Lymphomatoid granulomatosis (LG) is a rare T cell rich, B cell non-Hodgkin's lymphoma which is difficult to diagnose. We present a patient with LG who demonstrated many of the difficulties in diagnosis and highlighted the importance of reviewing the diagnosis if treatment does not have the anticipated effect.A 49 year old male smoker presented to another hospital with a 3 month history of weight loss and sweats. A chest radiograph showed a mass in the left lower lobe and bronchoscopic examination revealed inflammation involving the left lower lobe bronchus. Washings were negative for organisms and malignancy. A computed tomographic (CT) scan showed a cavitating mass in the left lower lobe with multiple smaller opacities throughout both lung fields. Percutaneous fine needle aspiration of the mass showed inflammation with necrotic debris. He was discharged but presented 1 week later with fever and rigors and was transferred to this hospital.On arrival he had a cough productive of copious, foul smelling, purulent sputum. His temperature was 40˚C. There was no lymphadenopathy or hepatosplenomegaly. Neurological examination was normal. C-reactive protein (CRP) was 59 mg/l. Blood, urine and sputum cultures, white cell count, serum angiotensin converting enzyme, P-and C-ANCA, autoantibody screen, complement, test for HIV, viral screening, and brucella titres were all negative or normal. A repeat bronchoscopic examination was non-diagnostic. A repeat CT scan showed a 7 cm cavitating lesion in the left lower lobe with an air/fluid level and minor ''inflammatory changes'' in the right lung.Empirical treatment for a suspected lung abscess was commenced using intravenous benzylpenicillin, gentamicin, and metronidazole. Over the next 21 days his pyrexia settled, sputum cleared, and the CRP level normalised. The chest radiograph remained unchanged. Four weeks later his purulent sputum, fever, and raised CRP level recurred. Open lung biopsy was considered, but the thoracic surgical team declined because of the evidence for active infection. Antibacterial therapy was recommenced with intravenous cefotaxime and metronidazole. As before, there was a good clinical response but without radiological resolution. Further symptomatic relapse occurred once the drugs were withdrawn. Seven months after initial presentation he deteriorated further. A CT scan showed the left lower lobe cavity unchanged but there were now numerous nodular densities throughout the right lung (fig 1). Repeat bronchial biopsies showed abnormal lymphoid tissue characterised by a polymorphous lymphoid infiltrate containing scattered enlarged blast-like cells. These stained positively for CD20, a B cell marker, and immunoglobulin rearrangement studies showed clonality. These findings suggested lymphomatoid granulomatosis.He was treated with methylprednisolone, vinblastine, and cyclophosphamide. Within 2 weeks his dyspnoea, fever, and right sided radiological abnormalities resolved. The left lower lobe lesion reduced by 40% after three cycles of chemotherapy. Howev...

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Background: Fine-needle aspiration cytology (FNAC) is used as a screening test to evaluate lymphadenopathy. The combined use of genetic analysis and flow cytometry for immunophenotyping has increased the accuracy of diagnosis and correct categorisation of lymphomas on cytological preparations. Aim: To show the utility of immunocytochemistry and polymerase chain reaction (PCR) in the evaluation of cytological preparations of lymph nodes. Methods: Fine needle aspirates were obtained from 33 patients (initial presentation, n = 27; recurrence, n = 6). Routine examination was undertaken using immunocytochemistry and DNA PCR to detect clonality and specific translocations. The cytodiagnosis and subclassification of lymphoma was correlated with histological diagnosis in the available follow-up biopsies. Results: 14 patients had a cytological diagnosis of non-Hodgkin's lymphoma (NHL), 4 had suspected NHL, 2 had atypical lymphoid proliferation and 13 had reactive hyperplasia. A World Health Organization (WHO) subtype was suggested in 8 patients. Incorporating the results of immunoglobulin heavy chain (IgH) and T-cell receptor (TCR) gene rearrangements enabled diagnosis of lymphoma in 17 patients, including 5 of the 6 patients suspected to have NHL or an atypical lymphoid proliferation. Identification of the translocations t (14;18) and t (2;5) helped WHO categorisation in 3 of the patients. The cytological findings were confirmed in 12 out of the 13 patients for whom histological follow-up was available. Seven of the 18 lymphoma patients were managed without a subsequent biopsy. We made one false-positive diagnosis of B-cell NHL on cytology. Conclusion: The use of immunocytochemistry and PCR is valuable in the definitive diagnosis and subtyping of malignant lymphomas on cytological preparations. The use of these techniques may avoid lymph node biopsies in some cases and allow definitive treatment based on aspirate findings alone.

Fourteen cases of breast lymphoma, identified from hospital records between 1990 and 2004, were reclassified according to the World Health Organisation criteria. Primary cases occurred more frequently and all cases were of B cell origin, predominantly involving the right breast. Most primary cases were diffuse large B cell lymphomas, whereas secondary cases were heterogeneous in type and most had a poor prognosis.

This study supports the use of phenotypic and T cell clonality investigations in identifying patients with true rCD.