PMC6363242_01
Axial lung window CT slices (a, b, c) at different levels demonstrate innumerable ill-defined solid nodules with peripheral ground-glass halos in a peribronchovascular distribution (blue arrows) and more prominent in the left lung. Air-bronchograms were seen (orange arrows).
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An outpatient chest CT showed innumerable bilateral ill-defined solid pulmonary nodules in a peribronchovascular distribution, which were new from a prior scan 6 months earlier (Figure 1).
Low power section (a) from lung biopsy showing a diffuse neoplastic lymphoid cells (arrows) infiltrating the lymphatic and bronchovascular bundles. (H&E, 100x) Medium power view (b) showing neoplastic cells involving walls of pulmonary vessels. Small, reactive lymphocytes are seen in the background. (H&E, 200x) High power view (c) shows large, atypical B-cells with irregular nuclear membranes, open chromatin, and prominent nucleoli invading vessel walls (angioinvasion). (H&E, 500x) The neoplastic B-cells were positive for EBV (d).
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fig2
The biopsies revealed EBV-positive DLBCL with features of LG grade 3 (Figure 2).
Immunostaining for CD3 (a) and CD5 (b) highlights background small, reactive T-cells. The large, atypical B-cells are negative. The large neoplastic B-cells are negative for CD5 and CD23 (c). CD20 is positive in large, atypical B-cells (d). The background small lymphocytes (reactive T-cells) are negative. The overall immunostaining pattern excludes both EBV+ CLL and EBV+ T-cell lymphoma as possible diagnoses.
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The flow cytometric findings are compatible with the morphology as no significant CLL/SLL population could be identified with CD5 and CD23 immunostaining (Figure 3).
Axial images from PET/CT obtained 4 weeks following baseline chest CT. Axial CT image in lung windows (a) shows marked progression and confluence of bilateral peribronchovascular lung opacities. Fused PET/CT image of the thorax (b) shows the pulmonary abnormalities to have intense FDG uptake with max SUV of 22.3. There were no FDG-avid lymph nodes or splenomegaly. Left pneumothorax and subcutaneous emphysema were a result of the patient's recent VATS biopsy. Axial fused image of the lower extremities (c) shows FDG uptake within multiple subcutaneous nodules.
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The patient underwent PET-CT 4 weeks following the initial chest CT (Figure 4).