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Primary lymphosarcoma of the maxillary alveolar process
Oral pathology
GENERAL
SECTION
Primary lymphosarcoma of the maxillary alveolar process J. F. Gould, M.B., C&B., B.D.S., F.R.C.S., F.F.D., J. H. P, Main, B.D.S., Ph.D., F.D.S., M.C. Path., Edinburgh, ScotlaqLd DEPARTMENT
OF DESTAL
SURGERY,
VNIVERSITY
and
OF EDINBURGH
L
ymphosarcoma is a rare condition of high malignancy. It may begin in the lymphatic tissue of one anatomic site, or it may be more diffuse ; in either case, it may spread to adjacent lymph nodes. It can also spread via the bloodstream and form distant metastases. Lymphosarcomas in the nasopharynx are not uncommon, but those presenting as solitary lesions in the jaws are rare. For this reason, the following case is considered to be of some interest. CASE REPORT The patient, a 55-year-old man, had a history of chronic bronchitis but was otherwise well. His remaining teeth had been extracted without difficulty in April, 1967, under general anesthesia. While healing took place elsewhere, the patient later noticed that a small lump had appeared over the socket of the maxillary right canine. There was no pain, and the patient sought no advice for 4 months, when he again visited his dental surgeon. The now enlarged swelling was lanced, with the liberation of pus. No improvement followed, and the patient was referred to t,he Department of Oral Surgery, Royal Infirmary of Edinburgh. Examination revealed a circumscribed swelling, about, 2 cm. in diameter, on the labial aspect of the upper right canine area of the alveolar ridge. The appearance strongly suggested an inflammatory lesion, and roentgenograms disclosed an underlying socket radiolucency with some surrounding bone loss. In the center of the radioluccncy lay a tiny radiopaque fragment, considered to 1~~ a sequestrum. The patient was afebrile. Routine hematologic findings were normal, as were the plasma disclosed no enlargement of the protein and serum electrolyte values. Clinical examination lymph nodes or of the spleen. An excision biopsy was performed, leading to a diagnosis of lymphosarcoma. Additional roentgenograms failed to suggest any evidence of secondary disease. When the biopsy wounds had healed, the patient was treated by megavoltage radiotherapy. Pathology
report
Gross. The specimen was a.n irregular with epithelium on one surface.
106
mass of soft
tissue, measuring
2.5 by 2 by 1 em.,
Volume Number
28 1
Primary
Fig. 1. Photomicrograph magnification, x160.)
lymphosarcoma
of representative
of maxillary
area of lymphoid
alveola’r
part
process
of specimen.
107
(Original
M~C~OSCO~~C. Sections stained with hematoxylin and eosin showed the specimen to consist of a large mass of chronic inflammatory cells with a layer of collagenous fibrous tissue corium and unkeratinized stratified squamous epithelium on the superficial aspect. The inflammatory cells were all of the lymphoid series, mostly of a primitive type with many mitotie figures (Fig. 1). The lymphoid area had no peripheral sinus, and there were no germinal follicles. The appearance was that of a lymphosarcoma.
DISCUSSION
Although a secondary malignant deposit may precede the clinical appearance of a primary lesion, the absence of clinical evidence of any other lesions and the failure of any deposits to appear in the areas outside the radiotherapeutic field suggested that in this patient the presenting growth was, in fact, the primary 1esion. In this case the oral sarcoma presented with the classic disguise, namely, a pyogenic inflammatory lesion. The history of the presence of pus and the radiographic suggestion of a sequestrum made this all the more credible. Kruger,” reviewing sixty-four cases of oral sarcoma treated in Hamburg, found that thirty-seven had been misdiagnosed as inflammatory lesions. The largest group, fifteen in all, were lymphomas. While lymphosarcoma may appear as a single lesion in the mouth, it may also occur there as a diffuse field change. Orsos3 reported a case involving both the mandibular and maxillary alveolar ridges. He assumed that it must have arisen from the lymphatic tissue normally present in the subepithelial tissue of this area. Steg and associates* described forty-seven cases of primary oral lymphoma from material at the Mayo Clinic, of which ten were lymphosarcomas. Cook,l reviewing the literature, was able to find thirty-four other cases of primary lymphoma of the oral cavity, of which fourteen were lymphosarcomas. The condition may run an acute fatal course or remit for long periods. Tillmans reviewed seven cases of lymphosarcoma with oral manifestations and
108
O.S., O.M. 6 0.1’. .Iuly. 1969
Gould and Naitb
found that the survival time varied from 8 months to 13 years. A ~wognosis of any value would therefore appear to be impossible. We are grateful to Dr. Stewart Fletcher, and to Mr. A. Hunter, M&E., for assistance
who
with
gave an opinion on the pathologic: the photomicrograph.
diagnosis,
REFERENCES
1. Cook, H. P.: Oral Lymphomas, ORAL SURG., ORAL MED. & ORAL PATII. 14: 690-704, 1961. 2. Kruger, E.: Clinical and Histologic Diagnosis of Oral Sarcomas, J. D. Res. 42: 354-372, 1961. 3. Orsos, 8.: Primary Lymphosarconm of the Gingivae, ORAL STRG., ORAL MED. R- ORAL PATH. 11: 426-430. 1958. Lymphomas of the Jaws, ORAL 4. Steg, R. F.; Dahlin, D. C., and Gores, R. J.: Malignant SURG.,ORAL MED.& ORAL PATH.~~: 128-141,1959. 5. Tillman, H. M.: Malignant Lymphomas Involving the Oral Cavity and Surrounding Structures, ORAL SURG., ORAL MED. & ORAL PATE. 19: 60-72, 7965.
GENERAL
SECTION
Primary lymphosarcoma of the maxillary alveolar process J. F. Gould, M.B., C&B., B.D.S., F.R.C.S., F.F.D., J. H. P, Main, B.D.S., Ph.D., F.D.S., M.C. Path., Edinburgh, ScotlaqLd DEPARTMENT
OF DESTAL
SURGERY,
VNIVERSITY
and
OF EDINBURGH
L
ymphosarcoma is a rare condition of high malignancy. It may begin in the lymphatic tissue of one anatomic site, or it may be more diffuse ; in either case, it may spread to adjacent lymph nodes. It can also spread via the bloodstream and form distant metastases. Lymphosarcomas in the nasopharynx are not uncommon, but those presenting as solitary lesions in the jaws are rare. For this reason, the following case is considered to be of some interest. CASE REPORT The patient, a 55-year-old man, had a history of chronic bronchitis but was otherwise well. His remaining teeth had been extracted without difficulty in April, 1967, under general anesthesia. While healing took place elsewhere, the patient later noticed that a small lump had appeared over the socket of the maxillary right canine. There was no pain, and the patient sought no advice for 4 months, when he again visited his dental surgeon. The now enlarged swelling was lanced, with the liberation of pus. No improvement followed, and the patient was referred to t,he Department of Oral Surgery, Royal Infirmary of Edinburgh. Examination revealed a circumscribed swelling, about, 2 cm. in diameter, on the labial aspect of the upper right canine area of the alveolar ridge. The appearance strongly suggested an inflammatory lesion, and roentgenograms disclosed an underlying socket radiolucency with some surrounding bone loss. In the center of the radioluccncy lay a tiny radiopaque fragment, considered to 1~~ a sequestrum. The patient was afebrile. Routine hematologic findings were normal, as were the plasma disclosed no enlargement of the protein and serum electrolyte values. Clinical examination lymph nodes or of the spleen. An excision biopsy was performed, leading to a diagnosis of lymphosarcoma. Additional roentgenograms failed to suggest any evidence of secondary disease. When the biopsy wounds had healed, the patient was treated by megavoltage radiotherapy. Pathology
report
Gross. The specimen was a.n irregular with epithelium on one surface.
106
mass of soft
tissue, measuring
2.5 by 2 by 1 em.,
Volume Number
28 1
Primary
Fig. 1. Photomicrograph magnification, x160.)
lymphosarcoma
of representative
of maxillary
area of lymphoid
alveola’r
part
process
of specimen.
107
(Original
M~C~OSCO~~C. Sections stained with hematoxylin and eosin showed the specimen to consist of a large mass of chronic inflammatory cells with a layer of collagenous fibrous tissue corium and unkeratinized stratified squamous epithelium on the superficial aspect. The inflammatory cells were all of the lymphoid series, mostly of a primitive type with many mitotie figures (Fig. 1). The lymphoid area had no peripheral sinus, and there were no germinal follicles. The appearance was that of a lymphosarcoma.
DISCUSSION
Although a secondary malignant deposit may precede the clinical appearance of a primary lesion, the absence of clinical evidence of any other lesions and the failure of any deposits to appear in the areas outside the radiotherapeutic field suggested that in this patient the presenting growth was, in fact, the primary 1esion. In this case the oral sarcoma presented with the classic disguise, namely, a pyogenic inflammatory lesion. The history of the presence of pus and the radiographic suggestion of a sequestrum made this all the more credible. Kruger,” reviewing sixty-four cases of oral sarcoma treated in Hamburg, found that thirty-seven had been misdiagnosed as inflammatory lesions. The largest group, fifteen in all, were lymphomas. While lymphosarcoma may appear as a single lesion in the mouth, it may also occur there as a diffuse field change. Orsos3 reported a case involving both the mandibular and maxillary alveolar ridges. He assumed that it must have arisen from the lymphatic tissue normally present in the subepithelial tissue of this area. Steg and associates* described forty-seven cases of primary oral lymphoma from material at the Mayo Clinic, of which ten were lymphosarcomas. Cook,l reviewing the literature, was able to find thirty-four other cases of primary lymphoma of the oral cavity, of which fourteen were lymphosarcomas. The condition may run an acute fatal course or remit for long periods. Tillmans reviewed seven cases of lymphosarcoma with oral manifestations and
108
O.S., O.M. 6 0.1’. .Iuly. 1969
Gould and Naitb
found that the survival time varied from 8 months to 13 years. A ~wognosis of any value would therefore appear to be impossible. We are grateful to Dr. Stewart Fletcher, and to Mr. A. Hunter, M&E., for assistance
who
with
gave an opinion on the pathologic: the photomicrograph.
diagnosis,
REFERENCES
1. Cook, H. P.: Oral Lymphomas, ORAL SURG., ORAL MED. & ORAL PATII. 14: 690-704, 1961. 2. Kruger, E.: Clinical and Histologic Diagnosis of Oral Sarcomas, J. D. Res. 42: 354-372, 1961. 3. Orsos, 8.: Primary Lymphosarconm of the Gingivae, ORAL STRG., ORAL MED. R- ORAL PATH. 11: 426-430. 1958. Lymphomas of the Jaws, ORAL 4. Steg, R. F.; Dahlin, D. C., and Gores, R. J.: Malignant SURG.,ORAL MED.& ORAL PATH.~~: 128-141,1959. 5. Tillman, H. M.: Malignant Lymphomas Involving the Oral Cavity and Surrounding Structures, ORAL SURG., ORAL MED. & ORAL PATE. 19: 60-72, 7965.