CLINICAL PRACTICE
CASE REPORT |
Lymphoma in the infraorbital region
RÜ
TÜ GEDIK, D.D.S.,
SAADET GEDIK, M.D.,
FAHRETTIN GÖZE, M.D., Ph.D. and
HAKAN DEVELIOGLU, D.D.S.
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ABSTRACT
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Background. B-cell lymphomas are rare neoplasms in the oral cavity. They are significant to dentists because the oral complications associated with treatment mean that dentists can play an important role in their detection.
Case Description. The authors describe the case of a 55-year-old man with non-healing ulcers, swelling and pain six months after maxillary left canine extraction. As it occurred in the infraorbital region after canine tooth extraction, the authors suspected B-cell lymphoma. Clinical examination revealed infraorbital edema with regional submandibular lymphadenopathy. Intraoral examination revealed a nonhealing ulceration with ill-defined borders in the surrounding mucosa. It was 5- x 5-centimeters in diameter and gray-white. The histopathologic examination showed diffuse, atypical, lymphoid cell infiltration and immunohistochemically positive staining. After the histopathologic examination, the authors referred the patient to a medical center for treatment.
Clinical Implications. Dentists should look for signs of B-cell lymphoma when a patient has extended pain and swelling after an extraction.
Lymphomas are malignancies of lymphoreticular origin that most frequently involve the lymph nodes.1 Lymphomas are divided into Hodgkin’s lymphoma, or HL, and non-Hodgkin’s lymphoma, or NHL. NHL commonly affects middle-aged and elderly people, and males have a slight preponderance over females.2–6
NHL is representative of a group of lymphoid neoplasms that is diverse in history, presentation, response to therapy and prognosis.4–8 NHL primarily appears in the head, neck and jaw areas. It typically is characterized by a swollen, nonpainful lymph node enlargement and a submucous lesion of the oral mucosa—sometimes bilaterally and especially at the junction of the soft and hard palates.8–13 It is uncommon for NHL to appear first or only orally. It is, however, important to be aware of this possibility, as it warns of the progression to other lymph nodes.11–16
Dentists can play an important role in the early detection of B-cell lymphomas.
An increased incidence of high-grade lymphomas occurs in people who have leukemia and AIDS.17–20 The involvement of these lymphomas in the oral mucosa, however, is rare and not well-documented.19–20
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CASE REPORT
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A 55-year-old man was referred to our faculty for diagnosis of nonhealing ulcers, swelling and pain that had occurred for six months after his maxillary left canine had been extracted. The patient had received medical treatment, but it did not help.
The patient’s medical history was negative for any syndromes or congenital or systemic diseases. Our clinical examination revealed infraorbital edema with regional submandibular lymphadenopathy. Intraoral examination revealed a nonhealing ulceration with ill-defined borders in the surrounding mucosa. It was 5- x 5-centimeters in diameter and gray-white (Figure 1
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The histopathogic examination revealed ulcerated squamous epithelium on the surface. Below the surface were small irregular bone spicules and diffuse infiltration of atypical large lymphoid cells with vesicular nuclei, some with prominent nucleoli and little eosinophilic cytoplasm (Figure 2). Under these cells were larger cells containing two or more hyperchromatic nuclei. We also observed numerous mitotic figures with a high proliferation rate. Immunohistochemically, tumor cells were stained with S-100-, CD3-, CD20+ focally, CD79a+ diffuse, CD45RO– and CD68+ focally (Figure 3). The diagnosis was B-cell lymphoma, a type of NHL.
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Figure 2. Cellular detail from the tumor showing atypical lymphoid cells with large irregular vesiculated nuclei, some with conspicuous nucleoli (hematoxylin and eosin stain 100 magnification).
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Figure 3. Around a vessel in the center are atypical lymphoid cells that immunohistochemically diffuse positive staining with cell marker CD79a (Vectastain ABC stain, Vector Laboratories, Burlingame, Calif., 40 magnification).
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DISCUSSION
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The occurrence of NHL in the oral mucosa is rare and not well-documented. Lymphomas are of significance to dentists because oral complications such as cheilitis, candidiasis and herpes infection are associated with treatment.6,10,19,20
In general, the oral manifestation of NHL occurs secondary to a more widespread distribution throughout the body. When the oral soft-tissue lesions first are present, they are relatively soft and often have overlying ulceration, and they often are characterized by an absence of other symptoms. If bone is the primary site, alveolar bone loss and tooth mobility frequently are noted. Swelling, pain, numbness of the lip and pathologically related fractures may be associated with the bone lesion.15–20
The cause of NHL still is unclear. Viruses have been suggested as a potential cause of the disease. An increased rate of lymphoma in patients who are congenitally immunosuppressed and in patients who receive immunosuppressive therapy has been reported.1–5
The most common clinical appearance of NHL in the mouth is a nonhealing, painless ulceration. The surface of the ulcer often has a pebbly, uneven surface that appears to glisten.1–3 NHL also may affect any aspect of the oral mucosa, although the gingival, palatal and tonsillar areas are involved most frequently.11–14
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CONCLUSION
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Lymphomas are of significance to dentists because of their oral presentation and because of the oral complications associated with treatment. By knowing the signs of B-cell lymphomas, dentists can play an important role in the early detection of the disease.
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Dr. Rüstü Gedik is an assistant professor, Cumhuriyet University Faculty of Dentistry, Oral Diagnosis and Radiology Department, 58 140 Sivas, Turkey, e-mail "rgedik{at}cumhuriyet.edu.tr". Address reprint requests to Dr. Gedik.
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Dr. Göze is a professor, University of Cumhuriyet, Faculty of Medicine, Department of Pathology, Sivas, Turkey.
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FOOTNOTES
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Dr. Develioglu is an assistant professor, Cumhuriyet University, Faculty of Dentistry, Department of Periodontology, Sivas, Turkey.
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REFERENCES
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