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Non-Hodgkin’s lymphoma of the anterior maxillary gingiva
Non-Hodgkin’s lymphoma of the anterior maxillary gingiva YOUN W. PARK, MD, FACS, Barberton, Ohio
A 52-year-old woman was referred from a dental office for swelling over the right side of the cheek. She first noted gradual onset of swelling and discomfort of the gum 2 months previously, at which time dental evaluation was done. Under the diagnosis of dental abscess, she was treated by means of tooth extraction and antibiotic therapy. However, the swelling persisted and extended laterally. The patient denied fever, weight loss, or night sweats. Examination revealed a nodular lesion on the right gingivolabial sulcus (Fig. 1) and a multinodular, rubbery mass involving the anterior and lateral aspects of the maxilla. A CT scan of the paranasal sinuses showed a superficial soft tissue density along the anterolateral wall of the right maxilla. Polypoid soft tissue densities within both maxillary antra were also shown. Biopsy specimens of the oral and right antral lesions revealed atypical infiltrates consistent with a diagnosis of non-Hodgkin’s lymphoma (NHL). The left antral biopsy showed only chronic inflammation. Chest x-ray films and CT scans of the chest, abdomen, and pelvis were negative. However, bone scan showed increased radioactivity involving the right maxilla. Bone marrow aspiration and a core biopsy specimen showed average cellular marrow with no diagnostic features. Immunoperoxidase studies of the tumor cells were not diagnostic. The patient was then treated with radiotherapy alone for stage IE NHL with intermediate-grade, diffuse, large, noncleaved cells (National Cancer Institute [NCI] working formulation). With treatment, the patient has entered a complete remission. DISCUSSION Although extranodular presentations of NHL in the head and neck area are common, occurrence in the oral cavity is relatively rare. A review of patients with extranodular head and neck lymphomas shows the most frequently involved site to be Waldeyer’s ring, representing 66% of head and neck lymphomas.1 The oral cavity was the primary site of presentation in 5% of cases, the nasal cavity/sinuses in 15%, and the salivary glands in 8%. An analysis of the reports with oral manifestations of NHL reveals that lesions of the palate (38 cases), gingiva (29 cases), mandible (16 cases), and maxilla From the Section of Otolaryngology, Northeastern Ohio Universities College of Medicine, and the Section of Otolaryngology, Barberton Citizens Hospital. Reprint requests: Youn W. Park, MD, 105 5th St., SE, Suite 4, Barberton, OH 44203. Otolaryngol Head Neck Surg 1998;119:146. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/11/74583 146
including the sinus (13 cases) represented 67% of the total 143 patients.2-5 Most of extranodal oral lymphomas are morphologically identified as B-cell proliferations, with the majority of these being composed of follicular center cells.4 The most common presenting symptom is an intraoral swelling or mass. However, pain, paresthesia or anesthesia, ulceration, and red or purple discoloration may also be noted. The evaluation of NHL includes a complete blood cell count, chemistry profile including lactate dehydrogenase and alkaline phosphatase, an x-ray film or CT scan of the chest, CT scan of the retroperitoneum and pelvis, and bone marrow biopsies. For those cases with stage I or II disease with limited involvement, radiotherapy alone can be used if it is low or intermediate grade histologically. Others are treated by chemotherapy or combined chemotherapy and radiotherapy. It also should be noted that NHL is the second most common AIDS-associated tumor of the oral cavity and is the most common oral malignancy found among intravenous drug abusers with AIDS. REFERENCES 1. Jacobs C, Weiss L, Hoppe RT. The management of extranodal head and neck lymphoma. Arch Otolaryngol Head Neck Surg 1986;112:654-8. 2. Eisenbud L, Sciubba J, Mir R, et al. Oral presentations in nonHodgkin’s lymphoma: a review of thirty-one cases. Oral Surg 1983;56:151-6. 3. Takahashi N, Isuda N, Tezuka F, et al. Primary extranodal nonHodgkin’s lymphoma of the oral region. J Oral Pathol Med 1989;18:84-91. 4. Howell RE, Handlers JP, Abrams AM, et al. Extranodal oral lymphoma. Part II. Relationships between clinical features and the Lukes-Collins classification of 34 cases. Oral Surg 1987;64:597-602. 5. Fukuda Y, Ishida T, Fujimoto M, et al. Malignant lymphoma of the oral cavity: clinicopathologic analysis of 20 cases. J Oral Pathol 1987;16:8-12.
Fig. 1. Multiple nodular lesion on the anterior and lateral aspects of the maxilla.
A 52-year-old woman was referred from a dental office for swelling over the right side of the cheek. She first noted gradual onset of swelling and discomfort of the gum 2 months previously, at which time dental evaluation was done. Under the diagnosis of dental abscess, she was treated by means of tooth extraction and antibiotic therapy. However, the swelling persisted and extended laterally. The patient denied fever, weight loss, or night sweats. Examination revealed a nodular lesion on the right gingivolabial sulcus (Fig. 1) and a multinodular, rubbery mass involving the anterior and lateral aspects of the maxilla. A CT scan of the paranasal sinuses showed a superficial soft tissue density along the anterolateral wall of the right maxilla. Polypoid soft tissue densities within both maxillary antra were also shown. Biopsy specimens of the oral and right antral lesions revealed atypical infiltrates consistent with a diagnosis of non-Hodgkin’s lymphoma (NHL). The left antral biopsy showed only chronic inflammation. Chest x-ray films and CT scans of the chest, abdomen, and pelvis were negative. However, bone scan showed increased radioactivity involving the right maxilla. Bone marrow aspiration and a core biopsy specimen showed average cellular marrow with no diagnostic features. Immunoperoxidase studies of the tumor cells were not diagnostic. The patient was then treated with radiotherapy alone for stage IE NHL with intermediate-grade, diffuse, large, noncleaved cells (National Cancer Institute [NCI] working formulation). With treatment, the patient has entered a complete remission. DISCUSSION Although extranodular presentations of NHL in the head and neck area are common, occurrence in the oral cavity is relatively rare. A review of patients with extranodular head and neck lymphomas shows the most frequently involved site to be Waldeyer’s ring, representing 66% of head and neck lymphomas.1 The oral cavity was the primary site of presentation in 5% of cases, the nasal cavity/sinuses in 15%, and the salivary glands in 8%. An analysis of the reports with oral manifestations of NHL reveals that lesions of the palate (38 cases), gingiva (29 cases), mandible (16 cases), and maxilla From the Section of Otolaryngology, Northeastern Ohio Universities College of Medicine, and the Section of Otolaryngology, Barberton Citizens Hospital. Reprint requests: Youn W. Park, MD, 105 5th St., SE, Suite 4, Barberton, OH 44203. Otolaryngol Head Neck Surg 1998;119:146. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/11/74583 146
including the sinus (13 cases) represented 67% of the total 143 patients.2-5 Most of extranodal oral lymphomas are morphologically identified as B-cell proliferations, with the majority of these being composed of follicular center cells.4 The most common presenting symptom is an intraoral swelling or mass. However, pain, paresthesia or anesthesia, ulceration, and red or purple discoloration may also be noted. The evaluation of NHL includes a complete blood cell count, chemistry profile including lactate dehydrogenase and alkaline phosphatase, an x-ray film or CT scan of the chest, CT scan of the retroperitoneum and pelvis, and bone marrow biopsies. For those cases with stage I or II disease with limited involvement, radiotherapy alone can be used if it is low or intermediate grade histologically. Others are treated by chemotherapy or combined chemotherapy and radiotherapy. It also should be noted that NHL is the second most common AIDS-associated tumor of the oral cavity and is the most common oral malignancy found among intravenous drug abusers with AIDS. REFERENCES 1. Jacobs C, Weiss L, Hoppe RT. The management of extranodal head and neck lymphoma. Arch Otolaryngol Head Neck Surg 1986;112:654-8. 2. Eisenbud L, Sciubba J, Mir R, et al. Oral presentations in nonHodgkin’s lymphoma: a review of thirty-one cases. Oral Surg 1983;56:151-6. 3. Takahashi N, Isuda N, Tezuka F, et al. Primary extranodal nonHodgkin’s lymphoma of the oral region. J Oral Pathol Med 1989;18:84-91. 4. Howell RE, Handlers JP, Abrams AM, et al. Extranodal oral lymphoma. Part II. Relationships between clinical features and the Lukes-Collins classification of 34 cases. Oral Surg 1987;64:597-602. 5. Fukuda Y, Ishida T, Fujimoto M, et al. Malignant lymphoma of the oral cavity: clinicopathologic analysis of 20 cases. J Oral Pathol 1987;16:8-12.
Fig. 1. Multiple nodular lesion on the anterior and lateral aspects of the maxilla.