Lymphoma of the Head and Neck

Milos J Janicek, MD
Madeleine D Kraus, MD
Roman A Klufas, MD

September 9, 1994

Presentation

A 30-year-old woman with cranial VI nerve palsy and an enlarging mass in the nasopharynx.

Imaging Findings

Coronal CT demonstrates a soft tissue mass (white arrows) in the parapharyngeal region and nasopharynx, extending to the sphenoid and posterior ethmoid sinuses (black arrows, see above link) without obvious bone destruction.

MR images demonstrate an intermediate T1 (arrow) and increased T2 (arrow) signal intensity mass in Waldeyer's ring region with diffuse homogeneous enhancement with gadolinium (arrow).

The mid sagittal T1-weighted image demonstrates extension of the mass (short white arrows) into the sphenoid sinus (black arrows, see above link) and the retroclival region (long white arrows, see above link) intracranially.

Gallium-67 scintigraphy of the head demonstrates intense uptake in the mass visible on CT and MRI.

Differential Diagnosis

Diagnosis

Discussion

Patterns of lymphomatous involvement of head and neck have been ategorized into four types (1):

1. Nodal lymphoma
   • Unilateral
   • Bilateral
2. Extranodal lymphoma
   • Confined to Waldeyer's ring
   • Outside Waldeyer's ring (extralymphatic)
3. Combined extranodal/ nodal lymphoma
4. Multifocal, extranodal involvement

NHL comprises 5% of head and neck cancers. Extranodal disease is a more common presentation in non-Hodgkin's than in Hodgkin's lymphomas. It is the second most frequent site of extranodal lymphoma after the gastrointestinal tract. Approximately 40-60% of patients presenting with head and neck disease will have systemic NHL. For staging, gallium-67 scintigraphy has the advantage of assessing the total body with a relatively high rate of detecting abnormalities, but with relatively nonspecific findings. (This method will also detect inflammatory conditions as well as gallium-avid tumors.) CT and MRI depict the local extent of the disease.

NHL can be unilateral or bilateral, with extension from the nasopharynx to the tonsils. Masses are indistinguishable from squamous cell cancer (SCC), except that SCC is less frequently multicentric and more often produces bone destruction. Both onditions may be associated with lymph node enlargement. MR may help to distinguish paranasal sinus extension from accompanying postobstruction fluid (bright on T2).

Pathology

NHL of Waldeyer's ring represents an uncommon mucosal site for lymphoma (the stomach and the colon are more common sites within the gastrointestinal tract) and may fit into the MALT lymphoma (MALToma) concept. Grossly, lymphomas are composed of soft lobulated off-white tissue without much structure. Microscopically, this tumor was composed predominantly of large cells and had numerous mitoses, consistent with an intermediate grade of lymphoma.

References

2. Harris NL. A revised European American classification of lymphoid neoplasma: a proposal from the International Lymphoma Study Group. Blood 1994;84:1361-1372.

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