Egyptian Journal of Oral & Maxillofacial Surgery:
B-cell lymphoma mimicking pericoronitis: a report of rare case
Malik, Altaf H.a; Shah, Ajaz A.a; Latoo, Sohailb
Departments of aOral & Maxillofacial Surgery
bOral Pathology, Government Dental College, Srinagar, Kashmir, India
Correspondence to Altaf H. Malik, Department of Oral & Maxillofacial Surgery, Government Dental College, Srinagar 190010, Kashmir, India Tel: +91 9419031831; fax: +01942455022; e-mail: firstname.lastname@example.org
Received September 2, 2012
Accepted October 19, 2012
Malignant lymphoma may occur in the oral cavity and oropharynx, but is most commonly located in Waldeyer's ring, particularly in the palatine and lingual tonsil. Non-Hodgkin's lymphoma mimicking feature of pericoronitis is a rare entity. Clinical features are nonspecific ulcerative lesions that do not heal. In the literature, the majority of cases are non-Hodgkin's lymphoma, diffuse large B cell type; however T-cell phenotype also may occur. We describe a 45-year-old woman who presented with an operculits in the left lower 3rd molar region, unresponsive to local antiseptic mouthrinses, antibiotics and other drugs and procedures for pericoronitis. After tissue biopsy, histopathological and immunohistochemical analyses confirmed a diagnosis of non-Hodgkin's lymphoma, B cell type.
Lymphoma is a general term for a complex group of malignancies of the lymphoreticular system (Virchow 1862–1863) 1. Non-Hodgkin’s lymphoma (NHL) usually involves lymph nodes but may also involve extranodal sites and can occur in the stomach, skin, lung, salivary glands and rarely in the mouth 2. Oral lesions of NHL may develop in the soft tissues or centrally within the jaws. Oral lesions appear as nontender swellings commonly affecting the vestibule, gingival, or posterior hard palate and develop slowly, mimicking a dental abscess of endodontic or periodontal origin. They may initially arise within the lymphatic tissues and may progress to an extranodular mass or to a nontender mass or masses in a lymph node region that may spread later to other lymph node groups and involve the bone marrow. Extranodal involvement is frequently seen in patients with NHL. The head and neck area has the highest regional incidence of extranodal lymphoma 3,4.
The aim of this publication is to highlight the importance of the full examination of oral lesions, as oral lesion could be the only manifestation of some underlying serious systemic disorder.
A 45-year-old woman presented to the Department of Oral & Maxillofacial Surgery Government Dental College Srinagar, India, with a history of a painful mass in the left posterior region of the lower jaw for 2 months (Fig. 1). She had consulted a dentist, who had made a diagnosis of pericorinitis and prescribed a treatment accordingly. There was no history of weight loss, malaise, fevers, night sweats, or history of trauma or drug intake or any other abnormality. There was no history of smoking or snuff use. The examination indicated a 1.5/2 cm mass of soft tissue arising from the distal aspect of the left lower third molar with no ulceration, discolouration, extraoral swelling or lymphadenopathy. She was provisionally diagnosed with squamous cell carcinoma. All her baseline investigations and chest and skull radiographs were normal, with no bone changes. During the initial appointment, the patient refused a biopsy, but subsequently returned with a huge swelling of 6/3 cm on the left side after 2 more months (Fig. 2). An incisional biopsy was planned, which was suggestive of NHL. Immunohistochemistry indicated diffuse large B-cell NHL with a positive Pan-B-cell marker CD20 (Figs 3 and 4). The patient was then referred to the Oncology Department of SMHS Hospital, and she was treated with radiotherapy, followed by a CHOP regimen. There was complete resolution of the symptoms and signs of the disease at the 3-month follow-up.
The head and neck is the second most common region for extranodal lymphomas after the gastrointestinal tract for NHL 5,6. Waldeyer’s ring, which is an area encompassed by the nasopharynx, tonsil and the base of the tongue, is the most common area of malignant lymphoma involvement. The tonsil is the most frequent site, followed by the nasopharynx 7,8. NHL arising within the oral cavity accounts for less than 5% of all oral malignancies, and ∼85% of the lesions involve the tonsils and the palate. Gingiva forms one of the rarest extranodal sites (0.44%). Diffuse large B-cell lymphoma is composed of large transformed B cells with immunoblastic features, which may develop in both children and adults. The majority of reported cases have the B-cell phenotype. The T-cell phenotype is much more likely for sinonasal than oropharyngeal lymphoma 9–12. Usually, lymphoma presents in the oral cavity as the first identifiable evidence of the disease 13,14. Sometimes, these may also present as squamous cell carcinoma and needs to be considered in the differential diagnosis 15. There is considerable evidence that lymphomas at specific sites show a local inflammatory process in the beginning, followed by an increased rate of cell division of lymphocytes, thereby increasing the risk of development of a malignant clone 2.
The prevalence of NHL is increasing among those who are immunocompromised, have received organ transplants and those with autoimmune disorders such as Sjögren’s syndrome or rheumatoid arthritis. An increased incidence of NHL has also been found in patients with AIDS13, and oral lesions of NHL are the first manifestation of AIDS 2.
In the present case, a gingival lesion was the only manifestation. Blood chemistry and radiographs were normal. The oral lesion revealed NHL and proper institution of the treatment helped in the regression of the disease.
Although NHL involving the oral region is uncommon, it should be considered in the differential diagnosis of malignant lesions in this area, because treatment and prognoses for these conditions are quite different. A proper clinical evaluation, in addition to a histopathologic as well as immunohistochemical evaluation of the biopsy specimen, is necessary for the correct diagnosis and will aid proper management.
Conflicts of interest
There are no conflicts of interest.
1. Cotran RS, Kumar V, Collins T Pathologic basis of Disease. 20047th ed. Philadelphia, Pennsylvania, USA WB Saunders Company:667–686
2. Wolvius EB, van der Valk P, van der Wal JE, van Diest PJ, Huijgens PC, van der Waal I, et al. Primary extranodal non-Hodgkin lymphoma of the oral cavity. An analysis of 34 cases. Eur J Cancer B Oral Oncol. 1994;30B:121–125
3. Rosai J, Lauren VA Surgical pathology. 2004;29th ed. India Elseveir:1879–1893
4. Henry K, Symmers WC Systemic pathology. 1987;Vol. 73rd ed. Edinburgh Churchill Livingstone:611–612
5. Van der Waal RI, Pas HH, Anhalt GJ, Schulten EA, Jonkman MF. Paraneoplastic pemphigus as the presenting symptom of a lymphoma of the tongue. Oral Oncol. 1998;34:567–570
6. Zapater E, Bagán JV, Carbonell F, Basterra J. Malignant lymphoma of the head and neck. Oral Dis. 2010;16:119–128
7. Mohammadianpanah M, Ahmadloo N, Mozaffari MA, Mosleh-Shirazi MA, Omidvari S, Mosalaei A. Primary localized stages I and II non-Hodgkin’s lymphoma of the nasopharynx: a retrospective 17 year single institutional experience. Ann Hematol. 2009;88:441–447
8. Thorp MA, Langman G, Sellars SL. Angiocentric T-cell lymphoma: an extensive lesion involving the posterior tongue, hypopharynx and supraglottis. J Laryngol Otol. 1999;113:263–265
9. Friedman AD, Cook JR, Scharpf J. Precursor T-cell acute lymphoblastic lymphoma presenting as a tongue mass. J Otolaryngol Head Neck Surg. 2009;38:E16–E18
10. Eros N, Marschalko M, Lorincz A, Harsing J, Csomor J, Szepesi A, et al. CD30-positive anaplastic large Tcell lymphoma of the tongue. J Eur Acad Dermatol Venereol. 2009;23:231–232
11. Guastafierro S, Falcone U, Celentano M, Cappabianca S, Giudice A, Colella G. Primary mantle-cell non-Hodgkin’s lymphoma of the tongue. Int J Hematol. 2008;88:206–208
12. Feinberg SM, Ou SH, Gu M, Shibuya TY. Burkitt’s lymphoma of the base of the tongue: a case report and review of the literature. Ear Nose Throat J. 2007;86:356–360
13. Beral V, Peterman T, Berkelman R, Jaffe H. AIDS-associated non-Hodgkin lymphoma. Lancet. 1991;337:805–809
14. Werder P, Altermatt HJ, Zbären P, Mueller-Garamvölgyi E, Bornstein MM. Palatal swelling as the first and only manifestation of extranodal follicular non-Hodgkin lymphoma: a case presentation. Quintessence Int. 2010;41:93–97
15. Chan AC, Chan JC Haematolymphoid tumours. In World Health Organization Classification of Tumours. Pathology and Genetics of Head and Neck Tumors. 2005 Lyon IARC Press:199–220
© 2013 Egyptian Associations of Oral and Maxillofacial Surgery