|Year : 2014 | Volume
| Issue : 2 | Page : 407-409
MALT lymphoma at the base of tongue of a 29-year-old woman treated with radiation therapy alone
Jin Ho Song1, Dong Il Sun2, Young Seon Hong3, Gyeong Sin Park4, Yeon Sil Kim1
1 Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University Medical College, Seoul, Korea
2 Department of ENT Head and Neck Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University Medical College, Seoul, Korea
3 Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University Medical College, Seoul, Korea
4 Hospital Pathology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University Medical College, Seoul, Korea
|Date of Web Publication||14-Jul-2014|
Yeon Sil Kim
Department of Radiation Oncology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University Medical College, 505 Banpo-dong, Seocho-gu, Seoul - 137 701
Source of Support: None, Conflict of Interest: None
Mucosa-associated lymphoid tissue (MALT) lymphoma is frequently reported in the gastrointestinal tract (GIT), but the incidence is low in the upper aerodigestive tract. In particular, MALT lymphoma of the tongue is very rare. Only four cases have been reported in the English literature to date. We report a case of 29-year-old woman who had a past history of peripheral T cell lymphoma of the head and neck and a new mass at the right base of tongue 3 years later. An incisional biopsy of the base of tongue revealed a new pathology, one that of extranodal marginal zone B cell lymphoma (MALT lymphoma). After staging work-up, she was diagnosed to be at the Ann Arbor stage IE. She was treated with 30.6 Gy of radiation therapy alone and there was no recurrence after 3 years follow-up.
Keywords: Base of tongue, mucosa-associated lymphoid tissue lymphoma, radiation therapy
|How to cite this article:|
Song JH, Sun DI, Hong YS, Park GS, Kim YS. MALT lymphoma at the base of tongue of a 29-year-old woman treated with radiation therapy alone. J Can Res Ther 2014;10:407-9
|How to cite this URL:|
Song JH, Sun DI, Hong YS, Park GS, Kim YS. MALT lymphoma at the base of tongue of a 29-year-old woman treated with radiation therapy alone. J Can Res Ther [serial online] 2014 [cited 2020 May 29];10:407-9. Available from: http://www.cancerjournal.net/text.asp?2014/10/2/407/136673
| > Introduction|| |
Non-Hodgkin's lymphoma (NHL) is a malignant tumor arising from the lymph nodes and/or other lymphoid tissues. The primary site is usually lymph nodes in three-fourth of patients, but in others it can be extranodal lymphoid tissues. Lymphoid tissue can be also formed in the organs that have mucosa; such as digestive tracts, bronchial tracts, and salivary glands. This formation is called mucosa-associated lymphoid tissue (MALT).  MALT lymphoma is an extranodal malignant tumor arising from this tissue. Since the time it was first reported in 1983 by Isaacson and Wright, this category of disease was not included in the Working Formulation for Clinical Usage, until it was reclassified as a part of 'the marginal zone B cell lymphoma' in the REAL classification in 1994. , MALT lymphoma is frequently reported in the gastrointestinal tract (GIT), but is rare in the upper aerodigestive tract, with only four cases of MALT lymphoma of tongue reported to our knowledge. ,,,
We report a case of 29-year-old woman with a past history of peripheral T cell lymphoma, who developed a MALT lymphoma in the base of tongue 3 years later and was successfully treated with radiation therapy.
| > Case report|| |
A 29-year-old woman with odynophagia visited our hospital. She had been previously diagnosed with peripheral T cell lymphoma (PTCL) 3 years ago and had been successfully treated with chemotherapy. She had no other special past, social, and family history.
At the time when she was diagnosed with PTCL, her chief complaint had been palpable masses on both sides of the neck. Physical examination revealed a bulging mass on the left side of the oropharyngeal wall and, two hard and fixed masses of 3 and 7 cm in length were palpable on both sides neck. PTCL was diagnosed in the excised mass from the right neck. The immunohistochemistry (IHC) results showed CD45RO (+), CD20 (−), CD3 (−), CD15 (−), CD30 (−), and molecular cytogenetics revealed positive results indicating rearrangement in the T cell receptor (TCR) gene [Figure 1]. The neck computed tomography (CT) and positron emission tomography-CT (PET-CT) results showed that the mass mainly involved areas from the left nasopharyngeal to oropharyngeal lateral wall. Multiple enlarged lymph nodes were observed along both internal jugular neck chains. There were no other specific findings in the staging work up, so she was diagnosed as PTCL, of the Ann Arbor stage II. She was treated chemotherapy consisting of six cycles of rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). Complete remission was achieved after chemotherapy and regular follow-up studies showed no evidences of recurrence.
|Figure 1: The histopathology of peripheral T cell lymphoma. The specimen was from the neck lymph node. (a) Diffuse infiltrates of large atypical lymphoid cells with pleomorphic nuclei. The lymphoma cells are (b) positive for CD45RO, a T cell marker, (c) negative for CD20, a B cell marker and (d) negative for CD3, a primitive T cell marker|
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Three years later, she visited our hospital again with odynophagia that had been progressed for 1 month. Physical examination and CT of the neck showed a new mass arising from the right base of tongue which also involved the right oropharyngeal wall [Figure 2]. An incisional biopsy showed a different pathology from the previous disease but one that of an extranodal marginal zone B cell lymphoma (MALT lymphoma). The IHC results were CD45RO (−), CD20 (+), CD79a (+), CD3 (−) and Bcl2 (+) [Figure 3], which corresponded to MALT lymphoma.
|Figure 2: Fiberscopy and neck CT findings of mucosa-associated lymohoid tissue lymphoma. (a) A prominent hypodense lobulate lesion involves the right base of tongue and the oropharyngeal wall. (b) No abnormal lymph nodes were seen|
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|Figure 3: The histopathology of MALT lymphoma. The specimen was from the tongue base biopsy. (a) Diffuse infiltrates of abnormal lymphoid cells in the epithelium, mainly consisting of centrocyte-like cells. Immunostaining are (b) positive for CD20, a B cell marker, (c) negative for cytokeratin, an epithelial cell marker (only the epithelial cells show positive results) and (d) negative for CD3, a T cell marker|
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Endoscopy; bone marrow biopsy; and CT of the neck, chest and abdomen were performed again for new staging. There was no evidence of regional or distant metastasis, and she was diagnosed as having extranodal marginal zone B cell lymphoma on the base of tongue of the Ann Arbor stage IE. The oncologist consulted our department for radical radiation therapy.
In simulation for radiation therapy, the neck was immobilized with an aquaplast mask and CT scan with contrast enhancement was performed. The main tongue mass was contoured as GTV (gross tumor volume) and the neck lymphatic chains from level I to level V was contoured as clinical target volume (CTV). The planning target volume was defined with a CTV plus 1.0-1.5 cm margin. The treatment plan was designed with bilateral fields in the upper neck (above the hyoid bone) and an anterior port with midline shield in the lower neck [Figure 4]. Six MV photons were used in the treatment. She was treated daily with from 180 cGy up to 3060 cGy of radiation, five times a week. Chemotherapy was not given.
|Figure 4: A simulation film of radiation treatment field and isodose line display. (a) Radiation fields consisted of two bilateral fields in the upper neck and an anterior port with a midline shield in the lower neck, (b) An isodose line is displayed in entire neck region|
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During the radiation therapy, she complained only of Grade I xerostomia. Other acute side effects, such as mucositis or decreased performance, did not occur. Not only the symptoms of odynophagia, but also xerostomia disappeared after 2-months' follow-up. Physical examination and imaging studies taken after 3 months of the completion of radiation therapy showed that the mass had regressed completely. Complete remission state was maintained in 38 months follow-up examination.
| > Discussion|| |
MALT lymphoma of the tongue is a very rare disease. Head and neck is the second most prevalent site of extranodal lymphoma after the GIT. However, a diffuse large B cell lymphoma is the common histopathology and the Waldeyer's ring, thyroid gland, and salivary glands are its most common sites. , MALT lymphoma generally arises in the lymphoid tissue that has been usually acquired as a result of pre-existing chronic inflammatory disorders, such as Helicobacter pylori infection of the stomach. Despite the fact that, MALT is normally present, such as in the tonsil or the Peyer's patches, the incidence of MALT lymphoma is very low. ,,
There are four cases of MALT lymphoma of tongue that have been reported around the world to our knowledge. ,,, One case reported of a 43-year-old man with a 1.9 × 1.0 cm tongue tumor. He underwent local resection and he is alive without recurrences at 6 months.  Another case is of a 62-year-old woman who was treated with conservative care only. The lymphoma spread to her orbital cavity and bone marrow after 5 years. She was treated with chemotherapy after 7 years of diagnosis and was alive with her disease in good condition 10 years later.  The other cases were of a 61 and 80-year-old women, both of whom also underwent only surgical resections and had no recurrences. ,
Our report concerns the case of a young woman with a past history with peripheral T cell lymphoma in the head and neck region. Although the site of involvement was close and there are some reports of peripheral T cell lymphoma that can mimic the extranodal marginal zone B cell lymphoma, the pathology of the two sites showed definitely different morphologies and immunohistochemical results.  MALT lymphomas tend to remain localized for prolonged periods and patients commonly present with a long history.  So local therapy alone, either surgery or radiotherapy, may be curative.  Deinbeck et al.,  treated 30 marginal zone lymphoma patients with median 40 Gy of radiation. Ninety percentage of these patients had extranodal presentation, and there was no infield recurrence after median 103 months follow-up.
However, there are also some reports that showed extraintestinal MALT lymphomas had more probability of dissemination and multiorgan involvement.  Ueda et al., reported nongastric MALT lymphoma patients had worse progression free survival than gastric MALT lymphoma, even when treated with rituximab-containing chemotherapy. 
So whether or not our treatment, radical radiation therapy on the tumor and regional lymphatics, was adequate is controversial. We treated the patient with radiation therapy alone without chemotherapy because she already had a past history of CHOP chemotherapy. We included the entire neck lymphatics because the base of tongue is a site of abundant lymphatics and have a high probability of lymph node metastasis. Since it is not known whether or not our treatment was enough, there needs to be a more long-term follow-up. Nevertheless, we expect that the treatment outcome would be favorable because the previous reports of the MALT lymphoma of tongue treated by surgery alone have shown good long-term results and our patient acquired complete remission early, which has lasted for more than 3 years.
| > References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]