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Cross-sectional imaging evaluation of atypical and uncommon extra-nodal head and neck Non-Hodgkin lymphoma: Case series
*Corresponding author: Ayman Nada, Department of Radiology, University of Missouri, Columbia, Missouri, United States. anada@health.missouri.edu
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Received: ,
Accepted: ,
How to cite this article: Mahmoud EM, Howard E, Ahsan H, Cousins JP, Nada A. Cross-sectional imaging evaluation of atypical and uncommon extra-nodal head and neck Non-Hodgkin lymphoma: Case series. J Clin Imaging Sci 2023;13:6.
Abstract
Extra-nodal Non-Hodgkin lymphoma (ENHL) of the head and neck is not uncommon and has variable clinical and imaging presentations. It represents about 25% of extra-nodal lymphomas. In addition, lymphoma is the third most common malignancy of the head and neck just after squamous cell carcinoma (SCC) and salivary gland neoplasms. Unlike SCC, ENHL usually presents as a well-defined mass in the oral cavity, along the pharyngeal mucosa, sinonasal cavity, orbit, and other different neck spaces. One of the common presentations of ENHL is the glandular type which can arise within the salivary or thyroid glands as marginal zone non-Hodgkin lymphoma. ENHL can infiltrate the bone resembling high grade osseous malignancies. Rarely, ENHL can present as perineural spread without definitive mass and manifest clinically with several neuropathies. In this case series, we presented different imaging features and presentation of ENHL of the head and neck. The knowledge of various presentations of ENHL of the head and neck can help early diagnosis and prompt management of these patients’ population.
Keywords
Computed tomography
Magnetic resonance imaging
Head and neck
Non-Hodgkin lymphoma
Extra-nodal
INTRODUCTION
Lymphoma is a malignant neoplastic proliferation of the immune system with 10% classified as Hodgkin and 90% as non-Hodgkin lymphoma (NHL). Hodgkin’s lymphoma occurs mainly in the lymph nodes, typically presenting with contiguous cervical, supraclavicular, and mediastinal lymphadenopathy. Only 4–5% of Hodgkin lymphoma is extra-nodal.[1-4] In contrast, NHLs are found in extra-nodal regions outside the lymphoid system in 40% of cases. The most frequently involved extra-nodal location of lymphoma in the head and neck is Waldeyer’s ring, a mucosal pharyngeal space rich in lymphatic tissue, composed of the palatine tonsils, lingual tonsils, and nasopharyngeal tonsils.[1] Other common extra-nodal locations include the oral cavity, sinonasal cavities, orbit, salivary, and thyroid glands.[1,5] There are numerous subtypes of NHL, but in the head and neck, the most common subtypes are diffuse large B cell, follicular, mucosa-associated lymphoid tissue (MALT), extra-nodal NK/T cell, Burkitt’s, mantle cell, small lymphocytic, and B cell lymphoblastic lymphomas. The most frequently encountered NHL is diffuse large B cell lymphoma (DLBL), which accounts for 30% of all lymphomas.[1,6] DLBL is often seen in the paranasal sinuses, jaw, and Waldeyer’s ring. Extra-nodal MALT lymphoma is an indolent lymphoma subtype and commonly develops within the thyroid and salivary glands, larynx, and ocular adnexa.[1,7] On the other hand, the aggressive NK/T-cell lymphoma is common in the sinonasal cavity.[1] The incidence of lymphomas is rising, increasing up to 35% in approximately the past 20 years. The increasing prevalence of lymphoma in developed countries may also be attributed to increased percentage of elder people.[8] Lymphoma represents the third most common malignancy in the head and neck region after squamous cell carcinoma and salivary gland neoplasms and accounts for 5% of all head and neck malignant neoplasms. In addition, the head and neck represent the second most common site for extra-nodal lymphomas following the gastrointestinal tract.[9-13] We will present various cases of extra nodal NHLs of the head and neck which occur in different head and neck subsites with diverse presentations.
CASE SERIES
Case 1: Sinonasal lymphoma
A 74-year-old woman presented for the evaluation of right facial pain. She had numbness and tingling feeling of the upper right palate, right cheek, and right lower jaw. Physical examination revealed impaired pinprick sensation on the right side of the face along the distribution of V2 nerve and diffuses hyperreflexia. It was thought to be trigeminal neuropathy due to a demyelinating disease, so magnetic resonance imaging (MRI) of the brain without and with IV contrast was performed. MRI showed asymmetric thickening and enhancement of the right V3 nerve with widening of the right foramen ovale and further extension into the lateral margin of the right cavernous sinus [Figure 1]. From the right cavernous sinus, there is notable thickening and enhancement through V2 nerve within foramen rotundum, and pterygopalatine fossa as well as thickening and enhancement of the right infra-orbital nerve [Figure 1]. This was interpreted as perineural invasion of an occult head and neck tumor, for which positron emission tomography with computed tomography (PET/CT) was performed. PET/CT revealed submucosal avid FDG activity within the medial wall of the right maxillary antrum, extending into the right pterygopalatine fossa [Figure 1]. Excisional biopsy was performed, and pathological evaluation demonstrated diffuse large B-cell lymphoma.
- Sinonasal diffuse large B cell lymphoma in a 74-year-old female. Axial 3D T1 MPRAGE after IV gadolinium administration (a and b) showed asymmetric submucosal enhancement along the medial wall of the right maxillary antrum and within the right retromaxillary space (black arrows). Asymmetric thickening and mass like enhancement of the right V3 nerve at the level of right foramen ovale was noted (white arrow). Coronal (c), and sagittal (d) 3D T1 MPRAGE after IV gadolinium administration confirmed the abnormal thickening and mass enhancement at the right Meckle’s cave, right foramen ovale, right masticator space and right retromaxillary spaces (arrows). Axial high-resolution non-contrast CT of the sinuses (e) revealed demineralization and lytic changes of the right maxillary medial wall, corresponding to abnormal enhancement on MRI. Axial fused PET/CT image at the level of maxillary antra (f) confirmed hypermetabolic mass along the right maxillary medial wall.
Case 2: Prevertebral lymphoma
A 58-year-old man presented to the neurosurgery spine clinic with a non-radiating neck pain of more than 1-year duration. The neck pain was aggravated by coughing or moving his neck and gradually getting worse with frequent spasms. The patient felt that the spasm involved both sides but was worse on the right. He had been placed on antispasmodic medication and gabapentin with minimal improvement of his symptoms. He denied any difficulty using his hands, any difficulty ambulating, and reported no bowel or bladder dysfunction. MRI spine revealed a large prevertebral enhancing mass extending into upper cervical spine with circumferential cord compression [Figure 2]. CT guided biopsy was performed and showed diffuse large B-cell lymphoma.
- Prevertebral diffuse large B cell lymphoma in a 58-year-old male. Sagittal T2 (a) and T1 with fat saturation after IV gadolinium administration (b) showed large ovoid T2 hyperintense, enhancing mass within the prevertebral space (black arrows). Abnormal bone marrow enhancement of C2 vertebral body, suspicious for osseous origin or infiltration by the soft-tissue mass. Sagittal T1 with fat saturation after IV gadolinium administration also showed significant intraspinal extension with large enhancing mass compressing the spinal cord (white arrow). Axial T1 with fat saturation after IV gadolinium administration (c), and high-resolution non-contrast CT in bone window at the same level (d) confirmed the osseous erosive changes (arrow heads), and large enhancing intraspinal component (white arrows).
Case 3: Buccal space marginal zone lymphoma
A 58-year-old man presented with right buccal swelling. The patient had been diagnosed with marginal zone lymphoma of the stomach 5 years earlier. The mass was superficial and easily biopsied. Pathological evaluation confirmed relapsed marginal zone lymphoma of the right buccal submucosa. CT neck with intravenous (IV) contrast demonstrated a well-circumscribed enhancing mass centered on the right buccal mucosa [Figure 3].
- Right buccal marginal zone lymphoma in a 58-year-old male. Coronal (a) and axial (b) contrast enhanced images of the CT neck showed enhancing right buccal submucosal mass with involvement of the inferior gingivobuccal sulcus (arrows).
Case 4: Glandular lymphoma
Case 4a: Thyroid lymphoma
A 12-year-old man presented for the evaluation of a thyroid goiter, accompanied by her parents. Her mother reported a rapidly enlarging anterior neck mass starting 2 months before the presentation. The patient endorsed heat intolerance, dry skin of the arms bilaterally, fatigue, and increased forgetfulness in the past few months. She denied any fevers, night sweats, or weight loss. The patient’s anti-TPO antibodies were 1011 IU/mL, and TSH was 1.04 mIU/L. Thyroid ultrasound revealed a highly heterogeneous appearance of the thyroid gland, without any discrete nodules [Figure 4]. The right lobe measured 6.53 cm in its greatest dimension, and left lobe measured 5.31 cm. Fine-needle aspiration cytology was performed from the left lobe which revealed atypical lymphocytes suspicious for lymphoma. However, there was no sufficient material for flow cytometry. The patient underwent left thyroid lobectomy. Histopathological analysis showed stage IE pediatric marginal zone lymphoma with background of Hashimoto’s thyroiditis. Following diagnosis with lymphoma, the patient underwent 18FDG-PET/CT scan for lymphoma staging. 18FDG-PET/CT demonstrated multiple FDG avid enlarged lymphadenopathy involving right level 2B, level 3, and supraclavicular lymph nodes.
- Thyroid marginal zone lymphoma in a 12-year-old female. Axial (a) and coronal (b) contrast enhanced images of the CT neck showed marked diffuse enlargement of the right thyroid lobe with diffuse heterogeneous enhancement and non-discrete masses (arrows). Note left thyroidectomy.
Case 4b: Parotid lymphoma
A 60-year-old woman presented with right parotid gland swelling. The mass was firm and slightly tender. She underwent a CT which showed a right parotid gland heterogeneously enhancing mass without obvious vascular nor mandibular invasion [Figure 5]. Ultrasound guided fine needle aspiration was performed but non-diagnostic. Then, an incisional biopsy of the right parotid mass was performed. The final pathology from the right parotid mass was positive for diffuse large B-cell lymphoma. PET/CT scan was done and showed increased uptake in the right posterior parotid gland with an SUV of 30.8, also there was uptake in the left external iliac lymph nodes with max SUV of 7.9.
- Right parotid diffuse large B cell lymphoma in a 60-year-old female. Axial (a) and sagittal (b) contrast-enhanced images of the CT neck at the level of right parotid gland showed an irregular enhancing mass within the deep lobe of the right parotid gland (arrows). The mass contacts the right retromandibular vein and abuts the inferior wall of right cartilaginous external auditory canal.
Case 5: Carotid space lymphoma
A 65-year-old man presented to clinic for the evaluation of a left neck mass. The patient first noticed it 1.5 months earlier and thought he had a bug bite on his left neck, but the area of swelling did not go down. His left neck had been feeling stiff and sore. He denied any associated tenderness or discomfort, otalgia, dysphagia, odynophagia, voice changes, other neck lumps or bumps, or unintentional weight loss. Flexible laryngoscopy was performed and revealed normal pharyngeal spaces without masses or concerning findings. The left neck mass examined with ultrasound which showed homogenous hypoechoic mass with increased vascular flow appreciated throughout the mass. No evidence of vascular invasion.
CT neck was obtained which revealed a well circumscribed oblong shaped enhancing mass within the left carotid space deep to the sternocleidomastoid muscle [Figure 6]. Contrast-enhanced MRI of the neck showed large lobulated mildly enhancing mass within the left carotid space, mildly compressing, and medially displacing the left carotid space vessels, that is, common, and internal carotid arteries as well as internal jugular vein [Figure 6]. The mass showed significant restricted diffusion on diffusion-weighted imaging (DWI) with decreased apparent diffusion coefficient (ADC) value [Figure 6]. Histopathological evaluation revealed high grade B cell lymphoma, NOS.
- Left carotid space diffuse large B cell lymphoma in a 65-year-old male. Coronal T1 (a) and T1 with fat saturation after IV gadolinium administration (b) showed large lobulated mildly enhancing mass within the left carotid space medially displacing and compressing the left internal jugular vein (arrows). The mass has significant predominantly homogeneous restricted diffusion on diffusion weighted image (c), and ADC (d). Axial PET (e), and fused PET/CT (f) images demonstrated significant hypermetabolism of the mass with increased FDG uptake (arrows).
Case 6: Osseous (facial, skull base and calvarial) lymphoma
A 24-year-old man presented for the evaluation of a right submandibular swelling that had been present for a couple of weeks. The patient denied pain, drainage, fever, chills, sweats, nausea, vomiting, or other enlarged lymph nodes. He stated that he had a tightness of the right lower jaw. There were no overlying skin changes nor specific exacerbating or relieving factors. Physical examination revealed a non-tender subcutaneous swelling of his left forehead across to his temple and the parietal scalp without overlying skin wounds or changes. In his right upper neck, there was a diffuse subcutaneous enlargement which was contiguous with the parotid tail without overlying skin change. High-resolution contrast-enhanced CT neck showed diffuse osseous infiltration of the left frontal, and temporal calvarial bones, left sphenoid, and posterolateral orbital wall as well as the left zygomatic arch [Figure 7]. The right submandibular gland was hypertrophied with bilateral cervical lymphadenopathy.
- Multifocal calvarial, skull base, and facial osseous high-f diffuse large B cell lymphoma in a 24-year-old male. Axial T2 (a) and axial 3D T1 MPRAGE after IV gadolinium administration (b) showed diffuse expansion, thickening and infiltration of the left fronto-temporal calvarial bones, associated with extra-cranial and intracranial enhancing masses (arrows). Coronal diffusion weighted image (c), and ADC (d), showed characteristic restricted diffusion of associated soft-tissue components. Axial high-resolution non-contrast CT head in bone window (e) demonstrated permeative pattern of osseous infiltration of the left fronto-temporal calvarial bones (arrows). Axial PET image (f) confirmed hypermetabolic activity of the mass (arrow).
The findings were concerning for osteomyelitis and reactive lymphadenopathy. The patient underwent contrast-enhanced MRI of the neck for further confirmation and characterization of CT findings. MRI demonstrated diffuse infiltration of the osseous structures with significant reduced diffusion and extra-osseous extra/intra-cranial enhancing masses without abscess formation. MR findings raise suspicion of underlying neoplastic process rather than inflammatory/infectious process. Core-needle biopsy was performed. Histopathological evaluation demonstrated high-grade B-cell lymphoma.
DISCUSSION
Extra-nodal non-Hodgkin lymphoma (ENHL) of the head and neck represents a diagnostic challenge for clinicians, radiologists, and even pathologists because it has a wide spectrum of presentations clinically and radiologically.[10-12,14] This diagnostic dilemma is even more relevant as the prevalence of lymphoma is rising. We described atypical and uncommon presentations of various types of ENHL within the head and neck. In our cohort, ENHL of the head and neck manifested as a subtle submucosal mass in the nasal cavity with extensive perineural spread. Other cases presented as a well-defined mass within the prevertebral, buccal, or carotid spaces. We also described osseous lymphoma that appeared as aggressive and infiltrative mass within the mandible and calvarium. Given the wide variety in clinical and radiologic presentations of head and neck lymphomas, it should be virtually excluded in any patients presented with nodal or extranodal mass in the head and neck region.[2,11,15,16] Knowledge of predisposing factors and various radiological signs helps to suggest ENHL of the head and neck and thus leads to biopsy confirmation, initiation of treatment at an early stage, and thus improved patients’ outcome.
Clinical presentation of ENHL of the head and neck
The clinical presentation of ENHL is non-specific and depends on the site of involvement.[3,16-18] ENHL of the head and neck typically develops in the sixth and seventh decades of life with a slight male predominance.[1,19] Exceptions are salivary, orbital, and thyroid lymphomas, which have a female predominance.[20,21] Constitutional symptoms such as fatigue, weight loss, fever >38°C, and night sweats with increased risk of infections are common.[1] Sinonasal lymphomas usually present with obstructive symptoms, rhinorrhea, epistaxis, non-healing ulcer, or pain.[1,22] Aggressive and high grade sinonasal lymphomas are typically associated with bone destruction, nasal septal perforation, and extension into orbit with development of proptosis.[1,2,23] Due to the aggressive behavior, it is very difficult to differentiate from sinonasal squamous cell carcinoma.[23] Orbital lymphomas usually involve the superotemporal quadrant and manifest as a painless enlarging mass with proptosis, eyelid swelling, and diplopia.[1,2,23] Thyroid lymphomas present as a rapidly enlarging neck mass. In general, indolent types of ENHL of the head and neck manifest clinically as slowly growing masses that could overlap with other benign head and neck masses such as parotid, oral/buccal, or orbital masses while more aggressive forms can present with bony erosion among other aggressive features.
It is also important to keep in mind various risk factors that are attributed to the development of lymphoma including infections, autoimmune disorders, congenital or acquired immunodeficiency syndromes, impairment of the cell cycle, host susceptibility, and immunosuppression due to organ transplantation.[1,8] The infectious factors are many and include human immune-deficiency virus (HIV), Epstein-Barr virus (EBV), Hepatitis C, Helicobacter pylori, and human T-cell leukemia virus-1.[8,19] Burkitt’s lymphoma is common in children and has strong association with the EBV.[1] Chronic HIV infection poses a 100 times increased risk of lymphoma. Autoimmune disorders such as Hashimoto’s thyroiditis and Sjogren syndrome increase the risk of thyroid and salivary gland lymphoma respectively.[1] In one study of patients with primary thyroid lymphoma, about 80% were associated with a history of Hashimoto thyroiditis. Environmental or occupational exposures to substances such as dioxin, agricultural pesticides, organophosphates, and organochlorines are also risk factors for development of NHL.[3,18,24-27]
Diagnostic workup for suspected lymphoma should include basic laboratory tests such as erythrocyte sedimentation rate, complete blood count, and liver function tests for better clinical staging.[1]
Common imaging features ENHL of the head and neck
On imaging, ENHL of the head and neck can have non-specific and overlapping features with other infectious, inflammatory, and neoplastic processes. Initial imaging evaluation of ENHL of the head and neck depends on the primary site of involvement. Ultrasound is the initial imaging modality for the evaluation of superficial masses within the orbit, cervical lymph nodes, thyroid, and salivary glands.[1,2,19,23,28-30] Deeper lesions, however, require evaluation with CT and MRI.[1,22,31,32]
The imaging criteria depend on site of involvement of ENHL of the head and neck as well as the histologic subtype [Table 1]. In general, the indolent types such as extra-nodal MALT appear as well circumscribed masses with homogenous density and enhancement on CT.[33,34] MR imaging criteria typically demonstrate well-defined masses of isointense signal on T1-weighted images and slightly hyperintense signal on T2-weighted images relative to surrounding muscles.[10-12] After IV gadolinium administration, the masses show moderate homogenous enhancement.[10] Higher grade and aggressive lymphomas can appear as infiltrative mass with overlapping criteria with head and neck squamous cell carcinoma.[26,32,35-38]
| Imaging modality | Indolent types, for example, extra-nodal mucosa-associated lymphoid tissue | Aggressive types, for example, nasal T-cell/NK cell lymphoma |
|---|---|---|
| CT | ||
| Morphology | Well circumscribed mass | Ranges from infiltrative pattern to a mass-forming pattern |
| Density and enhancement | Homogenous density and enhancement | Slightly heterogeneous |
| MRI | ||
| Morphology | Well-defined mass | Infiltrative mass Osseous invasion Perineural extension |
| Signal intensity | ||
| T1 | Isointense | Isointense |
| T2 | Slightly hyperintense | Isointense |
| DWI | Hyperintense | Hyperintense |
| ADC | Hypointense | Hypointense |
| Enhancement | Moderate homogenous enhancement | Heterogeneous enhancement |
| Calcification | No calcification | No calcification |
DWI is a very useful non-invasive technique in the evaluation of the head and neck masses, differentiating benign from malignant masses, necrotic malignancy from infection with abscess formation, and tumor recurrence from post-treatment changes.[9,39-44] DWI contrasts different tissues based on Brownian motion of water molecules within different tissue compartments.[39,42,43] ENHL of the head and neck typically has a restricted diffusion pattern with high signal intensity on DWI and dark signal on ADC.[39,42] ADC value can provide a quantitative measure to distinguish different malignancies. For example, Maeda et al. found that ADC value of 0.76 × 10−3mm2/s has 98% accuracy to distinguish lymphoma from squamous cell carcinoma.[39,45] While Wang et al. found a 92% accuracy when they used the same ADC value of 0.76 × 10−3 mm2/s.[39,46] Nodal disease, when present, appears as multiple homogenous lymph nodes that may show variable enhancement. Nodal necrosis or calcification may be seen before or after treatment.[10,11] Nodal necrosis that is present before the initiation of the treatment is more suggestive of high-grade disease. Definitive diagnosis relies on biopsy with examination of the tissue for architectural analysis and immunophenotyping.
Once the lesion has been proved to be ENHL, PET/ CT is imperative for accurate staging and evaluation of sites of involvement.[14,24] PET/CT has been shown to be insufficiently sensitive in detecting presence of bone marrow involvement. Therefore, bone marrow biopsy is important to exclude bone marrow disease, as 18% of ENHL have bone marrow involvement.[1] PET/CT is also essential for assessing treatment response and monitoring for recurrence by measuring metabolic activity through standardized uptake of FDG.[24,25]
Differential diagnosis of ENHL of the head and neck and how to distinguish based on imaging
The differential diagnosis of head and neck lymphoma is dependent on the site of involvement [Table 2].
| Site | Imaging features | Common differential diagnosis |
|---|---|---|
| Orbital | •Well circumscribed mass •Hyperdensity on CT •T2 Hypointense signal •Hyperintense DWI signal •Hypointense “dark” signal on ADC map |
•Idiopathic orbital inflammatory syndrome •Sarcoidosis •Granulomatosis with polyangiitis •Erdheim-Chester disease •Metastasis •Lacrimal tumors |
| Sino-nasal | •Polypoid mass •Submucosal infiltrative mass •Less likely to cause bony erosion compared to SCC |
•Sinonasal SCC •Sinonasal Adenocarcinoma •Olfactory neuroblastoma •Granulomatosis with polyangiitis •Sarcoidosis •Chronic or invasive fungal rhinosinusitis |
| Oral and maxillofacial | •Well circumscribed mass in the superficial spaces e.g., buccal space •Tonsillar mass •Submucosal pharyngeal mass •±lymphadenopathy |
•Oropharyngeal and oral cavity SCC •Neurogenic tumor, for example, Schwannoma •Minor salivary gland tumors |
| Glandular NHL | •Homogenous mass within parotid, submandibular, lacrimal, or thyroid gland •Diffuse glandular involvement •±lymphadenopathy •No calcification or necrosis |
•Warthin tumor •Mucoepidermoid carcinoma •Adenoid cystic carcinoma •SCC •Anaplastic thyroid carcinoma •Differentiated thyroid carcinoma |
| Osseous NHL | •Focal destructive mass with periosteal reaction •Diffuse infiltrative mass with permeative pattern |
•Osteosarcoma •Ewing sarcoma •Osseous metastasis |
NHL: Non-Hodgkin lymphoma, SCC: Squamous cell carcinoma
Orbital lymphoma should be differentiated from other disorders that present with diffusion restriction in particular idiopathic orbital inflammatory pseudotumor, IgG4 disease, granulomatosis with polyangiitis, and metastatic disease.[7,30,47-49]
Sinonasal NHL can be difficult to distinguish from granulomatosis with polyangiitis, squamous cell carcinoma, and esthesioneuroblastoma.[15,50-53] Lymphoma is more likely to present in nasal cavity rather than paranasal sinuses as seen in squamous cell carcinoma.[54-56]
Primary thyroid lymphoma can be confused with anaplastic thyroid carcinoma. Imaging can help distinguish these two entities.[57] Thyroid lymphoma tends to be homogeneous without calcification or necrosis.[57]
Nasopharyngeal NHL can have significant overlap with nasopharyngeal carcinoma on imaging.[58] However, nasopharyngeal carcinoma is more likely to infiltrate surrounding tissues and cause skull base bony erosion.[58,59]
Osseous NHL can be misinterpreted as primary or secondary malignant bone tumors.[60,61] The infiltrative pattern, decrease in ADC values and almost homogenous pattern of mass enhancement might differentiate osseous NHL from other primary or secondary osseous malignancies.
Impact of early diagnosis of ENHL of the head and neck on treatment and patients’ prognosis
Treatment for ENHL of the head and neck depends on the stage and pathological type of lymphoma. Standard treatment for early-stage lymphoma is chemotherapy followed by involved field radiotherapy. Patients with stage I and stage II disease usually respond well to therapy and prognosis is much better than those with advanced disease.[3,17,18,23,51] In advanced stage (bulky stage II, stage III, and stage IV) combined chemotherapy with cyclophosphamide, hydroxydoxorubicin, oncovin, prednisone, and Rituxan is needed.[3,18] If ENHL of the head and neck is suspected, timely diagnosis, and treatment improves clinical outcomes.
CONCLUSION
ENHL of the head and neck has a wide spectrum of clinical presentations and imaging criteria. High index of suspicion with knowledge of characteristic imaging features would help early diagnosis and prompt management.
Declaration of patient consent
The authors’ certify that they have obtained all appropriate patients’ contest.
Conflicts of interest
There are no conflict of interest.
Financial support and sponsorship
Nil.
References
- Imaging Hodgkin and non-Hodgkin lymphoma in the head and neck. Radiol Clin North Am. 2008;46:363-78.
- [CrossRef] [PubMed] [Google Scholar]
- Extranodal lymphoma of the head and neck: A pictorial essay. Radiol Bras. 2019;52:268-71.
- [CrossRef] [PubMed] [Google Scholar]
- Clinical presentation and characteristics of lymphoma in the head and neck region. Head Face Med. 2019;15:1.
- [CrossRef] [PubMed] [Google Scholar]
- Oral manifestations of lymphoma: A systematic review. Ecancermedicalscience. 2016;10:665.
- [CrossRef] [PubMed] [Google Scholar]
- Oral and maxillofacial non-Hodgkin lymphomas. Medicine (Baltimore). 2017;96:e7890.
- [CrossRef] [PubMed] [Google Scholar]
- Treatment outcome of diffuse large B-cell lymphoma involving the head and neck Two-institutional study for the significance of radiotherapy after R-CHOP chemotherapy. Medicine (Baltimore). 2017;96:e7268.
- [CrossRef] [PubMed] [Google Scholar]
- Differentiation of orbital lymphoma and idiopathic orbital inflammatory pseudotumor: Combined diagnostic value of conventional MRI and histogram analysis of ADC maps. BMC Med Imaging. 2018;18:6.
- [CrossRef] [PubMed] [Google Scholar]
- Malignant lymphoma of the head and neck. Oral Dis. 2010;16:119-28.
- [CrossRef] [PubMed] [Google Scholar]
- Multimodality imaging of extra-nodal lymphoma in the head and neck. Clin Radiol. 2022;77:e549-9.
- [CrossRef] [PubMed] [Google Scholar]
- Extranodal lymphomas: A pictorial review for CT and MRI classification. Acta Biomed. 2020;91:34-42.
- [Google Scholar]
- Extranodal lymphoma of the head and neck: A 67-case series. Eur Ann Otorhinolaryngol Head Neck Dis. 2015;132:71-5.
- [CrossRef] [PubMed] [Google Scholar]
- Extranodal lymphoma from head to toe: Part 1, the head and spine. Am J Roentgenol. 2011;197:350-6.
- [CrossRef] [PubMed] [Google Scholar]
- Head and neck tumors: Amide proton transfer MRI. Radiology. 2018;288:782-90.
- [CrossRef] [PubMed] [Google Scholar]
- Imaging in staging of malignant lymphoma: A systematic review. Blood. 2008;111:504-16.
- [CrossRef] [PubMed] [Google Scholar]
- Prognostic indicators of survival in sinonasal extranodal natural killer/T-cell lymphoma. Laryngoscope. 2019;129:2675-80.
- [CrossRef] [PubMed] [Google Scholar]
- Primary extranodal B-cell non-Hodgkin lymphoma mimicking an endodontic lesion: Report of 2 cases. J Can Dent Assoc. 2013;79:d93.
- [Google Scholar]
- Primary non-Hodgkin lymphoma of the sinonasal cavities: Correlation of CT evaluation with clinical outcome. Radiology. 1997;204:431-5.
- [CrossRef] [PubMed] [Google Scholar]
- Clinical features and outcome of the patients with sinonasal tract diffuse large B-cell lymphoma in the pre-rituximab and rituximab eras. Eur J Haematol. 2019;102:457-64.
- [CrossRef] [PubMed] [Google Scholar]
- Radiographic pattern of extra-nodal non-Hodgkin's lymphoma. Int J Stud Res. 2015;5:7.
- [CrossRef] [Google Scholar]
- Soft tissue pathology for the radiologist: A tumor board primer with 2020 WHO classification update. Skeletal Radiol. 2021;50:29-42.
- [CrossRef] [PubMed] [Google Scholar]
- An update on Burkitt lymphoma: A review of pathogenesis and multimodality imaging assessment of disease presentation, treatment response, and recurrence. Insights Imaging. 2019;10:56-72.
- [CrossRef] [PubMed] [Google Scholar]
- Differential diagnosis of sinonasal lymphoma and squamous cell carcinoma on CT, MRI, and PET/CT. Otolaryngol Head Neck Surg. 2018;159:494-500.
- [CrossRef] [PubMed] [Google Scholar]
- Hodgkin and non-Hodgkin lymphoma of the head and neck: Clinical, pathologic, and imaging evaluation. Neuroimaging Clin N Am. 2003;13:371-92.
- [CrossRef] [PubMed] [Google Scholar]
- FDG PET/ CT of extranodal involvement in non-Hodgkin lymphoma and Hodgkin disease. Radiographics. 2010;30:269-91.
- [CrossRef] [PubMed] [Google Scholar]
- Current status of PET/CT in the diagnosis and follow up of lymphomas. Rev Bras Hematol Hemoter. 2011;33:140-7.
- [CrossRef] [PubMed] [Google Scholar]
- imaging for staging and Response assessment in Lymphoma 1. Radiology. 2015;276:323-38.
- [CrossRef] [PubMed] [Google Scholar]
- Epidemiologic, prognostic, and treatment factors in sinonasal diffuse large B-cell lymphoma. Laryngoscope. 2019;129:1259-64.
- [CrossRef] [PubMed] [Google Scholar]
- Hodgkin's and non-Hodgkin's 'lymphoma of the head and neck. Laryngoscope. 2001;111:1565-9.
- [CrossRef] [PubMed] [Google Scholar]
- Sonographic appearance of primary thyroid lymphoma-preliminary experience. PLoS One. 2014;9:e114080.
- [CrossRef] [PubMed] [Google Scholar]
- Imaging Findings of Orbital Lymphomas Hajipur: East Central Railway zone; 2017. p. :1-22.
- [Google Scholar]
- Imaging characteristics of malignant sinonasal tumors. J Clin Med. 2017;6:116.
- [CrossRef] [PubMed] [Google Scholar]
- Sinonasal lymphoma: Case series and review of the literature. Int Forum Allergy Rhinol. 2014;4:670-4.
- [CrossRef] [PubMed] [Google Scholar]
- The insights of head and neck non-Hodgkin lymphoma. Medeni Med J. 2020;35:179-80.
- [CrossRef] [PubMed] [Google Scholar]
- Non Hodgkin's lymphoma of tongue-A case report. Indian J Med Paediatr Oncol. 2008;29:59-61.
- [CrossRef] [Google Scholar]
- NK/Tcell non-Hodgkin lymphoma: Case report and review of the literature. Exp Ther Med. 2020;21:91.
- [CrossRef] [PubMed] [Google Scholar]
- Extranodal NK/T-cell lymphoma in adolescents: Imaging findings of a consecutive 7-year case series. J Int Med Res. 2019;47:1210-20.
- [CrossRef] [PubMed] [Google Scholar]
- Mantle cell lymphoma: A rare vallecular tumour. Medeni Med J. 2020;35(1):67-70.
- [CrossRef] [PubMed] [Google Scholar]
- Nasal plasma blastic lymphoma in an HIV-negative immunocompetent patient. Medeni Med J. 2020;35:71-4.
- [CrossRef] [PubMed] [Google Scholar]
- Role of diffusion-weighted imaging in head and neck lesions: Pictorial review. Neuroradiol J. 2017;30:356-69.
- [CrossRef] [PubMed] [Google Scholar]
- The use of diffusion weighted imaging to evaluate pathology outside the brain parenchyma in neuroimaging studies. Br J Radiol. 2017;90:20160821.
- [CrossRef] [PubMed] [Google Scholar]
- Multiple b values of diffusion-weighted magnetic resonance imaging in evaluation of solid head and neck masses. Egypt J Radiol Nuclear Med. 2019;50:54.
- [CrossRef] [Google Scholar]
- Diffusion-weighted imaging for head and neck squamous cell carcinoma: Quantifying repeatability to understand early treatment-induced change. Am J Roentgenol. 2014;203:1104-8.
- [CrossRef] [PubMed] [Google Scholar]
- The role of diffusion-weighted magnetic resonance imaging in the differentiation of head and neck masses. J Clin Med. 2018;7:130.
- [CrossRef] [PubMed] [Google Scholar]
- Diffusion-weighted imaging of the parotid gland: Can the apparent diffusion coefficient discriminate between normal and abnormal parotid gland tissues? Erciyes Med J. 2017;39:125-30.
- [CrossRef] [Google Scholar]
- Usefulness of the apparent diffusion coefficient in line scan diffusion-weighted imaging for distinguishing between squamous cell carcinomas and malignant lymphomas of the head and neck. AJNR Am J Neuroradiol. 2005;26:1186-92.
- [Google Scholar]
- Head and neck lesions: Characterization with diffusion-weighted echo-planar MR imaging. Radiology. 2001;220:621-30.
- [CrossRef] [PubMed] [Google Scholar]
- Orbital lymphoma: Imaging features and differential diagnosis. Insights Imaging. 2012;3:337-44.
- [CrossRef] [PubMed] [Google Scholar]
- Orbital neoplasms in adults: Clinical, radiologic, and pathologic review. Radiographics. 2013;33:1739-58.
- [CrossRef] [PubMed] [Google Scholar]
- Sinonasal lymphoma presenting as a probable sanctuary site for relapsed B acute lymphoblastic leukaemia: A case report and review of the literature. Case Rep Hematol. 2015;2015:697957.
- [CrossRef] [PubMed] [Google Scholar]
- Clinicopathological analysis of sinonasal malignant lymphoma in an HTLV-1 endemic area in Japan-special focus on primary sinonasal diffuse large B-cell lymphoma. J Clin Exp Hematopathol. 2019;59:101-7.
- [CrossRef] [PubMed] [Google Scholar]
- Outcome and failure patterns of localized sinonasal lymphoma in cats treated with first-line single-modality radiation therapy: A retrospective study. Vet Comp Oncol. 2019;17:528-36.
- [CrossRef] [PubMed] [Google Scholar]
- Case report maxillary sinus natural killer/T-cell extranodal lymphoma mimicking a dentoalveolar abscess. Case Rep Dent. 2019;2019:6701783.
- [CrossRef] [PubMed] [Google Scholar]
- Extranodal natural killer/T cell lymphoma, nasal type: A diagnostic challenge. BMJ Case Rep. 2019;12:232404.
- [CrossRef] [PubMed] [Google Scholar]
- Differentiation between sinonasal natural killer/T-cell lymphomas and diffuse large B-cell lymphomas by RESOLVE DWI combined with conventional MRI. Magn Reson Imaging. 2019;62:10-7.
- [CrossRef] [PubMed] [Google Scholar]
- Extranodal NK/T cell lymphoma, nasal type, with retrobulbar extraconal phlegmon and naso-oral fistula Rare disease. BMJ Case Rep. 2019;12:227160.
- [CrossRef] [PubMed] [Google Scholar]
- Primary thyroid lymphoma: CT findings. Eur J Radiol. 2003;46:233-9.
- [CrossRef] [PubMed] [Google Scholar]
- Nasopharyngeal carcinoma with skull base erosion cytologic findings. Iran Red Crescent Med J. 2012;14:492-4.
- [Google Scholar]
- Primary bone non-Hodgkin lymphoma of the cervical spine: Case report and review. Turk J Neurosurg. 2014;24:438-42.
- [CrossRef] [PubMed] [Google Scholar]
- Bone and soft tissue non-Hodgkin lymphoma of the maxillofacial area: Report of two cases, literature review and new therapeutic strategies. Int J Surg. 2014;12:S23-8.
- [CrossRef] [PubMed] [Google Scholar]
