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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 36-39

Oral presentation of non-HIV-related non-Hodgkin's lymphoma


ADC, R & R, New Delhi, India

Date of Submission20-Dec-2019
Date of Acceptance27-Dec-2019
Date of Web Publication31-Jan-2020

Correspondence Address:
B K N Babu
ADC, R & R, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODD.JODD_8_19

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  Abstract 


Here, we report a case of non-Hodgkin's lymphoma (NHL) in a 51-year-old male patient with manifestations in the oral cavity, presenting as multiple ulcers and swelling. The other findings include the small lymphocytic lymphoma with extranodal involvement, distortion of facial symmetry, and cervical lymphadenopathy. A comprehensive evaluation by the dental clinician is crucial to identify the disease in its initial stage, for better prognosis and management. Early and prompt diagnosis of NHL by fine-needle aspiration cytology supplemented by immunocytochemistry may aid in early prevention of the disease with further investigations of biopsy and immunohistochemistry.

Keywords: Cervicofacial, dorsum, extranodal, small lymphocytic lymphoma, tongue


How to cite this article:
N Babu B K, Bhat S, Saxena V. Oral presentation of non-HIV-related non-Hodgkin's lymphoma. J Dent Def Sect. 2020;14:36-9

How to cite this URL:
N Babu B K, Bhat S, Saxena V. Oral presentation of non-HIV-related non-Hodgkin's lymphoma. J Dent Def Sect. [serial online] 2020 [cited 2020 Jul 2];14:36-9. Available from: http://www.journaldds.org/text.asp?2020/14/1/36/276411




  Introduction Top


Hodgkin's lymphoma (HL) has an incidence rate of 1%–4% in the extranodal sites, whereas approximately 40% of non-HL (NHL) cases occur in the extranodal sites and commonly involve the cervicofacial region. NHL has twice the preponderance over extranodal onset as compared with HL. The gastrointestinal tract is the most common site of extranodal disease, occurring in over 50% of patients, followed by the head-and-neck region which varies from 11% to 33%.[1] A very small proportion of head-and-neck NHLs occur within the oral cavity. We have reported a case of NHL where oral manifestations of NHL are predominant over the tongue. There are very less literature and reported cases of oral manifestations of NHL. In 3%–4% of these NHL cases, the initial manifestation is in the oral cavity and the features are quite perplexing. They present with a wide array of sign and symptoms like in acquired immune deficiency syndrome, squamous cell carcinoma, salivary gland tumors, space infections, periodontal disease, and osteomyelitis,[2] which emulate clinical conditions such as patients with oral lesions for which they frequently report to a dental surgeon. These traits of NHL cause difficulty in the early diagnosis, prognosis, and management. The case report highlights the extraoral and intraoral features of NHL in a 51-year-old male who presented with a swelling involving the anterior part of the tongue in the dorsum region and was diagnosed as small-cell NHL CD20 positive. The patient was treated with chemotherapy, and after 4 weeks of administration of chlorambucil and prednisolone, the swelling in the tongue subsided completely.


  Case Report Top


A 51-year-old African male originating from the central part of Africa reported with complaints of swelling in the face and neck region, multiple ulcers in the oral cavity, and difficulty in eating food for 8–9 weeks. On examination, a swelling in the anterior part of the tongue dorsum region and along the left side of the neck and below the chin was found. Later, a similar kind of the swelling was noticed in the armpits and in the groin region. Concurrently, he also developed multiple ulcers in the various region of the oral cavity. The swellings in these regions gradually increased to the present size. There was a history of weight loss. The patient had sought numerous medical consultations and was put on various antibiotics without any relief. The multiple nonhealing ulcers and difficulty to eat made him report to a dentist.

On general examination, multiple lymph nodes in the cervical, inguinal, and intra-abdominal region were palpable. There was obvious facial asymmetry with enlargement of lymph nodes in the submental, submandibular (level 1), and upper jugular (level 2) region, with the largest one measuring approximately 5 cm × 3.5 cm in size. The lymph nodes were asymptomatic, fixed, and firm in consistency. The skin overlying the lymph nodes was normal without any secondary changes [Figure 1] and [Figure 2].
Figure 1: Facial features in frontal and profile depicting the extraoral swelling

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Figure 2: Facial features in frontal and profile depicting the extraoral swelling

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Intraoral examination revealed multiple large ulcers on the upper lip, buccal vestibule, and floor of the tongue. The glaring finding was a swelling in the anterior part of the tongue in the dorsum region, measuring 2 cm × 2.5 cm in size [Figure 3] and [Figure 4].
Figure 3: Presentation over the mucosa and tongue

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Figure 4: Presentation over the mucosa and tongue

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Ultrasonography of the abdomen was done where hepatosplenomegaly retroperitoneal and mesenteric lymphadenopathy was detected [Figure 5]. Further investigations were ordered to diagnose the condition; fine-needle aspiration cytology (FNAC) of the upper jugular group bone marrow biopsy was done. FNAC smear showed predominantly monomorphic population of small lymphocytes in a hemorrhagic background with lymphocytes showing irregular margins with prominent one or two nucleoli. Minimal atypia was seen. Bone marrow biopsy report was suggestive of chronic lymphocytic leukemia (CLL). To confirm the diagnosis, biopsy of the right submandibular lymph node was done. Microscopic examination report unveiled a diffuse infiltrate by a monomorphic population of small lymphoid cells. Immunohistochemistry reported that tumor cells were CD45 and CD20 positive indicative of small-cell NHL.
Figure 5: Diagnostic ultrasonography

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The patient was treated with chemotherapy, and after 4 weeks of administration of chlorambucil and prednisolone, the facial symmetry was restored, the oral lesions, i.e., ulcers and swelling in the tongue, subsided completely [Figure 6] and [Figure 7].
Figure 6: Post-treatment picture

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Figure 7: Post-treatment picture

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  Discussion Top


Based on the lymphoid cell lineage and its behavior, more than 20 different subtypes have been identified.[3] The majority are of B-cell lineage, namely diffuse large B-cell lymphoma, small lymphocytic lymphoma (SLL), and Burkitt lymphoma.[4],[5],[6] SLL is clinically related to CLL which also involves the B-cells along with lymph node involvement. The CLL can be differentiated from NHL by immunohistochemistry studies, which identifies distinct proteins on the surface of the B-cells known as CD20 and CD45. SLL is primarily seen in the middle age and above, with a mean average age of 55–61 years. The male-to-female predilection for SLL is approximately 2:1.[7],[8] The early presentation of SLL is painless involvement of a cervical group of lymph nodes, namely the submental, submandibular, and jugular groups; lymph nodes of the armpit and groin region are also involved. The patient may also present with symptoms of fever, night sweat, and weight loss. The above-mentioned findings coincide with our case presentation.

A comprehensive evaluation is necessary for the early diagnosis and treatment. The investigation should include FNAC, biopsy, and immunohistochemistry studies. Timely diagnosis and early referral reduces the morbidity in these patients.


  Conclusion Top


Refractory oral lesions and cervical lymphadenopathy mimicking the malignancy should forewarn the clinician for a comprehensive evaluation consisting of detailed clinical examination and histopathological and radiological procedures for timely diagnosis and appropriate treatment. Lymphomas have a good prognosis, when timely treated, they reciprocate very well to chemotherapy and oral lesions begin to heal completely.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Iguchi H, Wada T, Matsushita N, Oishi M, Yamane H. Anatomic distribution of hematolymphoid malignancies in the head and neck: 7 years of experience with 122 patients in a single institution. Acta Otolaryngol 2012;132:1224-31.  Back to cited text no. 1
    
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: 121-5.  Back to cited text no. 2
    
3.
Inchingolo F, Tatullo M, Abenavoli FM, Marrelli M, Inchingolo AD, Inchingolo AM, et al. Non-Hodgkin lymphoma affecting the tongue: Unusual intra-oral location. Head Neck Oncol 2011;3:1.  Back to cited text no. 3
    
4.
Chi HS, Lee KW, Chiang FY, Tai CF, Wang LF, Yang SF, et al. Head and neck extranodal lymphoma in a single institute: A 17-year retrospective analysis. Kaohsiung J Med Sci 2012;28:435-41.  Back to cited text no. 4
    
5.
Hart S, Horsman JM, Radstone CR, Hancock H, Goepel JR, Hancock BW. Localised extranodal lymphoma of the head and neck: The Sheffield Lymphoma Group experience (1971-2000). Clin Oncol (R Coll Radiol) 2004;16:186-92.  Back to cited text no. 5
    
6.
Silva TD, Ferreira CB, Leite GB, de Menezes Pontes JR, Antunes HS. Oral manifestations of lymphoma: A systematic review. Ecancermedicalscience 2016;10:665.  Back to cited text no. 6
    
7.
Ben-Ezra J, Burke JS, Swartz WG, Brownell MD, Brynes RK, Hill LR, et al. Small lymphocytic lymphoma: A clinicopathologic analysis of 268 cases. Blood 1989;73:579-87.  Back to cited text no. 7
    
8.
Morrison WH, Hoppe RT, Weiss LM, Picozzi VJ Jr., Horning SJ. Small lymphocytic lymphoma. J Clin Oncol 1989;7:598-606.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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