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Lymphoma of Cheek: a Case Report

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Lymphoma of Cheek: a Case Report European Review for Medical and Pharmacological Sciences 2012; 16(4 Suppl): 4-7 Lymphoma of cheek: a case report M. MALAGUARNERA, M. GIORDANO, C. RUSSO, L. PUZZO*, M. TRAINITI**, A.S. CONSOLI**, V.E. CATANIA** Research Center The Great Senescence, Senescence, Urological, and Neurological Sciences Department, University of Catania, Italy *Department of Anatomy Pathology, University of Catania, Italy **Department of General Surgery, University of Catania, Italy Abstract. – Lymphoma of cheek is a rare ad Certain viruses such as the Epstein Barr virus, uncommon disease, representing 2,5% of malig- which normally causes glandular fever, might nant lymphoma. The cause is unknown but there contribute to the development of lymphomas and are a lot of risk factors such as Helicobacter py- in particular Burkitt lymphoma, an high grade of lori and Epstein Barr virus. Symptoms are aspe- cific and may be confused with otolaryngologi- B cell malignancy. EBV favorites the rate of this cal benign diseases. We present a case of B cell lymphoma because it has the potential to trans- lymphoma of the cheek, which presented with a form normal human B lymphocytes into growing history of a slowly growing swelling of 3 months immortalized cells. It is present in about 50% of duration, resistant to NSAIDs and antibiotic ther- Hodgkin’s lymphoma and with varying frequen- apy. Biopsy of the mass led to diagnosis of lym- cy in non Hodgkin’s lymphomas11,12. One rare phoma. Blood investigations, ultrasonography type of lymphoma, which usually affects the and CT scan helped to reach this result. This case report shows that an accurate clinical ex- stomach is known to be caused by a type of bac- amination, a cytohistological and immune-histo- terial infection known as Helicobacter pylori chemical diagnosis by fine-needle aspiration (MALT = mucosa associated lymphoid tissue). biopsy (FNAB) are fundamental to obtain a diag- Similar association is known to date with PCL. nosis and to decide therapy. Case Report Key Words: Non-Hodgkin’s lymphoma, Lymphoma, Cheek. A 66 years old non smoker, non tobacco addict woman presented with a history of a slowly growing swelling over her right cheek of 3- months duration resistant to NSAIDs and antibi- Introduction otic therapy. It caused difficulty in opening her mouth in the past 3 months. During this period Non Hodgkin’s lymphomas (NHL) are a group the patient also accused weight loss, fever, might of highly various malignancies and have great ten- sweats, weakness and nausea. dency to affect organs and tissues that do not ordi- The local examination revealed a firm to hard narily contain lymphoid cells. 20 to 30% of non nodular subcutaneous mass on the right side of Hodgkin’s lymphoma arises from extra-nodal sites1. face reaching up to right lower jaw. The overly- The head and the neck are the second most ing skin was tense and shiny, the mass was well common region for extra nodal lymphoma after circumscribed and appeared to be free from mu- gastrointestinal tract. Nevertheless, primary cosa and bone. There was no lymph node en- cheek lymphoma (PCL) is almost rare and really largement. uncommon representing 2.5% of malignant lym- Her routine blood investigations showed an phoma2-8. enhancement of the VES (96 mm 1° hour), C-re- The cause of PCL likewise the most common active protein (3,70 mg/dl), alkaline phosphatase NHL is unknown. Currently lymphomas are more (211 v.n. 32-100) and LDH (653 v.n. 250-500). likely to develop in immunosuppressive people or Besides in her CBC it was possible to note an in elderly, especially over the 6th decade of life9,10. increment of WBC (11,23 × 103/microL) and However, despite the increased risk, NHL is still neutrophils 85,7% accompanied by an absolute uncommon in these people. and relative lymphopenia. 4 Corresponding Author: Michele Malaguarnera, MD; e-mail: [email protected] Lymphoma of cheek: a case report Ultrasonography revealed a hypoechoic well to the regional lymph nodes14,15. Particularly, circumscribed mass with the maxima diameter of nasal non Hodgkin’s lymphoma is rare in West- 4 cm and a laterocervical and submandibular ern countries but it is very common in East Asian lymphadenopathy. Therefore, patient was sub- countries and Latin America16. jected to fine needle aspiration biopsy (FNAB) The diffuse large B-cell lymphoma (DLBCL) that showed a lymphomatous swelling. appears to be the most common type of primary CT scan confirmed the presence of a solid, iso- oral and paraoral NHL8,17 dense, hypervascolarizated mass of 2,5 cm diame- There are no characteristics clinical features of ter in her right cheek in absence of laterocervical lymphoma of the oral region and they depend by node involvement and metastasis. A percutaneous the site of the swelling, the lymph node involve- biopsy was performed in order to obtain an ment and/or the presence of metastasis. The most histopathological typing that revealed a small dif- common beginning symptoms are local mass, fuse B cell CD20+ non-Hodgkin’s lymphoma. pain or discomfort, dysphagia or sensation of a The immunophenotyping showed B-cell type foreign body in the throat, in the case of tonsillar CD20 and CD79a positive and CD3, CD10, NHL. It is frequent that a NHL may be confused CD15, CD30, CD68 negative. It was also found with a benign disease. Therefore, is useful oto- small lymphocytes with round or cleaved nucleus, laryngology examination. minor component of blasts and plasmacytoid cells, Sometimes, it is also possible found facial hemi- compatible with a lymphocyte proliferation. plegia and parestesia because of a neural involve- The patient was considered no operable. ment. However, peripheral neuropathy is an unusu- Therefore, she received three cycles of al complication of lymphoma18,19 like so distinct chemotherapy (Fludarabine 3.75 mg e.v. days 1-3 muscular involvement20,21. Our patient presented a + Mytoxantron 15 mg e.v. day 1). This was fol- slowly growing swelling resistant to antibiotics and lowed by 18 cycles of local radiotherapy to the NSAIDs, weight loss, fever, might sweats, weak- diseased area on 6 MeV linear accelerator. She ness and nausea. Therefore, the symptoms were received a total dose of 36 Gy. similar to other types of oral cancers. Following the treatment there was a partial re- The first step, to make a correct diagnosis, is gression of the tumor but after two months of the an inspection and palpation of oral cavity and re- regression, patient refused to continue the thera- gional lymph nodes. py because of the worsening of performance sta- A part of that instrumental techniques, percu- tus caused by pharyngeal infiltration and side ef- taneous ultrasound (US) and computed tomogra- fects of radiotherapy (dysphagia, asthenia, pares- phy (CT) scan are well established procedure. thesias). Subsequently the patient had a ischio- Cytohistological diagnosis is mandatory for di- pubic fracture after a long period of bone pains agnosis and treatment with an accurate fine nee- and she died because of acute lung edema. dle aspiration diagnosis of PCL is critical to be realized in time to avoid surgical management and obviates the need for an exploratory la- Discussion paratomy. FNAB is considered a safe, rapid and easy procedure with high diagnostic accuracy. The tumors of oral cavity include several types Percutaneous biopsy should be performed to es- of malignancies in correspondence of lip, tongue, tablish the diagnosis. cheek and pharynx. In the USA, the annual inci- Flow cytometry (FC) has significantly en- dence is 19 cases on 100,000 people and the life hanced the diagnostic role of FNAB, particularly expectative to five years is about 52%. in the case of hematolymphoid malignancies. FC Non Hodgkin’s lymphoma is one of the possi- is extremely sensitive in the detection of antigen ble cancers in the head and neck region and, be- expression and identifies small clonal population. tween extra nodal non Hodgkin’s lymphomas, FC analysis distinguishes lymphomas from this is the second most common site after gas- chronic inflammation through the detection of trointestinal tract13. In the head and neck, clonality based in surface of Ig light chain ex- Waldeyer’s ring is the most common site of ori- pression studies. In lymphomas, IG light chain gin and may be accompanied by cervical node expression is usually restricted to either kappa or involvement. Nose, paranasal sinus, orbits, sali- lambda, whereas inflammatory processes reveal a vary gland are other possible organs affected in mixed expression of kappa and lambda light decreasing order of frequency, with rare spread chains. 5 M. Malaguarnera, M. Giordano, C. Russo, L. Puzzo, M. Trainiti, A.S. Consoli, V.E. Catania FC also has limited capability in classifying Finally, an accurate clinical examination, a cy- lymphomas into different, well recognized subcate- tohistological and immune-histochemical diag- gories. This is made possible by studies of surface nosis by FNAB and flow cytometry became fun- marker expression and is best applicable for low damental steps to decide a proper therapeutic grade lymphomas22. Through this technique is pos- protocol. sible to distinguish malignant lymphomas from non-lymphoid neoplasm, evaluating the presence of positive staining for leukocyte common antigen References (LCA). Diffuse large B-cell lymphoma is most commonly positive for CD20 and CD 79a and less 1) ZUCCA E, ROGGERO E, BERTONI F, C AVALLI F. Primary extranodal non-Hodgkin’s lymphoma. Part 1: Gas- commonly positive for germinal centre cell mark- trointestinal, cutaneous and genito urinary lym- ers CD10 and BCL68,23. phomas. Ann Oncol 1997; 8: 727-737. A correct and early diagnosis is important to 2) EISENBUD L, SCIUBBA J, MIR R, SACHS S-A. Oral pre- begin on time therapy.
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