Oral presentations in non-Hodgkin's lymphoma: a review of thirty-one cases. Part I. Data analysis

A rare case of high-grade non-Hodgkin's lymphoma with oral and multiple extranodal manifestations

Lymphomas are a group of malignant diseases affecting the lymphoreticular system. Lymphoma is the second most common neoplasm of the head and neck after squamous cell carcinoma, but the incidence of lymphomas in the oral cavity and orbit is rare. Non-Hodgkin's lymphoma (NHL) is less predictable than Hodgkin's but has a greater predilection to extranodal tissues. Non-Hodgkin's incidence in extranodal sites accounts for about 20% to 30%, but in the oral cavity, its around 0.1% to 5%. The rarity of incidence in the oral cavity and atypical radiographic features diagnosing a lymphoma is quite a challenge for clinicians. Here we describe a case of 31-year-old male patient with high-grade non-Hodgkin's lymphoma involving oral cavity with metastasis to orbit, skeletal structures, testes, liver, pancreas and nasopharynx, which is quite rare.

Oral Malignant Non-Hodgkin Lymphoma: A Retrospective Single-Center Study

This study aimed to retrospectively evaluate the incidence of oral non-Hodgkin lymphoma (NHL) in patients referred to the Academic Hospital of the Magna Graecia University of Catanzaro from 2002 to 2020. A retrospective single-center study was performed. Patients with a histologically confirmed diagnosis of oral NHL were included. Demographic data and clinical parameters were digitally recorded, focusing on the NHL-specific localization and symptomatology. The study sample was evaluated by analyzing descriptive statistics with absolute and relative frequencies. A total of 26 patients with intraoral NHL were identified with a progressive increase in NHL occurrence during the observation period. Clinical manifestations included swelling/mass (80.7%), eventually associated with pain and ulcerations. The most common localizations were in soft tissues: buccal mucosa (38.4%), tongue (19.2%), gingiva (11.5%), cheek (11.5%). Oral NHL is rare. Clinical manifestations were unspecific, so a misdiagnosis could occur. The extranodal B-cell form of oral NHL, particularly diffuse large B-cell lymphoma, was the most common frequent oral NHL in this southern Italian population, with a progressively increased occurrence in almost 20 years.

Oral manifestations of extranodal lymphomas - a review of the literature with emphasis on clinical implications for the practicing dentist

OBJECTIVE

Lymphoma is a heterogenous group of malignant tumours with proliferation of lymphoid cells or their precursors. Lymphomas in the head and neck region are usually found in Waldeyer's ring. Intraoral lymphomas are rare and the clinical presentation and roentgenological appearance may resemble other and benign conditions, entailing a risk for diagnostic delay. The objective of the present literature review was to identify subjective symptoms, clinical presentations and roentgenological appearances which should raise suspicion of lymphoma.

MATERIALS AND METHODS

The literature review identified 41 case series with head and neck lymphomas (n = 3880) and 384 case reports (n = 567 cases) of intraoral lymphomas. Information of demographics, clinical presentation, subjective symptoms and roentgenological appearance was registered.

RESULTS

The most common clinical presentation was a broad-based swelling or bulging mass with or without simultaneous ulceration, frequently with a relatively rapid growth pattern. Subjective symptoms varied considerably. Intraosseous lymphomas were frequently associated with paresthaesia or numbness. The most common roentgenological finding was a radiolucency with diffuse demarcation.

CONCLUSIONS

The clinical presentation, symptomatology and roentgenological appearance of intraoral lymphomas varied. Diagnostic delay was usually associated with a lymphoma initially misdiagnosed as a lesion of dental aetiology or a reactive lesion. Inadequate healing after tooth extraction or symptoms of numbness or pain without obvious dental origin should merit further clinical and roentgenological examination. Biopsy is indicated when there is the slightest doubt of the true nature of mucosal lesion.

Clinical manifestations of oral lymphomas - Retrospective study of 15 cases in a Taiwanese population and a review of 592 cases from the literature

BACKGROUND/PURPOSE

Due to the rarity of oral lymphoma (OL), we aimed to evaluate the clinical features of OL and discuss these findings in light of the literature.

METHODS

English language literature (1980-2019) related to OL was searched in two electronic databases. Patients (2000-2019) diagnosed with OL were also selected from the database of the Oral Pathology Department in our institution. The clinical features, radiographic appearance, and histopathological diagnosis in these selected cases from publications and our institution were then analyzed.

RESULTS

607 cases of OL (15 in our institution and 592 from literature) in patients aged between 0 and 92 years (average, 51.8 years) with a male to female ratio of 1.6:1 were included. The most common diagnosis was diffuse large B-cell lymphoma (n = 205), followed by Burkitt lymphoma (n = 72) and T-cell lymphoma (n = 37). The most frequent site was the gingiva, followed by palate, maxilla, mandible, tongue and buccal mucosa. The most frequent symptoms were swelling, ulceration, paresthesia, mobile tooth and pain. Radiographic findings included ill-defined osteolytic lesion, thickening of the periodontal ligament, loss of lamina dura and tooth displacement.

CONCLUSION

Despite the rarity of extranodal lymphomas in oral cavity, their occurrence may be part of disseminated disease. Detailed history-taking, clinical and imaging examination and awareness of the patient's signs and symptoms are important for early diagnosis and an improved prognosis. The current data form a useful basis for clinical investigation and teaching regarding lymphoma occurring in the oral cavity.

Evaluation of a case of diffuse large B-cell lymphoma

Lymphomas are a group of malignant blood cell tumors that develop from lymphocytes representing 2.2% of all malignant neoplasms of the head and neck. Two main categories of lymphomas are Hodgkin's lymphoma and non-Hodgkin's lymphoma (NHL) of which 90% are of the NHL type. Several classification systems have existed for lymphomas, the objectives of which are to help in identification of homogeneous group of well-defined entities and facilitating the recognition of uncommon diseases that require further classification as it affects prognosis and therapeutic implications. Diffuse large B-cell lymphoma (DLBCL) is the most common NHL in the oral cavity involving Waldeyer's ring, base of the tongue, buccal mucosa and hard palate. DLBCL can be divided into germinal center B-cell-like, activated B-cell-like or type 3 gene expression profiles. This paper highlights a case report of DLBCL revisiting the intricacies and difficulties involved in establishing a diagnosis.

Gastrointestinal tract metastasis of mandibular diffuse large B-cell lymphoma

Not only diffuse large B-cell lymphoma is a malignancy, but also is initially and orally diagnosed in early stages. However, it could be misdiagnosed with other oral pathologies. However yet, early diagnosis is still crucial for the prognosis, morbidity, and mortality in such cases. Additionally, whole-body scanning with positron emission tomography/computed tomography should be performed for diagnosis and treatment process.

HIV-associated large aggressive extranodal lymphoma of the oral cavity

Malignant lymphomas form a heterogeneous group of neoplasms of the lymphoid tissue with different clinical courses, depending on the treatment and the prognosis. Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) have been associated with an increased risk for the development of lymphoproliferative disorders. The incidence of lymphoma is associated with 60-fold increase in seropositive patients as compared to seronegative patients. The present case describes a diffuse aggressive extranodal lymphoma in a known HIV patient.

A vanishing lymphoma in the cheek

BACKGROUND

We describe the unusual case of a 66-year-old woman who presented with a cheek mass that completely abated with oral steroids.

CASE REPORT

Multiple separate biopsies of the mass were negative or inconclusive. MRI revealed a large mass, yet after a short steroid course, this mass was completely undetectable on clinical examination. A repeat biopsy eventually revealed follicular lymphoma.

DISCUSSION

Lymphomas are known to be steroid sensitive; the medication is an essential component of the common CHOP therapy. While known to occur in the central nervous system, to the best of our knowledge, the presence of a 'vanishing' lymphoma has not been documented in the head and neck. We discuss the likely physiology of the vanishing lymphoma, and the diagnostic difficulty it presents.

CONCLUSION

When a lymphoma is suspected, patient care may be optimized if biopsy is delayed until steroids have been discontinued.

Primary diffuse large B cell lymphoma of the base of tongue: a rare entity

Primary lymphomas of the oral cavity are uncommon and of the tongue even rarer. It is more common in the masticatory mucosa than the lingual and buccal mucosa. We describe a 63 year old male who presented with dysphagia & change in voice. Computed tomography revealed a 4.8 × 3.7 cm mass localized to the base of tongue. He underwent biopsy and IHC studies & was diagnosed as having diffuse large B cell lymphoma. The patient was successfully treated with wide excision of the lesion and is undergoing chemotherapy now. Although oral lymphoma of tongue is very uncommon, it should always be considered in differential diagnosis of various benign and malignant lesions in this region. A proper clinical evaluation and histopathologic as well as immunohistochemical evaluation of biopsy specimen are required to establish the diagnosis and for further management. This is one of the few cases of non-Hodgkin's lymphoma of the base of tongue being reported from India.

Malignant lymphoma of the oral cavity and the maxillofacial region: overall survival prognostic factors

Objective: To identify the overall survival and prognostic factors of malignant lymphoma of the oral cavity and the maxillofacial region. Study Design: Clinical records data were obtained in order to determine overall survival at 2 and 5 years, the individual survival percentage of each possible prognostic factor with the actuarial technique, and the survival regarding the possible prognostic factors with the actuarial technique and the Log-rank and Cox’s regression tests. Results: Of 151 subjects, an overall survival was 60% at 2 years, and 45% at 5 years. The multivariate analysis demonstrated statistically significant differences for clinical stage (p=0.002), extranodal involvement (p=0.030), presence of human immunodeficiency virus (p=0.032), and presence of Epstein-Barr virus (p=0.010). Conclusion: The advanced clinical stage and the larger number of involved extranodular sites are related to a lower overall survival, as well as, the presence of previous infections such as the human immunodeficiency and the Epstein-Barr virus.

Key words:Lymphoma, oral cavity, survival.

Magnetic resonance imaging (MRI) and dynamic MRI evaluation of extranodal non-Hodgkin lymphoma in oral and maxillofacial regions

OBJECTIVE

The purpose of this study was to evaluate the diagnostic value of magnetic resonance imaging (MRI), especially dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), in extranodal non-Hodgkin lymphoma (NHL) of oral and maxillofacial regions.

STUDY DESIGN

Thirteen cases with extranodal NHL were examined using MRI. T1-weighted images (T1WI) and T2-weighted images (T2WI) or short TI inversion recovery (STIR) images were obtained in all cases. Contrast-enhanced images and DCE-MRI were acquired in 10 and 7 cases, respectively. On DCE-MRIs, we analyzed the parameters as follows: contrast index at maximal contrast enhancement (CImax), maximum contrast index (CI) gain/CImax ratio, and washout ratios (WR(300), WR(600), and WR(900)) at 300, 600, and 900 seconds after contrast medium injection.

RESULTS

The signal intensity of all lesions was hypointense to isointense on T1WIs and showed variable contrast enhancement patterns. On T2WIs and STIR images, the signal intensity was isointense to hyperintense in almost all cases. Analysis of DCE-MRI parameters in extranodal NHLs resulted in the identification of 4 types of CI curves according to CImax and WR: (1) CImax greater than 2.0 and WR(900) greater than 40%, (2) CImax greater than 2.0 and WR(900) less than 40%, (3) CImax less than 1.5 and WR(900) greater than 40%, and (4) CImax less than 1.5 and WR(900) greater than 40%.

CONCLUSIONS

The signal intensities on MRI were not specific to extranodal NHL and resembled those of other tumor types. When CImax was less than 1.5 or WR900 was less than 40%, these parameters contributed to diagnosis in extranodal NHLs.

Diffuse large B-cell lymphoma with oral manifestations

Non-Hodgkin lymphomas (NHLs) are a heterogenic group of lymphoproliferative diseases with their different behavior pattern and response to treatments. As a Hodgkin disease, NHL occurs from lymphoid tissues and can spread to other organs. Prognosis depends on histologic type, grade, and treatment. In the World Health Organization classification, aggressive B-cell lymphomas are diffuse large B-cell lymphoma, Burkitt lymphoma/leukemia, and precursor lymphoblastic leukemia/lymphoma. They may present either nodal or extranodal disease, which may be either localized or disseminated. Diffuse large B-cell lymphoma is the most common type of lymphoma in adults and is clinically, morphologically, and genetically a heterogeneous group of malignant proliferations of mature B cells, too. Diffuse large B-cell lymphoma is the most common type of NHL and accounts for about 30% of the cases. In this clinical report, we evaluated clinically and histopathologically a 64-year-old male patient who had mild pain and edema in his mandibular premolar region, and the excisional biopsy showed diffuse large B-cell lymphoma.

Diffuse swelling of the buccal mucosa and palate as first and only manifestation of an extranodal non-Hodgkin 'double-hit' lymphoma: report of a case

BACKGROUND

Most of the lymphomas arising in the oral cavity are of B-cell origin. Among these, diffuse large B-cell lymphomas are the most common. Diffuse large B-cell lymphomas may exhibit more than one chromosomal rearrangement and are then referred to as 'double-hit' or 'triple-hit' lymphomas.

CASE REPORT

We present a case of an intraoral 'double-hit' lymphoma in a 76-year-old male who had been referred by an oral surgeon in private practice. Intraoral examination exhibited a firm, exophytic lesion in the region of the right hard palate and buccal mucosa with extension to the soft palate. Radiographic examination exhibited a massive thickening of the right sinus membrane, and arrosion of the lateral and basal cortical sinus walls in the right maxilla. After diagnosis of the lesion, the patient was treated with six cycles of chemotherapy.

DISCUSSION

Lymphomas arising within the oral cavity account for less than 5% of all oral malignancies and typically affect the palatine tonsils and the palate. 'Double-hit' lymphomas are associated with older age, usually present with an advanced stage of disease, and show an aggressive clinical behaviour. They normally have a poor prognosis, even when treated with intensive chemotherapy regimens. Nevertheless, in the case presented, the patient was free of symptoms 1 year after initial diagnosis.

Primary Nasopharyngeal non-Hodgkin lymphomas: a retrospective review of 26 Moroccan patients

Background

Nasopharyngeal non-Hodgkin lymphomas (NNHL) are extremely rare. In this study, we will report the progress achieved in the management of this disease in our institute.

Methods

We retrospectively reviewed the records of 26 patients having primary NNHL who were managed between January 1997 and December 2008, to evaluate and compare their clinical characteristics and treatment outcome. Clinical variables, including age, sex, stage, and treatment modality, were assessed. Disease free survival and overall survival were measured. Survival curves were constructed using the KaplanMeier method. The log-rank test was used to compare them.

Results

Median age of our patients was 52.7 years. Nasal obstruction, nasal discharge and epistaxis were the frequent symptoms in NNHL patients. Histology of NNHL were mainly large B-cell and follicular lymphoma. Four patients (15.4%) were at stage I, 15 (57.6%) at stage II, and 7 (27%) were at stage III/IV. The patients were treated with chemotherapy alone (27%) or chemotherapy plus radiotherapy (73%). At early stage (stage I/II), the patients were managed with chemo-radiotherapy. When the whole treatment was completed, 18 patients (69.2%) achieved complete response and remained disease free. After 25.9 months median follow-up, overall survival at 1 year was 87% and disease free survival at 1 year was 71%. The difference in term of overall and disease free survival between stage I, II, III and IV was significant (Log rank test: p = 0.02 for overall survival and p = 0.01 for disease free survival).

Conclusion

From our study, we conclude that histological characteristics, principle of treatment and outcome of primary NNHL patients are particular and more studies have to be directed.

Systemic lymphoproliferative diseases

With advancements in diagnosis and treatment for lymphoma, it is important that physicians be up to date in the management of these lymphoproliferative disorders, their associated complications, and the complications of treatment. The importance of a thorough examination of the oro-facial complex and neck on all patients cannot be overemphasized. Oral and maxillofacial surgeons continue to make significant contributions in what has become a multidisciplinary approach to managing lymphoproliferative disease.

Malignant non-Hodgkin's lymphoma (NHL) of the jaws: a review of 16 cases

Non-Hodgkin's lymphoma (NHL) is rarely found in the jaw. We present 16 cases and the purpose of this study was to analyze the clinical signs and symptoms. The treatment and the progression evolution are also mentioned. The diagnosis was usually difficult and was often misleading and so delays before the first bone biopsy were frequent. The therapy of this rare, diffuse, large cell lymphoma was very variable from one case to another but the majority of the patients were treated with a combination of chemotherapy and radiotherapy.

Oral non-Hodgkin's lymphoma: review of the literature and World Health Organization classification with reference to 40 cases

Forty cases of oral cavity non-Hodgkin's lymphoma (NHL) were evaluated for sex, age, location, clinical presentation, and World Health Organization (WHO) histological subtype. Fifty-three percent were female and the mean age was 71. The upper jaw (maxilla or palatal bone), mandible, palatal soft tissue, and vestibule and gingivae (maxillary or mandibular soft tissue involvement only) were, respectively, the most common locations. Swelling, ulceration, and radiographic destruction of bone were the most frequent signs. Most of the lymphomas were of B cell lineage (98%), and the majority of these B cell lymphomas (58%) were histologically subtyped as diffuse large B cell lymphoma, which is considered to have an aggressive clinical course. An immunohistochemical panel was used in the majority of cases to confirm the lineage and to help characterize the subtype. B and T cell specific markers were used to show lineage of the neoplastic cells. Additional markers were used to help confirm specific subtypes that characteristically show specific positivity to some of these antibodies. Molecular studies to detect monoclonal immunoglobulin heavy chain (IgH) gene rearrangements and Bcl-1 and Bcl-2 gene translocations were performed in cases in which the diagnosis was in question. The current WHO classification is also reviewed in detail.

Rare oral cavity presentation of a B-cell lymphoblastic lymphoma. A case report and review of the literature

Lymphoblastic lymphoma is an uncommon malignancy, with most cases showing a T-cell phenotype and presenting as a mediastinal mass. By contrast, B-cell lymphoblastic lymphoma/leukemia is a rare high-grade malignancy that comprises approximately 10% of all lymphoblastic lymphomas. Lymphomas of the oral cavity are rare and typically present as intraosseous lesions that are most commonly diffuse large B-cell type. Here we present what we believe is the first B-cell lymphoblastic lymphoma initially presenting in the oral cavity. The case involves a 46-year-old white woman who presented with a mass in the right mandible. This report discusses this rare malignancy, including clinical presentation, histopathologic features, immunologic profile, treatment, and prognosis. This case emphasizes the importance of recognizing rare entities that may present in the oral cavity and the impact of the disease and its management.

Non-Hodgkin's lymphoma manifest as gingival hyperplasia in a renal transplant recipient

Gingival hyperplasia is a frequent complication in transplant patients who receive cyclosporine or calcium channel blockers. We studied an unusual case involving a renal transplant recipient with post-transplant non-Hodgkin's lymphoma that manifested as gingival hyperplasia. We initially consider that it was a side effect of cyclosporine and nifedipine. The lesion did not respond to dose reductions or the withdrawal of cyclosporine and nifedipine, and the gingival hyperplasia progressed in a localized fashion, becoming ulcerated and bleeding easily. Histological examination revealed the presence of malignant lymphoma.

Characteristics of 40 primary extranodal non-Hodgkin lymphomas of the oral cavity in perspective of the new WHO classification and the International Prognostic Index

Non-Hodgkin lymphomas (NHLs) are often present outside the lymph nodes. Although primary extranodal NHLs (PE-NHL) form a substantial part of all NHLs, reports on oral PE-NHLs are rare. Forty patients with PE-NHL of the oral cavity have been studied for the distribution of gender, age, oral subsite and presenting complaint, histological subtype according to the WHO classification, clinical stage, treatment, and follow-up. The data are reviewed against the background of the literature. Furthermore, the International Prognostic Index has been taken into consideration. All patients had a lymphoma of B-cell lineage. Two-thirds of patients presented with locoregional disease. Mean survival time was 38 months, with a mean recurrence-free survival time of 31 months. There was no statistically significant difference in survival time between patients with bone versus soft tissue localisation of the PE-NHL. In view of the rarity of PE-NHL involving the oral region multicenter studies are needed for evaluation of the usefulness of the International Prognostic Index for non-Hodgkin lymphoma in this particular part of the body.

Localized B-cell non-Hodgkin's lymphoma of oral cavity and maxillofacial region: a clinical study

OBJECTIVE

Non-Hodgkin's lymphomas (NHL) are the third most common group of malignant lesions in the oral cavity and maxillofacial region. Most such lymphomas have been shown to be predominantly of B-lineage. The purpose of the present study is to analyze the clinical signs and symptoms and the clinical staging of B-cell NHL of this region.

STUDY DESIGN

Eighteen adults, with B-cell NHL manifestations of the oral cavity and maxillofacial region, were available for this study. The clinical stage according to the Ann Arbor system was assessed by history, physical, and laboratory examination. Hematoxylin and eosin--stained slides and paraffin blocks were available for all cases. Histologic diagnosis was based on the WHO classification of tumors.

RESULTS

The mean age of patients at the time of biopsy was 64 years. At the time of the disease presentation, according to the Ann Arbor system, 11 patients were in stage IE, 2 patients in stage IIE, 2 patients in stage IIIE, 1 patient in stage IVE, and 2 patients in stage IV. The typical clinical appearance was a painless local mass lateral or bilateral. Often there is a superficial ulceration of the tumor mass. Tonsillar NHL was the most frequent site occurring in 8 patients followed by NHL of the oral cavity, of the salivary glands, and of the mandible. Grading revealed that most cases were high grade (11 cases), followed by the cases of low grade (5 cases) and intermediate grade (2 cases). All the different histologic types may be observed, but the most frequently encountered is the diffuse large type.

CONCLUSIONS

The B-cell NHL may involve both osseous and soft tissues of the oral cavity and maxillofacial region. The favored sites are tonsils, palatal mucosa and parotid glands. The typical clinical appearance is a painless local mass lateral or bilateral. Often there is a superficial ulceration of the tumor mass. According to the Ann Arbor system, the majority of the cases at the time of diagnosis are in stage I or II. Most patients have high grade disease. All the different histologic types may be observed, but the most frequently encountered is the diffuse large type.

Oral Involvement in Lymphomatoid Papulosis

Oral involvement in cutaneous CD30+ T-cell lymphoid proliferations is rare and has received little attention in the dermatologic literature. The authors report 2 patients with self-healing, recurrent papulonodular eruptions with the classic clinical, histopathological and immunophenotypic features of lymphomatoid papulosis, which developed two ulcerated papules and an ulcerative nodule on the dorsum of the tongue, respectively. The lesions appeared coincident with a new cutaneous relapse of the disease. Histopathological and immunophenotypic features were similar to those of the cutaneous lesions. All lesions regressed spontaneously after several weeks. Since then, and after follow-up periods of 3 and 7 years, respectively, no evidence of extracutaneous involvement has been detected. Oral involvement in lymphomatoid papulosis is an uncommon event, probably without prognostic significance. Previously reported cases are reviewed. The differential diagnosis of atypical T-cell lymphoid infiltrates observed in the oral mucosa is discussed.

Orofacial non-Hodgkins lymphoma in Nigerians

PURPOSE

In this study, we sought to determine the occurrence of primary non-Hodgkins lymphoma (NHL) in the oral and maxillofacial region among Nigerians.

PATIENTS AND METHODS

We retrospectively studied hospital records that included radiographs of all patients with a histopathologically confirmed diagnosis of NHL in the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria, between January 1992 and December 1997. Data were expressed as mean +/- SD or number (%).

RESULTS

During the study period, 66 cases of NHL were recorded. Seventeen patients had concomitant extranodal lymphomas involving the gastrointestinal tract, nasopharynx, skin, lungs, kidney, and thyroid, in descending order. Three patients (4.5%) presented primarily with extranodal oral and maxillofacial disease. The ages of these patients ranged from 18 to 50 years (mean +/- SD, 32.3 +/- 16.3 years; median, 29 years). Within the same period, there were 121 cases of Burkitts lymphoma. The onset of lesions varied from 6 to 20 weeks. Two patients had intermediate-grade lesions; the remainder had low-grade lesions. Two presented with stage II disease, and the remainder were stage I. All of the patients had chemotherapy with remission of their lesions but were followed up to 6 months. Most of them did not complete the treatment cycles due to financial and social constraints.

CONCLUSIONS

The rarity of primary NHL of oral and maxillofacial region has been aptly shown in this study. The need for the establishment of an effective oncology policy with the active collaboration of voluntary agencies is emphasized. This would ensure ready availability of the required chemotherapeutic agents and hospital care at affordable costs.

Lymphoma in the infraorbital region

BACKGROUND

B-cell lymphomas are rare neoplasms in the oral cavity. They are significant to dentists because the oral complications associated with treatment mean that dentists can play an important role in their detection.

CASE DESCRIPTION

The authors describe the case of a 55-year-old man with nonhealing ulcers, swelling and pain six months after maxillary left canine extraction. As it occurred in the infraorbital region after canine tooth extraction, the authors suspected B-cell lymphoma. Clinical examination revealed infraorbital edema with regional submandibular lymphadenopathy. Intraoral examination revealed a nonhealing ulceration with ill-defined borders in the surrounding mucosa. It was 5- x 5-centimeters in diameter and gray-white. The histopathologic examination showed diffuse, atypical, lymphoid cell infiltration and immuno-histochemically positive staining. After the histopathologic examination, the authors referred the patient to a medical center for treatment.

CLINICAL IMPLICATIONS

Dentists should look for signs of B-cell lymphoma when a patient has extended pain and swelling after an extraction.

Non-Hodgkin lymphomas of oral cavity

Non-Hodgkin lymphomas (NHL) often show up in an extranodal pattern, especially in the head and neck. Intraoral locations are much less frequent, particularly when they are single. This, in turn, can lead to a prolonged diagnosis and even to inadequate treatment. Different patients with initial extranodal location of NHL which were not previously diagnosed and in which it was manifested only intraorally are presented in this paper. These cases are presented together with the additional examinations used for the early diagnosis and with the corresponding clinical pictures, as well as with the overview of other cases from the available literature.

Primary extranodal malignant lymphoma affecting the periodontium

BACKGROUND

Non-Hodgkin's lymphoma may arise in extranodal tissues within the head and neck region. These lesions may occur in the oral cavity, but rarely appear on the gingiva. Due to their malignant nature, rapid identification, diagnosis, and treatment of non-Hodgkin's lymphomas are essential to patient survival.

METHODS

An unusual case of primary extranodal non-Hodgkin's lymphoma is described. The small lesion arose on the gingiva and alveolar mucosa. Upon excision, the tissue was submitted for microscopic examination, with the expectation that the lesion would be benign and excision would constitute the entirety of treatment. However, a diagnosis of primary extranodal large B-cell lymphoma was returned.

RESULTS

In addition to excision of the lesion, the patient underwent a complete work-up to rule out other systemic lesions. Chemotherapy and radiation therapy were performed. The patient has remained healthy, without recurrence of lymphoma for 3 years.

CONCLUSIONS

This case reinforces the importance of submitting excised tissues for microscopic examination even when the lesion appears totally benign. In addition, it highlights the need for complete excision of suspected lesions, with generous borders of normal tissue. With current periodontal plastic surgical techniques, most defects remaining after soft tissue biopsy can be managed with good esthetic results.

Characteristics of oral and paraoral malignant lymphoma: a population-based review of 361 cases

BACKGROUND

Lymphoma is the second most common neoplasm of the head and neck; almost 50% of all lymphomas occur in this region. Waldeyer's ring is the most common site of lymphomas involving the oral region. The purpose of this study was to review the characteristics of a large series of malignant lymphoma of the oral region.

METHODS

Three hundred sixty-one consecutive cases of malignant lymphoma of the oral region were identified in the Tumor Registry between 1969 and 1998.

RESULTS

The 361 cases (200 males and 161 females) of malignant lymphoma of the oral region accounted for 3.5% of all oral malignancies. The mean age was 62.5 years and the most prevalent site of involvement was the tonsil (32.7%), followed by the parotid gland (16.1%). Sixty-five percent of the lesions were diagnosed as large-cell (38%) or small-cell (27%) lymphoma. One quarter of the patients died of the disease in a mean of 2.78 years after diagnosis. Of a total 26 patients who died from other causes, 12 died because of other cancers, including 7 (27%) with leukemia and 5 (19%) with oral carcinoma. The prognosis is based, at least partially, on the histologic grading (low, intermediate, or high) and the anatomic stage of the disease. Localized low-grade lymphomas have a more favorable prognosis compared with those that are disseminated and/or have high-grade cellular changes.

CONCLUSION

Lymphoma is the second most common malignant oral disease. Thorough head and neck and oral examination is necessary to identify lesions that may represent lymphoma.

[Intraoral non-Hodgkin's lymphoma. Presentation of 4 clinical cases]

The non-Hodgkin lymphomas (NHL) represent an heterogeneous group of malignancies of lymphoreticular histogenesis. In most cases, they initially arise within lymph nodes but so-called extranodal lymphomas are also found. The NHL has low incidence in the oral cavity. It may involve bone and/or soft tissues as a primary or secondary manifestation. We present a review of the literature and four clinical cases of intraoral NHL. The first couple of cases are primary forms, the third one is associated to HIV infection and the last one is an oral presentation as a component of more widely disseminated disease.

Unusual gingival presentation of post-transplantation lymphoproliferative disorder: a case report and review of the literature

Post-transplantation lymphoproliferative disorder is a well-documented complication of solid organ or bone marrow transplantation. Histologically, it is characterized by an abnormal proliferation of lymphocytes, which can range from benign B-cell hyperplasia to malignant lymphoma. Non-Hodgkin's lymphoma (NHL) is associated with several risk factors, such as congenital or acquired immunodeficiency states, autoimmune disorders, and infectious agents (eg, Epstein-Barr virus). Primary sites of presentation in the head and neck are Waldeyer's ring, paranasal sinuses, salivary glands, the oral cavity, and the larynx. Clinical appearance of gingival NHL varies but is usually found to be an asymptomatic gingival enlargement or mass resembling a pyogenic granuloma. We present a patient with a gingival ulceration that was subsequently diagnosed as Epstein-Barr virus malignant lymphoma resulting from the immunosuppression needed to prevent graft-versus-host disease after bone marrow transplantation.

Primary non-Hodgkin's lymphoma of the mandible treated with radiotherapy, chemotherapy, and autologous peripheral blood stem cell transplantation

Extranodal presentation in non-Hodgkin's lymphoma (NHL) is uncommon, and the mandible is very rarely involved. Primary NHL of the mandible, for the most part, has intermediate or high malignancy and has a much greater incidence of local recurrence compared with other sites of involvement. A 48-year-old Japanese man with NHL of the mandible received radiotherapy, followed by high-dose chemotherapy supported with peripheral blood stem cell transplantation (PBSCT). High-dose cyclophosphamide, Adriamycin, and vincristine were used for pretransplant conditioning. He achieved complete remission and has survived in continuous complete remission for more than 72 months to date. Marrow-ablative chemotherapy facilitated by PBSCT is thought to be useful as part of the primary therapy for patients with NHL who have poorer prognoses.

Critical review of lymphomatoid papulosis of the oral cavity with case report

A 60-year-old woman was referred to the Department of Dental Medicine at Long Island Jewish Medical Center for evaluation of multiple lesions of the tongue. She reported a long history of recurrent papular cutaneous eruptions that waxed and waned. A biopsy specimen of one of the cutaneous lesions was diagnosed as lymphomatoid papulosis. Sporadic, recurrent oral ulcers that resolved spontaneously were noted 10 to 14 days before the initial visit. These ulcers had recurred for the past 17 years. The most recent oral lesion was an erythematous, irregular, solitary ulcerated area on the middle third dorsum of tongue. The area quickly enlarged, ultimately developing extensive surface necrosis. Shortly after, a similar lesion on the posterior dorsum of the tongue developed. Biopsy specimens of the former lesion showed numerous, large, atypical, pleomorphic, and hyperchromatic cells with abundant mitoses. The large, atypical cells were immunohistochemically proven to be T lymphocytes. A diagnosis of lymphomatoid papulosis was made. Two weeks later, the tongue lesions had spontaneously and totally resolved. The clinical, histomorphologic, and immunohistochemical features, as well as gene rearrangement studies of this rare entity, are presented.

Primary non-Hodgkin's lymphoma of the jaws: immunohistochemical and genetic review of 10 cases

PURPOSE

Non-Hodgkin's lymphoma (NHL) comprises a group of malignant lymphoproliferative diseases characterized by clonal expansion of lymphocytes at various levels of ontogenetic development. The aim of this study was to review the immunohistochemical and cytogenetic features of 10 cases of NLH of the jaws to determine their respective derivation.

PATIENTS AND METHODS

Histopathologic and immunohistochemical review of 10 cases of large-cell lymphomas of the jaws, together with Southern blot analysis of 2 of the cases, was performed and results compared with the findings in the literature.

RESULTS

In the 10 cases studied, the average age of onset of the NHL was 51 years, with a male-to-female ratio of 3:2. Tumefaction was the first clinical sign of disease. Eight of 10 cases were high-grade, large-cell NHLs, centroblastic type. Two cases were high-grade, large-cell NHL, immunoblastic type.

CONCLUSION

The immunohistochemical and Southern blot data remain the principal laboratory aids in the diagnosis and characterization of NHL, and they provide critical information for guiding clinicians to the appropriate treatment protocol for these malignancies.

Non-Hodgkin's lymphoma and periodontitis. A case report

BACKGROUND

We describe an unusual case of extra-nodal non-Hodgkin's lymphoma that developed in the maxillae associated with localized severe periodontitis in a 64-year-old Caucasian male. The lymphoma was diagnosed less than 2 years following routine periodontal surgery and 8 weeks after the extraction of hopeless teeth in the associated area.

METHODS

Two months following the extractions, the patient experienced pain and swelling in the maxillary right edentulous area mimicking an abscess, and reported for emergency care. An expansile lesion measuring 2.0 x 2.5 cm in diameter was noted on radiographic examination to extend into the right maxillary sinus. A definitive biopsy diagnosis of high-grade, small, non-cleaved, diffuse non-Hodgkin's lymphoma of the right posterior maxillae was established. The patient was subsequently treated by a combination of radiation, chemotherapy, and bone marrow transplantation.

RESULTS

The maxillary tissues healed uneventfully, and the patient has been closely observed for approximately 5 years without symptoms or recurrence of the lymphoma.

CONCLUSIONS

This case highlights the need for careful debridement of extraction sockets associated with severe periodontitis and argues for the routine submission of extracted teeth with adjacent soft tissue for microscopic analysis, to assist in the early diagnosis of potentially life-threatening malignancies.

Gastric and gingival localization of mucosa-associated lymphoid tissue (MALT) lymphoma. An immunohistochemical, virological and clinical case report

Non-Hodgkin's lymphomas (NHL) of the mucosa-associated lymphoid tissue (MALT) are characterized by their mucosal and glandular tissue localization. The case described here falls into the European-American classification of a low-grade B-cell lymphoma of the MALT type, with a gingival lesion 2 years after a gastric lesion. The pathogenetic mechanisms of NHL in oral MALT and the diagnosis and treatment are discussed.

HIV-associated oral pleomorphic B-cell malignant lymphoma

A 48-year-old HIV-seropositive homosexual patient presented with an ulcerative lesion in the left side of the soft palate, extensively involving local soft tissue structures. On histologic evaluation the lesions appeared to be a large-cell high-grade B-cell pleomorphic lymphoma with anaplastic and plasmacytoid features harboring Epstein-Barr virus genome in the tumor cells. Although known to be associated with HIV infection, this is a rare subtype of a malignant lymphoma arising in a patient positive for HIV. Its meaning is yet unknown in biologic and prognostic terms.

Malignant lymphoma of the mandible: report of a case

Extranodal malignant lymphoma is relatively rare. When it occurs in the oral region, it is sometimes misdiagnosed as inflammatory disease. This report details a case of malignant lymphoma that involved the fight mandibular region.

[Initial diagnosis of malignant lymphomas with manifestations in the mouth cavity and adjacent tissues]

The present study investigates a series of 89 lymphomas of the head and neck seen over a 40-year period. The lymphomas were classified according to the Kielclassifikation and staged using the Ann Arbor system. A total of 78 patients had a non-Hodgkin's lymphoma, 50 high grade and 28 low grade. Eleven patients had Hodgkin's disease. Fifty-seven cases were extra-nodal and 52 nodal; 20 were combined. The 5-year survival with Hodgkin's disease was 52.2%, with non-Hodgkin's disease, 66.5%. Low- and high-grade lymphomas had the same 5-year survival (P = NS). Stages I and II had a better prognosis than stages III and IV (P = 0.3).

Oral pseudolymphoma: a report of two cases

Although 2% to 10% of lymphomas present first in the oral cavity and lymphomas are the third most common oral malignancy, pseudolymphoma is a very infrequent problem within oral pathology. Two cases of oral pseudolymphoma are presented. Both were old persons with an infiltrative lesion on the oral mucosa that histologically showed a dense polymorphous infiltrate with some nuclear atypia that raised the problem of lymphoma versus pseudolymphoma. Both lesions disappeared with no relapse after 2-years' follow-up. Histologically, case 1 was mainly a lymphohistiocytic infiltrate whose histiocytic component showed nuclear features that mimicked Hodgkin's cells. In case 2, the infiltrate was mainly composed of histiocytes and eosinophils. The suspicion of malignancy here was a consequence of a high mitotic rate of histiocytes and of the large hyperchromatic nuclei of the intraepithelial lymphocytes. Similarities and differences with other pseudomalignant (lymphomatoid papulosis and atypical histiocytic granuloma) and inflammatory (traumatic ulcerative granuloma with stromal eosinophilia) disorders, as well as with some histiocytoses, are discussed. In the absence of a wider experience on this subject, an objective description of new cases seems appropriate.

Case of bilateral non-Hodgkin's lymphoma after dental extractions in a patient with the human immunodeficiency virus

It has long been known that immunocompromised patients have an increased risk of getting malignant neoplasms, with lymphomas predominating. This increase in lymphomas is especially notable in the population infected with the human immunodeficiency virus (HIV). Before the outbreak of the human immunodeficiency virus these neoplasms rarely occurred in the maxillofacial region; they are now being seen with a greater frequency. This report details a case of bilateral non-Hodgkin's lymphoma that was initially misdiagnosed as an odontogenic infection.

HIV-related tumors of the oral cavity

In HIV-infected patients with AIDS the most frequent malignancies are Kaposi's sarcoma and non-Hodgkin's lymphoma. In these patients, the natural history of these tumors is quite different from those of HIV-negative subjects. These tumors may present atypical clinical aspects, may be very aggressive, and the coexistence of immunosuppression and opportunistic infections may render their treatment more difficult. The aim of this article is to provide updated information on the epidemiology, pathogenesis, natural history, and management of tumors that develop in the oral cavity of patients with AIDS.