PULMONARY MALIGNANT LYMPHOMAS AND
PSEU.DOLYMPHOMAS: CLASSIFICATION,
THERAPY, AND PROGNOSIS
SIDNEY L. SALTZSTEIN, M.D.*
P ATIENTS WITH SO-CALLED LYMPHOMAS OF
the lung have a better prognosis than
those with other pulmonary tumors and those
with lymphomas of other sites. This fact has
led to a variety of opinions about the exact
nature of these tumors--sometimes even doubt
as to whether they are neoplasms-and what
the best method of trea.ting them is. This re-
port correlates the cellular morphology and
incidence of lymph node involvement by these
From the Division of Surgical Pathology, Department
of' Pathology, Washington IJniversity School of Medi-
cine, 600 S. Kingshighway, St. Louis 10. Mo., and The
Barnes Hospital Group, St. Louis, Mo.
T h e sincere appreciation of the author is extended
to Dr. Jesus Guerra-Medina, who aided in the early
phases of this report, and to the many who responded
to our letters.
Case 1 of this series was previously reported as case 2
by Rose,"" and by Jarkson e t al.:4'1it has been illus-
trated in bmks by Ackermanl and LiebowPO Case 3 of
this series was originally submitted to Dr. L. V.
Ackerman of this Department by Dr. E. Grant Murphy,
Flint, Mi&. Follow-up infonuation was made available
by Dr. R. N. Romanski, Flint, Mich. Case 4 was pre-
viously reported by R o s P 11s case 1. Case 6 was first
seen in this Department by 'Dr. H. J. Spjut. Operative,
autopsy, and clinical material were supplied by Dr.
Robert Schaeffer, formerly Assistant Chief of Pathology,
Veterans Administration Hospital, St. Louis, Mo. In
case 7, the details of radiotherapy and clinical fol-
low-up were supplied by Dr. W. C. Smullen, Decatur,
Ill. Case 8 was originally submitted to Dr. L. V.
Ackerman by Dr. W. Platt, St. Louis, Mo., and fol-
Iow-up information was made available by Dr. D. E.
Kilker, St. Louis, Mo. Case !3 was originall submitted
to Dr. I,. V. Ackernian by C d . M. W. BayEss, then of
the 406th Medical General Laboratory, Camp Zama,
Japan. Subsequent information has been supplied by
Colonel Bayliss, now Chief, Pathology Service, Brooke
Army Hospital, Fort Sam Houston, Texas, and by
Capt. Walter C. Bauer, formerly of the Armed Forces
Institute of Pathology, Washington, D.C. Case 10 was
originally submitted to Dr. L. V. Ackerman by Dr.
C . L. Green, El Paso, Texas, who also supplied fol-
low-up information. In case IS, clinical data and
permission to include the case in this series were
supplied by Dr. I. J. Flance and Dr. M. Bergman, St.
Louis, Mo. The pathological material was supplied by
Dr. J. Hasson and Dr. R. C. Ahlvin, St. Louis, Mo.
Figures 1A and B and 4 are reprinted from a paper
by Roseso in J. Thoracic Surg., 1957, with the permis-
sion of the author, the journal. and its publisher, the
C. V. Mosby Company, St. Louis, Mo.
* Present address: Department of Pathology, San
Diego County General Hospital, North End of Front
Street, San Diego 8. Calif.
.Received for publication Nov. 9, 1962.
928
tumors with the mortality produced by them
in an attempt to clarify their natural history
and define the most effective methods of treat-
ment.
Much of this variance oE opinion is caused
by the haphazard inclusion in reported series
of many different entities, including dissem-
inated malignant lymphomas involving the
lung, unexplained accumulations of lymphoid
tissue in the lungs of patients who died of
other causes, inflammatory lesions composed
primarily of lymphocytes ("pseudolympho-
mas"), and true primary malignant lympho-
mas of the lung. Similarly, malignant lym-
phomas of the lymphocytic type, reticulum
cell type, and Hodgkin's type, and inflamma-
tory pseudolymphomas usually are separated
in individual case descriptions but frequently
are lumped together when the natural history,
therapy, and prognosis of the disease are con-
sidered.
DEFINITION
A primary lymphocytic tumor of the lung
will be defined as either a malignant lym-
phoma of the lymphocytic type or an inflam-
matory pseudolymphoma that originally in-
volves only the lung, or the lung and its
regional lymph nodes, and in which there is
no evidence of dissemination of the tumor for
at least 3 months after the diagnosis is estab-
lished. This latter restriction was arbitrarily
chosen to exclude those cases that already
must have been disseminated, although not
recognized as such, at the time that the diag-
nosis of the lung tumor was established. Also
to be excluded are instances in which the
diagnosis of lymphocytic tumor was not made,
or strongly suspected, during life. This elim-
inates from discussion incidental autopsy find-
ings, from which little or nothing of the course
of the disease can be learned.
A legitimate objection can be raised to the
grouping together of malignant lymphomas of
the lymphocytic type and inflammatory pseu-
dolymphomas, but we know of no way to
No. 7 MALIGNANT
PULMONARY LYMPHOMAS
& PSEUDOLYMPHOMASSaltatein
separate the cases of malignant tumors from
the inflammatory ones on the basis of either
the photomicrographs or verbal descriptions
in previous reports. Fortunately, the conclu-
sions to be drawn from the data grouped in
this manner overcome the objection.
Primary pulmonary reticulum cell sarcoma
(malignant lymphoma, reticulum cell type)
and primary pulmonary Hodgkin’s disease
(malignant lymphoma, Hodgkin’s type) will
be defined in analogous manners to primary
lymphocytic tumors. T h e term “lymphoma”
will be used when referring to the entire
group, including lymphocytic tumors, reticu-
lum cell sarcoma, and Hodgkin’s disease.
In the lymphocytic type of malignant lym-
phoma, we include the well-differentiated and
poorly differentiated lymphocytic lymphoma
of Rappaport et al., 76 that corresponds to Gall
and Mallory’s34 lymphocytic lymphoma (or
lymphosarcoma) and lymphoblastic lym-
phoma.
The reticulum cell type of malignant lym-
phoma (Rappaport et al.76) or reticulum cell
sarcoma would include Gall and Mallory’ss4
categories of stem cell lymphoma and clas-
matocytic lymphoma. We have not’seen ‘*giant
follicular” lymphoma of the lung, but would
categorize one by cell type, with the further
description of “nodular,” in the manner of
Rappaport et a1.76 Malignant lymphomas of
the Hodgkin’s type will not be discussed, as
we have no cases primarily involving the lung.
MATERIALS
AND METHODS
One hundred and two cases of primary
‘‘lymphomas’’of the lung were gathered from
2 sources. Fourteen cases have been seen in this
Department, 8 from Barnes Hospital and 6
in consultation. Clinical histories, roentgeno-
grams, histological sections, and follow-up
data of these cases were re-examined. I n addi-
tion, all authors of case reports (in the Eng-
lish language) were contacted in an attempt
to obtain follow-up data and often more clini-
cal and pathological information. Approxi-
mately 80% of the authors responded to our
letters. Information gathered in this manner
leaves much to be desired, especially from the
standpoints of accuracy of diagnosis and com-
pleteness of follow-up but is of sufficient inter-
est and value to be worthy of study. All of the
cases from both sources are summarized in
Tables 1 and 2.
Many previously reported cases of “lym-
929
phoma” of the lung have been excluded from
discussion by the definitions stated previously.
In Fleming and Howie’s33 case, the tumor was
so widely disseminated that its origin in the
lung cannot be assumed in spite of the long
history of lung disease. The second case in the
addendum to the article by Samuels et a1.81
may well have been a primary lymphocytic
tumor of the lung and is included in Table
1 . Their other 6 cases all had previous diag-
noses of malignant lymphoma made on other
tissue removed from the patients and thus
cannot be considered to have originated in
the lung. T h e series reported by Kirklin and
Hefke44 and Williamsloo lack sufficient infor-
mation as to whether the cases were truly
primary in the lung. Bower’s16 patient had
widely disseminated tumor at autopsy 1 month
after thoracotomy and therefore can be sus-
pected of having had disseminated tumor at
the time of operation. A similar reason would
exclude O’Donnell’s67 first case,
In the cases of Pekelis,eQCutler,26 Fleming
and Howie,33 Tenczar,94 the second case of
O’Donnel1,e’ the first case of Sternberg et al.,89
and the fourth case of Kress and Brantigan47
the patients died with or of lung disease, and
a diagnosis of lymphoma was not made or
suspected until an autopsy was performed;
hence they are not included.
In a few instances, considerable doubt exists
about the certainty of the diagnosis. Pekelis’69
report leads one to believe that his case may
have been “oat cell” carcinoma of the bronchus.
Prichard and Bradshaw 73 considered their
fifth case to be a “hamartoma,” and after re-
viewing their sections,’2 we agree that it is
either this or an ectopic lymph node. In Fal-
coner and Leonard’s32 tenth case lymphocytic
involvement may have been limited to the
lung and hilar nodes, but the patient had
leukemia and no autopsy was performed.
These authors did not believe that the lesion
began in the lung. Drewes and Willmann28
did not feel that their first case represented
lymphosarcoma but rather “pleomorphic sar-
coma.” One cannot be certain if the cases re-
ported by Williamsloo had histological con-
firmation of the diagnoses of lymphosarcoma.
Stout91 referred to a case seen by S e v e r a n ~ e , ~ ~
but the latter said that the surgeon later be-
lieved that the tumor originated in the
mediastinum rather than the lung.
The cases alluded to by Stout903 9 1 included
the previously reported cases of Anlyan et a1.P
(Continued on page 937.)
 '3
OQ
1
TABLE 0
PRIMARY LYMPHOCYTIC TUMORS OF THE LUNG
Lymphoma
-.
Pt.
age, No progression I'rogres4un
Yr. Germ. - - _-
Case Author Yr. Race cent. or X-ray Chemo- Orig. Subseq. Orig. Subseq.
no. Case no. publ. Sex OP. Nodes follic. ther. ther. article inform. article inform.
-.

1 Sugarbaker & 1940 ? ? ? ... ... ... ? ? ? ? 92

Cravergs ?
?
2' ChurchilP 1947 45 I'pp. & mid. Neg. ... Immed. ... 6 mo. ... Clin. recess. Died unkn.
... 1953 lobect. postop. & 5 3 & 84 yr. cause 13 yr.I9
F'. at 53 & 89 treat. success.
I
yr.78 80 X ray
3 Spatt & 1947 34 Lobect. Neg. ... ... ... 1; yr. Lost 12 ... ...
Grayzelse W y.SO
... F
B \\Xs101 1948 57 Lobect. Pos. Few Immed. ... ... Died coro- ... ...
... ... poorly postop. & nary 16: F
hl devel. 3 yr.16,80 yr.16,80,101 2
n
5 Maier6J 1948 50 Pneumonect. Neg. ... 2 yr. & 7 yr. ... 3 yr. ... ... Clin. recess. a t
W postop.57*80 2 y r . & 7 yr. 5:
M treat. success. +
X ,ay;Ji.60 died
coronary 135 c?
w

6 Anlyan3 1950 63 Lobect . Neg. ... 4 yr. post- ... ... ... ... yr.80
Clin. recess. 4 Q,
a
... W yr.; treat. SUC- O0
OP.
M cess. X ray;8o
liv. & well
l l f yr.45
7 Weissman & 195 1 52 Pneumonect. ? ... ... *.. I yr. ... ... Died 2 yr. genl.
Christie99 W lymphoma80
... M
8 ... Lobect. Ncg. ... ... ... 3 yr. 8 yr.5mR ...
F.
9 Beck & Reganis9 1951 47 Lobect. Neg. Follic. ... ... 1 ) yr. ... ... Gastric lym-
... phoma 2 yr.; re-
F ' sect.;80 liv. &
well 10+ yr.8
10 Behrend'O 1951 59 Lobect. Neg. ... ... ... 1 yr. Died; time ... ...
... ... & cause
F unknowns0
11 Touroff 96 1951 ... Lobect. Neg. ... _.. ... 2+ yr. Since losts0 ... ...
... ...
...
5
 2
12 Betts & 1951 ... Biopsy Pos. ... ... ... ... ... Died 3 mo. ... ?
Overholtl* ...
M
13t Blades” 1951 61 Biopsy Pos. ... Postop. ... ... ... Died 9 mo. ...
... W lymphoma
M
141 Ochsner & 1951 50 Pneumonect. Pos. .. Postop. ... 9 yr. Died 14 yr.; ... ...
DeCampe6 W “prob. 0th.
3 F causes”8Q
15 Overholta8 1952 30 Lobect. ? Follic. ... ... ? ? ? ?
... W
M
16 CicheroZz 1952 40 Pneumonect. ? ... ... ... Died 1$ ...
... ... yr. dissern.
M turn.
17 DvofLEek & 1952 44 Pneurnonect. Pericard. ... ... ... ... ... Died 1; rno.; ...
Cermlk*O ... invad. turn. mediast.
M & hilar nodes
18 Saiokhan & 1953 70 Lobect. Neg. ... ... Died ... ... ...
Morrison EPZ W cerebrovasc.
M accid. 5 wk.
19 Robbins78 1953 67 Lobect. ? “Giant ... ... ... GI bleed. ... ...
4 follic. 7 mo.; gas-
M’ lym- trect.; no
phoma” tum.; died
8 mo. no
evid. d i ~ . ? ~
20 Grimes et al.*B 1954 68 Pneumonect. ? ... Postop. ... Liv. & well Liv. & well ... ...
1 2 yr. 4: yr.80
F.
21 2 1954 45 Pneumonect. Neg. ... ... Liv. & well Liv. & well ... ...
5 yr. 7 yr.80
F ’
22 Davis et alJ7 1956 39 Pneumonect. Neg. ... ... ... Liv. & well ... ... ...
... 114 yr.
F
23 Van Hazel & 1956 59 Pneumonect. Neg. ... Postop. Died 34.yr. ... ... ...
Jensik98 W card. fail.
2 F
24 3 70 Lobect. Neg. ... ... ... Liv. & well Lost at 2 ... ...
W 2 yr. yr.4*
M
25 4 53 Biopsy Neg. ... ... Liv. & well Lost a t 5f ... ...
C 5f yr. yr .42
M
26 7 46 Lobect. Neg. ... ... ... Liv. & well Liv. & well ... ...
W 14 yr. 6$ ~ r . 4 ~
F
*Reported as case 3 by Robbins.?n tReported as case 1 by Hall & Blades.39 fReported as case 6 by Sternberg et aI.89 $Reported as case 4 by present
author. IlReported as case 1 by present author. flReported also by Stout.g1 **Reported as case 4 by Berghuis et al.I1
 TABLE1 (Continued)
PIIIMXIIY LYlIPHOCY?'IC TI'MORS OF T H E LI'SG ----__I
.. -. ........... ~

Lyinphomn
ft.
as, No progression Progression
yr. Germ. ____-- _______
Case Author Yr. Race ccnt. or X-ray Chcmo- Orig. Subscq . Orig. Subseq.
no. Case no. publ. Sex OP. Nodes follic. ther. ther. article inform. article inform.
D,!a&sll n mi-- t', ., r
I956 7
In7 I *ICU..I"LLCL.L. AICS. mua. Picop. iv ... ... ...
2?
... \i7 follic." opp. lung
F
28 Starkey57 1956 ? Biopsy ? ... ... ... ... ... Died 9 mo. ...
1 ...
. .
29 2 ? Biopsy ? ... ... Died 10 mo. ...

30 3 ? Resect. ? ... , . . Liv. & well ... ... ... c:

4 yr. 9
2:
n
31 4 ? Resect. ? ... ... .. Liv. & well ... ... ... E
... 7 yr. 4
. . fi
32 Coolcy et a1.25 1956 46 Lobect. Ncp. ... Postop. Liv. & well Liv. & well ... ... G
1 \v 2$ J-r. 93 ,rr.11.2a I

hl W
2 67 I'ncumonect. Keg. ... I'ostop. ... Died 20 ... ... ... m
33 Lw
\v daj-; no
F lymphoma
a t autop.
31 3 35 Pneumonect. Pos. Postop. & Liv. & well Liv. & well ... ...
\I- 3 nio. 8) yr. 15 yr.11,23
F
35 64 Pneumonect. Pos. Postop. Died 2 mo.; ... ... ...
\I, causc unkn.
F
36s Roseso 1957 38 Lobect . Neg. ... Liv. & well Liv. & well ... ...
1 \v 6 mo. 6f yr.
F
37ij 2 75 Pneun~onect. Keg. ... .. Died 44 yr.; ... ... ...
\v no tum. at
F autopsy
38 Chevallier 1957 46 Pneumonect. ? ... ... .. Liv. & well ... ... ...
et 3 yr.
... ni'
39 Pickern" 1958 65 Lobect. Neg. ... ... ... ... ... ... Died 3f y.
... W pancreatitis
F (loc. persist.
without nodal
involv.)7o
40 Justin-Besancon 1959 50 Biopsy 7 ... Immed. ... ... ... Gastrect. lyrn- ...
et aL4* ... postop. phoma 5) yr.;
... F &at6& resect. ilium
7 yr. lymphoma 6
yr. with X
ray; parotid
involv. 6) yr.;
died 7+ yr.
lymphoma
41 Sternberg et 1959 53 Lobect ? ... ... 3f yr. ... ... Died T B 5; ...
3 C postop. yr.; no au-
M top.; I re-
curr. lyrn-
phoma
42 4 44 Lobect. ? ... ... 31 Yr. ... ... Clin. recurr. ...
... foll. by postop. 2 j yr.;
F pneumonect. died 4f yr.
prob. lym-
phoma; no
autop.
43 5 68 Lobect . Pos. "Follic. Postop. ... Liv. & well Liv. & well ...
W (pict.) lym- 2f Yr. 53 yr.66
F phoma"
44 Schulzes4 1959 46 Lobect. Neg. ... Postop. ... Liv. & well ... ... ...
... ... 29 yr.
M
45 Hall & Blade+' 1959 70 Biopsy Neg. ; Postop. ... ... ... Died 2; yr.
3 W rnediast.
F & super.
vena cava
involv.
46 Ergin & 43 Lobect . Pos. Postop. ... Liv. & well ... ... ...
Kemlersl 1960 C 2) yr.
M
Lobect. I Germ. ... ... ... Liv. & well .,, . . I
47 dei Regat077 1960 75
... ... centers 31 yr.77
F
48** McDonald6s 1960 42 Lobect. Neg. ... Postop. ... Liv. & well Liv. & well ... ...
... ... 2 yr. 2t yr.60
M
49 Rcrghuis et al." 1961 46 Lobect. Neg. ... ... ... Liv. & well ... ... ...
1 ... 6 rno.
F
*Reported as caw 3 by Robbins.78 IRcported as case 1 by Hall & Blad~s.8~ $Reported as case 6 by Sternberg et $Reported as case 4 by present
(0
author. IlReported as case 1 by present author. flReported also by Stout.g1 **Reported as case 4 by Berghuis et al." w
w
 1 (Continued)
TABLE s
k-L
PRIMARY LYMPHOCYTIC TUMORS OF THE LUNG
________ ._
_. - - _- -
__ -
Lymphoma
~

Pt. __-
age, No progression Progression
_-
yr . Germ.
Case Author Yr. Race cent. or X-ray Chemo- Orig. Subseq. Orjg. Subseq.
no. Caseno. publ. Sex OP. Nodes folk. ther. ther. article inform. article inform.
______
Berghuis et al.” (Contd.)
50 2 60 Pneumonect. 1’0s. ... I’ostop. I’ostop. Liv. & well ... ...
i yr.
F.
51 3 38 Pneumonect . Dir. cx- “Follic. ... ... ... ... Died 1 day;
tens. lym- sol. 1.5-cni.
M’ phoma” tum.
52 5 50 Lobect Neg. ... ... Postop. Liv. & well ... ... ...
3) yr.
M.
53 6 43 Pneumonect. Ncg. ... Postop. ... Liv. & well
6 mo.
F ‘
54 7 4 Lobect. ? ... I’ostop. ... Died 1 mo. ; ... ... ...
broncho-
M’ pleural
fistula
55 Baron & 37 Biopsy I (ex- ... 1’0s top. ... Liv. & well ... ...
Whitehouse7 1961 W tens. into 9: yr.
1 F mediast .)
56 2 64 Lobect. “Sug;; ... ... ... Liv. & wcll
W gest. 2; yr.
M
57 3 49 Lobcct . Neg. ... Postop. ... Liv. & well ... ... ...
2: yr.
F.
58 4 56 Wedge re- ? ... Postop. 5 mo. ... Died 6 mo.
sect. post op. lymphoma
F.
59 5 57 Lobect. 1’0s. ... Postop. ... Liv. & wcll ... ... ...
1 t yr.
M’
60 Pritchard & 52 Lobect . ? ... Immed. ... ... ... Abd. involv.
Bradshaw73 1961 ... postop. 19 mo.; X-ray
1 M & 19 mo. ther.; died
postop. 2 1 mo.
61 L 45 Lobect. ? ... Immed. .. ... .. Incr. hilar Liv. & well 8
postop. shadow 2 yr.: yr .72
F‘ & 2 yr. X-ray ther.;
postop. liv. &well
7 yr.
Pritchard & Bradshaw" ( C o d . ) 3
Died 5 day ... ... .
l
62 4 70 Pneumonect. ? ...
... pneumonia;
M no autop.
63 6 50 Segment. re- ? Germ. Postop. ... ... ... 1: 1110. & Liv. & uwll 4
... sect. centers 2% yr.; yr.'l 2
illustr. X-ray spr.; 3
F r
n o treat.
64 7 61 Lobect. Neg. ... Liv. & well Liv. & wcll ... ... 2
W 2 2 yr. 4 yr.72 54
F
65 Kress & 47 Lobect. Ncg. ... ... ... Liv. & well ... ... ...
Brantigan47 1961 W 6 yr. z
1 F
66 2 59 Lobect. & Neg.46 ... Postop. ... Liv. & well Liv. & well ...
W wedge re- 75 yr. 12 yr.40
M sect.
67 3 60 Mult. wedge Neg.46 ... Irnmed. ... Liv. & well Liv. & well ...
W resect. postop. 1; yr. 2 5 yr.46
F & 3 mo.
postop. -e
7mo.& 7 mo. ... ... Grad. pro- ... 2
68 5 55 Lobect. Neg.46 ...
W 4 yr. postop. gress. lym-
postop. phoma to 0
M z>
VI
death. .5. yr. Alive but
69 6 60 Biopsy ? ... Immed. No fur-
W post op . ther worsening F?
M X-ray 14 yr.46
changes ?
6 mo. h!
..
d

I0 1 47 Pleural ... ... Died 2 yr.; ...

... decorti- lymphoma in
F cation lungs & medi- ;
ast. nodes
71 Samuels et a1.81 1959 51 Bronchos- 7 ; antcr. ... Postop. ... ... ... 1+ 5
7 w COPY mediast.
F mass on
Ez
X ray %
72 7 Lattes4*
1961 48 Lobect. Ncg. Occas. ... ... 2 mo. ...
... C germ.
F centers
13 lI Moore" 1961 67 Lobect. ? Germ. Postop. ... 1; yr. ... ... ...
W centers
M
14 Ellisonao 1961 ? Lobect. ? ... ... ... 8 yr. ... ... ...
... ?
?
*Reported as caw 3 by Robbins.78 tReported as case 1 by Hall & Blades."g $Reported as case 6 by Sternberg ct al.89 $Keported as case 4 by present
author. (!Reported as case 1 by present author. TReported also by Stout.g1 **Reported as case 4 by Berghuis ct al.11
 W
m
1 (Concluded)
TARLE 0

PRIMARY LYMPHOCYTIC TCMORS OF THE LUNG

Lymphoma
Pt. -__- -
age, No progression Progression
yr. Germ. Subseq.
Case Author Yr. Race cent. or X-ray Cherno- Orlg. Subseq. Orig.
no. Case no. publ. Sex OP. Nudes follic. ther. ther. article inform. article inform.
EllisonaO (Contd.)
75 ? Pneumonect. ? ... ... ... 2 yr. ... ... ...
... I
?
76 Lindskog et aI.s2 1962 62 Pneumonect. Neg. ... Postop. ... ... Liv. & well ... ...
... ... 54 yr.6l
Fi
77 Pres. author 1963 i.5 Pneumonect. Neg. ... ... ... 6 yr. ... ...
5
F .
78 6 57 Lobect. ? . , Postop. .. Died 3 mo. ... ...
... X-ray fibro- Fz
M sis lungs; no g
turn. at
autop. 4
79 7 51 Lobect. Neg. (in . , Postop. .. Liv. & well ... ... f:
\
!I pen- 4; yr. .2"
M bronch. F
(0
tiss.) m
80 8 54 Imbert. Neg. Liv. & well .. ... ... 09
4+ yr.
F '
81 9 48 Lobect. Neg. ... , , . Liv. & ? ... ...
well 4 yr.
82 10 .. ... , , . Liv. & well ... ...
3f yr.
83 12 80 Lobect. Neg. , , . Liv. & well ... , . . ...
W 10 mo.

84 13 ... ... Liv. & well ... ...

1 yr.
M
85 14 72 Lobect. Neg. ... Liv. & well ... ... ...
W 2 mo.
M
*Reported as case 3 by Rubbins78 iReported as case 1 by Hall & Blades.89 $Reported as case 6 by Sternberg et a1.88 $Reported as case 4 by present
author. ]]Reported as case 1 by present author. TReported also by **Reported as case 4 by Berghuis et al.ll
No. 7 PULMONARY MALIGNANT LYMPHOMAS & PSEUDOLYMPHOMAS Saltatein 937
Maier,55 Spatt and Grayzel1,se the subse- the present series. Castleman17 briefly men-
quently reported one of Pickern,71 the case tioned 2 cured cases of lymphocytic tumors of
of Severance85 referred to in the previous para- the lung but later18 rejected these cases be-
graph, and cases numbered 72, 73, and 80 in cause they were not his own material. T h e

FIG.1. Case 1. A, Large mass demonstrated in the upper lobe of the left lung. Histologically, this lesion was
a pseiidolymphoma. (WU ill. 49-17, 18.) B, Gross photograph of the pseudolymphoma of the up-
per lobe of the left lung demonstrated on the roentgenogram in Fig. 1A. (WU ill. 48-7010.) C, True germinal
center in the midst of the infiltrate of a pseudolymphoma. The presence of germinal centers is the most re-
liable criterion favoring the diagnosis of pseudolymphoma. (WU ill. 61-1672A. H. & E. X350.)
938 July 1963
CANCER Vol. 16

TABLE2
PRIMARY RETICULUM CELL SARCOMA OF THE LUNG
__
Pt.
age, yr.
c.we Author Yr. Race X-ray Chemo-
no. Case no. publ. sex OP. Nodes Cystic ther. ther.
.~ .......
. ... ...
~

1 Giraud e t aL3' 1947 3; Thoracot 7 Yes

...
ii'
Ochsner & de- 1951 46 Pneumonect. Keg. ... ... ...
CampB: w
4 M
:i Ransdell e t '11.72 1951 37 Lobect . ? (tLlIl1. Yes Postop. ...
IV in vena
M CaVa
'4 Nobile6A 1952 15 ... ... Yes ... ...
...
ii'
5 Rohbins78 1953 53 Biopsy ? ... Postop. ...
1
F '
6 Van Haeel& 1956 21 I'ncumonect. Seg. Yes ... Postop.
Jensikg8 w
5 F
7 Mait.r" 1956 40's ? ? ... ... ...
2
F.
8 Starkey*' 1956 ? Biopsy ? ... ... ...
5 ?
?
9 Schutz & Kiihn83 1956 54 Pneumoncct. ? ... ... ...
F.
10 Cooley ct al:2s 1956 59 Biopsy Pos. ... Postop. ...
6 W (clin.)
M
11 Bcrghuis ct al.1' 1961 37 ... Pos. ... Postop. ...
10 1%'
M
12 Ellison?" 1961 42 Pneumonect. Neg. Ycs ... ...
... \v
M
13 Little63 1962 80 Lobect. Neg. Yes Postop. ...
w
M
14 Garlands; 1962 50 Lobect. "Turn.I t . ... Postop. ...
... W behind"
M
15 Pres. author 1963 45 Lobect. Neg. ... ... ...
W
F
16 1963 32 Biopsy Pericard. ... Postop. ...
IV & super.
F vena cava
involv.
(gross)
17 1963 53 Pneumoncct . Neg. Yes ... ...
w
M
-
*Reported as case 2 by Sternberg et aLsg

first 2 cases of Ochsner and decamps5 could
not be verified by Ochsner,66 and these authors
similarly believed that the cases should be
rejected.
CASEREPORTS
Case 1. N.L.P., a 75-year-old woman, en-
tered Barnes Hospital, St. Louis, Mo., in 1948
because of chest pain associated with an upper
respiratory infection 6 months before admis-
sion. A chest roentgenoFa*l at that time
showed a wedge-shaped mass in the left upper
lobe (Fig. IA). Sputum cytology was inter-
preted as "suspicious" twice and as "positive
for malignant cells" once. In the latter in-
stance, the cells were thought to be undiffer-
entiated (oat cell) carcinoma of the lung. A
left pneumonectomy was performed on Dec.
No. 7 PULMONARY LYMPHOMAS
MALIGNANT & PSEUDOLYMPHOMAS
Snltzstein 939
Case 2. R.A.K., a 45-year-old woman, no-
(17 CASES) ticed weakness, fatigue, and a 40-lb. weight loss
No progress. lymphoma Progress. lymphoma
for 8 or 9 months before admission to Barnes
Hospital. Chest roentgenograms showed a
Orig. Subseq. Orig. Subseq. mass in the right lower lobe. She had no pe-
article inform. article inform. ripheral lymphadenopathy, and her hernogram
Dieddur. ._. ... ... was within normal limits. Cytological exami-
OP. nation of bronchial washings showed no ma-
lignant cells. A right lower lobectomy was
Liv. & well Liv. & u-ell ... ... performed on June 3, 1955, for what was
14 yr. 11 yr.66
thought to be an abscess. A 1 0 ~ 8 ~ 7 - c cystic
m.
... ... Persist. Died tum. mass occupied almost the entire lobe (Fig. 2).
mass 2 mo. 6 mo.a0974 The walls of the mass were about 2 cm. in
... ... Died, time ... thickness. Grossly, the hilar nodes were en-
unkn. larged. On microscopic examination, the lesion
was composed of pleomorphic reticulum cells.
Died Died tum. When first seen, some of these cells suggested
5 m0.79
Reed-Sternberg cells so that the original diag-
Liv. & well Liv. & well ... ... nosis was Hodgkin‘s sarcoma: but on review,
54 yr. l l +yr.42 the lesion was felt to be reticulum cell sar-
Liv. & well Liv. & well ... ... coma. The hilar lymph nodes showed only
3 yr. 9 yr.68 hyperplasia on section. No postoperative X-
ray therapy or chemotherapy was given. When
Liv. & well ... ... ... last contacted on Feb. 5, 1962, 6 years and 8
64 yr. months after operation, she was enjoying good
? ? ? ? health.
Case 3. K.R., a 32-year-old woman, was ad-
Liv. & well ... ... Died 4 yr. mitted to another hospital because of a 7-cm.
22 yr. “late
death”” ,23 mass in the hilum of the right lung found on
... ... Lytic les. ... a routine roentgenogram. Roentgenograms of
clavicle 4 the chest 2 years previously showed no lesion;
mo.; died but in retrospect, those taken 1 year before
“pneumonia”
44 mo. did show a hilar lesion. Physical examination
... ... 9 mo. abdom. ... and laboratory data were within normal limits.
involv. ; died At operation on Aug. 12, 195,5, the entire mid-
tum. 10 ino. dle lobe of the right lung was replaced by a
Liv. & well Liv. & well ... ... 7-cm. spherical mass that extended into the
5 mo. 1 yr.64
pericardium and superior vena cava. No ob-
Liv. & well Iiv. & well ... ... viously enlarged nodes were seen in the medi-
5 yr. 5 yr. 11 astinum. A biopsy of the lung was performed,
mo.ae
Liv. & well ... ... ... and a diagnosis of reticulum cell sarcoma was
6%yr. made (Fig. 3). Necrosis was not a prominent
feature. No tissue outside of the lung was
... ... Died turn. ... examined microscopically. In spite of 2 courses
1; yr.
of X-ray therapy, she died I-%years after op-
Liv. & well ... ... .., eration with roentgenographic evidence of
1; yr. masses in both lungs. No peripheral adenopa-
thy was ever noted. No autopsy was performed.
Case 4. G.W. was a 3S-year-old housewife.
Fourteen months prior to her admission to
26, 1948. A 6-cm. mass, which proved to be a Barnes Hospital, chest roentgenograms showed
typical lymphocytic tumor (Fig. IB), was found a rounded mass in the upper lobe of the right
in the upper lobe. The tumor contained prom- lung. She had noticed shoulder pain for 6
inent germinal centers (Fig. IC), some fibrosis, months prior to admission. No lymphadenopa-
and a few plasma cells and reticulum cells thy was found when she was examined, and
among the lymphocytes. None of the 11 lymph the blood counts were normal, Cytological ex-
nodes examined microscopically contained tu- amination of sputum and bronchial washings
mor. T h e patient died 4 years and 7 months and a bronchial biopsy all showed no tumor.
after operation of other causes: no tumor was On June 23, 1955, a right upper lobectomy
found at autopsy. was performed. T h e hilar and mediastinal
940 J u l y 1963
CANCEK
Frc. 2. Case 2. Gross pho-
tograph of a malignant lym-
phoma, reticulum cell type,
of the lower lobe of the right
lur~gshowing necrosis of the
central portion of the tumor
1e;icIing to cyst formation.
OWU ill. 55-3939.)
nodes appeared normal, and the anterior seg-
ment of the upper lobe was solid (Fig. 4).
Microscopically, the usual pattern of a lym-
phocytic tumor of the lung (Fig. 5A), with a
few abortive germinal centers, was seen. In-
FIG. 3. Caw 3. Reticulum cell sarcoma of the right
middle lobe. (WU ill. 62-3562. H. & E. XGOO.)
Vol. 16
vasion of a large vein (Fig. 5B) by lymphocytes
was noted. Scattered through the infiltrate
were some macrophages and neutrophils. All 7
lymph nodes were free of tumor on histological
examination. No postoperative X-ray therapy
or chemotherapy was given. When last seen on
March 2, 1962, 6-q3 years after operation, she
was in good health, and her chest roentgeno-
grams showed no tumor.
Case 5. H.C.E., a 55-year-old school teacher,
had always enjoyed good health. A routine
chest roentgenogram taken 3 months before
her admission to the hospital disclosed a
density in the middle lobe of the right lung.
Physical and laboratory examinations on ad-
mission to Barnes Hospital showed no ab-
normalities. Thoracotomy was performed on
June 19, 1956, and after a frozen section diag-
nosis of “undifferentiated carcinoma” was
made, a right pneumonectomy was performed.
Almost the entire middle lobe and a 4-an.
portion of the adjacent lower lobe were re-
placed by a firm, tan, meaty tumor. Micro-
scopically, although germinal centers were not
a feature, the usual pattern of a lymphocytic
tumor was seen. Twenty-four hilar lymph
nodes contained no tumor when sectioned.
No X-ray therapy or chemotherapy was given
postoperatively. When last contacted on June
18, 1962, 6 years postoperatively, she was with-
out evidence of recurrent disease and had
missed only 1 day 01 school since the opera-
tion.
Case 6. was a 57-yeal=olcI man- He
was first seen at the Cochran Veterans Adminis-
No. 7 PULMONARY
MALIGNANT & PSEUDOLYMPHOMASSaltatein
LYMPHOMAS
tration Hospital, St. Louis, Mo., because of
cough and chest pain for 4 weeks. He had had 1
episode of chills and fever during this period.
Physical examination was unrewarding except
for evidence of a right pleural effusion. The
hemograin was normal. Chest roentgenograms
were interpreted as showing an infiltrative
process in the lower lobe of the right lung.
Examinations of pleural fluid, obtained sev-
eral times by thoracentesis, as well as sputum
and bronchial washings, disclosed no tumor.
Bronchial biopsy showed only squamous meta-
plasia. Thoracotomy was performed on Oct. 3,
1956, and a solid tumor was found involving
the middle and lower lobes. Hilar and medi-
astinal nodes were not enlarged, but numer-
ous nodules of what grossly appeared to be
tumor were seen on the pleura. The right
middle and lower lobes were resected, but the
pleural nodules were not biopsied. Grossly,
the tumor was solid and pink, involving both
lobes. Microscopically, no germinal centers
were seen, and the infiltration was composed
solely of lymphocytes. No nodes were exam-
ined histologically.
Postoperatively, the patient received 2,000r
to anterior chest, posterior chest, and supra-
clavicular ports. Three months later he died
after a course marked by respiratory difficul-
ties. At autopsy, no tumor could be found on
microscopic examination. The lungs showed
the changes associated with irradiation fibrosis
throughout much of the parenchyma. (Fig. 6).
The bone marrow was normal.
Case 7. L.A.B., a 51-year-old man, was ad-
mitted to Barnes Hospital with a history of a
6-cm. mass in the hilum of the right lung on
roentgenogram. Physical examination was
within normal limits, and the only abnormal
94 1
laboratory finding was a hemoglobin level of
17.3 gm.per 100 ml. When the right middle
lobe and a portion of the right upper lobe
were resected on Oct. 8, 1957, no enlarged
lymph nodes were seen. I n the middle lobe
there was a 6x3x3-cm. nonencapsulated tu-
mor that surrounded, but did not involve,
the middle lobe bronchus. In the adjacent
resected portion of the upper lobe there was a
similar tumor. Microscopically, the usual pic-
ture of a lymphocytic tumor with prominent
germinal centers (Fig. 7) was seen. Lympho-
cytic infiltration was noted about the bron-
chial line of resection. No nodes were avail-
able for microscopic examination.
Because of the infiltrate at the line of re-
section, the patient received a total of 2,400 r
(air) to the anterior and posterior ports of the
chest in December, 1957, and further therapy
to the right lung root in January, 1958. When
last heard from in April, 1962, 4 years and 6
months after operation, he was in good health.
Case 8. A.W., 54 years of age, was admitted
to another hospital because of atelectasis of
her right lung demonstrated on roentgeno-
grams for 14 months. Her only symptom
was a sensation of being “run down.” Except
for atelectasis, physical examination and lab-
oratory data were within normal limits. A
bronchial biopsy performed 1 year previously
showed many lymphocytes beneath the mu-
cosa. Thoracotomy was performed on March
18, 1958, and a solid mass was found involving
the right middle and lower lobes. The hilar
nodes were enlarged but on frozen section
showed no tumor. A right pneumonectomy
was carried out. Grossly, a firm, gray-pink
lesion, resembling unresolved pneumonia, af-
fected the middle and lower lobes. Section
FIG.4. Case 4. Gross pho-
tograph of a pseudolym-
phoma of the upper lobe
of the right lung. (WU ill.
55-4286.)
942 CANCER,July 1963 Vol. 16

PIC. 5. Case 4. A, Peripheral. area of a pseudolymphoma, showing an infiltrate of lymphocytes in the alveolar
septa and about vessels in the septa. This pattern also would not help distinguish a malignant lymphoma from
a lymphoid pseudolymphoma. (WU ill. 61-1761. H. & E. X85.) R, “Invasion” of a vein by the infiltrate of a
pseudolymphoma. No radiotherapy was given, and the patient is alive and well 6% years after lobectomy.
(WU ill. 62-1388. H. & E. ~38.)
No. 7 PULMONARY
MALIGNANT
LYMPHOMAS
& PSEUDOLYMPHOMAS
* Sdtzstein
FIG.6. Case F. Autopsy section of lung opposite to the one resected for malignant lymphoma, showing the
changes associated with irradiation fibrosis. ( W U ill. 62-3561. H. & E. ~ 1 3 0 . )
showed the usual pattern of a lymphocytic
tumor without apparent germinal centers. A
scattering of other inflammatory cells was
noted as was some necrosis and fibrosis. The
only node available for study was the one
upon which the frozen section had been per-
formed, and the absence of tumor was con-
firmed on paraffin section. No postoperative
X-ray therapy or chemotherapy was given,
and she was enjoying good health on June 24,
1962, 434 years postoperatively.
Case 9. A.H.C., a 48-year-old infantry colo-
nel, was admitted to the U.S. Army Hospital,
Camp Zama, Japan, in early April, 1958, be-
cause of an infiltrate seen in the lower lobe of
his right lung on a routine chest roentgeno-
gram. On review of his old roentgenograms,
the lesion could be seen as far back as October,
1955. Cytological examination of bronchial
washings were interpreted as “suspicious of
small cell carcinoma.” A right lower lobectomy
was performed. T h e lobe was dark red and
meaty with an ill-defined, 4-cm. area in the
center. Histological examination showed the
usual picture of a pulmonary lymphocytic
tumor without germinal centers in the lung
943
and no tumor in the nodes. When seen 6
months later at Letterman Army Hospital,
San Francisco, Calif., he was in good health
and subsequently returned to active duty.
He is known to be alive in 1962, but further
details are unavailable.
Case 10. A.J-S., a 43-year-oldhousewife, had
a coin lesion in the upper lobe of the right
lung (Fig. 8A). She had noticed no symptoms.
Lobectomy was performed on July 17, 1958.
Grossly, there was a 1.5-cm. nodular mass in-
volving the pleura and underlying pulmonary
parenchyma. The cut surface was gray and
appeared fibrous. Microscopically, no germinal
centers could be demonstrated in the lung,
which was infiltrated by sheets of lymphocytes
and other inflammatory cells (Fig. 8B). The
nodes were free of tumor. When last seen on
Dec. 29, 1961, Sl/, years after operation, she
was in good health.
Case 11. P.W.M., a 53-year-oldman, had no
symptoms except for a slight cough when a
routine chest roentgenogram showed a lesion
in the upper lobe of his right lung. Bronchial
biopsy did not afford a diagnosis. A right
944 J u l y 1963
CANCER Vol. 16

FIG.7. Case 7. Trne germinal centers in the alveolar septa1 infiltrate of a pseudolymphoma. (WU ill. 62-
1386. H. 85 E. X285.)

FIG. 8. Case 10. A, Lamioc)gram denionstrating coin lesion in the upper lobe of the riglit lung. This
lcsion also was a pcuddyniphoma. (WU ill. GI-356.) B, Ccntral arca of a pseudolymphoma, show-
ing an infiltrate composed predominantly of lymphocytes in and about a lmnclius. Exccpt for tlic mixecl na-
tore of the infiltrate, the pattern would riot help distinguish a malignant lymphoma from a lymphoid pseu-
tlolymphoma. (WU ill. 61-17G5A. H. & E. x108.8.)
No. 7 PULMONARY
MALIGNANT
LYMPHOMAS
& PSEUDOLYMPHOMAS
pneumonectomy was performed on March 4,
1961. In the upper lobe there was a 6x5-cm.
cavity with a wall 1 cm. in thickness. Bronchi
were noted leading into the cavity. On micro-
scopic examination, the tumor proved to be a
reticulum cell sarcoma (Fig. 9) with much
central necrosis and some fibrosis about the
periphery. Fifteen lymph nodes were free of
tumor on section. The patient was living and
well when last contacted on Aug. 25, 1962,
almost ly2years after operation.
FIG. 9. Case 11. Reticulum cell sarcoma with central necrosis and cyst formation. (WU ill. 62-1387. H&
E. X285.)
Case 12. E.F., an 80-year-oldman, was found
to have a coin lesion in the lower lobe of the
left lung (Fig. lo). This lesion had produced
no symptoms. Left lower lobectomy was per-
formed on Aug. 7, 1961, for a 2x2x3-cm.
gray-pink, moderately firm tumor found just
beneath the pleura. On section, lymphoid
germinal centers were readily discernible in
the pattern of a lymphocytic tumor of the
lung. No tumor was seen in the 6 lymph
nodes. When last seen on June 4, 1962, 10
months after operation, he was in good health
without radiological evidence of recurrence.
Case 13. J.R.L., a 49-year-old white man,
had a routine chest roentgenogram that showed
Snltzstein
945
a coin lesion in the lower lobe of his right lung.
He was entirely asymptomatic, and physical
and laboratory examinations on admission to
another hospital were normal. After a pre-
liminary bronchoscopy, which showed no ab-
normalities, thoracotomy was performed on
Aug. 4, 1961. A 5x5-cm. soft mass was present
in the right lower lobe (Fig. 11A). No enlarged
lymph nodes were seen, and the involved lobe
was resected. Grossly, there was an 8x6-cm.
triangular area of gray-yellow, firmer tissue
which stood out against the uninvolved pul-
monary parenchyma. Histological sections
showed an infiltrate of lymphocytes of the
characteristic pattern, solid toward the center
and in separated, intraseptal nodules periph-
erally. Germinal centers were quite prominent,
as was an admixture of other inflammatory
cells (Fig. 11B). When last seen in August,
1962, 1 year and 1 month after operation, he
was well.
Case 14. R.D.M., a 72-year-old white man,
had a routine chest roentgenogram that
showed a lesion in the upper lobe of the left
lung. The patient had no symptoms, and physi-
cal and laboratory examination on admission
946 CANCER
July 1963 Vol. 16

to Barnes Hospital disclcised no abnormalities. TABLE3

Bronchoscopy was unrewarding. On March LYMPHOCYTIC TUMORS-COMBINED
31, 1962, thoracotomy was performed, and a LITERATURE AND BARNES HOSPITAL
large firm mass was noted in the upper lobe. SERIES (85 CASES)
No enlarged lymph nodes were seen, but mul- Liv. or
tiple l-mm. nodules were seen on the visceral died
pleura. A lobectomy tvari performed. Occupy- Nodal other Died Unknown
metast. Causes* lymphoma follow-up Total *
ing most of the interior segment of the lobe
was a firm,white, granular mass without dis- Absent 41 (4) 1 0 42 (4)
tinct encapsulation (Fig. 12). Sections showed Unknown 16 (2) 11 2 29 (2)
Present 9 ... 5 0 14 ...
a tumor composed of poorly differentiated
lymphocytes involving the lung parenchyma,
more solidly centrally, ;ind as more isolated *Numbers in parentheses indicate nonfatal recur-
intraseptal nodules peripherally. The small rences that responded to radiotherapy or surgery.
nodules on the visceral pleura proved to be
foci of similar tumor cells. No germinal cen-
ters were seen. Five lymph nodes were free of
chills, fever, cough, chest pain, weakness, fa-
tigue, and weight loss.
Distinguishing these lesions from other tu-
mors of the lungs may be difficult or impos-
sible for the surgeon and radiologist. Chest
roentgenograms may show anything from soli-
tary coin lesions (Figs. 8A and 10) to massive
involvement of any lobe (Fig. 1A) or of an
entire lung. T h e lesions usually are well
delimited but not sharply encapsulated. Calci-
fication is not a feature. Reticulum cell sar-
comas frequently show central cavitation (Fig.
2). T h e presence or absence of hilar lymph
node enlargement is of little help in differen-
tiating these from other pulmonary tumors.
Bronchoscopy and cytological studies of bron-
chial secretions are useful at times, but the
pathologist must be wary of confusing lympho-
cytic tumors with “oat cell” bronchogenic
carcinoma, as happened in case 1 4 1 and case 9.
During the operation, the firm nature of
the so-called lymphomas, together with their
FIG. 10. Case 12. Chest roentgenogram showing frequent peripheral location and the roent-
coin lesion in the lower lobe of the left lung (arrow).
Histologically, this lesion was :I pseudolymphoma. (WU genographic picture, usually lead the surgeon
ill. 62-5129.) to perform a lobectomy. It is only when the
resected and sectioned tumor is examined,
grossly and microscopically, that its identity
tumor. When last seen on May 28, 1962, he is established. Here again, the lymphocytic
was without signs, symproms, or radiological
evidence of recurrent disease.
TABLE4
CLINICAL AND PATHOLOGICAL DESCRIPTION RETICULUM CELL SARCOMA-COMBINED
LITERATURE AND BARNES HOSPITAL
Our 14 patients are typical of the entire SERTES (17 CASES)
group of patients with so-called lymphomas Liv. or
in that the great majority of the lesions were Nodal died other Died Unknown
discovered on routine roktgenograms of the metast. causes lymphoma follow-up Total
chest. I n only 3 instances did symptoms direct Absent 5 1 0 6
a physician’s attention directly to the lungs. TJnknown 3 2 1 6
Present 1 4 0 5
These 3, in common with those with symp- - - - -
tomatic cases in the literature, experienced TOTAL 9 7 1 17
 FIG. 11. Case 13. A, Gross photograph of a pseudolymphoma of the lower lobe of the right lung. (WU ill.
61,-6779.) B, Mixed inflammatory infiltrate, predominantly lymphocytic, in the center of a pseudolymphoma.
(WU ill. 62-223A. H. & E. X340.)
948 CANCERJuly 1963
FIG.12. Case 14. Gross
photograph of a malig-
nant lymphoma, lyrnpho-
cytic type, of the upper
lobe of the left lung. il-
lustrating the essential
identity to gross cxamina-
tion of this lcsion and
a pseudolymphoma. (WU
ill. 62-2534.)
tumors have been confused on frozen section
with oat cell bronchogenic carcinoma (case 5 ) .
The gross and microscopic characteristics of
these tumors have been described adequately
by others. Grossly, the usually single tumors
vary in size from several centimeters to lesions
large enough to occupy all of a lobe, or even
larger. They are quite firm, usually abut on
the pleural surface (Figs. lB, 2, 4, 11A, and
12), and on section have it pink-white appear-
ance in the fresh state. The line of demarca-
tion from the remaining normal tissue is mod-
erately sharp, but the ~uiriors are not en-
capsulated. Lymphocytic tumors are usually
solid, but about half of the reticulum cell sar-
comas are cystic (Fig. 2). Microscopically, the
lymphocytic tumors show dense aggregates of
I the average age of patients with lymphocytic
; -0 I 2 4 5
YEARS AFTER tllAGNOSlS
FIG. IS. Graph of expected and observed cumula-
tive survival data for primary pulmonary lymphocytic
tumors and reticulum re11 sarcomas. (WU ill. 62-7089.)
Vol. 16
lymphocytes toward the center (Fig. 8B), re-
placing or infiltrating most of the pulmonary
parenchyma. Toward the periphery, the infil-
trate becomes less dense, and a nodular pat-
tern of intraseptal growth (Fig. 5A), usually
about capillaries, is readily discernible. Peri-
bronchial and bronchial invasion is common,
but rarely is there a large tumor projecting
into a major bronchus. True germinal centers
(Figs. 1C and 7) and other inflammatory cells
are often present. Fibrosis is frequent, but
more than an occasional small focus of necrosis
is rare.
The reticulum cell sarcomas are composed
of masses of large, pleomorphic reticulum
cells that infiltrate all pulmonary structures
(Figs. 3 and 9). These tend to be more sharply
circumscribed without any nodular intraseptal
pattern about the periphery. Necrosis is often
quite marked about the cavities described
grossly.
RESULTS
As one studies the 2 series, the validity and
value of separating cases into the lymphocytic
tumors and reticulum cell sarcomas can be
readily demonstrated. Both groups show an
approximately equal sex incidence. However,
tumors is 53.0 years (52.3 years for the patients
in the literature and 56.5 years for our pa-
tients), while the average age of those with
reticulum cell sarcoma is only 42.2 years (42.0
No. 7 PULMONARY
MALIGNANT & PSEUDOLYMPHOMAS
LYMPHOMAS Sultzstein
years for the patients from the literature and
43.3 years for our series). This difference of
10.8 years is statistically significant (t=2.28;
P<0.05).
The over-all course of the 2 groups is sum-
marized in Tables 3 and 4. In both, the
deleterious effect of nodal metastases on prog-
nosis is illustrated. Only 1 patient with each
type of tumor died of disseminated disease
when the nodes were known to be uninvolved
at the time of operation. The effect of cell
type is also noteworthy. Only 17 of 85 (20.0%)
of the patients with lymphocytic tumors are
known to have died of the disease, while 7 of
17 (41.2%) o f the patients with reticulum cell
sarcoma have died of it (x2=3.52; P=0.06).
T h e better prognosis of the lymphocytic tu-
mors is illustrated further by the accumulative
survival data (Fig. 13). The observed accumu-
lative 5-year survival for patients with these
lesions is 70% of the expected age-adjusted
accumulative 5-year survival calculated from
the United States Life Tables,62 while the cor-
responding ratio for patients with reticulum
cell sarcoma is 53%.
Two peculiar cases of lymphocytic tumors
of the lung in which it is difficult to evaluate
adequately the progress of the disease warrant
special mention. One of these is case 39, re-
ported by Pickern.71 A lobectomy was per-
formed on a 65-year-old white woman, and
the lymph nodes removed were not involved
by lymphoma. Three years and 8 months later,
she died of acute pancreatitis without clini-
cal evidence of recurrence of the tumor. At
autopsy, examination of tissue from the region
of the bronchial stump and thoracotomy scar
showed only an infiltrate composed mostly of
lymphocytes. We would be inclined to consider
this an example of progression of the tumor,
LYMPHOCYTIC TUMORS-INTERVAL FROM
IIIAGNOSIS TO D E A l H (17 CASES)
~~
Time, yr. No. cases
0 to 3 4
3 (representing 9 recurrences) had histological
t to 1
I to If 1 confirmation of this recurrence, and this was
11to 2 5 a patient with gastric lymphosarcoma, a lesion
2 to 2f 1
>23 3*
*Of the 3 patients surviving more than 2 1/2 years,
1 showed evidence of recurrence at 2 years and 4
months, and a second, a gradual progression of the
disease from time Of operation until death 5 years
later. Only 1 patient had no evidence of recurrence
at 2 1/2 yews.
- 949
TABLE6
RETICULUM CELL SA4RCOMA-INTERVAL
DE.\TH (7 CASES)
FROM DIAGNOSIS ‘1‘0
Timc, yr. RTo.cases
0 to f 3
ftol 1
1 to 1) 1
1) to 2 0
2 to 2) 0
>2f 1
Unknown 1
except that we had an opportunity to examine
the sections,TO and this infiltrate surrounds,
but carefully avoids, tracheobronchial lymph
nodes. This would be most unusual behavior
for a malignant lymphoma, and for this reason
we have not included this case among those
who have died of lymphocytic tumors. The
other one is case 41. The patient had proved
tuberculosis in the interval between operation
and death and apparently died of it. No au-
topsy was performed, but the authors89 do
raise the possibility that this 53-year-old col-
ored man still had the lymphocytic tumor.
With the absence of clinical or autopsy evi-
dence of recurrent tumor, and the presence of
an adequate explanation of the man’s course,
we again have elected not to consider this a
case of death due to a lymphocytic tumor.
Case 69, last known to be dying of lymphoma
1% years after biopsy, is considered for pur-
poses of discussion to be dead.
A study of the interval from diagnosis to
death (Tables 5 and 6) shows that the great
majority of patients died, or showed evidence
of recurrence, before 30 months had passed.
When this is coupled with a study of the non-
fatal recurrences of lymphocytic tumors in
Table 7 (there were no nonfatal recurrences of
reticulum cell sarcoma), in which it again can
be shown that the majority of recurrences oc-
curred before 30 months, one can legitimately
draw the conclusions that “late” recurrences
are a rarity, and that the first 30 months of
follow-up is the critical period. Only 1 (case 9)
of the 6 Datients with nonfatal recurrences
similar to pulmonary lymphosarcoma in prog-
nosis relative to other tumors of the organ,
and in over-diagnosis.l The patient with gas-
tric recurrence was cured by operation, and
the 8 others apparently were cured by radio-
therapy or no therapy. On the other hand, of
950 J u l y 1963
CANCER Vol. 16

7
TARLE
1.Y MPHOCYTIC TUMOKS-NONFATAL RECURRENCES ( 6 CASES)
__- ~ ~ _ _ __I _-~--___
Origin,dly
Re(-urrcnce
Casc Interv,il to & evi i. SOd‘ll - ______-____
no. for rccurr. mctast. Operation Therapy Result
-- - ___-
63 1 1 mo.; X ray lungs; Unknown Scgment. 0;0 Liv. & well 4 yr.
2; yr.; X ray lungs resect.
9 2 yr.; resect. gastric NO Lobect. Surg. Liv. & well 10 y-.
lymphoma
61 2 yr.; X ray lungs L~nltnown 1.obect. X ray Liv. & wcll 8 yr.
5 26 mo.; X m y lungs; No Pneu- X ray; LXed coronary 138 yr.
7+ yr.; X ray lungs monect. X ray
6 4 yr.; X ray lungs NO Lobcct. X ray Liv. & well 11 2 yr. ;
2 56 yr.; X ray lungs No Lobect. X ray; Died unknown causes
84 yr.; X ray lungs X ray without rccurr. tumor
& enlarged salivary p:lands 13 yr.
_- . _ - __ . __ -- -

the 17 patients who have died of lymphocytic
tumors, only 3 are known to have had the re-
currences treated by irradiation.
SljKGICAL ‘rHERAPY
the 9 who are living or who have died of
other causes had a lobectomy or pneumonec-
tomy. Six of the 9 who had a lobectomy or
pneurnonectomy are alive or died of causes
other than reticulum cell sarcoma.

T h e effect on prognosis of lymphocytic tu-

mors of the particular type of operation per- RADIOTHERAPY
formed is demonstrated in Table 8. “Ade-
quate” operation is arbitrarily defined as lo- An adequate evaluation of the effects of
becroniy or pneumoncctomy and “inadequate” radiotherapy cannot be carried out because of
operation as anything less extensive than these lack of details of the characteristics of the
procedures. The validity of this definition is therapy given. The comparative results when
warranted by the difference in survival of the radiotherapy of any type or amount was given
2 groups (~“21.5; P<0.005). However, this in the immediate postoperative period, or not
difference must be qualified in that many of given in this period, for lymphocytic tumors
the instances of “inadequate” operation were are tabulated in Table 9. Similar proportions
those in which extensive disease or metastases of the group who are still living or have
were present a t the time of operation, render- died of other causes (28 of 66, or 42.4%) and
ing the lobe or lung unresectable in the opin- of the group who have died of lymphocytic
ion of the operating surgeon. tumors (6 of 17, or 35.3yL) received radio-
The data for patienis with reticulum therapy.
cell sarcoma are not so conclusive. Six of 1,ooking at the data from another view-
point, 28 of 34 (82.4%)) who received radio-
therapy and 38 of 49 (77.6%) of those who
TARLE 8 did not receive it are either living or have died
LYMPHOCYTIC TUMORS-EFFECT OF TYPE 01 other causes (?=0.28; P=l). It can also be
OF SCRGICAL PROCEDURE ON seen in Table 9 that radiotherapy was given
Sl’RVIVAL (83 ICASES)*
~. ~ __ significantly more often ii the nodes were in-
Inndeq. op. volved (10 of 14, or 71.4%) than if they were
(biopsy, seg-
ment. rescct., not involved (13 of 42, or 31.0%) or of un-
Adeq. op. wedge resect., known status (11 of 27, or 40.7%) (x2=6.46;
(lobect. or pleural de-
pncumonect.) cortication 1 Total P=0.03 for 2 degrees of freedom). While it
__ __ would appear from the figures that radiother-
Died lymphoni,~ 7 10 17
Liv. or died apy is of value in the group with positive nodes
other causes 60 6 66 (8 of the 9 who are surviving or have died of
- - - other causes received radiotherapy, while only
TOTAL 67 16 83
2 of the 5 who have died of lymphocytic tu-
‘Thc 2 patients for whom follow-up data are not mors received it), this difference is not sta-
available are not included. One had a lobectomy and
the other an unknown procedure. tistically significant, probably because of the
No. 7 PULMONARY
MALIGNANT
LYMPHOMAS Saltzstein
& PSEUDOLYMPHOMAS . 95 1
small size of the 2 groups (-+1.83 with Yates’ TABLE10
correction for continuity; P=O.19). This same LYMPHOCYTIC TUMOR AND RETICULUM
data can be rearranged to show that 8 of: the CELL SARCOMA-STUDY OF 5 YEAR
SURVIVORS*
10 patients with nodal metastases who re-
ceived radiotherapy are alive, or have d i d of Postop. X-ray No postop.
therapy X-ray therapy
other diseases, while only 1 (case 56) of the 4
with nodal metastases who did not receive Node Total No. No. with No. No. with
radiotherapy is still alive 2% years postopera- metast. no. pt. pt. recurr. pt. recurr.
tively. In the original report,’ 1 of this man’s Lymphocytic tumor
“. .
nodes showed . changes suggestive of early Present 5 5 0 ... ...
Unknown 4 1 It 3
lymphoblastomatous involvement . . .”
on mi- Absent 16
- -4 - lt
-
12
-
1;
3Q
croscopic examination. TOTAL 25 10 2 15 4
The number of patients with reticulum Reticulum cell sarcoma
cell sarcoma receiving and not receiving radio- Present 1 1 0 ... ...
therapy is too small to allow any meaningful Unknown 2 ... ... 2 0
Absent
- -
3 ... ...
- -
3
-
0
evaluation of the results of therapy, but 2 of
the 9 patients who are living or who have died TOTAL 6 1 0 5 0
of other causes received radiotherapy, while 5 *The results given are for 25 patients with lympho-
of the 7 who died of the disease received it. cytic tumors who were living or had died of other
causes after 5 years and for 6 patients with reticulum
[The I patient (case 9) for whom no follow-up cell sarcomas who were alive after 5 years.
data are available is not included in these tClinical recurrence.
$Questionable recurrence (case 41).
figures. This patient is not known to have $In 2 instances, the recurrence was clinical; in 1,
received radiotherapy.] Rearranging this same histological.
data, 2 of the 7 patients who received radio-
therapy and 7 of the 9 who did not are living
or have died of other causes. This would sug-
gest that radiotherapy is being given more those who did received so many different
often to the patients with a poorer prognosis, modalities that its evaluation will not be at-
and this suspicion is confirmed when one real- tempted.
izes that all 5 of the patients with positive
nodes received radiotherapy, while only 2 of
STUDY OF 5-YEAR SURVIVORS
the 11 with nodes free of tumor or of unknown
status received this form of treatment (x2=6.2 Another way to evaluate therapy is to study
with Yates’ correction for continuity; P= the treatment given patients who have sur-
0.012). vived for a relatively long period of time.
So few patients received chemotherapy and Using the data presented in Tables 5 and 6
regarding the time from diagnosis to death or
onset of recurrences, 5 years can be consid-
ered a reliable interval to use. The treatment
TABLE9 given 25 patients with lymphocytic tumors
LYMPHOCYTIC TUMORS-NUMBER OF and 6 with reticulum cell sarcoma, who sur-
PATIENTS RECEIVING AND NOT RECEIV- vived 5 or more years, is summarized, along
ING RADIOTHERAPY I N T H E IMMEDIATE
POSTOPERATIVE PERIOD (83 CASES)* with the status of the regional nodes and sub-
~~

Radiotherapy, No radio- sequent course, in Table 10, Again it would

no. pt. therapy, no. pt. appear that with both lesions, radiotherapy
is of value if the nodes are involved, support-
Liv. Liv.
ordied Died ordied Died ing the data in Table 9. Three of the 5 pa-
Nodal other lym- other lym- tients in Table 10 with nodes containing
metast. causes phoma causes phoma Total lymphocytic tumor actually have survived 10
Absent 13 0 28 1 42 years or more.
Unknown 7 4 9 7 27 Similarly, of all 9 patients with lymphocytic
Present 8 2 1 3 14
- - - - - tumors and positive nodes who are living, or
TOTAL 28 6 38 11 83 have died of other causes, for any interval
*The 2 patients for whom follow-up is not known are after diagnosis, 8 have received radiotherapy.
not included. The 1 patient (case 27) who received On the other hand, it cannot be shown that
preoperative radiotherapy is included among those who radiotherapy is of any value in preventing the
received therapy.
952 CANCER
J u l y 1963 Vol. 16

nonfatal recurrences (see also Table 7) in spite lesion, its tendency to grow intraseptally about
of its apparent value in treating these recur- the periphery and more solidly in the center,
rences. or any tendency to grow about or in bronchi
or bronchioles. A histological distinction be-
DIFFE,KI.NTIAL DIAGNOSIS tween a benign and malignant lesion will not
be possible in some instances, and only care-
T h e strikingly low incidence of disscmina- ful observation of the patient’s subsequent
tion and fatal outcome of pulmonary lympho- course will allow one to make a diagnosis with
cytic tumors is strcing evidence against certainty. This situation is analogous to that of
accepting all oT these lesions as malignant lymphoid tumors ol the eyelids.1 Of our 11
lymphomas. Some of them certainly must be cases of lymphocytic tumors, only case 6 and
so, as dissemination leading to death does case 14 are believed to be malignant lympho-
occur. Many OF the others, we feel, must repre- mas.
sent some sort of chronic inflammatory prucess We have not attempted to divide the
in which the lymphocyte has beconie the pre- cases from the literature into benign inflam-
dominant cell-that i i, a pseudolymphoma matory lesions and true malignant lymphomas,
analogous to the fibrous, xanthornatous, and as we Feel that this cannot be done from half-
plasma cell pseudotumors previously de- tones of photomicrographs and descriptions of
scribed.1ns n ~ 97, T h e etiology and pathogenesis the microscopic appearance of the lesion, but
oF this lesion remain obscure, and in reality, requires careful study of the actual sections.
all anyone has examined is the end stage of T h e pulmonary reticulum cell sarcomas
the lesion. Similar moi phologic entities exist more frequently behave malignantly, as shown
elsewhere in the body--soft tissue,4!) salivary by their higher mortality rate. If one care-
glands (benign lymphoepithelial lesion or fully applies the usual diagnostic criteria, he
Fviikulici’s disease), orbit, about gastric ulcers, should be able to separate s;ttis€actorily the
with chronic gastritis, and in die rectum.1 cases of malignant lymphoma of the reticulum
We have seen dense lymphocytic infiltration cell type from reactive processes characterized
almost anywhere else in the body associated by proliferation of reticulum cells, T h e ob-
with chronic inflammation. servation that 8 o€ the 17 lesions described in
If some of the lymphocytic tumors of the Table 2 were grossly cystic (Fig. 2), a feature
lung are to be considered inflammatory and restricted to reticulum cell sarcoma, is felt to
hence benign, it becomes nece5sary to be able represent central necrosis of the tumor with
to distinguish them Erom malignant lympho- drainage through die tracheobronchial tree
mas. rather than origin in a pre-existing cyst or
Features supporting a diagnosis of inflam- abscess.
mation include a mixed cellular infiltrate
(Figs. 8R and I1B) (mature lymphocytes pre- R E C O ~ ~ N ITHERAPY
)FD
dominating), the presence of true germinal
centers, not merely nodules of lymphocytes Treatment of pulmonary lymphocytic tu-
(Figs. 1C and 7), and, of course, lymph nodes mors should be primarily surgical. T h e sur-
free of lymphoma. Gcrminal centeis, when vival figures (Table 3) show that, in the
present, have proved to be the most useful absence of nodal involvement, lobectomy or
criterion to us. T h e opposite of each of these pneumonectomy is adequate therapy for lym-
would favor a diagnosis of malignant lym- phocytic tumors of the lung, be they malig-
l~homa--uniform infiltrate of lymphocytes, es- nant lyniphonias or pseudolymphomas. T h e
pecially C i the lymphocytes are not mature importance of avoiding unnecessary radiother-
(“poorly differentiated ’), no true germinal apy is demonstrated by our case 6. This man’s
centers, and nodes invohed by the lymphoma. postoperative respiratory insufficiency, which
Pleural sectling, particularly if the nodules let1 to his death, wab due ai least in part to
are composed entirely OF immature lympho- changes associated with irradiation (Fig. 6)
cytes, again Favors malignancy. I n reality, these in his remaining lung. I n cases i n which the
are criteria of Rappaport et al.7a for lymph nodes are free of tumor, radiotherapy should
nodes modified to allciw application to the be reserved For recurrences. Its efficacy in the
lung. treatment of presumed recurrences is apparent
OF no help in differentiating a benign from Table 7. Depending on the original op-
from a malignant lesion are the si7e of the eration and the character of the recurrence,
No. 7 PULMONARY LYMPHOMAS
MALIGNANT & PSEUDOLYMPHOMAS
Saltzstein
surgery may also have a place in the treatment
of recurrent disease. If on the other hand, the
nodes do contain tumor, it appears (Table 10)
that adequate radiotherapy is of real value.
The data for reticulum cell sarcoma (Table
4) are not as conclusive, mostly because of the
paucity of cases. Here we cannot be adamant
about withholding postoperative radiotherapy
in the absence of involved nodes, but the
figures do not contradict this concept. Here
again, there is some support for the use of
radiotherapy when the nodes are involved by
reticulum cell sarcoma (Table lo).
SUMMARY
Study of 102 pulmonary “lymphomas,” in-
cluding 14 from personal experience, shows
the prognostic and therapeutic significance of
separating lymphocytic tumors from reticulum
cell sarcomas and of determining regional
lymph node involvement by the tumor.
Lymphocytic tumors occur in older people
and have approximately half the death rate of
reticulum cell sarcomas. In both instances, the
great majority of recurrences, fatal and non-
fatal, occur in 2% years or less.
95 3
Lobectomy or pneumonectomy is the pre-
ferred surgical procedure. Death from a lym-
phocytic tumor in the known absence of
regional lymph node involvement is a rarity
(2.4%), and militates against the use of post-
operative X-ray therapy in this clinical situa-
tion. On the other hand, if the nodes do con-
tain tumor, the data indicate that radiotherapy
in the postoperative period is of value. The
group of patients with reticulum cell sarcoma
is quite small, but the same statements appear
reasonable.
We believe that many, if not most, of the
lymphocytic tumors represent benign inflam-
matory “pseudolymphomas,” rather than true
malignant lymphomas. The pseudolymphomas
of the lung are characterized histologically by
an infiltrate of mature lymphocytes and other
inflammatory cells, true germinal centers, and
lymph nodes free of lymphoma. Malignant
lymphocytic lymphomas are composed almost
solely of lymphocytes that often are immature;
true germinal centers are not seen, and the
lymph nodes frequently are involved by the
lymphoma. Reticulum cell sarcomas of the
lung have the same microscopic pattern that
they do elsewhere.

REFERENCES
L. V.: Surgical Pathology, 2d ed. St.
1. ACKERMAN, cosis. Am. Reo. Tuberc. 78: 468-473, 1958.
Louis, Mo. T h e C. V. Mosby Company. 1959; pp. 221- 16. BROWN, C. J. 0.:Personal communication, 1961.
225; 3433-345; 408; 428-429; 1005-1007; 1018-1019. 17. CASTLEMAN, B.: In discussion of MCDONALD,
2. AHLYAN,A. J.; Personal communication, 1961. J. R.69
3. ANLYAN,A. J.; LOVINCOOD, C. B., and KLASSEN, 18. CASTLEMAN, B.: Personal communication, 1961.
K. P.: Primary lymphosarcoma of lung; report of case. 19. CASTLEMAN, B.; IVERSON, L.,and MENENDEZ, v. P.:
Surgery 27: 559-563, 1950.
Localized mediastinal lymph-node hyperplasia re-
4. AUFSES,A. H.: Pneumonectomy for prima local- sembling thymoma. Cancer 9 822-830, 1956.
ized lymphoma. J. M t . Sinai Hosp. 17: 693-63 1951. ~ , MANN~S,
20. C H E V A L L IJ.; P., and RENAULT,P.:
5. AUFSES,A. H.: In discussion of VAN HAZEL, W., Lymphosarcome rimitif du poumon. Semaine h69.
and JENSIK, R. J.O* Paris 33: 3652-3655, 1957.
6. AUFSES,A. H.: Personal communication, 1961. 21. CHURCHILL, E. D.: Malignant lymphoma of lung
7. BARON,M. G., and WHITEHOUSE, W. M.: Primary and pulmonary coccidioidomycosis; clinic on surgical
lymphosarcoma of lung. Am. J. Roentgenol. 85: 294- lesions of lung with consolidation. S . Clin. North
308, 1961. America 27: 1113-1120, 1947.
8. BECK,W. C.: Personal communication, 1961. 22. CICHERO,P.: Sarcoma primitivo del polmone.
9. BECK,W. C., and RECANIS,J. C.: Primary lym- Pathologica 44: 9-16, 1952.
phoma of lung; review of literature, report of 1 23. CLACETT, 0.T.: Personal communication, 1961.
case, and addition of 8 other cases. J . Thoracic Surg. 24. COOLEY,1. C.: Personal communication, 1961.
22: 323-328, 1951. 25. COOLEY, J. C.; MCDONALD,J. R., and CLACETT,
10. BEHREND,M.: Personal communication. Cited by 0. T.: Primary lymphoma of lung. Ann. Surg. 143:
BECK,W. C., and RECANIS, J. C? 18-28, 1956.
11. BERCHUIS, J.; CLAGETT,0. T., and HARRISON, 26. CUTLER, M.: Lymphosarcoma; clinical, pathologic
E. G., JR.: Surgical treatment of primary malignant and radiotherapeutic study, with report of 30 cases.
lymphoma of lung. Dis. Chest 40: 29-44, 1961. Arch. Surg. 30: 405-441, 1935.
12. BETIS, R., and OVERHOLT, R.: Personal com- 27. DAVIS,E. W.; PEABODY, J. W., JR., and KATZ, S.:
munication. Cited by BECK,W. C., and REGANIS, J. C? Solitary pulmonary nodule; 10-year study based on 215
13. BLADFS, B.: Personal communication. Cited by cases. J . Thoracic Surg. 32: 728-771, 1956.
BECK,W. C., and RECANIS, J. C? 28. DREWES, J., and WILLMANN,K. H.: Das primare
14. BLADES,B.: I n discussion of VAN HAZEL, W.. and Lungensarkom. Langenbecks Arch. klin. Chrr. 274
JENSIK, R.J?* 95-106, 1953.
15. Bowm, G. C.: Pulmonary lymphosarcoma with 29. DvoRAEEK~C., and CERMAR,M.: Primirni lym-
alveolar-capillary block and associated cocadioidomy- fosarkom plic. L t k . listy 7: 545-549, 1952.
 CANCER
July 1963
30. ELLISON, R. G.: Person.al communication, 1961.
31. ERCIN,M. T., and KEIILER,R. L.: Primary lym-
phosarcoma of lung; report of case and summary of
literature. A . M. A . Arch. Surg. 80: 1005-1012, 1960.
32. FALCONER, E. H., and LEONARD, M. E.:Pulmonary
involvement i n lymphosarcoma and lymphatic leu-
kemia. A m . J. M. Sc. 195: 294-301, 1938.
33. FLEMING, H. A., and IHowrE, J. B.: Pulmonary
lvmphosarcoma; rcport of case. New Zealand M. J .
5 0 364-368. 1951.
34. GALL,E. A., and MALLORY, T. B.: Malignant
lymphoma; clinico-pathologic: survey of 618 cases. Am.
J. Path. 18: 381-429, 1942.
35. GARLAND, L. H.: In discussion of LIITLE,J. B.M
36. GARLAND, L. H: Personal communication, 1962.
37. GIRAIJD, P.; BERNARD, R.;METRAS, and ORSINI,A.:
Tumeur maligne du poumon developpee aux depens
d'un kystc akrien. Arch. franc. ptdiat. 4: 44-47. 1947.
38. GRIMES, 0. F.; WEIRICA. W., and %RPHENS, H. B.:
Primary lymphosarcoma of lung; report of 2 cases. J .
Thoracic Siwg. 277: 376-SR3, 1954.
39. HALL,E. R.. JR., and BLADES, B.: Primary lym-
phosarcoma of lung. Dis. Chest 36: 571-578, 1959.
40. HOCHBERC, L. A., and CRASTNOPOL, P.: Primary
sarcoma of bronchus and lung. A. M. A . Arch. Surg.
73: 74-98, 1956.
41. JACKSON, E.: BERTOM, IT., and ACKERMAN, L. V.:
Exfoliative cytology; adjunct in diagnosis of bronchi-
ogenic carcinoma. J. Thoracic Surg. 21: 7-23, 1951.
42. JENSIK,R. J.: Personal communication, 1961.
43. JUSTIN-BESANGON, L.; MOUTIER, F.; LEMOINE, J. M.;
CORNET, A., and MACDELAIINE, M.: Lymphomatose
maligne z i localisations Yisckrales succcssive: siirvie de
huit a n n h . Bull. et me'm. SOC. me'd. h6p. Paris. 75:
759-766, 1959.
44. RIRKLIN,B. R., and H'SFKE, H. W.: Roentgcno-
logic study of intrathoracic lymphoblastoma. Am. J .
Roentgenol. 2 6 681-690, 1931.
45. KLASSEN, K. P.: Personal communication, 1961.
4 G . KRESS, M. 11.: Personal communication, 1961.
47. KRW, M. B., and BRANTICAN, 0. C.: Primary
lymphosarcoma of lung. Ann. Int. Med. 55: 582-597,
1961.
48. LATTKS, R.: Personal communication, 19'61.
49. LATTES, R., and P A ~ E R M., R.: Benign lym-
phoid masses of probable hamartomatous nature;
analysis of 12 cases. Cancer 15: 197-214, 1962.
50. LIEBOW, A. A.: Tumors of the Lowcr Respiratory
Tract: Atlas of Tumor Patholow. sect. 5 . fasc. 17.
Washington, D.C. Armed Forces In'stitute of Pathology.
1952; . pp.
_ 132-135.
51. LIEBOW,A. A.: Personal communication, 1962.
52. Imnsrroc. G. E.; Limow, A. A,, and GLRNN,
W. W. L.: Thoracic and Cardiovascular Surgery with
Related Patholoq. New York, N.Y. Meredith Pnblish-
ing Company. 1962; pp. 401-404.
53. L ~ EJ. , B.: Large solitary pulmonary nodule.
In X-Ray Seminar Number 10. J . A . M . A . 180 234-
235, 1062.
54. LITTLE,J. B.: Personal communication, 1962.
5.5. MAILR,H. C.: Primary lymphosarcoma of lung.
J . Thoraric Surg. 17: 841-845, 11948.
56. MAIER,H. C.: Case 14, primary lymphosarcoma
(btmign lymphoma?) of lung. In Thoracic Tumors.
Cancer Seminar 1: 89-90, 1952.
57. MAIER.H. C.: In discurision of VAN HAZEL,W.,
and JENSIK, R. JPS
58.' MAIER,H. C.: Personal communication, 1961.
Vol. 16
59. MCDONAID,J. R.: Case 21, primary malignant
lymphocytic lymphoma (lung). In CASTLEMAN, B., and
MCDONALD, J. R.: Seminar on diseases of the lower
respiratory tract and mediastinurn. Zn Proceedings of
the Twenty-Fifth Seminar of the American Society of
Clinical Pathologists, Sept. 11, 1959. American Society
of Clinical Pathologists. 1960; pp. 9-11.
60. MCDONALD, J. R.: Personal communication, 1961.
61. MOORE,R.: Personal communication. 1961.
62. NATIONAL OFFICEOF VITALSrAnsncs: United
States life tables, 1949-51. Vital StatistAfiec. Rep. 41:
1-31, 1954; 8-9.
63. N E U B U E RK.:~ ~C,ase 11, lymphoma of lung. In
Thoracic Tumors. Cancer Seminar 2: 249-252, 1960.
64. NOBILE, F.: Rilievi anatomo-isto-patologid ed
istogenetici sull'istiocitosarcoma primitivo del polmone.
Arch. ital. anat. e istol. pat. 25: 29-44, 1952.
65. OCHSNER, A., and DECAMP, P. T.: Personal com-
munication. Cited by BECK,W. C., and REGANIS, J. C.*
66. OCIISNER, S.: Personal communication, 1961.
67. O'DONNELL, T. J.: T w o cases of lymphosarcoma
of lung. Irish J . M. Sc. [1926]: 324-326, 1926.
68. OVERHOLT, R. H.: Case 2, lymphosarcoma (be-
nign lymphoma?) of lung. In Thoracic Tumors. Can-
cer Seminar 1: 65-67, 1952.
69. PRK~I.IS, E.: Linforsarcoma peribronchialc con
sviluppo prevalentcmente intrapolmonare rapido. Path-
ologica 23: 66-71, 1931.
$0. PERFZ-MESA, C.: Personal communication, 1961.
71. PICRREN, J. W., Conductor: Clinico-pathological
confercncc; RQSWell Park Memorial Institute, Buffalo.
N.Y., June 15, 19.57. New York J . Med. 58: 3657-3662.
1958.
72. PRICHARD, R. W.: Personal communication, 1961.
73. PRICHARD. R. W., and BRADSHAW, H. H.: Primary
lymphoid tumors of lung. Arch. Path. 71: 420-428, 1961.
74. RANSDELL, H. T., JR.: Personal communication.
1961.
I-..
1:). RANSDKLT,, H. T., JR.; BAILEY, A. W., and ELLISON,
R. G.: Primary reticulum cell sarcoma of lung arising
in wall of pulmonary cyst; case report. Am. Surgeon
17: 689-696, 1951.
76. RAPPAPORT, H.; WINTER,W. J.. and HICKS, E. B.:
Follicular lymphoma; re-evaluation of its position in
scheme of malignant lymphoma, based on survey of
2.53 cases. Cancer 9: 792-821, 1956.
77. nm REGATO, J. A.: Personal communication, 1960.
78. ROBBINS, L. L.: Roentgenological appearance of
parenchymal involvement of lung by malignant lym-
phoma. Cancer 6: 80-88, 1953.
79. ROBBINS, L. L.: Personal communication, 1961.
80. ROSE,A. H.: Primary lymphosarcoma of lung.
.I. Thoracic Surg. 33: 254-263, 1957.
81. SAMIJFLS,M. L.; HOWE,C. D.; DODD,G. D., JR.:
FULLER, L. M.: SHULLENBERGER, C. C., and LEARY, W. L:
Endobronchial malignant lymphoma; report of 5 cases
in adults. A m . J. Roentgenol. 85: 87-95, 1961.
82. SAROKHAN, J., and MORRISON, D. A.: Primary
lymphosarcoma of lung. Ann. Surg. 138: 140-142, 1953.
83. SCHETZ, W., and K ~ H N K , .: Das primare Reto-
thelsarkom der Lunge. Thoraxchirurgie 4: 272-277.
1956.
84. SCHULZE,W.: Das primare Lyrnphosarkom der
Lunge. Fortschr. Geb. Riintgenstrahlen 91: 457-469,
19.59.
85. SEVERANCE,A. 0.: Personal communication, 1961.
86. S P A ~S., D., and GRAYZEL, D. M.: Primary lym-
phosarcoma of lung (case report and review of litera-
No. 7 PULMONARY MALIGNANT
LYMPHOMAS
%
2 PSEUDOLYMPHOMAS ‘ SUlt%SteirZ 955
ture). Ann. Int. Med. 27: 632-638, 1947. ANDERSON, M. W., and KNAFF,L. J.: Xanthomatous
87. STARKEY, G. W. B.: Zn discussion of VAN HAZEL, and inflammatory pseudotumors of lung. Cancer 15:
W., and JENSIK, R J.” 522-538, 1962.
88. STERNBERG, W. H., and SIDRANSKY, H.: Pathologic 96. TOUROFF, A.: Personal communication. Cited by
observations on primary malignant lymphomas of BECK,W. C., and RECANIS, J. C?
lung. Bull. Tulane M. Fac. 1 9 1-10, 1959. 97. UMIKER,W. O., and IVERSON, L.: Postinflamma-
89. STERNBFRG, W. H.; SIDRANSKY, H., and OCHSNER, tory “tumors” of lung; report of 4 cases simulating
S.: Primary malignant lymphomas of lung. Cancer 12: xanthoma, fibroma, or plasma cell tumor. J . Thoracic
806-819, 1959. Surg. 28: 55-63, 1954.
90. STOUT,A. P.: In discussion of OVERHOLT, R. H.BB 98. VANHAZEL, R. J.: Lymphoma of
W., and JENSIK,
91. STOUT, A. P.: Personal communication, 1961. lung and pleura. J . Thoracic Surg. 31: 19-44, 1956.
92. SUGARBAKER, E. D.: Personal communication, 99. WEISSMAN, I., and CHRISTIE,
J. M.: Primary lym-
1961. phosarcoma of lung; report of case. A. M . A . Arch.
93. SUGARBAKER, E. D., and CRAVER, L. F.: Lympho- Surg. 62: 129-133, 1951.
sarcoma; study of 196 cases with biopsy. J. A. M. A . 100. WILLIAMS, E. R.: Radiological study of intra-
115: 17-23, 1940. thoracic lymphogranuloma and lymphosarcoma. Brit.
94. TENCZAR, F. J., Ed.: Case 31. Zn Clinical Patho- J. Radiol. 8: 265-279, 1935.
logical Conferences of Northwestern University Medi- 101. WILLIS.R. A.: Pathology of Tumours. London,
cal School. Quart. Bull. Northwestern Univ. M . School England. Butterworth & Co. (Publishers), Ltd., 1948;
27: 138-144, 1953. p. 766.
95. TITUS, J. L.; HARRISON, E. G.; CLAGETT, 0. T.; 102. WILLIS,R. A.: Personal communication, 1961.