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University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 88
University J Dent Scie 2015; No. 1, Vol. 3
Abstract : Non Hodgkin's lymphoma (NHL) belongs to a group of lymphoid neoplasm that is diverse in manner of presentation, response to therapy & prognosis. NHL cases might occur extra-nodally and in 3% of these cases the initial presentation may be in the oral cavity. Extra-nodal NHL of the oral cavity is rare but patients with oral lesions of NHL commonly present at the dental clinic in the first instance. Thus a careful clinical and histopathological examination along with other laboratory investigations will help in diagnosing the disease at an early stage, resulting in better prognosis. Usually the oral manifestation of NHL is secondary to a more widespread involvement throughout the body. Other times it may represent a primary extra nodal disease confined to oral cavity or jaws. This case report presents a painless swelling in the mandibular left posterior gingival region which unusually came out to be NHL on histopathological & immunohistochemical
1Aparna Dave Professor, Department of Oral & Maxillofacial Pathology, SGT Dental College & 2Hospital, Gurgaon. India, V.P. Shetty Prof& HOD, Department of Oral & Maxillofacial Pathology.
3SGT Dental College & Hospital, Gurgaon. India, Pulin Saluja Senior Lecturer, Department of Oral 4& Maxillofacial Pathology, SGT Dental College & Hospital, Gurgaon. India, Manpreet Arora
Reader, Department of Oral & Maxillofacial Pathology. SGT Dental College & Hospital, Gurgaon. India
INTRODUCTION Lymphomas are heterogeneous group of
clonal malignant disease with a spectrum of behavior ranging
from relatively indolent to highly aggressive and potentially
fatal. They share the single characteristic of arising as the
result of somatic mutation in a lymphocytic progenitor1.
Lymphomas unlike leukemia are solid tumors.
A broad division of the group into Hodgkin Lymphoma and
Non Hodgkin Lymphoma (NHL) is widely accepted.
Extranodal presentation of Hodgkin lymphoma is rare but
NHL is relatively common group of neoplasm2 that presents
up to 40% of time at an extra nodal site. 2% to 3% of these
extra nodal cases may primarily arise in oral cavity and jaws.
Waldeyers ring is more frequently involved in head and neck
region. Orbit, salivary glands are the other sites of
involvement3. Oral NHL can involve the paranasal sinuses-
but can also arise from within the soft tissue or bone, floor of
the mouth and cheek. However the involvement of the gingiva
is relatively uncommon. Owing to scarcity of reported cases
of oral lymphomas, the interpretation of the biological-
behavior and treatment options involving this disease entity
becomes difficult. A thorough clinical, histopathological, and
immunohistochemical evaluation is therefore essential for the
diagnosis and management of oral NHL.
Case report
A 65 year old male patients reported to the OPD with
complain of painless growth and mobility in relation to 33, 34
and 35. The growth was of 3 months duration. On
examination, the patient was afebrile, gave no history of
weight loss and did not exhibit any palpable lymph nodes.
On intraoral examination, an ill defined gingival growth, pink
in color, irregular in shape, soft to firm in consistency was
seen extending from mandibular left lateral incisor to
mandibular left premolar region and also involved the lingual
vestibule (Figure 1).
Figure 1: Intraoral picture showing gingival swelling wrt left
mandibular canine premolar region.
PRIMARY EXTRA-NODAL B - CELL TYPE OF NON HODGKIN'S LYMPHOMA MANIFESTING AS GINGIVAL SWELLING IN POSTERIOR MANDIBLE : A RARE CASE REPORT.
Journal of Dental Sciences
University
Key words : Non Hodgkin Lymphoma, extra nodal, neoplasmlymphocytic progenitor
Source of support : NilConflict of Interest : None
Case Report
Figure 2: Panoramic radiograph showing ill defined
radiolucency with moth eaten appearance with respect to
edentulous region of 36 37 and floating tooth wrt 38
Radiographically ill defined radiolucency in edentulous
region wrt 36,37 was seen with moth eaten appearance along
the superior region, floating tooth appearance wrt 38,loss of
trabecular pattern within the lesion suggestive of malignant
changes wrt to area of interest (Figure 2). Clinical diagnosis
of squamous cell carcinoma of the gingiva was given.
Incisional biopsy was done under local anesthesia and the
tissue was sent for histopathological examination.
Microscopic examination revealed presence of a highly
cellular connective tissue stroma with a stratified squamous
surface epithelium. A diffuse infiltration of atypical lymphoid
cells exhibiting pleomorphism, hyperchromatism and
abnormal mitosis was noted. A provisional diagnosis of Non
Hodgkin Lymphoma was given (Figure 3, 4)
.Immunohistochemistry showed CD20 positivity and CD3
negativity favoring the diagnosis of B cell type NHL (Figure
5). Examination of peripheral blood did not show any
significant finding. No other foci of lymphomatous process
could be noted.
Figure 3: Photomicrograph showing atypical lymphocytes
arranged in sheets (H&E 10X)
Figure 4 : Photomicrograph showing Rounded
hyperchromatic atypical lymphocytes (H&E 40X)
Figure 5: Immuno histochemical analysis of the specimen
showing cells diffusely positive for CD20 (20X).
Discussion : Lymphomas characterized by diffuse or nodular
sheets of lymphocytes and lymphoblasts without the presence
of Reed Sternberg cells are classified as Non Hodgkin
Lymphoma4. NHL has great tendency to affect organs and
tissue that do not ordinarily contain lymphoid cells. 20 - 30%
of NHL arises from extra nodal sites. Tonsils, nasopharynx,
base of tongue, paranasal sinuses, orbits and salivary glands,
maxilla5 are the sites involved in the head and neck region.
Jaw involvement is not so common however maxilla is more
frequently involved than mandible6. Mandible accounts for
0.6% of isolated NHL7 and it is rare to find extranodal NHLs
in the gingiva8.
The most common presenting symptoms are local swelling,
pain or discomfort or at times ulcer9. Generalized symptoms
such as fever, weight loss, night sweats, fatigue and pruritus
are more frequent in HL than NHL10.Determining the origin
of these lesions is difficult if there is both hard and soft tissue
involvement.
The oral NHL may mimic more commonly benign oral and
dental pathological conditions. Diagnosis of NHL is often
difficult because of clinical features that can mimic other
pathological conditions (eg fibroma, periodontal disease,
pyogenic granuloma etc)11. Thus the lesion may easily be
misdiagnosed without any particular identifiable features.
Also there is a lot of variation in racial incidence, histology
and immunological subtypes of lymphomas making the
diagnosis more difficult. The prevalence of NHL is increasing
day by day specially among the immunocompromised
individuals. There is increased evidence of NHL in patients
suffering from AIDS and oral lesions of NHL have been the
first manifestation of AIDS in most of the cases12. Therefore
it is important to remember that lymphoma should be the part
of the differential diagnosis in any oral lesions.
NHL at histological level can be broadly grouped into two
major subcategories - diffuse and nodular4. The histological
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 89
University J Dent Scie 2015; No. 1, Vol. 3
subtyping is based on differentiation of lymphoid precursor
cell. The more primitive anaplastic tumors are high grade and
the more differentiated tumors which bear a greater
resemblance to mature lymphocytes are low grade. Early
Rapports classification was used and it was based on
morphology pattern, small cells were lymphocytic and large
cells were histiocytes. Lukes Collins classification of 1974
was immunologic based classification with morphologic
consideration. Keels classification is also immunologic based
but includes grades of malignancy. The working formulation
was devised to divide tumors into low, intermediate and high
grade tumors at the same time maintain the distinction
between nodular (follicular) and diffuse type as well as the
concept of cell size. Revised European American Lymphoma
(REAL) classification superseded working classification. In
most recent WHO classification of neoplastic disease of
hemopoetic & lymphoid tissue adopted this REAL
classification of lymphoid neoplasm with some
modification13. In our case, the patient reported with gingival
swelling without any other systemic complaints of weight
loss or long standing fever, or lymph node involvement which
suggest atypical presentation of this uncommon lesion.
As the occurrence of NHL in oral mucosa is uncommon and
the clinical presentation varies the only reliable method to
distinguish these lesions is by employing both biopsy and
immunological techniques. Therefore, apart from H & E
staining different immune histochemical markers are useful
to confirm the lineage of the neoplastic cell as B cell or T
lymphocytes. CD20 is often used as a B cell marker whereas
CD3, CD45 are frequently used as a marker of T cell lineage.
In the present case immunohistochemical expression of CD20
was seen variable staining which is indicative of B cell type
NHL.
The overall prognosis of NHL depends on the stage of the
tumor and aggressiveness of the malignant cell. A proper
clinical evaluation is very important as well as is the
histopathologic evaluation. Many a times these lesions
present a very benign appearance resulting which we may
miss the diagnosis. So, it is important to have an
understanding of tumors that could mimic an ordinary
swelling. Lymphomas should be considered in differential
diagnosis of oral lesions as patients with oral lesions of NHL
might present at the dental clinic in the first instance. Hence,
dentist can play an important role in early detection of the
disease, thus improving the prognosis.
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University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 90
University J Dent Scie 2015; No. 1, Vol. 3
Legends
Figure 1: Intraoral picture showing gingival swelling wrt left
mandibular canine premolar region.
Figure 2: Panoramic radiograph showing ill defined
radiolucency with moth eaten appearance with respect to
edentulous region of 36 37 and floating tooth wrt 38
Figure 3: Photomicrograph showing atypical lymphocytes
arranged in sheets (H&E 10X)
Figure 4 : Photomicrograph showing Rounded
hyperchromatic atypical lymphocytes (H&E 40X)
Figure 5: Immuno histochemical analysis of the specimen
showing cells diffusely positive for CD20 (20X).
CORRESPONDING AUTHOR :
Dr. Pulin Saluja
T2 ,604, Sushant Estate ,sector 52,
Gurgaon, Haryana
E-mail: [email protected]
Phone No: 9910791584
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 91
University J Dent Scie 2015; No. 1, Vol. 3