Abstract
Malignant lymphoma is a lymphoreticular malignancy with considerable geographic variation. The objective of the present study was to provide a preliminary report on patients with head and neck non-Hodgkin’s lymphoma (NHL) in a selected Iranian population. In a retrospective review from 1981 through 2001, all cases of NHL occurring in the head and neck region were selected. Histological slides were reviewed and classified according to the Working Formulation. Clinical data including patients’ age, sex, initial anatomic site of disease and presenting symptoms were also recorded. Information on 381 cases of NHL was retrieved from the archived medical records; 281 cases were nodal and 100 extranodal. The mean age of the patients with nodal and extranodal disease was 39.3 and 47.7 years, respectively. A significant difference in gender was noted in the nodal group ( P < 0.001), but not in the extranodal cases. The most common site of involvement in the extranodal subjects was Waldayer’s ring. According to histopathologic evaluation, 72% of the specimens were intermediate-, 14% were high-, and 12% were low-grade malignancies. Considering the relative frequency of head and neck lymphoma, establishment of a uniform reporting method seems necessary in order to compare different reports from various populations.
Malignant lymphomas are a diverse group of malignancies arising from the lymphoreticular system ; they constitute the third most common neoplasm in the head and neck region after squamous cell carcinoma and salivary gland tumors . Hodgkin’s disease and non-Hodgkin’s lymphoma (NHL) are the two main types of malignant lymphoma . NHL comprises approximately 5% of head and neck malignancies and displays a wide range of appearances comparable with Hodgkin’s disease . Hodgkin’s- and non-Hodgkin’s lymphomas can be found in the head and neck region; but extranodal disease, with or without lymph node involvement, is more common among NHL patients . The head and neck is one of the most common sites for extranodal lymphomas , which can occur in areas such as Waldayer’s ring (i.e. the tonsils, pharynx and base of the tongue), salivary glands, orbit, paranasal sinuses, and thyroid glands . In Hodgkin’s disease there are two age peaks at the time of initial diagnosis: 15–35 years and after the age of 50 years. NHL demonstrates a wider age distribution and generally occurs during adulthood and rarely in children . The clinical appearance is usually an enlarging mass that may or may not show ulceration. Lesions are frequently asymptomatic although they may be associated with pain or fever and weight loss .
NHL consists of a wide variety of clinico-histopathologic and immunologic subtypes which demonstrate different causative factors including Epstein–Barr virus infection, immunodeficiency and genetic susceptibility .
There are several classification systems for categorizing NHL. The Working Formulation classification scheme is based on cellular morphology and can provide important data on the overall survival of patients . Accordingly, lymphoma is divided into three prognostically different groups (low-, intermediate- and high-grade malignancies) . NHL is treated mainly with radiotherapy and/or chemotherapy; the appropriateness and extent of which depends on the stage and grade of lymphoma assessed by this classification .
Previous studies have suggested a worldwide variation in the incidence of NHL . Considering that this disease is relatively common in the head and neck region and due to the limited number of studies on NHL in Iran, the current investigation was designed to provide a preliminary report on patients with head and neck NHL in a selected population from Iran.
Materials and methods
This project was approved by the Ethics Committee of Tehran University of Medical Sciences. The medical records of cancer patients were reviewed from 1981 to 2001 and the medical charts of all patients diagnosed with non-Hodgkin’s lymphoma of the head and neck were retrieved for the current investigation. Age, sex, clinical presentation and lesion site were recorded for each subject according to the clinical data provided in their medical charts. Samples lacking information on age and gender were not included in the study.
Hematoxylin and eosin-stained slides were collected from the pathology archive and re-evaluated by two pathologists. Grading was carried out based on the Working Formulation classification system using a double-headed microscope. Both observers had to agree on the final grade for each specimen, and disagreements were resolved by reaching a consensus following discussion and reexamination. All cases that did not receive unanimous grades from the examiners were excluded from the study sample. Statistical analysis was performed using the χ 2 test and P -values of less than 0.05 were considered significant.
Results
The records of approximately 80,000 patients referred to the Cancer Institute over a 20-year period were reviewed. The total number of patients with head and neck NHL was 453, of which 381 samples were included in the study and the rest were excluded due to incomplete clinical data or uncertain diagnoses.
The mean age of patients with head and neck NHL was 46.3 years with a range of 7 months to 98 years. The male to female ratio was calculated as 2.2/1. Of the 381 cases, 281 had nodal and 100 showed primary extranodal NHL, which constituted the two study groups. The nodal series consisted of 210 males and 71 females, with a mean age of 39.3 years, ranging from 7 months to 98 years. In the extranodal series there were 58 males and 42 females, ranging in age from 2.5 to 75 years (average age, 47.7 years). A statistically significant difference was found between the two sexes in the nodal ( P < 0.001), but not in the extranodal group ( P = 0.11). The most common site of extranodal involvement was Waldayer’s ring followed by the salivary glands and jaw bones ( Table 1 ). All patients were Caucasian.
| Extranodal non-Hodgkin’s lymphomas | No. (%) |
|---|---|
| Tonsil | 22 (22) |
| Nasopharynx | 13 (13) |
| Base of tongue | 1 (1) |
| Scalp | 9 (9) |
| Thyroid gland | 4 (4) |
| Salivary glands | |
| Parotid | 15 (15) |
| Submandibular | 11 (11) |
| Jaw bone | 16 (16) |
| Orbit | 1 (1) |
| Paranasal sinus | 3 (3) |
| Gingiva | 2 (2) |
| Zygoma | 1 (1) |
| Face skin | 1 (1) |
| Larynx | 1 (1) |
| Total | 100 (100) |
Patients with salivary gland lymphomas ranged in age from 6.5 to 75 years (mean age, 47.44 years; median age, 51 years) and demonstrated a male to female ratio of 1.16/1. Submandibular tumors mainly occurred in men (8 of 11 cases), while lymphomas of the parotid gland were more common in women (9 of 15 cases). The mean age of the subjects with parotid neoplasms (51.26 years) was higher than those with submandibular tumors (42.22 years). Histologically, 86% of the salivary lymphomas were intermediate grade with the rest exhibiting high- or low-grade features. The initial chief complaint was a palpable lesion in all individuals.
16 cases (13 men and 3 women) occurred in the jaw bones, of which 4 and 9 were observed in the maxilla and mandible, respectively. There was no information on the location of three tumors. The mean age of patients with gnathic lesions was 41.62 years (range 4.5–72 years), which was similar in both jaws (excluding the three cases). Most neoplasms found in this region were intermediate-grade lymphomas. All patients initially presented with clinically detectable jaw expansion.
Histologic diagnoses of the studied NHL lymphomas based on the Working Formulation are shown in Table 2 . In both groups the majority of cases were diagnosed as intermediate grade (72%), mainly of the diffuse large cell subtype (251 cases). There were 331 (86%) cases with a diffuse histologic pattern as opposed to 50 (13%) samples demonstrating a follicular pattern.
| Grade | Extranodal no. (%) | Nodal no. (%) | Total |
|---|---|---|---|
| Low | 21 (21) | 28 (9.96) | 39 (12.86) |
| Intermediate | 69 (69) | 206 (73.3) | 275 (72.1) |
| High | 10 (10) | 47 (16.72) | 57 (14.96) |
The most common clinical presentation observed in NHL subjects was clinical swelling and lymphadenopathy, which was observed in 378 and 240 out of 381 patients, respectively.
Results
The records of approximately 80,000 patients referred to the Cancer Institute over a 20-year period were reviewed. The total number of patients with head and neck NHL was 453, of which 381 samples were included in the study and the rest were excluded due to incomplete clinical data or uncertain diagnoses.
The mean age of patients with head and neck NHL was 46.3 years with a range of 7 months to 98 years. The male to female ratio was calculated as 2.2/1. Of the 381 cases, 281 had nodal and 100 showed primary extranodal NHL, which constituted the two study groups. The nodal series consisted of 210 males and 71 females, with a mean age of 39.3 years, ranging from 7 months to 98 years. In the extranodal series there were 58 males and 42 females, ranging in age from 2.5 to 75 years (average age, 47.7 years). A statistically significant difference was found between the two sexes in the nodal ( P < 0.001), but not in the extranodal group ( P = 0.11). The most common site of extranodal involvement was Waldayer’s ring followed by the salivary glands and jaw bones ( Table 1 ). All patients were Caucasian.
