lymphoma in sinonasal tract

7/27/2019 Lymphoma in Sinonasal Tract

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Case ReportA ninety year old lady presentedin the emergency room (ER) ofCampbellton Regional Hospital inNew Brunswick, Canada with rightnasal obstruction and pain over

her right cheek and a nose bleedthat she has been experiencing forthe past six months. She also hadanosmia, headache, blocked rightear and right epiphora. She wassuffering with chronic renal failure

Ear, ThroaT, NosE DisorDErs

Abstract

An Unusual Case of Large B-cellLymphoma of the Sinonasal Tractin a Ninty Year Old Woman

Lymphoma accounts for 3 to 5% of malignant tumours, non-Hodgkins lymphoma

(NHL) accounts for 60% of all lymphoma. NHL of the sinonasal tract is an uncom-mon neoplasm that can be morphologically difcult to distinguish from non-neoplastic

destructive lesions or malignant neoplasm. Only Immuno histochemistry could give a

denite diagnosis. These represent 1.5 to 15% of NHL in the United States,1 2.6 to 6.7%

of all lymphoma in Asia.2 B cell phenotype are most frequently found in the Western

Hemisphere while T cell lymphomas are found in Asian countries. B-cell lymphoma of

sinonasal tract occur in 6th to 8th decade of life and have a better prognosis.3 Review

of the literature shows that early diagnosis and prompt treatment with local radiation

(XRT) or combined modality treatment (CMT) have shown good prognosis.4

Keywords:Non Hodgkins lymphoma, diffuse large cell B-cell lymphoma (DLBCL),disease free survival (DFS), overall survival (OS), epistaxis, rapid rhino (Arthrocare

ENT products)

About the authorsK. Shenoy, MD, DLO, FRCS, FACS1, W. Wang, MD2

ENT Service Chief, Campbellton Regional Hospital, New Brunswick, Campbellton, Canada. 2Pathology Service Chief, Campbellton Regional Hospital

ew Brunswick, Campbellton, Canada.


2/429 Journal of Current Clinical Care Volume 2, Issue 5, 2012

B-Cell Lymphoma of the Sinonasal Tract

and chronic anaemia. The patienthad lost weight and had symptomsof nocturnal sweating and fever.

Examination of right nasalcavity showed eshy haemorrhagicpolypi and total obstruction. Shehad mucopurulent discharge. Herleft nasal cavity was patent andthere was no polyp. There wasmild tenderness over her rightcheek. She was anemic with Hb6.5gm/dl. Her blood urea and cre-

atinine was high due to chronicrenal failure. Emergency CT scan(Figure 1) showed diffuse homog-enous shadow in the right nasalcavity compressing septum to theleft and homogenous opacity inthe right maxillary, ethmoidal andfrontal sinuses. There was blockingof middle meatal complex, ethmoi-

dal sinuses and frontal recess onthe right side.In the ER her nose was packed

with Rapid Rhino to control theepistaxis and was transferred tothe surgical ward and transfusedwith a couple of units of blood tocorrect the haematocrit and intra-venous antibiotics ceftriaxone 2

gm every 24 hrs was given for72 hours. She was transferred tothe operating room (OR) for thebiopsy of eshy polypi and eht-moidal, frontal recess and middlemeatal clearance. The nasal cav-ity was again packed with RapidRhino for 48 hours.

The biopsy was reported as

large B-cell lymphoma (Figure 2)

Key Point

Sinu-nasal

lymphoma

are rare.

Figure 1: CT scan o sinuses showing the

tumour in the right nasal cavity pushing

the nasal septum, occupying the right

maxillary, ethmoidal and rontal sinuses,eroding medial and inerior wall o orbit.

Figure 2: Section in high power show thelymphoma cells which are large, oval or ir-

regular shaped, sometimes with multinucle-

ated nuclei, vesicular chromatin, single or

amorphophlic nucleoli, and scanty basophilic

cytoplasm and with increased mitotic activi-

ties are also seen.




and the patient was transferredto the oncologist in Quebec, Can-ada as the patient was from that

region. Unfortunately the patientrefused radiation and combine-modality treatment (CMT) withoncologist and died after fourmonths from diagnosis.

Discussion

Lymphoma of the nasal cavityand paranasal sinuses are uncom-

mon.5

Most of the malignancies inthe sinonasal tract are carcinoma.2Lymphoma of sinonasal tract aredifcult to differentiate from undif-ferentiated (anaplastic) carcinoma,immunohistochemistry is requiredfor reaching a diagnosis.3 Theycould appear heterogenous withrespect to pathologic and clinical

behaviour. Their rarity and nonuni-formity of treatment makes under-standing the natural history andtreatment difcult.4 Diffuse LargeB-cell lymphomas (DLBCL) arecommon type in B-cell lymphomaand their incidence is more in max-illary sinus followed by ehmoidalsinus and nasal cavity, very rarely

reported in frontal sinus.1

The patient can present withnasal obstruction, anosmia,epistaxis, mucopurulent discharge

and headache or pain over thecheek. Most of the patients are intheir 6th to 8th decade of life. Theycan also have general symptomslike loss of weight, nocturnal sweat-ing and fever.3

Macroscopically the tumourconsists of greyish white to greyishbrown soft tissue with focal area of

haemorrhages.Microscopically fragments oftissues of uniform small and largecells arranged in diffuse pattern.These cells possess mild to mod-erate basophilic cytoplasm andhyperchromatic nuclei, condensedchromatin, irregular and cleavednuclear outline with 1 to 2 nucleoli.

Area of haemorrhage and necro-sis is also seen along with brillarmaterial in the background.3 Inimmunohistochemistry slides theproliferation shows strong stain-ing for leukocyte common anti-gen (CD45) and the B-cell marker(CD10).

Lymphoma of sinonasal tract

have variable behaviour and may

Key Point

Present with

nasal obstruc-

tion, head-

ache, facial

pain, blood

stained dis-charge and

sinus symp-

toms.

Difcult to di-

agnose unless

immunohisto-

chemistry is

done.

Sinu-nasal lymphoma are rare.Present with nasal obstruction, headache, acial pain,

blood stained discharge and sinus symptoms.

Difcult to diagnose unless immunohistochemistry is done.Once diagnosed prompt combined modality treatment with

chemotherapy and radiotherapy can give a good prognosis.

SUMMARY OF KEY POINTS




be invasive in nature, though B-celllymphoma have claimed a betterprognosis. Some published stud-ies suggest that radiation alone

for early stage disease providesgood local and regional control.Chemotherapy did not improveon relapse rate and only used forextensive disease. Chemotherapywas three cycles of cyclophospha-mide, doxorubicin, vincristine andprednisone-based regimen.

More recent studies have

shown combine-modality treat-ment (CMT) with chemotherapyand local-regional radiation; pro-vide signicant improvement indisease-free survival (DFS) andoverall survival (OS) especially forlymphomas of nasal cavity andparanasal sinuses. Distant metasta-sis remain a problem where local

regional radiation and systemicchemotherapy is recommendedfor these patients.4 Early detectionand prompt treatment could give agood prognosis.

AcknowledgementAuthors would like to thank Ms.France Carrier who assisted in the

literature search and Mr. Pritam

Shenoy who was key in typing thismanuscript.

Dr. Pradeep Shenoy takes respon-

sibilities in the integrity of the con-tents of this article.

Competing interest none declared.

References1. Neves MC, Lessa MM, Voegels RL, Butugan O. Primary

non-Hodgkins lymphoma o rontal sinus: Case report

and review o literature. Ear Nose Throat J.2005;84:47-

51.

2. Kamath MP, Kamath G, Bhojwani K, Pai M, Shameem

A, Agarwal S. Sinonasal lymphoma : A case report. EarNose Throat J.2006;85:325-327.

3. Murthy VS, Murthy CN, Belgavi CS ,Chandra

S,Munishwara GB. Primary non-Hodgkins lymphoma

o the nose and paranasal sinuses: a case report.

Indian J Pathol Microbiol.2003;46:82-84.

4. Proulx GM, Cauda-Garcia I, Ferry J, Harris N, Greco WR,

etal. Lymphoma o the Nasal Cavity and Paranasal

Sinuses:Treatment and outcome o Early-Stage Dis-

ease. Am J Clin Oncol.2003;26:6-11.

5. Hausdorf J, Davis E, Long G, etal.Non-Hodgkins lym-

phoma o the paranasal sinuses: clinical and patho-

logical eatures and response to combined-modality

therapy. Cancer J Sci Am.1997;3:303-311.Key Points

Once diag-nosed prompt

combined mo-

dality treat-

ment with

chemotherapy

and radio-

therapy can

give a good

prognosis.

Sinu-nasal lymphoma is a rare entity. I diagnosed early by immunohistochemistry, combined modality o treatment

with radiation and chemotherapy could give a good prognosis.

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lymphoma in sinonasal tract

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