PULMONARY PARENCHYMAL AND ENDOBRONCHIAL INVOLVEMENT IN A PATIENT WITH MYCOSIS FUNGOIDES

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Pulmonary involvement in lymphoma is uncommon and endobronchial disease is rarer still. We present a case of parenchymal and endobronchial mycosis fungoides and review management. CASE PRESENTATION: A 69 year old male never smoker was seen for cough and new lung nodules. His medical history was significant for folliculotropic mycosis fungoides diagnosed 10 years prior, with large cell transformation and hepatic only relapse. He last received chemotherapy with brentuximab-vedotin six weeks prior to being evaluated. Treatment with levofloxacin had not improved the cough, which progressively worsened in the past month. He also endorsed chills but no fevers. The patient had previously received steroids in 2016 for an ‘inflammatory nodule’ in the lung. Significantly, as evidence of his disease progression, the patient had also undergone an ERCP a few months prior, requiring biliary stents for obstruction due to lymphoma in the lumen of the biliary duct. Exam revealed normal vital signs and was only significant for chronic tenderness of the right upper quadrant when palpated. Laboratory examination revealed an elevated white blood cell count without lymphopenia, elevated lactate dehydrogenase, normal aspergillus galactomannan and normal beta-d-glucan levels. Chest radiographic was unremarkable. CT scan of the chest revealed multiple new pulmonary nodules, some of which were cavitating. Additionally, new endobronchial disease was appreciated in the left mainstem bronchus (LMB) and right mainstem bronchus (RMB). In the current context primary concerns were multifocal pneumonia (potentially fungal), tuberculosis and progression of lymphoma. The patient underwent flexible bronchoscopy and the LMB (Fig. 1) and RMB (Fig. 2) lesions, a representative right upper lobe nodule and right middle bronchoalveolar lavage all revealed transformed mycosis fungoides. The patient has been off chemotherapy since and the endobronchial disease has not recurred since. DISCUSSION: Mycosis fungoides (MF) is a cutaneous T-cell lymphoma (CTCL) and the lungs are most frequently involved in extra-nodal CTCL. Pulmonary involvement with alveolar and nodular patterns (though not endobronchial disease) has been reported in MF. The nodules may cavitate, mimicking multifocal infections and may also progressively enlarge. Endobronchial disease with any lymphoma is rare and a handful of cases with bilateral endobronchial disease (as ours) have been identified – this may lead to variable degrees of lobar or segmental collapse and a more acute presentation. Systemic chemotherapy, radiotherapy and endobronchial debulking have all been reported with success and as a result stenting for endobronchial lymphomas may not be required. Pulmonary involvement in lymphomas should also be followed serially with imaging to assess progression and any response to treatment. CONCLUSIONS: Pulmonary involvement in MF is rare and may not need stenting. Reference #1: Pulmonary manifestations in patients with cutaneous T-cell lymphomas. Baser S et al. Cancer. 2007. DISCLOSURES: No relevant relationships by Bryan Husta, source=Web Response No relevant relationships by Vishisht Mehta, source=Web Response