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Weekly Chest CasesArchive of Old Cases

Case No : 1282 Date 2022-05-16

  • Courtesy of Hyun-ju Lim, Kun Young Lim, Soo-Hyun Lee, Hyae Young Kim / National Cancer Center
  • Age/Sex 66 / M
  • Chief ComplaintRight chest wall pain Weight loss (-4kg for 3 months)
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4

Diagnosis With Brief Discussion

Diagnosis
Pyothorax associated lymphoma
Radiologic Findings
Fig.1. Chest radiograph shows calcified pleural thickening and increased extrapulmonary opacity in right lower hemithorax.
Fig. 2-4. Contrast-enhanced CT scan reveals lenticular empyema cavity with calcified wall and adjacent soft tissue mass in right lower hemithorax. The mass is extending into the chest wall and peritoneal cavity with a direct invasion of ribs and diaphragm.
Fig. 5. 18D-FDG-PET CT scan shows strong FDG uptake of soft tissue mass.
Brief Review
Malignant neoplasm is a rare complication of chronic empyema. Various malignant cell types can be associated with chronic empyema including malignant lymphoma, squamous cell carcinoma, malignant mesothelioma, and various sarcoma.
Among them, malignant lymphoma is the most common cell type (pyothorax associated lymphoma; PAL) and the most are non-Hodgkin’s lymphoma of exclusively B-cell phenotype.

PAL is usually secondary to iatrogenic pneumothorax for the treatment of tuberculosis. The development of PAL is triggered by a longstanding empyema lasting for more than 20 years after pneumothorax treatment. The current pathophysiologic understanding of the disease suggests that both chronic Epstein-Barr virus infection and immunocompromised conditions from long-standing inflammation due to chronic empyema may be the causative mechanism of the development of PAL.

PAL manifests as a lenticular or crescent-shaped soft tissue mass straddling the thickened pleura at the margin of a coexistent empyema cavity. It has a tendency to invade adjacent structures including the chest wall, rib, lung, and diaphragm. Heterogeneous attenuation due to necrosis, simulating empyema necessitates, is common in PAL (which is uncommon in the other types of non-Hodgkin’s lymphoma).

There are previous reports of distant involvement of PAL including cervical, mediastinal and abdominal lymph nodes; superficial lymph nodes; adrenal glands; liver; stomach, kidneys; central nervous system; spleen; small intestine, and pancreas.

Differential diagnoses of PAL are benign complications of chronic empyema including empyema necessitates and other rare empyema-associated malignant tumors such as mesothelioma, angiosarcoma, malignant fibrous histiocytoma, and squamous cell carcinoma.

The prognosis of PAL is poor.
References
Ueda T et al. AJR 2010;194:76-84
Bae JY et al. J Korean Scoc Radiol 202;81(5):1109-1120
Bligh MP et al. Radiographics 2017;37:439-461
Please refer to
Case 1241 Case 1052 Case 460
Keywords

No. of Applicants : 104

▶ Correct Answer : 51/104,  49.0%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - , Japan HIROAKI ARAKAWA
  • - Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
  • - ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
  • - Showa General Hospital , Japan MASAFUMI KAIUME
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - , Korea (South) CHANGSU KIM
  • - Chungbuk National University Hospital , Korea (South) JIYUN KANG
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Other , Korea (South) SEONGSU KANG
  • - Asan Medical Center , Korea (South) YUJEONG EO
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Shimada General Medical Center , Japan HAYATO NOZAWA
  • - , Korea (South) SUNHYANG LEE
  • - Other , Korea (South) HYEON IL CHOI
  • - , Korea (South) HYEWON CHOI
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Inje University Pusan Paik Hospital , Korea (South) JIYEON HAN
  • - Kyeongpook National University Hospital , Korea (South) HYEONJUN JANG
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Chonnam National University Hwasun Hospital , Korea (South) MYUNG WON SONG
  • - Kyoto University Hospital , Japan YASUHISA KURATA
  • - Chungbuk National University Hospital , Korea (South) JUNGHYUN LEE
  • - , Korea (South) YEONG UK HWANG
  • - Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
  • - , Japan MIDORI UENO
  • - Chungbuk National University Hospital , Korea (South) MIHYEON PARK
  • - Other , Korea (South) MINSU KIM
  • - , Qatar NABIL SHERIF MAHMOOD
  • - Osaka metropolitan university Hospital , Japan TATSUSHI OURA
  • - GHICL , France MANUEL TOLEDANO
  • - Other , Korea (South) SEONG WON JANG
  • - Dokkyo Medical University , Japan HIROAKI ARAKAWA
  • - Chonnam National University Hwasun Hospital , Korea (South) JEONG YEOP LEE
  • - Chonnam National University Hospital , Korea (South) KIM SANG GYUN
  • - Other , Korea (South) KYU-CHONG LEE
  • - Kyoto University Hospital , Japan SATOSHI IKEDA
  • - Paras hospital, Panchkula , India SHALEEN RANA
  • - Samsung Medical Center , Korea (South) SUHO KIM
  • - Chungbuk National University Hospital , Korea (South) HYE SOO CHO
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Hanyang University Hospital , Korea (South) SUNJIN RYU
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Nerimahikarigaoka hospital , Japan TAKANA HAYASHI
  • - Sotiria Hospital, Athens , Greece VASILIOS TZILAS
  • - , Japan YUKI HAYASHI
  • - , Korea (South) HM PARK
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 16/104,  15.4%
  • - Wakayama Red Cross Hospital , Japan TOMOAKI OTANI
  • - Jichi Medical University Hospital , Japan JUN KANZAWA
  • - McGill University Health Center , Canada ALEXANDRE SEMIONOV
  • - Kyoto University Hospital , Japan YUSUKE UTSUNOMIYA
  • - NIMS, HYDERABAD , India BHASKAR K
  • - National Center of Neurology and Psychiatry , Japan MOTO NAKAYA
  • - , Italy PAOLO BALDASSARI
  • - , Japan CHIAKI SATO
  • - Ichinomiya Nishi Hospital , Japan CHIHIRO KIGUCHI
  • - Osaka University , Japan AKINORI HATA
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - McGill , Canada MUTAZ ADNAN KHAIRO
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Soonchunhyang University Hospital Bucheon , Korea (South) YE RIN KIM
  • - Eskisehir Sehir Hastanesi , Turkey MURAT SAHIN
  • - Chonbuk National University Hospital , Korea (South) DONG HAN SHIN
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Current Editor : Eui Jin Hwang, M.D., Ph.D Email : weeklychestcases@gmail.com

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