large b cell lymphoma stages | B-Cell Primitive extraganglionnaire non-Hodgkin's lymphoma mimicking endodontic lesion: two case studies

B-Cell Primitive extraganglionnaire non-Hodgkin's lymphoma mimicking endodontic lesion: two case studies



Summary

Intra-bone buccal non-Hodgkin's lymphoma (NHL) is rare. We present 2 cases of the upper maxillary NHL, which appeared to be from the apical abscesses on endodontics-treated teeth. While the X-rays showed no particular signs, tissue biopsies revealed, in both cases, the presence of a large B-cell diffuse NHL. No other damage was detected. The 2 patients were treated with chemotherapy and radiotherapy, with good results. Since the primitive NHL of the upper maxillary can mimic dental inflammatory lesions, it is essential to perform tissue biopsy when symptoms persist after the administration of a specific treatment.

Non-Hodgkin's lymphoma (NHL) in the oral cavity represents less than 5% of buccales1 malignant tumours. The NHL can take birth in lymph nodes or extraganglionnaires sites. At least 40% of NHL are in extraganglionnaires sites, most often in the gastrointestinal tract. Then come the head and neck, and more particularly the lymphoid tissues of the Waldeyer2 lymphatic ring which include the nasopharynx, the Palatine tonsils, the base of the tongue and the oropharynx. Large-cell diffuse lymphoma B1 is the most commonly observed phenotype in extraganglionnaires sites.

The tonsils are the most common intraoral seat, followed by the palace. Primitive bone sites can be manifested in the form of an extension of the maxillary inférieur3, an enlarged tooth canal and a mentonnier4 hole, a loss of alveolar bone or dentaire1 mobility. These signs may also be accompanied by swelling, pain, lip paresthesia or pathologique1 fracture. However, the NHL can also mimic other pathological lesions and take the clinical form of GINGIVALE5, 6, 8-Parodontale7 disease, PÉRICORONARITE9, Apicale1 radiotransparency, or dentaire10 abscess. It is often difficult to make a definitive diagnosis.

We present 2 cases where an NHL mimicking an apical abscess in endodontics-treated teeth has posed diagnostic difficulties.

Case Study 1
A 50-year-old white male consulted us for an apical abscess on tooth 12, on which a canal treatment had been performed 6 months earlier. During this 6-month interval, the patient had been treated twice by antibiotic therapy for acute exacerbation. The patient said he felt numbness and swelling in the anterior area of the upper maxilla, between the right and left canine teeth, under the nose.

Clinical examination of soft tissues revealed no apparent anomalies. No signs of fistula or swelling associated with tooth 12 were observed. Periapical radiography revealed that a channel treatment had been performed on tooth 12, but there was no distinct periapical radiotransparency (Fig. 1). Similarly, the Panorex showed no particular signs (Fig. 2). A root resection was performed under Neuroleptic analgesia, and a retrograde filling with a temporary restoration material of the zinc-eugenol oxide reinforced. was performed on tooth 12.

During the procedure, significant bone destruction was observed around the apexes of all anterior upper teeth, from teeth 13 to 23. Many samples of what appeared to be the chronic granulation tissue were collected for pathological examination. The initial pathology report referred to an atypical infiltration that was compatible with malignant lymphoma.

More extensive immunophénotypiques analyses led to a definitive diagnosis of large B-cell diffuse NHL. Postoperative tomography (CT) and three-dimensional reconstruction confirmed the presence of a large area of bone destruction (measuring 1.8 cm by 2.9 cm) on the anterior side of the upper maxilla (Fig. 3 and 4). Whole-body bone scan and gallium scan showed non-specific diffuse uptake throughout the upper maxilla.

All blood tests were normal, including levels of IgG, beta-2-microglobulin, and LDH, all of which were within the normal range. No other interventions were recommended at this stage, but the patient was regularly monitored by TDM. The patient's clinical condition continued to improve after surgery and the patient posted good postoperative recovery.

Twelve months later, the CT of the skull and facial mass showed that the lytic process with marbling was still present in the anterior upper maxillary region. A new whole-body bone scan revealed that there was always increased diffuse uptake of technetium in the entire upper maxilla, as these results were unchanged from the previous examination. A second gallium scan, performed during the 6-month follow-up visit, showed the same non-specific uptake in the upper maxilla.

Repeating TDM every 4 months always showed destructive damage to the upper maxilla. The patient's vital signs and blood tests were within normal limits and the patient was otherwise healthy.

At the request of the treating oncologist, another biopsy of the lytic lesion in the anterior upper maxillary was performed under general anesthesia. The analysis revealed that there was bone filling above the apex of all the incisors. However, a granulomatous tissue area of 1.5 cm by 1.0 cm, adjacent to the apexes of teeth 12 and 13, was observed; These tissues were excised and sent for pathological analysis. The pathology report again confirmed a diffuse NHL with large B cells. Other tests, including a bone marrow puncture, did not reveal any other damage; It was therefore determined that the patient had lymphoma at the IAE Stage (table 1) with bony damage to the upper maxilla.

Table 1 Ann Arbor14 lymphoma Stage Determination system

Clinical definition Stage

I a single lymph node (i) or Extraganglionnaire site (IE)

II 2 or more lymph nodes located on the same side of the diaphragm (ii) or with Extraganglionnaire (IIE)

III Ganglionic damage on both sides of the diaphragm (iii), including the Spleen (IIIS), or Extraganglionnaire impairment (3rd), or both (3rd)

IV Many extraganglionnaires sites

Note: Each stage may also be assigned the letter A and B or to indicate the absence or presence of constitutional symptoms (including fever, night sweats and weight loss of more than 10%).

The patient underwent 4 cycles of R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin hydrochloride [hydroxydaunomycine], vincristine sulfate [Oncovin] and prednisone). Subsequently, unwitting measures were taken and the patient underwent radiation therapy. The patient responded very well to adjuvant radiotherapy and his condition continues to improve, 15 months after the first biopsy.

Case Study 2

A 31-year-old white woman was directed to a endodontist for the treatment of recurrent swelling in the anterior left region of the upper maxillary associated with teeth 22 and 23. These teeth were not alive. The necrotic pulp was removed and a non-surgical endodontic treatment was performed on these teeth.

The patient returned 2 months later, saying she had not observed any "real improvement". No useful observations were found. The patient continued to experience repetitive swelling and returned again 3 months later, this time showing signs of infection and a fistula. The patient stated that pus had passed from the area of tooth 22 and that she had been feeling a little better since then. At that time, the pulp vitality (cold test and electrical test) tests revealed that adjacent teeth 21 and 24 were non-living, even if they had not undergone any treatment.

The patient was directed to an oral and maxillofacial surgeon for an assessment of the area of interest. The clinical examination revealed the presence of firm and sensitive swelling of the labial vestibule above teeth 22 and 23. The radiographic examination showed no particularly important signs or any characteristic radiotransparency (Fig. 5).

The exploration of the area was carried out under neuroleptic analgesia in order to be able to practice, if necessary, a biopsy and a root resection with retrograde closure of the teeth 22 and 23 with a temporary restoration material. During surgery, a significant destruction of the labial cortex of these 2 teeth was observed, as well as overt erosion between the roots of the teeth extending to the lingual face of the root tips (Fig. 6). Multiple fragments were taken from a firm mass of soft granulomatous tissues associated with this bone destruction for pathological examination. The preliminary report reported a malignant infiltration suggestive of lymphoma. Further consultations and immunophénotypiques analyses confirmed that it was a diffuse lymphoma with large B cells.

The CT of the skull and the facial mass and the 3d reconstruction of the head were normal, if not the presence of a destructive bone lesion measuring 1.6 cm by 5 to 6 mm in the anterior left region of the upper maxilla (Fig. 7 and 8). CT of the neck, upper mediastinum, two lungs, and bone thorax were normal, as were basic blood tests and assays of hepatic enzymes. It was determined that this was a large-cell diffuse lymphoma of the IAE clinical stage maxillary (table 1).

The patient received 4 cycles of R-CHOP chemotherapy, which were followed by radiation therapy. During the first perfusion, the patient reacted to the rituximab, a reaction that was controlled by acetaminophen and diphenhydramine (BenadrylMC) administration. The patient also had nausea after the 3rd cycle, which were treated by the administration of a respiter and by intravenous hydration. During the recovery period following radiotherapy, the patient presented a mild to moderate dysgeusia due to the use of a stent during radiotherapy treatments. Four months after the initial biopsy, the patient's condition was overall good.

Discussion

Large-cell B diffuse lymphoma is the most common NHL, representing 30 to 40% of all CAS11-14. Although little is known about the causes of the NHL, the differences in incidence according to the ethnic group suggest a strong genetic influence. Acquired or congenital immunodeficiency is an important risk factor, which may be related to altered immune response to Epstein-Barr15,16 virus. There is no doubt that precise chromosomal translocation plays a role in the emergence of NHL, causing dysregulation of oncogenes or tumor-suppressing genes and promoting unhindered proliferation of cellules1.

Tumours usually occur in middle-aged and older adults, with a median age of 56 years14. At the time of diagnosis, 40% of patients are in stage I (single lymph node) or stage II (reaching 2 lymph nodes on the same side of the diaphragm) and 40% have Extraganglionnaire (IE or IIE), depending on the ANN Arbor14 Hodgkin Lymphoma Classification System (table 1). Stage III indicates a ganglionic attack on both sides of the diaphragm, while stage IV is characterized by diffuse or scattered interference. The letters A and B indicate, respectively, the absence or presence of constitutional symptoms. None of the 2 patients described previously had any constitutional symptoms, and in both cases the attack was extraganglionnaire. These were the IAE stage lymphomas.

Diffuse lymphomas with large B cells account for 85% of the bony lymphomas of the upper maxillary and inférieur17,18. In the 2 cases presented here, the tumor was in the upper maxillary and was associated with a endodontics-treated tooth. No apical radiotransparency was apparent and the radiological observations were of no particular character. Initially, tumours usually take the form of the host bone at x-ray, and some tumors may be mistaken for dentaires19 abscesses. In general, the edges are poorly defined because of the invasive nature of the neoplasm. The internal structure is usually entirely radiolucent, with some occasional areas of radio-opacity and Ostéoformation réactionnelle19. CT shows a characteristic lytic bone destruction, with a localized "raised" appearance. New lamellar bone tissues are often formed in the periosteum and presence of a variable mass of mous18 tissues. A widening of the lower dental channel was also observé4.

The biopsy, complete with immunological studies of tissues, is the only reliable technique to make a definitive diagnosis. The tumor consists of layers of large lymphoid cells that present large vesicular nuclei, prominent Nucleoli, and a basophile abondant1,14 cytoplasm. Since the ability to cure large-cell diffuse lymphomas B depends on the initial chemotherapy protocol, it is crucial to choose the right dosage regimen. This requires, however, the determination of the stage of the disease (table 1), as well as a complete history to determine the individual risk factors.

Routine analyses include a complete blood formula and biochemical analyses of the serum, an X-ray of the lungs, thoracic, abdominal and pelvic CT, and a bilateral biopsy of the iliac ridge bone marrow. Other tests, such as magnetic resonance imaging (MRI), gallium scan, lymphography, and occasional abdominal laparotomy may also be required. Prognostic factors of risk include age (in years), stage of tumor, number of extraganglionnaires sites, patient response to doxorubicin-based polychemotherapy, and serum levels of LACTICODÉSHYDROGÉNASE14. The R-CHOP protocol is most commonly used. Radiotherapy is usually delivered at a dose of 40 to 50 Gy.

In some patients whose lymphomas are indolent (CAS 1), there are instances where no initial treatment is indicated. Radiotherapy and chemotherapy can be carried out later, if necessary. In general, the prognosis of indolent lymphomas is dark. Although survival is long – the average interval is 8 years – these lymphomas are considered incurable.

In cases of aggressive lymphoma (CAS 2), 90% of patients are treated with polychemotherapy and the remission rate is 40%. In patients who respond well to chemotherapy, the prospects are good; In some cases, a resolution of the disease is observed after a single treatment cycle. On the other hand, the prognosis is dark in people who do not respond to treatment, and the disease is usually fatal in a few weeks1.

Conclusion

Dentists should be attentive to clinical situations that do not respond to conventional treatments and should avoid multiple procedures without first doing a biopsy, as this could delay the treatment of what Could be an aggressive neoplastic state. The NHL primitive extraganglionnaire can mimic an apical abscess associated with a endodontics-treated tooth, and this may delay diagnosis and onset of treatment and influence the prognosis and eventual outcome.