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Year : 2012  |  Volume : 8  |  Issue : 1  |  Page : 135-137

Primary diffuse large B cell lymphoma of the base of tongue

1 Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
2 Department of Otorhinolaryngology, Inha University School of Medicine, Incheon, Korea
3 Department of Pathology, Inha University School of Medicine, Incheon, Korea
4 Department of Internal Medicine, Konkuk University Medical Center, Chungju, Korea

Date of Web Publication19-Apr-2012

Correspondence Address:
Moon Hee Lee
Department of Internal Medicine, Inha University Hospital and College of Medicine, 7-206, 3rd st. Shinheuong-dong, Jung-gu, Incheon 400-711
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.95195

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 > Abstract 

Primary non-Hodgkin's lymphoma of tongue is very rare. We report a case of an elderly female who presented with a mass lesion and pain primarily involving the tongue and was diagnosed with diffuse large B cell lymphoma. Computed tomography revealed a 3-cm enhanced mass localized to the right tongue base. The patient was treated with three cycles of combination rituximab and CHOP chemotherapy, followed by external beam radiotherapy. The patient had a complete response after treatment, and three years following treatment, the patient has no signs of recurrence.

Keywords: Lymphoma, rituximab, tongue

How to cite this article:
Lim JH, Lim JY, Kim YM, Kim CS, Choi SJ, Yi HG, Choi WG, Lee MH. Primary diffuse large B cell lymphoma of the base of tongue. J Can Res Ther 2012;8:135-7

How to cite this URL:
Lim JH, Lim JY, Kim YM, Kim CS, Choi SJ, Yi HG, Choi WG, Lee MH. Primary diffuse large B cell lymphoma of the base of tongue. J Can Res Ther [serial online] 2012 [cited 2020 Jul 9];8:135-7. Available from: http://www.cancerjournal.net/text.asp?2012/8/1/135/95195

 > Introduction Top

Although lymphomas represent the third most common group of malignant lesions of the oral cavity, following squamous cell carcinomas and salivary gland neoplasms, the incidence is only 3-5%. [1] Non-Hodgkin's lymphoma (NHL) of the tongue is extremely rare. Primary oral cavity lymphomas account for only 1% of all lymphomas and 2-12% of extranodal lymphomas, malignant lymphoma of the tongue even rarer. [2],[3],[4] Primary oral cavity lymphomas can arise from Waldeyer's ring, which is rich in lymphoid tissue, or less frequently, from an extranodal site. The most frequent intraoral sites for lymphomas are the hard palate, vestibule, and gingival. [1],[5] Most of the reported few cases of primary extranodal NHL of the tongue had associated cervical lymph node involvement and manifested as an ulcerated exophytic lesion. Primary NHL of the tongue is a very rare diagnosis. With these considerations in mind, we report a patient who presented for evaluation of a tongue mass which was diagnosed as diffuse large B cell lymphoma without lymph node involvement.

 > Case Report Top

A 74-year-old woman was admitted to the Head and Neck Surgery Department of our hospital with a two-month history of a rapidly growing, large mass involving the right half of the dorsal surface of the tongue. The medical and family histories were negative for significant disorders.

The results of laboratory analyses obtained on admission were as follows: white cell count, 8,200/μl; hemoglobin, 11.6 g/dl; platelet count, 213,000/μl; lactate dehydrogenase, 397 U/l (reference range, 180-460 U/l); calcium, 10.1 mg/dl; uric acid, 6.6 mg/dl; blood urea nitrogen, 14.8 mg/dl; creatinine, 0.9 mg/dl; aspartate aminotransferase, 17 IU/l; and alanine transaminase, 11 IU/l. No lymphadenopathy or hepatosplenomegaly was detected on physical examination. Inspection of the oral cavity revealed a large mass lesion. Computed tomography (CT) scan of the oropharynx exhibited a mass arising from the base of the right aspect of the tongue and extending to the right oropharynx and left of the midline of the base of the tongue. There was no significant lymph node enlargement in the neck area. A CT of the abdomen, pelvis and chest also showed that there were no enlarged lymph nodes in trunk. A biopsy was performed and the specimen obtained from the right tongue mass revealed hyper cellularity and the presence of numerous large nuclei. Histologic analysis showed diffuse infiltrates and atypical cells consistent with a lymphoma [Figure 1]. Immunohistochemical staining of the lymphoma cells showed reactivity for CD20 and Bcl 6. The histopathologic and immunophenotypic findings established the diagnosis of a diffuse large B cell lymphoma. The bone marrow examination was unremarkable. Serologic testing for HIV was negative. A positron emission tomography (PET) CT was performed as part of the staging work-up and there were no other lesions, with the exception of the right tongue hypermetabolic lesion (maximal standardized uptake value, 38.32; [Figure 2]). The patient received a total of three cycles of chemotherapy with combination rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP), followed by external beam radiotherapy (total radiation dose, 3600 cGy in 20 fractions). Evaluation of the clinical response with PET-CT after chemotherapy followed by radiotherapy demonstrated a complete response. The patient is under follow up for three years with no evidence of recurrence.
Figure 1: (a) Pathologic finding of tongue mass area biopsy showing atypical lymphoid cell proliferation (H&E, ×400). (b) CD20 immunostain of diffuse large cell B cell lymphoma of the tongue

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Figure 2: Oropharynx CT scan (a) showing mass with well-defi ned margins and PET-CT (b) showing hypermetabolic lesion of the tongue mass. Maximal standard uptake value of the lesion in PET- CT was 38.32

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 > Discussion Top

Malignant lymphomas account for 3.5% of all oral malignancies. [6] Only a few cases of primary lymphomas in the oral cavity have been reported in the English literature. The predominant histologic type of oral lymphomas is difficult to discern because of the small number of cases described. The hardship to acquire sufficient biopsy for distinguishing lymphoma subtype also makes difficult in accurate diagnosis. The age of presentation of oral lymphomas is highly variable. The clinical features of primary lymphomas involving the tongue cannot be defined due to the very low incidence and the unusual characteristics. Our patient presented with local painful swelling without ulcerations of the mucosa. Involvement of the musculature of the tongue by lymphomas can cause restriction of movement, dysarthria, and dysphagia; however, our patient did not complain of these symptoms. Little is known about the etiologic factors for primary lymphomas involving the oral cavity. Some cases of oral lymphomas, such as plasmablastic lymphomas, have been reported in association with the acquired immune deficiency syndrome. [7],[8] The limited number of cases of oral cavity lymphomas hinders an understanding of the biological behavior and therapeutic options. Our patient in this report was HIV-negative.

Neither an absolute strategy nor guidelines for the treatment of primary extranodal lymphomas of the tongue has been clearly delineated. [9] Although it has been suggested that treatment of oral cavity lymphomas should include radiotherapy alone or surgical excision for biopsy followed by radiotherapy without systemic chemotherapy in cases with solitary or localized lesions, the efficacy of such recommendations has not been validated because of the limited data. [10] Some patients are treated with chemotherapy with or without radiotherapy, as was our patient. The standard treatment for patients with above the level of stage II diffuse large B-cell lymphoma except primary extranodal organ non-hodgkin lymphoma had been combination chemotherapy with CHOP. The addition of monoclonal antibody to CD20 (rituximab) to CHOP has been found to improve the complete response rate and prolongs the event-free and overall survival in patients with diffuse large B-cell lymphoma, without a clinically significant increase in toxicity. [11] To more accurately define the different therapeutic options for the primary tongue lymphomas, more prospective, randomized studies are needed that involve a large number of cases and multi-institutional trials. We selected combination rituximab and CHOP chemotherapy, even though our patient was elderly, because our patient had a relatively large mass in the tongue (> 3 cm by CT) and a good performance status (ECOG PS 1) without additional co-morbidity to prohibit systemic chemotherapy.

In conclusion, we have presented a rare case of extranodal primary NHL of the tongue. Patients with tongue lesions have a potentially wide spectrum of benign and malignant lesions. The diagnosis of this condition is important. A biopsy of the tongue should be obtained to rule out suspicious variants, including malignant lymphomas.

 > Acknowledgments Top

This work was supported by INHA UNIVERSITY Research Grant.

 > References Top

1.Zapater E, Bagan JV, Carbonell F, Basterra J. Malignant lymphoma of the head and neck. Oral Dis 2010;16:119-28.  Back to cited text no. 1
2.Terada T. Primary non-Hodgkin B-cell lymphoma of the tongue. Br J Oral Maxillofac Surg 2010;49:e18-9.  Back to cited text no. 2
3.Fukuda Y, Ishida T, Fujimoto M, Ueda T, Aozasa K Malignant lymphoma of the oral cavity: clinicopathologic analysis of 20 cases. J Oral Pathol 1987;16:8-12.  Back to cited text no. 3
4.Feinberg SM, Ou SH, Gu M, Shibuya TY. Burkitt's lymphoma of the base of the tongue: a case report and review of the literature. Ear Nose Throat J 2007;86:356-60.  Back to cited text no. 4
5.Kemp S, Gallagher G, Kabani S, Noonan V, O'Hara C. Oral non-Hodgkin's lymphoma: review of the literature and World Health Organization classification with reference to 40 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:194-201.  Back to cited text no. 5
6.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. 6
7.Lim JH, Lee MH, Lee MJ, Kim CS, Lee JS, Choi SJ, et al. Plasmablastic lymphoma in the anal canal. Cancer Res Treat 2009;41:182-5.  Back to cited text no. 7
8.Delecluse HJ, Anagnostopoulos I, Dallenbach F, Hummel M, Marafioti T, Schneider U, et al. Plasmablastic lymphomas of the oral cavity: A new entity associated with the human immunodeficiency virus infection. Blood 1997;89:1413-20.  Back to cited text no. 8
9.Guastafierro S, Falcone U, Celentano M, Cappabianca S, Giudice A, Colella G. Primary mantle-cell non-Hodgkin's lymphoma of the tongue. Int J Hematol 2008;88:206-8.  Back to cited text no. 9
10.Mohammadianpanah M, Ahmadloo N, Nazer Mozaffari MA, Mosleh-Shirazi MA, Omidvari S, Mosalaei A. Primary localized stages I and II non-Hodgkin's lymphoma of the nasopharynx: A retrospective 17-year single institutional experience. Ann Hematol 2009;88:441-7.  Back to cited text no. 10
11.Coiffier B, Lepage E, Briere J, Herbrecht R, Tilly H, Bouabdallah R, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med 2002;346:235-42.  Back to cited text no. 11


  [Figure 1], [Figure 2]

This article has been cited by
1 Primary diffuse large B cell lymphoma of the base of tongue: A rare entity
Aminder Singh,Neena Sood,Harpreet Kaur,Bhavna Garg
American Journal of Otolaryngology. 2014;
[Pubmed] | [DOI]


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