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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 21  |  Issue : 1  |  Page : 50-52

Atypical clinical presentations of lymphomas: Two case reports


Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication4-Mar-2016

Correspondence Address:
Sachin Kolte
Department of Pathology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.178106

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  Abstract 

Chest wall and cheek swelling are rare sites of involvement by lymphoma. We hereby present two such cases with atypical presentations. Case 1: A 48-year-old male patient presented with a painful swelling over right cheek, which was clinically and radiologically suspected to be cellulitis and thus, incised and drained. Later patient presented to our hospital and fine-needle aspiration (FNA) was performed, which revealed cytological features consistent with non-Hodgkin's lymphoma. Case 2: A 30-year-old female patient presented with right anterior chest wall swelling, which was clinically diagnosed as cold abscess. However, FNA revealed cytological features consistent with Hodgkin's lymphoma. Both cases being reported were thought to be of infective etiology, which were however, diagnosed as lymphoma on FNA and thus led to a different management plan.

Keywords: Abscess, cheek, chest wall, extranodal lymphoma


How to cite this article:
Sekhon S, Kolte S, Gupta K, Yadav A. Atypical clinical presentations of lymphomas: Two case reports . J Mahatma Gandhi Inst Med Sci 2016;21:50-2

How to cite this URL:
Sekhon S, Kolte S, Gupta K, Yadav A. Atypical clinical presentations of lymphomas: Two case reports . J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2020 Jul 11];21:50-2. Available from: http://www.jmgims.co.in/text.asp?2016/21/1/50/178106


  Introduction Top


Lymphomas represent the lymphoid neoplasms, which arise as discrete tissue masses, mostly presenting as enlarged nontender lymph nodes, but may present as extranodal lymphomas, commonly involving the gastrointestinal tract and head and neck. [1]

Extranodal involvement is much less common in Hodgkin's lymphoma than in non-Hodgkin's lymphoma. [2] There has been marked increase in the occurrence of extranodal lymphomas in past two decades. [3] Cheek and chest wall are rare sites of lymphoma with high rates of misdiagnosis as they have no specific characteristics. [4] We hereby present two such cases presenting as abscess and thus masquerading lymphoma.


  Case Reports Top


Case 1

A 48-year-old male patient presented with a progressively growing swelling over his right cheek region [Figure 1] since 1 month and difficulty in opening the mouth for past few days. Clinical diagnosis of abscess was made for which incision and drainage was done at the local hospital. As the patient did not respond well to the treatment, he was referred to our hospital. Blood tests (including complete hemogram and blood sugar) were within normal limits. Ultrasound revealed thickened and inflamed subcutaneous tissue with no fluid collection. Fine needle aspiration (FNA) showed monomorphic population of large immature lymphoid cells. The features were consistent with non-Hodgkin's lymphoma, large cell type [Figure 1].Based on FNA diagnosis patient was further evaluated. Computed tomography (CT) revealed the extent of the lesion involving right masseteric, buccal, parapharyngeal space and parotid with narrowing of oropharyngeal airway. Homogenously enhancing mediastinal and subdiaphragmatic lymphadenopathy were also observed.
Figure 1: Cheek swelling with incision mark: Monomorphic population of large immature lymphoid cells (Giemsa, ×40)

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A tiny right axillary lymph node was detected on further examination, which was biopsied. Sections showed medium to large size cells having round hyperchromatic nuclei with scant cytoplasm with frequent mitosis. Immunohistochemistry revealed tumor cells to be positive for leukocyte common antigen and CD20 and negative for cytokeratin and CD3. Histological features were thus consistent with non-Hodgkin's lymphoma, diffuse large B cell type.

Case 2

A 30-year-old female patient presented with a mass over her chest wall since 2 months. She had no history of cough or fever. Her vital signs were stable. On local examination, the mass was 3 cm × 2 cm in size with overlying skin being unremarkable. There was no lymphadenopathy and the rest of the physical examination was normal. Clinically, it was suspected to be cold abscess and the patient was sent for FNA for confirmation.

Fine-needle aspiration, however, revealed polymorphous population of lymphoid cells, neutrophils, eosinophils and plasma cells. Numerous atypical cells with prominent nucleoli and classical Reed-Sternberg cells were also seen [Figure 2]. Cytological features were consistent with Hodgkin's lymphoma, mixed cellularity type.
Figure 2: Binuclear reed Sternberg cells in a background of lymphocytes and plasma cells, inset shows a typical reed Sternberg cell (Giemsa, ×40)

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Computed tomography chest was done to evaluate the extent of the lesion that revealed a homogenously enhancing soft tissue mass 5.6 cm × 5.4 cm in the right anterior chest wall involving anterior mediastinum and extrapleural region along with erosion of right first rib. Mediastinal lymphadenopathy was also observed.

The patient was started on therapy with doxorubicin, bleomycin, vinblastine, and dacarbazine. The swelling subsided after the first cycle and thus, the patient responded to the therapy.


  Discussion Top


Incidence of extranodal lymphomas has been increasing since the past two decades [3] and due to their varied presentations the misdiagnosis rate is very high. [4] The presence of extranodal disease also has prognostic implications. Whenever there is secondary involvement of extranodal sites (excluding the spleen) distant from primary nodal disease, the disease is considered to be Stage III or IV. In patients who present with primary extranodal disease, the disease will be categorized as Stage I or II. Thus, it is important to determine whether extranodal involvement represents a primary manifestation or dissemination of systemic disease as the prognosis is much less favorable in systemic disease. [2] Our cases posed as infective in etiology and after workup turned out to be extranodal lymphoma with a poor prognosis.

Non-Hodgkin's lymphoma is one of the possible cancers in the head and neck region, and among extranodal non-Hodgkin's lymphomas, this is the second most common site after gastrointestinal tract. [5] In the head and neck, Waldeyer's ring is the most common site of origin and may be accompanied by cervical node involvement. Nose, paranasal sinus, orbits and salivary gland are other possible organs affected in decreasing order of frequency, with rare spread to the regional lymph nodes. [6]

There are no characteristic clinical features of lymphomas of the oral region, and they depend on the site of the swelling, the lymph node involvement and/or the presence of metastasis. The most common beginning symptoms are local mass, pain or discomfort, dysphagia or sensation of a foreign body in the throat, in the case of tonsillar non-Hodgkin's lymphoma.

A correct and early diagnosis is important to begin therapy on time.

The oral non-Hodgkin's lymphoma may mimic more common benign oral and dental pathologic conditions. [7] Thus, it may be misdiagnosed. Awareness of this clinical entity in the oral region is important to distinguish it from infective and more common carcinomas.

Our case report shows that cheek lympoma can simulate abscess and change the treatment to mere incision and drainage rather than chemotherapy. This was a diffuse large B-cell lymphoma which is the most common type of primary oral and paraoral non-Hodgkin's lymphoma. [8]

Hodgkin's disease usually presents in supradiaphragmatic lymph nodes, with cervical, anterior mediastinal and axillary nodes occurring in decreasing frequency. [9] Many cases of malignant non-Hodgkin's lymphoma presenting as a solitary chest wall mass have been reported but, chest wall abscess is a rare presentation of extranodal Hodgkin's lymphoma with only a few reports. [10] Hodgkin's lymphoma of the chest wall may be due to direct invasion from localized disease or primary chest wall lymphoma.

Our case report shows that clinical presentation of lymphoma may resemble cold abscess, suggesting treatment with antitubercular drugs.


  Conclusion Top


Both cases reported were thought to be of infective etiology, which were however, diagnosed as lymphoma on FNA and led to a different management plan. Thus, an accurate clinical examination assisted by FNA is fundamental steps to decide a proper therapeutic protocol.

Declaration of patient consent

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

 
  References Top

1.
Maheshwari GK, Baboo HA, Gopal U, Wadhwa MK. Primary extra-nodal non-Hodgkin's lymphoma of the cheek. J Postgrad Med 2000;46:211-2.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Guermazi A, Brice P, de Kerviler EE, Fermé C, Hennequin C, Meignin V, et al. Extranodal Hodgkin disease: Spectrum of disease. Radiographics 2001;21:161-79.  Back to cited text no. 2
    
3.
Gurney KA, Cartwright RA. Increasing incidence and descriptive epidemiology of extranodal non-Hodgkin lymphoma in parts of England and Wales. Hematol J 2002;3:95-104.  Back to cited text no. 3
    
4.
Cen X, Ma M, Guo H, Wu S, Wang Y, Qiu Z, et al. Primary extranodal lymphomas: Analyses of clinical characteristics and misdiagnoses of 139 cases. Beijing Da Xue Xue Bao 2003;35:143-5.  Back to cited text no. 4
    
5.
Wang CC. Primary malignant lymphoma of the oral cavity and paranasal sinuses. Radiology 1971;100:151-3.  Back to cited text no. 5
    
6.
Bloomfield CD, Gajl-Peczalska KJ, Frizzera G, Kersey JH, Goldman AI. Clinical utility of lymphocyte surface markers combined with the Lukes-Collins histologic classification in adult lymphoma. N Engl J Med 1979;301:512-8.  Back to cited text no. 6
    
7.
Royer B, Cazals-Hatem D, Sibilia J, Agbalika F, Cayuela JM, Soussi T, et al. Lymphomas in patients with Sjogren's syndrome are marginal zone B-cell neoplasms, arise in diverse extranodal and nodal sites, and are not associated with viruses. Blood 1997;90:766-75.  Back to cited text no. 7
    
8.
Epstein JB, Epstein JD, Le ND, Gorsky M. Characteristics of oral and paraoral malignant lymphoma: A population-based review of 361 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:519-25.  Back to cited text no. 8
    
9.
Hellman S, Devita V. Cancer Principle of Oncology. 6 th ed. Philadelphia: Lippincott Williams and Wilkins; 2001.  Back to cited text no. 9
    
10.
Khalbuss WE, Grigorian S, Mignone J, D'Agostino HJ. Chest wall abscess: An unusual presentation of Hodgkin's lymphoma. Diagn Cytopathol 2005;33:33-5.  Back to cited text no. 10
    


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