Head and Neck Lymphomas: Tip of the Iceberg?

Author(s): Suresh Babu M.C., Govind Babu.K, Lakshmaiah KC, Lokanatha D, Premalatha C.S., Suma MN, Rajeev LK, Linu Jacob Abraham, Lokesh KN, Rudresha AH, Sunny Garg, Vishwanath Sathyanarayanan

Background: Lymphomas comprise around 5% of all head and neck neoplasms and is the second most common extra nodal non hodgkin’s lymphoma (NHL). However there is sporadic data on this entity from the subcontinent and hence we undertook this study. Methodology: This retrospective observational study was conducted at a tertiary care oncology center in India on diagnosed cases of NHL between January 2007 and December 2013. All patients were diagnosed based on histopathology and immunohistochemistry. Staging work up was done in all patients. Patients were considered as primary Head and Neck lymphomas if there was head and neck as the predominant site with or without regional lymph node involvement. Results: A total of 39 patients were studied. The age at presentation ranged from 29 to 78 years. The most common site of presentation was oral cavity (26%; n=10), followed by parotid and thyroid (18% each; n=7), eye (12%, n=5), maxilla (8%; n=3), paranasal sinuses (8%; n-=3) cheek (8%, n=3), and nasal cavity (2%, n=1). 41% (n=16) cases were in stage I, 43% (n=17) in stage II, 3% (n=1) in stage III, and 13% (n=5) were in stage IV. Most common histology was DLBCL (71%; n=28), followed by plasmablastic (10%; n=4), marginal zone (8%, n=3), mantle cell (3%; n=1), follicular lymphomas (5%; n=2), and NK/T cell lymphoma (3%; n=1). Most of the patients were of low risk (67%; n=26), followed by intermediate (23%; n=9), and high risk (10%; n=4). Patients were treated with anthracycline based chemotherapy +/- radiotherapy. In this study, stage I and stage II patients had a better prognosis and overall survival, median OS 28 months and 11 months, respectively. In stage III and IV, it was 7 and 3 months, respectively. According to site, the best median overall survival was seen with parotid (27 m), paranasal sinus (26m), and oral cavity (23 m), followed by thyroid (18 m) nasal cavity (17 m), maxilla (11 m), eye (8 m), and cheek (7 m). Conclusions: Head and neck lymphoma is probably the tip of the iceberg and is an undereported entity.

1. Boring CC, Squires TS, Tong T (1993). Cancer statistics. CA Cancer J Clin 43: 7–26. http://dx.doi.org/10.3322/canjclin.43.1.7
2. Urquhart A, Berg R (2001). Hodgkin’s and non-Hodgkin’s lymphoma of the head and neck. Laryngoscope 111: 1565– 1569. http://dx.doi.org/10.1097/00005537-200109000-00013
3. Zapater E, Baga´ n JV, Campos A, Armengot M, Abril V, Basterra J (1996). Non-Hodgkin’s lymphoma of the head and neck in association with HIV infection. Ann Otolaryngol Chir Cervicofac 113: 69–72.
4. Vega F, Lin P, Medeiros J (2005). Extranodal lymphomas of the head and neck. Ann Diagn Pathol 9: 340–350. http://dx.doi.org/10.1016/j.anndiagpath.2005.09.020
5. Harris NL, Jaffe ES, Stein H, Isaacson PG (1994). A revised European–American classification of lymphoid neoplasm: a proposal from the International Lymphoma Study Group. Blood 84: 1361–1392.
6. Nathu RM, Mendenhall NP, Almasri NM, Lyunch JW (1999). Non-Hodgkin’s lymphoma of the head and neck: a 30-year experience at the University of Florida. Head Neck 21: 247–254. http://dx.doi.org/10.1002/(sici)1097-0347(199905)21:3%3C247::aid-hed10%3E3.0.co;2-6
7. Talmon Y, Gilbey P, Falah R, Samet A, Cohen H, Khoury J (2007). Primary B cell lymphoma of the tongue. IMAJ 9: 755–756.
8. Jovanovic MB (2008). An exophytic localized lymphoma of the tongue base. Otolaryngol Head Neck Surg 139: 468–469. http://dx.doi.org/10.1016/j.otohns.2008.05.011
9. Feinberg SM, Ou SH, Gu M, Shibuya TY (2007). Burkitt’s lymphoma of the base of the tongue: a case report and review of the literature. Ear Nose Throat J 86: 356–360.
10. Levine AM (1992). Acquired-immunodeficiency syndromerelated lymphoma. Blood 80: 8–20.
11. Weber A, Rahemtullah A, Ferry JA (2003). Hodgkin and nonHodgkin lymphoma of the head and neck: clinical, pathologic, and imaging evaluation. Neuroimaging Clin N Am 13: 371–392. http://dx.doi.org/10.1016/s1052-5149(03)00039-x
12. Lima I, Carneiro AS, Amorim CA, Santiago MB (2008). Hodgkin lymphoma as a complication of primary Sjo¨ gren’s syndrome. Mod Rheumatol 18: 200–202. http://dx.doi.org/10.1007/s10165-008-0030-7
13. Coltrera MD (1999). Primary T-cell lymphoma of the thyroid. Head Neck 21: 160–163. http://dx.doi.org/10.1002/(sici)1097-0347(199903)21:2%3C160::aid-hed10%3E3.0.co;2-f
14. Cheung MM, Chan JK, Lau WH et al (1998). Primary nonHodgkin’s lymphoma of the nose and nasopharynx: clinical features, tumor immunophenotype, and treatment outcome in 113 patients. J Clin Oncol 16: 70–77.
15. Cuadra-Garcı´a I, Proulx GM, Wu CL et al (1999). Sinonasal lymphoma: a clinicopathologic analysis of 58 cases from the Massachusetts General Hospital. Am J Surg Pathol 23: 1356–1369.
16. Shima N1, Kobashi Y, Tsutsui K et al. Extranodal non-Hodgkin’s lymphoma of head and neck. A clinicopathologic study in the Kyoto-Nara area of Japan. Cancer. 1990 Sep 15;66(6):1190-7 http://dx.doi.org/10.1002/1097-0142(19900915)66:6%3C1190::aid-cncr2820660619%3E3.0.co;2-u
17. Jacobs C, Hoppe RT. Non-Hodgkin’s lymphomas of head and neck extranodal sites. Inr J Radiat Oncol Biol Phys 1985; 11:357-364 http://dx.doi.org/10.1016/0360-3016(85)90158-0
18. Economopoulos T, Asprou N, Stathakis N, Fountzilas G, Pavlidis N, Papaspyrou S, Dervenoulas J, Belia M, Papageorgiou E, Theoharis D, et al Primary Extranodal Non-Hodgkin’s Lymphoma of the Head and Neck..Oncology. 1992;49(6):484-8. http://dx.doi.org/10.1159/000227097
19. Conley SF, Staszak C, Clamon GH, Maves MD. Non-Hodgkin’s lymphoma of the head and neck: The University of Iowa experience. Laryngoscope 1987; 97:291-300. http://dx.doi.org/10.1288/00005537-198703000-00007
20. Wong DS, Fuller LM, Butler JJ, Shullenberger CC. Extranodal- non-Hodgkin’s lymphomas of the head and neck. AJR 1975: 123:471- 481. 6 http://dx.doi.org/10.2214/ajr.123.3.471
21. Etemad-Moghadam S, Tirgary F, Keshavarz S, Alaeddini M. Head and neck non-Hodgkin's lymphoma: a 20-year demographic study of 381 cases. Int J Oral Maxillofac Surg. 2010 Sep;39(9):869-72. doi: 10.1016/j.ijom.2010.03.029. Epub 2010 Jun 9. http://dx.doi.org/10.1016/j.ijom.2010.03.029
22. Liang R, Ng RP, Todd D, Choy D, Khoo RKK, Ho FCS. Man- agement of stage 1-11 diffuse aggressive non-Hodgkink lymphoma of the Waldeyer’s ring: Combined modality therapy versus radiotherapy alone. Hematol Oncol 1987; 5:223-230. http://dx.doi.org/10.1002/hon.2900050309
23. Nissen NI, Ersboll J, Hansen HS et al. A randomized study of radiotherapy versus radiotherapy plus chemotherapy in stage 1-11 non- Hodgkin’s lymphomas. Cancer 1983; 52: 1-7. http://dx.doi.org/10.1002/1097-0142(19830701)52:1%3C1::aid-cncr2820520102%3E3.0.co;2-m
24. Teshima T, Chatani M, Hata K et al. Radiation therapy for pri- mary non-Hodgkin’s lymphoma of the head and neck in stage 1-11, Strahlenther Onkol 1986; 162:478-483.
25. Cabanillas F, Bodey GP, Freireich EJ. Management with che- motherapy only of stage I and II malignant lymphoma of aggressive histologic types. Cancer 1980; 46:2356-2359 http://dx.doi.org/10.1002/1097-0142(19801201)46:11%3C2356::aid-cncr2820461107%3E3.0.co;2-x