Nasal T/NK cell lymphoma: report of 3 cases involving the palate

Extranodal NK/T Cell Lymphoma, Nasal Type with Palatal Involvement: A Rare Case Report and Literature Review

T-cell lymphomas are infrequently encountered in the head and neck area, with the most common subtype being Extranodal NK/T cell lymphoma, nasal type (ENKTL-NT). ENKTL-NT shows a predilection for midline facial structures presenting with ulcerative destructive lesions, whereas palatal involvement is one of the most prominent signs from the oral cavity. Herein, we describe a case of a 76-year-old Greek man with nasal obstruction and an extensive painful necrotic ulcer with ragged borders on the left distal portion of the soft palate and palatine tonsil of 4-months duration. After an initial non-diagnostic biopsy from the nasopharynx, a second incisional biopsy from the palatal lesions was performed. Histopathology was suggestive of an angiocentric lymphoproliferative neoplasm and immunohistochemical examination and in situ hybridization for EBV RNA led to a final diagnosis of ENKTL-NT. The patient was placed under combined chemotherapy and radiotherapy and no recurrence has been noted. Additionally, a retrospective review of the cases in the English literature with an established diagnosis of ENTKL-NT between 2000 and 2019, based on the latest WHO classification of Head and Neck tumors, is performed.

Recurrent Extranodal NK/T-Cell Lymphoma Presenting as a Perforating Palatal Ulcer and Oro-Nasal Fistula

Nasal-type extranodal natural killer/T-cell lymphoma (ENKTL) is a rare disease presenting with non-specific symptoms, typically originating in the nasal cavity, palate, or midfacial region. Oral cavity is an extremely rare site for this type of lymphoma. In this report, we present a case of palatal perforation and oro-nasal fistula as a manifestation of recurrent ENKTL. Complicated disease entity should be considered when surgeons deal with palatal perforation and oro-nasal fistula.

Extranodal nasal-type NK/T-cell lymphoma of the palate and paranasal sinuses

Background:

Extranodal nasal-type natural killer (NK)/T-cell lymphoma represents a rare entity, typically originating in the nasal cavity, palate or midfacial region. Signs and symptoms include non-specific rhinitis and/or sinusitis, nasal obstruction, epistaxis, facial swelling and development of deep necrotic ulceration in the midline of the palate, causing an oronasal defect. Differential diagnosis includes fungal infections, Wegener’s granulomatosis, tertiary syphilis, other non-Hodgkin’s lymphomas and malignant epithelial midline tumors.

Case Report:

We present a case of a 40-year-old man complaining of headache, facial pain, nasal congestion and fever. Examination revealed a large deep necrotic ulcer in the middle of the palate, presenting as an oronasal defect. Endoscopic rhinoscopy revealed crusts in the nasal cavities, moderate perforation of the nasal septum cartilage and contraction of the middle and inferior conchae. Computer tomography showed occupation of the maxillary sinuses, ethmoidal cells and sphenoidal sinus by a hyperdense soft tissue mass. Laboratory investigation revealed increased erythrocyte sedimentation rate. A wide excision of the lesion was performed. Histopathological and immunohistochemical evaluation established the diagnosis of extranodal nasal-type NK/T-cell lymphoma. The patient was treated with CHOP chemotherapy, involved-field radiotherapy and autologous bone marrow transplantation. A removable partial denture with obturator was fabricated and inserted to relieve problems caused by the oronasal defect.

Conclusions:

Extranodal nasal-type NK/T-cell lymphoma is a very aggressive, rapidly progressing malignant neoplasm with a poor prognosis, which can be improved by early diagnosis and combined treatment.

Extranodal natural killer/T cell lymphoma, nasal type presenting as a palatal perforation and naso-oral fistula

Extranodal natural killer/T cell lymphoma (ENKL), nasal type, a rare disease presenting with vague non-specific symptoms, can impose great diagnostic difficulties and may masquerade several infectious, rheumatological or neoplastic conditions. Here, the authors report a case of ENKL presenting as a palatal perforation, naso-oral fistula and fever in a 21-year-old man, which was initially misdiagnosed as bacterial osteomyelitis, invasive fungal infection and Wegener's granulomatosis. The case report underlines the possibility of ENKL occurring at a young age, its rapidly progressive and locally destructive nature, associated diagnostic challenges and the importance of immunophenotyping in establishing the diagnosis.

Necrotizing sialometaplasia of the parotid gland associated with angiocentric T-cell lymphoma: a case report and review of the literature

A very rare case of necrotizing sialometaplasia of the parotid gland associated with angiocentric T-cell lymphoma was described. A 66-year-old male had left neck and pharyngeal masses and biopsy specimen showed a monotonous proliferation of atypical lymphoid cells with massive necrosis in the parotid gland. Angiocentric pattern or vascular invasion by the lymphoid cells was observed and the involved parotid gland exhibited squamous metaplasia of the ducts and acini; necrotizing sialometaplasia. Immunohistochemical analysis revealed a cytotoxic T-cell phenotype of the lymphoid cells (CD3+, CD4-, CD5+, CD8+, CD56-, Granzyme B+, TIA-1+, Perforin-) but in situ hybridization showed no relation to Epstein-Barr virus. Although necrotizing sialometaplasia is relatively rare in the parotid gland, angiocentric T-cell lymphoma should be considered for a causative condition of necrotizing sialometaplasia.

Extranodal sinonasal natural killer/T-cell lymphoma presenting as chronic sinusitis and necrotic wound infection

A case of a 43-year-old white woman who was admitted to our clinic with the complaints of chronic sinusitis and wound infection after Caldwell-Luc operation performed for chronic sinusitis is presented. Necrotic lesion then extended to the nasal cavity and skin of the face. The biopsy revealed natural killer/T-cell lymphoma. The patient was treated with chemotherapy; however, the patient died owing to sepsis. Sinonasal lymphoma is a rare disease. It is managed with chemotherapy and radiotherapy. The prognosis is poor. A high index of clinical suspicion is required for early diagnosis.

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.

Necrotizing sialometaplasia of the palate associated with angiocentric T-cell lymphoma

In this article we present 2 cases of necrotizing sialometaplasia (NS) associated with angiocentric lymphoma of the midline. Immunohistochemical analysis confirmed a T-cell origin, and in situ hybridization in one case revealed its relationship to Epstein-Barr virus. These findings suggest that vascular occlusion by the neoplastic cells produces ischemia, which leads to local infarction contributing to the salivary gland lesion. To our knowledge, the association between angiocentric lymphoma and NS has been previously reported in only one instance, and we suggest that this particular type of lymphoma should be added to the list of related conditions for NS.

Ewing sarcoma family of tumors in unusual sites: confirmation by rt-PCR

Ewing sarcoma family tumors originating in the palate or adrenal gland are extremely rare and may cause difficulty in diagnosis. More common tumors primary to these sites need to be excluded before one arrives at the correct diagnosis. We have recently diagnosed 2 such cases. The 1st case was that of a 24-year-old woman who presented with a swelling in the right side of the hard palate. The 2nd case was diagnosed in a 28-year-old woman who presented with a mass in the right adrenal gland. In both cases, the diagnosis of Ewing sarcoma family of tumors was confirmed by immunohistochemical studies and reverse transcriptase-polymerase chain reaction (RT-PCR). The hard palate case is the 1st and the adrenal gland the 3rd case of Ewing sarcoma family of tumors arising in these sites, in which the diagnosis was confirmed by RT-PCR and/or cytogenetics. Accurate diagnosis of Ewing sarcoma family of tumors is crucial for the management of patients, and when found in such rare locations, diagnosis should be supported by immunohistochemical and/or molecular genetic studies.

Extranodal NK/T-cell lymphoma, nasal type

Extranodal NK/T-cell lymphoma, nasal type (ENKTCL), previously known as lethal midline granuloma is a distinct clinico-pathological entity associated with Epstein-Barr virus that typically causes destruction of the midface, palatal and orbital walls. In addition, ENKTCL can involve the skin, soft tissue, testes, gastrointestinal and upper respiratory tract. ENKTCL neoplastic cells express some T-cell associated antigens, most commonly CD2 and cytoplasmic CD3epsilon and, in favour of an NK-cell origin, CD56. Early stage disease may respond to radiotherapy alone, however late stage disease does not respond well to any available therapies. Overall, patients with ENKTCL have a cumulative probability of survival at 5 years ranging from 37.9% to 45.3%.

An undiagnosed case of malignancy: case report

The following report describes the treatment carried out by a UK high street dental technician on an elderly patient with a large malignancy invading the oral cavity through the hard palate from the nose. The lesion remained undiagnosed during treatment for three months. The consequences of this error, and the future role of the clinical dental technician are discussed.

Sinonasal NK/T-cell lymphoma with upper gastrointestinal bleeding: a case report

Natural killer (NK)/T-cell lymphoma is the most common malignant lymphoma among sinonasal lymphomas. Diagnosis is difficult and prognosis is poor. Herein, we report the case of a 22-year-old male patient with sinonasal NK/T-cell lymphoma who first presented with nasal obstruction and left facial swelling. There was a mushroom-like mass over the hard palate, diffuse mucosal swelling in the left nasal cavity, and left orbital cellulitis. The patient underwent a Caldwell-Luc operation, functional endoscopic sinus surgery, and wide excision of the palate tumor. Pathologic examination of the maxillary sinus, nasal cavity, and palate tumor showed an NK/T-cell lymphoma. Two days after the operation, the patient suddenly had bloody stool and suffered hematemesis. A series of examinations revealed a small intestinal hemorrhage. Emergent exploratory laparotomy showed an ulcerative tumor mass with bleeding over the jejunum. Pathologic examination of the mass showed that it was the same as the sinonasal mass, an NK/T-cell lymphoma. We reviewed previous studies on nasal NK/T-cell lymphoma and found no report discussing patients with NK/T-cell lymphoma of both nasal and non-nasal origins. From this case, we learned that in patients with sinonasal NK/T-cell lymphoma, other sites may be involved.

Mantle cell lymphoma of the hard palate: a case report and review of the differential diagnosis based on the histomorphology and immunophenotyping pattern

To our knowledge, mantle cell lymphoma (MCL) has never been reported in the hard palate, but it is commonly observed in the nasopharynx and Waldeyer's tonsillar ring. MCL is characterized by a diffuse infiltrate of small lymphocytes with the expression of CD5, CD20, and cyclin D1 (Bcl-1), but not CD10. MCL presenting in the hard palate must be accurately distinguished from other forms of so-called small B-cell lymphomas-such as small lymphocytic lymphoma, follicular lymphoma, and extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue-because MCL possesses a worse prognosis. Awareness of MCL of the hard palate will prompt pathologists to perform adequate immunohistochemical analysis to aid in confirming the diagnosis.

Angiocentric T-cell lymphoma presenting as midface destructive lesion: case report and literature review

A case of angiocentric T-cell lymphoma presenting as a midface destructive lesion is reported. Angiocentric T-cell lymphoma typically manifests as an aggressive, progressively destructive, and necrotizing disorder, often with a fatal outcome. This case was characterized microscopically by the presence of an atypical lymphoid population that expressed a CD45+, CD3+ cytoplasmic, CD5+, and CD56- T-cell phenotype within a background of a polymorphous inflammatory infiltrate. Because of the rarity of the disorder, the differential diagnosis is discussed. Recent advances in clinical immunodiagnostics, the variations in therapeutic modalities, and the prognosis of the disease as reported in the recent literature are reviewed.