The diagnosis of sinonasal lymphoma: a challenge for rhinologists

Abstract

The presenting symptoms of sinonasal lymphoma are usually similar to those of benign inflammatory diseases. Adequate amount of biopsy tissue is required for a definitive diagnosis because tumor coexisting with necrosis or inflammation is not uncommon. Therefore, the diagnosis of sinonasal lymphoma is a challenge for rhinologists. Thirty-two patients diagnosed as having sinonasal lymphoma from 1990 to 2010 in our hospital were included in this study. The presenting symptoms of these patients included nasal obstruction, rhinorrhea, bloody discharge/epistaxis, post nasal drip, facial swelling, neck mass, orbital symptoms, fever, and body weight loss. The average period between patients' awareness of their symptoms and their decision to seek medical help was 8.9 months. When they were referred to our hospital, the first impression of 20 patients (62.5%) was benign or malignant nasal neoplasm, and that of the other 12 patients (37.5%) was rhinitis or rhinosinusitis. These patients then received image studies and biopsy or surgical intervention. Most patients needed repeated biopsies, endoscopic sinus surgery, turbinectomy, or Caldwell-Luc operation for a definitive diagnosis. Their histopathologic classification included NK/T cell lymphoma (n = 13, 40.6%), peripheral T cell lymphoma (n = 12, 37.5%), and diffuse large B cell lymphoma (n = 7, 21.9%). Peripheral T cell lymphoma and NK/T cell lymphoma mostly occurred in the nasal cavity, whereas sinus involvement without nasal disease is common in B-cell lymphoma Our results reveal that patients with sinonasal NHL tend to ignore their symptoms until they become serious, and a definitive diagnosis usually requires repeat and deep biopsy.

Sinonasal natural killer/T-cell lymphoma presenting as pyrexia of unknown origin with nasal symptoms

“…(9) In a similar fashion, a definitive diagnosis of NK/T-cell lymphoma was only made in our patient after deep-seated histological specimens were obtained during FESS. This clearly shows that simple punch biopsies may not harvest adequate amounts of tissue in these patients.…”

“…Indeed, surgical procedures such as FESS, turbinectomy or the Caldwell-Luc procedure have been reported to be more useful for harvesting adequate biopsy specimens for the pathological examination of sinonasal lymphoma. (9) In patients with persistent symptoms of sinusitis despite 'adequate' treatment, a high index of suspicion should be exercised for more sinister conditions such as nasal lymphoma. Apart from chronic sinusitis symptoms refractory to conventional treatment, our patient also had the red-flag 'B' symptoms of fever and weight loss.…”

Primary non-Hodgkin lymphoma of the sphenoid sinus with visual disturbance: A report of two cases

“…Previous studies have reported that T-cell and natural killer/ T-cell lymphomas mainly occur in the nasal cavity, whereas B-cell lymphomas commonly occur in the sinus without nasal disease (10,11). Clinically aggressive lymphomas, including Burkitt's lymphoma and diffuse large B-cell lymphoma of the sphenoid sinus, exhibit atypical characteristics, including destruction of adjacent bone such as the skull base and infiltration of the dura mater with intracranial invasion (12).…”

Lymphomas of the head and neck in dermatological practice

“…The difficulty in the diagnostic process leads to a presentation of an advanced stage of the lymphoma, which then predicts poor prognosis for the patient. As the nature of the disease is one of progressive tissue necrosis, multiple large biopsy specimens are required before sufficient tissue with scattered malignant cells is discovered [45][46][47][48][49][50]. Careful immunohistochemical assessment is thus vital in order to differentiate these lymphomas from other malignancies as well as benign inflammatory processes.…”

“…Patients wait an average of 8.9 months to seek medical help after becoming aware of their symptoms. This late presentation in the office contributes to the advanced stage of lymphoma and thus associated poor prognosis [49].…”