11.6
Lymphoma
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 26‐year‐old woman is referred by her oncologist for urgent dental assessment. The patient complains of increasing discomfort and mobility of the lower right second molar tooth of 1 week’s duration. There is no previous history of symptoms from this tooth.
Medical History
- Hodgkin lymphoma (mediastinal bulky disease) diagnosed 4 years ago with multiple antineoplastic treatment regimens used in the past:
- ABVD: doxorubicin (also known as adriamycin)/bleomycin/vinblastine/dacarbazine
- ESHAP: etoposide/methylprednisolone/cytarabine/cisplatin
- IVAC: ifosfamide/etoposide/citarabine
- Total body irradiation (40 Gy) delivered to the mediastinal region
- Allogeneic haematopoietic stem cell transplantation (allo‐HSCT) undertaken 2 years ago, with several severe complications post transplantation:
- Aspergillus fumigatus sinusitis
- Cytomegalovirus reactivation
- Reservoir infection
- Severe pericardial effusion
- Septicemia due to Staphylococcus aureus and Streptococcus pneumoniae
- Severe neuropathy in lower limbs
- Thrombocytopenia
Medications
- Brentuximab
- Prednisone
- Fluconazole
- Aciclovir
- Alprazolam
- Magnesium and vitamin B supplements
Dental History
- Irregular dental attender; only attends when in pain
- Brushes teeth 3 times daily using a soft manual toothbrush
- Diet – due to discomfort from her mouth, predominantly eats soft food
Social History
- Lives with her parents and sister; good family support
- Previously worked in the hospitality industry (currently on leave due to ill health)
- Transport: drives her own car
- Alcohol consumption: nil
- Tobacco consumption: nil
Oral Examination
- Good oral hygiene
- Erythematous, friable and tender oral mucosa
- Ulcerated lesion with necrotic background surrounding the cervical region of #47 (Figure 11.6.1)
- Grade III mobility and pain on percussion of molar #47
- Missing tooth #46
- Fillings in #16, #36, #37 and #47
Radiological Examination
- Orthopantomogram undertaken (Figure 11.6.2)
- Severe vertical bone loss in mesial of #47
- #47: radiolucent periapical lesion with ill‐defined borders extending to the inferior alveolar nerve canal
Structured Learning
- What are the differential diagnoses for a in the mouth which has a similar clinical/radiographic appearance as associated with #47?
Figure 11.6.1 Extrusion of the lower right second molar and gingival ulcer with necrotic bakground.
Figure 11.6.2 Orthopantomogram showing #47 radiolucent periapical lesion with ill‐defined borders.
- Diffuse periapical infection (atypical presentation)
- Benign lesions: ameloblastomas followed by nasopalatine duct cysts and Stafne bone cavities
- Malignant lesions: metastatic lesions followed by carcinomas
- Diffuse periapical infection (atypical presentation)
- Why is medication‐related osteonecrosis of the jaw (MRONJ) not included in the differential diagnosis?
- The patient received radiation therapy which does not meet the MRONJ case definition (see Chapter 16.2)
- Currently, she is taking brentuximab, an antibody–drug conjugate which at the moment has not been related to the appearance of MRONJ
- Following electric pulp testing, #47 responds positively and is not hypersensitive to stimulation. What other features indicate that the periapical lesion may be non‐dental in origin and could be malignant?
- Spontaneous tooth mobility and extrusion
- The patient has a history of lymphoma
- She is immunosuppressed (radiochemotherapy)
- Necrotic gingival ulceration
- Radiolucent periapical lesion with ill‐defined borders
- Given #47 is hypermobile, the patient asks for it to be extracted as she cannot eat on it. What factors do you need to consider in your risk assessment?
- Social
- The patient may be fatigued by the cytotoxic treatment and/or the sequelae of radiotherapy and/or sequelae of pericardial effusion
- Assess whether it is feasible to perform it in the dental chair due to neuropathy of the extremities
- An escort is recommended
- Medical
- A full blood count is needed to rule out anaemia, neutropenia and/or thrombopenia
- Consider antibiotic prophylaxis as healing is likely to be delayed
- Assess the need for corticosteroid supplementation (see Chapter 12.1)
- Complications of allo‐HSCT including thrombocytopenia (see Chapters 11.4 and 11.7)
- Dental
- Currettage and histological study of the periapical lesion/extracted tooth is mandatory
- A further biopsy of the oral mucosa is recommended to rule out cytotoxic mucositis, graft‐versus‐host disease and other causes of erythematous, friable and tender oral mucosa
- Social
- The patient reports feeling slightly anxious and asks if she can have sedation. What would you advise?
- The patient is regularly taking alprazolam so she may have developed tolerance to benzodiazepines
- Respiratory function may be impaired due to radiotherapy focused on the mediastinum
- The blood test results would need to be confirmed as the patient may be anaemic and at increased risk of hypoxia
- The histopathological report confirms that the currettaged tissue and mucosal biopsy have the features of squamous cell carcinoma. What risk factors does this patient have for this to have developed?
- The patient has received multiple chemotherapy regimens, including intensive chemotherapy to enable her allo‐HSCT
- She remains immunocompromised and is taking systemic steroid long‐term
General Dental Considerations
Oral Findings
- Extranodal manifestation of non‐Hodgkin lymphoma (Figure 11.6.3)
- B‐cell lymphomas are the most common in the head and neck
- Oral involvement is more common among HIV‐infected patients
- Painless enlarged cervical nodes
- Tumour on the gingiva and the palate
- Ulceration on the gingiva and the palate
- Parotid, tonsils and cavum (ear) involvement
- Maxillary bone involvement (~45%)
- Extranodal manifestation of Hodgkin lymphoma
- Very uncommon (~1% of all lymphomas in Waldeyer’s ring)
- Oral manifestations clinically similar to non‐Hodgkin lymphoma
Figure 11.6.3 Radionuclide bone imaging showing mandibular invasion.
- Oral lesions related to immunosuppression (see Chapter 12)
- Viral, fungal and bacterial infections
- Oral complications related to radiochemotherapy (see Chapter 12)
- Mucositis, oral ulceration, petechiae, oral paraesthesia, xerostomia
- Oral complications related to bone marrow transplantation (see Chapter 11.7)
- Mucositis, oral infections, oral ulceration, petechiae, graft‐versus‐host disease, malignancies (e.g. carcinoma, Kaposi sarcoma, lymphoma)
Dental Management
- Compliance for the delivery of dental care can vary depending on the stage of lymphoma and concurrent cancer therapy
- Treatment should be modified based on reassessment of the patient on the day of the appointment (Table 11.6.1)
Section II: Background Information and Guidelines
Definition
Lymphomas are a heterogeneous group of malignancies that arise from the clonal proliferation of B‐cell, T‐cell and natural killer (NK) cell subsets of lymphocytes at different stages of maturation. T‐cells are programmed for antigen recognition in the thymus whereas B‐cells mature in the marrow and encounter foreign antigen for the first time within the lymph node germinal centre (GC). Hence B‐cells may be divided into GC or post‐GC, with the latter developing eventually into plasma cells, which secrete the soluble form of B‐cell receptor, namely immunoglobulin (Ig) or antibody.
Lymphomas represent approximately 5% of malignancies and are broadly classified into Hodgkin lymphoma (HL) and non‐Hodgkin lymphoma (NHL). HL is further classified into classic and non‐classic types and NHL into B‐cell, T‐cell and NK cell types (Table 11.6.2). For clinical purposes, lymphoma is termed as aggressive (high grade) and indolent (low grade).
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