Lymphomas of the Head and Neck

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Lymphomas of the Head and Neck

• Tal Marom, MD

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(No Transcript)
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Lymphoma

• Cancer of the lymphatic system
• Lymphoma is differentiated by the type of cell
  that multiplies and how the cancer presents
  itself
• Two main groups Hodkgins disease and NHL
• US prevalence (HD) 3 cases/100,000 (incidence
  ?)
• US prevalence (NHL)16 cases/100,000 (incidence?)

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Hodgkin vs. Non-Hodgkin Ly.
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Hodgkin vs. Non-Hodgkin Ly.
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Hodgkin vs. Non-Hodgkin Ly.
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Reed Sternberg Cell
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HN Lymphoma

• Lymphoma is the second most common primary
  malignancy occurring in the head and neck, and
  incidence of aggressive non-Hodgkin lymphoma is
  rising in young and middle-aged patients.
• 25 of all extra-nodal lymphomas occur in the
  head and neck, and 8 of supraclavicular
  fine-needle aspirates are diagnosed as lymphoma.
• REAL classification (Revised European American
  Lymphoid neoplasm) indolent, aggressive and
  Hodgkin disease

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Clinical presentation

• Neck- lymphadenopathy, ulcerated mass
• Oropharynx- enlarged tonsil, tongue base
  thickening
• Nasopharynx mass, SOM
• Nose paranasal sinuses- ulcerated destructive
  lesion susp. NK/T cell Lymphoma (midline lethal
  granuloma), associated with EBV
• Thyroid - neck swelling, hoarseness, dysphagia,
  or neck pressure/tenderness
• Salivary glands- masses
• Base skull cranial neuropathy, facial pain,
  hearing loss, vertigo, proptosis, or visual
  symptoms

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Physical examination

• History cough, fever, GI, abdominal masses,
  pruritus
• Full PE, look for peripheral adenopathy

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Differential diagnosis

• infectious etiologiesBacteriaViruses (eg,
  infectious mononucleosis, cytomegalovirus,
  HIV)Parasites (eg, toxoplasmosis)
• Nasal granulomatous diseaseWegener
  granulomatosisLymphomatoid granulomatosisInfecti
  ons (eg, leishmaniasis, syphilis, TB)
• Mediastinal presentationInfections (eg,
  histoplasmosis, tuberculosis)SarcoidosisOther
  neoplasms
• Benign lymphoid hyperplasiasB-cell predominant
  - Cutaneous lymphoid hyperplasia (CLH),
  angiolymphoid hyperplasia with eosinophilia,
  Kimura disease, and Castleman diseaseT-cell
  predominant - T-cell CLH, lymphomatoid contact
  dermatitis, and lymphomatoid drug eruption
• Other neoplasmsSquamous cell carcinomaNasopharyn
  geal carcinomaThyroid carcinoma

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Lab studies

• CBC
• Chemistry, liver, LDH
• ESR
• Urine
• Serum ß2 microglobulin (worse prognosis)
• CXR
• Total body CT
• Galium scanning
• Genetic studies

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Procedures

• Fiberoscopy- NPH, larynx
• FNA-C from neck mass
• Excisional/Incisional Bx
• Diagnostic TE
• (Bone marrow, LP, liver, explorative laparotomy)

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Ann Arbor Lymphoma staging

• Stage I - Involvement of a single LN region/
  lymphoid structure
• Stage II - Involvement of 2 or more LN regions
  on the same side of the diaphragm or
  localized contiguous involvement of
  only one extra-lymphatic site and LN
  region
• Stage III - Involvement of LN regions or
  lymphoid structures on both sides of
  the diaphragm
• Stage IV - Disseminated involvement of one or
  more extra- lymphatic organs with or
  without LN involvement and/or
  involvement of the bone marrow or liver

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Treatment

• Chemotherapy major modality
• Radiotherapy
• Surgery ???
• Relapse !!!

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Chemotherapy

• Hodgkin disease
• - MOPP (mechlorethamine nitrogen mustard,
  vincristine, procarbazine, and prednisolone)
• 2 post-Rx ALL, infertility
• - ABVD (doxorubicin (Adriamycin), bleomycin,
  vinblastine, and dacarbazine)
• - For advanced disease BEACOPP
  (cyclophosphamide, doxorubicin, etoposide,
  procarbazine, prednisolone, vincristine, and
  bleomycin with granulocyte colony-stimulating
  factor)

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Chemotherapy

• Non-Hodgkin Lymphoma
• CHOP (cyclophosphamide, doxorubicin, vincristine,
  and prednisolone)
• Purine analogues

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Other procedures

• Stem cell transplantation
• IL-2
• Recomninat INF-a
• Bone marrow transplantation?

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Radiotherapy

• Mantle field includes the submandibular,
  cervical, supraclavicular, infraclavicular,
  axillary, mediastinal, and hilar lymph nodes
• It can be extended to cover the Waldeyer ring and
  the skull base with lateral portals for lymphomas
  involving the skull base
• Combined Chemo Radio

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Surgical treatment

• Excision of necrotic tissue may be necessary in
  nasal NK/T-cell lymphoma
• MALT lymphomas are often treated surgically with
  or without local radiotherapy
• Lymphomas of the CNS and skull base are treated
  with surgical decompression when necessary