy PAOLO BALDASSARI
- Tiger Gate Hospital , Japan SHIN-ICHI CHO
- Other , Korea (South) SEONGSU KANG
- Samsung Medical Center , Korea (South) JUHYUN KIM
- Osaka University , Japan AKINORI HATA
- Shimada General Medical Center , Japan HAYATO NOZAWA
- Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
- Gifu University Hospital , Japan Yo Kaneko
- , Japan KANAE TAKAHASHI
- The University of Tokyo Hospital , Japan RYO KUROKAWA
- Other , Korea (South) KYOWON GU
- , Korea (South) SEUNGHYUN LIM
- Other , Korea (South) MARI A
- Mallinckrodt Institute of Radiology , United States NAGANATHAN MANI
- Other , Korea (South) MINSU KIM
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Seoul Veterans Hospital , Korea (South) SEONG WON JANG
- Other , Korea (South) KYU-CHONG LEE
- Toranomon Hospital , Japan KAORU SUMIDA
- Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
- National Center for Global Health and Medicine , Japan TOMOKI IMOKAWA
- Private sector , Greece VASILIOS TZILAS
- , Japan YUKI HAYASHI
- Kyemyung University Dongsan Hospital , Korea (South) DONG HYEON KIM
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 25/96, 26.0%

- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
- Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
- Other , Korea (South) HYEJIN YANG
- Chonbuk National University Hospital , Korea (South) MINGI SHIN
- Osaka Red Cross Hospital , Japan YUSUKE UTSUNOMIYA
- National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- HHS , Canada S LEE
- Seoul National University Bundang Hospital , Korea (South) SUNG HYUN YOON
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Yeungnam University Medical Center , Korea (South) JONGSOO PARK
- McGill , Canada MUTAZ ADNAN KHAIRO
- Soonchunhyang University Hospital Bucheon , Korea (South) SEONGHWAN BYUN
- Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- TB centre kasaragod. , India rikhy krishnan
- Kyoto University Hospital , Japan SATOSHI IKEDA
- Ichinomiya Nishi Hospital , Japan Takao Kiguchi
- The University of Tokyo Hospital , Japan HIROSHI TAKUMIDA
- , Japan KAZUMA TERAUCHI
- Kyoto university , Japan AKIHIKO SAKATA

▶ Semi-Correct Answer : 3/96, 3.1%

- Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
- , Brazil FERNANDO MORANDINI
- Muhimbili National Hospital , Tanzania FREDERICK RICHARD LYIMO

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1241 Date 2021-08-02

Discussion

No. of Applicants : 96