Abstract
Primary lymphomas of the oral cavity are uncommon and of the tongue even rarer. It is more common in the masticatory mucosa than the lingual and buccal mucosa. We describe a 63 year old male who presented with dysphagia & change in voice. Computed tomography revealed a 4.8 × 3.7 cm mass localized to the base of tongue. He underwent biopsy and IHC studies & was diagnosed as having diffuse large B cell lymphoma. The patient was successfully treated with wide excision of the lesion and is undergoing chemotherapy now. Although oral lymphoma of tongue is very uncommon, it should always be considered in differential diagnosis of various benign and malignant lesions in this region. A proper clinical evaluation and histopathologic as well as immunohistochemical evaluation of biopsy specimen are required to establish the diagnosis and for further management. This is one of the few cases of non-Hodgkin’s lymphoma of the base of tongue being reported from India.
1
Introduction
Lymphomas form a group of uncommon solid malignant tumors with a wide spectrum of clinical and pathological features. Primary Non-Hodgkin’s Lymphoma represents the second leading malignancy of oral cavity, after squamous cell carcinoma . The incidence of DLBCL is higher in Asian patients than in Western patients. Men are affected more often than women, and most patients present between the sixth and eighth decades of life. Patients with an underlying immunodeficiency disorder tend to be younger . In the western population, 5%–10% of all cases of primary or secondary non-Hodgkin’s lymphoma (NHL) occur in Waldeyer’s ring, which includes the palatine tonsils, lymphoid tissue of the nasopharynx, soft palate, and base of the tongue. Findings of primary NHL in the base of tongue, the soft palate, and multiple sites in oral cavity are less common. Waldeyer’s ring shares many of the histopathological tendencies of the rest of mucosa-associated lymphoid tissue, such as a high frequency of diffuse large B-cell lymphoma and relative rarity of follicular lymphoma in spite of its rich endowment of reactive lymphoid follicles .
2
Case report
A 63-year-old-man presented with a history of dysphagia of 1 year duration followed by swelling in the right submandibular region & change in voice from last 6 months. No other significant history was there. The patient had no known medical illnesses or allergies. He did not smoke, chew tobacco or consume alcohol. He had no family history of any malignancies. On oral examination a globular mass was seen in the base of tongue reaching the posterior pharyngeal wall. Tonsils were normal There was swelling in the right submandibular region measuring 2 × 2 cm. Clinically possibility of vellecular cyst was kept. No organomegaly or any other lymph node enlargement was noted. His routine investigations including complete hemogram, urine analysis, coagulation profile, chest X-ray, ultrasonography of abdomen & pelvis, echocardiography, 99 m Tc thyroid scan showed no significant abnormalities. He was HIV negative. X ray neck showed soft tissue swelling above the hyoid bone compressing the airway. He had outside MRI report without films with impression of homogenously enhancing base of tongue? salivary gland neoplasm? Lymphoid hyperplasia. Computed tomography revealed a large lobulated 4.8 × 3.7 cm mass in the pharyngeal mucosal space showing minimal enhancement localized to the base of tongue and involving the pre-epiglottis space, both vallecula, anterior part of epiglottis, obliterating oro-pharyngeal air column reaching the posterior pharyngeal wall. ( Fig. 1 ) Extension into the supragllotic region till hyoid bone with partial effacement of left pyriform sinus was noted. There was no significant lymphadenopathy. Possibilities of cystic lymphovascular malformation & malignancy (less likely) were kept. Hemiglossectomy was performed & sent for histopathological examination which demonstrated lining of stratified squamous epithelium below which are seen diffuse sheets of tumor cells having round hyperchromatic nuclei, inconspicuous nucleoli & scanty cytoplasm along with many large cells with vesicular nuclei infiltrating the skeletal muscle bundles ( Fig. 2 ). A diagnosis of non-Hodgkin’s lymphoma was given. Immunohistochemical evaluation showed positive immunoreactivity for LCA (leukocyte common antigen) and CD 20. CD 3 & cytokeratin (CK) were negative ( Fig. 3 ). The patient was extensively investigated for other sites of involvement. However no other sites in the body were found to be involved. Bone marrow studies were not showing any lymphomatous infiltration. Thus, a final diagnosis of the primary non-Hodgkin’s lymphoma, diffuse large cell B cell type of the oral tongue was given. Currently the patient is on chemotherapy and on follow up.
2
Case report
A 63-year-old-man presented with a history of dysphagia of 1 year duration followed by swelling in the right submandibular region & change in voice from last 6 months. No other significant history was there. The patient had no known medical illnesses or allergies. He did not smoke, chew tobacco or consume alcohol. He had no family history of any malignancies. On oral examination a globular mass was seen in the base of tongue reaching the posterior pharyngeal wall. Tonsils were normal There was swelling in the right submandibular region measuring 2 × 2 cm. Clinically possibility of vellecular cyst was kept. No organomegaly or any other lymph node enlargement was noted. His routine investigations including complete hemogram, urine analysis, coagulation profile, chest X-ray, ultrasonography of abdomen & pelvis, echocardiography, 99 m Tc thyroid scan showed no significant abnormalities. He was HIV negative. X ray neck showed soft tissue swelling above the hyoid bone compressing the airway. He had outside MRI report without films with impression of homogenously enhancing base of tongue? salivary gland neoplasm? Lymphoid hyperplasia. Computed tomography revealed a large lobulated 4.8 × 3.7 cm mass in the pharyngeal mucosal space showing minimal enhancement localized to the base of tongue and involving the pre-epiglottis space, both vallecula, anterior part of epiglottis, obliterating oro-pharyngeal air column reaching the posterior pharyngeal wall. ( Fig. 1 ) Extension into the supragllotic region till hyoid bone with partial effacement of left pyriform sinus was noted. There was no significant lymphadenopathy. Possibilities of cystic lymphovascular malformation & malignancy (less likely) were kept. Hemiglossectomy was performed & sent for histopathological examination which demonstrated lining of stratified squamous epithelium below which are seen diffuse sheets of tumor cells having round hyperchromatic nuclei, inconspicuous nucleoli & scanty cytoplasm along with many large cells with vesicular nuclei infiltrating the skeletal muscle bundles ( Fig. 2 ). A diagnosis of non-Hodgkin’s lymphoma was given. Immunohistochemical evaluation showed positive immunoreactivity for LCA (leukocyte common antigen) and CD 20. CD 3 & cytokeratin (CK) were negative ( Fig. 3 ). The patient was extensively investigated for other sites of involvement. However no other sites in the body were found to be involved. Bone marrow studies were not showing any lymphomatous infiltration. Thus, a final diagnosis of the primary non-Hodgkin’s lymphoma, diffuse large cell B cell type of the oral tongue was given. Currently the patient is on chemotherapy and on follow up.
