Lymphoma With Pleral Effusion As The Initial Manifestation:seven Cases Report And Review Of The Literature

Objective: To study the clinical features of lymphoma with pleural effusion as the initial manifestation and to improve the level of the differential diagnosis of an uncommon cause of pleural effusion.Methods: Seven cases with pleural effusion caused by lymphoma as the initial manifestation diagnosed at the First Affiliated Hospital of Guangxi Medical University from July 2012 to August 2015 were retrospecitively ananlysed,and the relevant literature was review with regard to its clinical manifestations,imaging findings,blood and pleural fluid laboratory tests,diagnosis and treatment.Collected the clinical data of tuberculous pleurisy patients who diagnosed by thorascopic biopsy of the pleura at the same period,then discussed the value of serum and pleural effusion tests in differential diagnosis lymphoma pleural effusion from tuberculous pleural effusion.Results: 1.(1)Seven cases: Male to female ration is 2.5:1.Their average age was 45.3 years old.Two cases had acute onset and others had chronic onset.(2)Main symptoms: Dyspnea(6/7),dry cough(5/7),weight loss(3/7),fever(1/7);Physical examination revealed pleural effusion sign(7/7),regional lymphadenopathy(4/7),and hepatosplenomegaly(0/7).(3)Blood laboratory results: Anemia(5/7);Elevated CRP(7/7);Elevated ESR(5/7);Elevated LDH(6/7);Elevated CA125(6/7).(4)Imaging findings: Enlarged lymph nodes in the hilus or mediastinum(2/7);Hilus or mediastinum mass(2/7);Pleural thickening(1/7);Bilateral pleural effusion(5/7),polyserositis(5/7).(5)Plerual effusion laboratory results: All cases were exudate;Lymphocytes predominated(3/7);Elevated ADA(3/7);Elevated LDH(6/7);Elevated CA125(6/7);Found abnormal lymphocytes(2/7).(6)Diagnosis: By medical thoracoscopy biopsy of the pleural(1/7);With superficial lymph node biopsy(5/7);Combine mediastinal lesions biopsy with superficial lymph node biopsy(1/7).Misdiagnosed: Tuberculosis(4/7),and lung carcinoma(1/7).(7)Pathology: All cases were non-Hodgkin's lymphoma,and 6 cases were performed on immunohistochemical analysis to comfirm the final diagnoses.(8)Therapy and prognosis: Accepted chemotherapy and improved(2/7);without accept chemotherapy and loss follow-up(5/7).2.Rusults of literature review: 157 cases of lymphoma with pleural effusion as the initial manifestation were reported from 1980 to 2017,and male to female ration is 3.1:1.Their average age was53.2 years old.The main clinical manifestations were dyspnea,dry cough,fever and chest discomfort;Except for pleural effusion sign,19 cases had superficial lymph nodes enlargement and 7 cases had hepatosplenomegaly.Elevated serumLDH from reported cases were observed in about 58%.Imaging were shown enlarged lymph nodes in the hilus or mediastinum(21/155),pleural thickening(25/155),hilus or mediastinum mass(23/155),and polyserositis(29/155).The majority cases of pleural fluid were exudative and lymphocytes predominated.More than half of report cases observed elevated pleural ADA and LDH level,and 65% of these were 1.25 times greater than normal reference range in LDH,while 46.8% of these were above 45 u/L in ADA.The positive rate from the pleural effusion cytology by finding abnormal lymphocytes was approximately30%.Before being correctly diagnosed,nearly half of cases were misdiagnosed as tuberculosis,while a small number cases as lung carcinoma,pneumonia etc.The time of diagnosis from the onset to the lymphomawere spent 1 week to 18 months,and the average time was about 6 weeks.After comfirmed the digonosis of lymphoma,97 cases undertook chemotherapy,of which 73 cases show improvement and 24 cases were death.29 cases for some reasons didn't receive chemotherapy,of which 11 cases alive but 18 cases were death.The rest of the cases with unknow prognosis.3.There was statistically significant difference between the lymphoma group and tuberculous pleurisy group in serum LDH,CEA,CA125 and pleural ADA,CEA.Conclusions:(1)Lymphoma with pleural effusion as the initial manifestation is more mommon in aged men,and the mainly type are NHL.(2)These patients often lack of lymphoma typical manifestations,but multi-system involved and elevated serum LDH are not rare.Pleural effusion laboratoryresults are exudative and lymphocytes predominated.Elevated pleural ADA,pleural LDH is 1.25 times higher than upper limit of normal,or the proportion of pleural LDH to serum LDH is higher than 1 can be found in more than half of cases,but the positive rate by finding abnormal lymphocytes is less than 50%.(3)When pleural ADA and LDH are both elevated,it should be differential diagnosis from tuberculous pleural effusion.The final diagnosis need histopathology and immunohistochemistry.(4)Chemotherapy can reduce the pleural effusion.The prognosis between lymphoma patients with pleural effusion and who without pleural effusion is inconclusive.