대한흉부영상의학회 Weekly Chest Cases

Case No : 1424 Date 2025-02-03

Courtesy of Hyungin Park / Inje University Haeundae Paik Hospital
Age/Sex 75 / M
Chief ComplaintGeneral weakness

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Diagnosis With Brief Discussion

Diagnosis: Pyothorax-associated lymphoma
Radiologic Findings: Fig 1. Chest PA shows right CPA blunting, pleural thickening with calcification in the right mid thorax
Fig 2-5. CT scans reveals locuated right lower pleural fluid collection with diffuse pleural thickening and calcification, with adjacent passive lung atelectasis. Huge infiltrative enhancing mass is located inferiorly to a chronic empyema cavity, with hepatic extension
Fig 6-7. Axial and coronal FDG PET/CT images show intense FDG uptake along the periphery of the mass.
Brief Review: Pyothorax-associated lymphoma is a rare but important complication of chronic empyemas, with a poor prognosis. It is most commonly reported in Asia, especially Japan. Patients most commonly present with chest or back pain and/or swelling due to PAL involvement. 
PAL is commonly reported in patients with chronic pyothorax due to tuberculous pleuritis or in patients who have undergone artificial pneumothorax therapy for tuberculosis. The current pathophysiologic understanding of the disease suggests that both chronic Epstein-Barr virus (EBV) infection and an immunocompromised condition from long-standing chronic inflammation due to chronic empyema may be the causative mechanism of development of pyothorax-associated lymphoma. Chronic inflammation of the pleura is hypothesized to lead to the local production of immunosuppressive cytokines, thereby allowing the clonal proliferation of EBV-transformed B cells to evade immune surveillance. The high prevalence of PAL in Asia may be explained by its high incidence of EBV and tuberculosis infections PAL is seen on CT scans as a soft tissue mass located eccentrically at the margin of a chronic empyema cavity. PALs demonstrate expansile growth along the pleura and can invade adjacent structures, such as the liver, mediastinum, or chest wall.
Because of overlapping imaging findings of benign and malignant pleural diseases, a suspicious pleural mass should always be biopsied for a definitive diagnosis.
References: 1. Hu JY, Lee KH, Yun G. Case 322: Pyothorax-associated Lymphoma. Radiology. 2024 Feb;310(2):e223090. doi: 10.1148/radiol.223090. PMID: 38411510.
2. Lee HY, Goo JM, Lee HJ et al. The value of computed tomography for predicting empyema-associated malignancy. JCAT 2006;30:453-459
3. Ueda T, Andreas C, Itami J et al. Pyothorax-Associated Lymphoma:Imaging Findings. AJR 2010;194:76-84
Keywords

No. of Applicants : 68

▶ Correct Answer : 55/68, 80.9%

- Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
- Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
- , Japan SUZUNE TSUKAMOTO
- medical scanning , Japan HIROAKI ARAKAWA
- IUHW Narita Hospital , Japan ISSEI FUKUDA
- ZIGONG TCM HOSPITAL OF CHINA , China CAO CUN YOU
- Shiga University of Medical Science , Japan AKITOSHI INOUE
- Kyoto University , Japan AKIHIKO SAKATA
- McGill University Health Center , Canada ALEXANDRE SEMIONOV
- Oita university , Japan AYUMI KAMEI
- Kyoto City Hospital , Japan YUSUKE UTSUNOMIYA
- Inje University Haeundae Paik Hospital , Korea (South) HYUNGIN PARK
- Vita Hospital , Brazil DIOGO LAGO PINHEIRO
- , China FANG YING GEN
- Secomedic Hospital , Japan FUMINORI MIYOSHI
- Oita University, Faculty of Medicine , Japan FUMITO OKADA
- Seoul Medical Center , Korea (South) HYUK GI HONG
- university of montreal , Canada Andrei Bogdan Gorgos I
- University of Yamanashi , Japan TAKAAKI HASHIMOTO
- Osaka University , Japan AKINORI HATA
- Kaneda hospital , Japan HIROFUMI MIFUNE
- The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
- , Japan YOSHIKI ISHII
- University of Yamanashi , Japan HIROAKI WATANABE
- Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
- Other , Korea (South) CHAEHUN LIM
- Osaka Metropolitan University Hospital , Japan SHU MATSUSHITA
- , Myanmar MAW MAW OO
- , Japan SHUNJIRO NOGUCHI
- , Japan MARINO TANIGUCHI
- Jichi Medical University, School of Medicine , Japan MITSURU MATSUKI
- University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
- Shiga General Hospital , Japan YUSAKU MORIBATA
- Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
- Osaka metropolitan university Hospital , Japan TATSUSHI OURA
- Mie university , Japan SHIKO OKABE
- GHICL , France MANUEL TOLEDANO
- Dokkyo Medical University , Japan HIROAKI ARAKAWA
- Other , Korea (South) SEOL A LEE
- TB centre kasaragod. , India rikhy krishnan
- Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
- Paras hospital, Panchkula , India SHALEEN RANA
- Kyoto University , Japan SHO KOYASU
- , Japan SHUHEI NORIMOTO
- Kyung Hee University Medical Hospital , Korea (South) JEONG TAEK YOON
- Yonsei University,Severance Hospital , Korea (South) SEO BUM CHO
- Kantou Rousai Hospital , Japan KAORU SUMIDA
- Matsunami General Hospital , Japan TARO TAKEDA
- , Korea (South) NAEUN OH
- , Japan YUMI MAEHARA
- Toyota Kosei Hospital , Japan YUKI HAYASHI
- the first affiliatited hospital of nanjing medical univercity , China HAI XU
- University of Yamanashi , Japan KOJIRO ONOHARA
- , Japan JUN YOSHIDA
- Jiangsu province hospital , China WANGJIAN ZHA

▶ Correct Answer as Differential Diagnosis : 4/68, 5.9%

- , Korea (South) DONG-HO BANG
- , Korea (South) JIN YOUNG LEE
- Ajou University Hospital , Korea (South) YOU NA KIM
- Fukuoka university , Japan KEISUKE SATO

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 1424 Date 2025-02-03

Discussion

No. of Applicants : 68