Marmara Medical Journal Volume 9 No:2 April 1996

N O N -H O D G K IN 'S LYM PH O M A OF TONSILS

(Received 28 December, 1995)

A . K of, M.D.*** / A . O za ga r, M.D.*** / A . Tutkun, M.D.**

Batman, M.D.** / C. Uneri, M.D.* / M . A . $ehitoglu, M .D.*

’ Professor, D epa rtm e nt o f O torhinolaryngology, Faculty o f M edicine, M arm ara U niversity, Ista n b u l, Turkey.
’ * A ssociate Professor, D e pa rtm e nt o f O torhinolaryngology, F aculty o f M edicine, M arm ara U niversity, Istanbul,
Turkey.
* " Resident, D e pa rtm e nt o f O torhinolaryngology, F aculty o f M edicine, M arm ara U niversity, Ista nb ul, Turkey.

ABSTRACT first noticed 3 weeks previously and continued to

It is well known that non-Hodgkin's lymphoma of
various histologic types, including Burkitt's lymphoma
and chronic lymphocytic leukemia (diffuse well-
differentiated lymphocytic lymphoma), frequently
appears in the oral cavity's soft tissues, including the
soft palate and Waldeyer's ring. An unusual case of
non-Hodgkin’s lymphoma primarily with tonsillar
involvement was evaluated. The clinical course of the
disease was presented with the current literature
search.
Key W ords : Non-Hodgkin’s, Lymphoma, Tonsil.
INTRODUCTION
Non-Hodgkin's lymphomas represent a small
percentage of head and neck cancers. Cervical
adenopathy is one of the most common presenting
sign for patients with lymphoma. Approximately 10%
of patients with lymphomas will present extranodal
head and neck sites (1-3). These sites include
Waldeyer's ring (lymphatic tissue in the tonsil,
nasopharynx, and base of tongue) and
extralymphatic involvement of tissue adjacent to
lymph nodes, such as paranasal sinuses, salivary
glands, oral cavity and larynx (4-5).
enlarge. He was diagnosed and treated as cryptic
tonsillitis for 10 days before presenting our clinic.
He was otherwise well, and had no history of fever,
nightsweats, malaise or weight loss. On physical
examination, a 5x5 cm mass was noted on the left
tonsillar fossa. He was also hoarse, but there were no
palpable cervical nodes.
His white blood count was 4800 cells/mm3 with 4%
bands, 57% polys, and 39% lymphocytes.
Hemoglobin was 10,9g/dl. He had also other
laboratory d e term inatio ns, including lactic
dehydrogenase and alkaline phosphatase levels-
lumbar puncture; a chest roentgenogram; and bone
marrow biopsy which were all in normal values. ACT
scan of the retroperitoneum, pelvis and abdomen
was negative.
ACT scan of the head and neck showed a mass
lesion originating from the left tonsillar fossa and
protruding into the oropharengeal passage and
nasopharyngeal area. Soft palate was also distorted
on the left side (Fig 1).
An excisional biopsy was performed and histopatho-
logical analysis of the mass showed non-Hodgkin’s
lyphoma of the "intermediate grade" diffuse mixed
small and.large cell type (Fig 2).

Lymphoma occurs especially in the palatine tonsils.

These lesions may be unifocal or may involve many
areas, particularly palatine tonsils. They are more
likely to be large and the surgeon is surprised to find
such a large lesion with a relatively brief history of
symptoms. Tonsil is grossly enlarged. Involvement of
the tonsil may be the first symptom of systemic
lymphoma, which may be spread in the body.
CASE REPORT
A 72 year-old man was presented in May-1994 with a
history of a mass in the mouth. The mass had been
DISCUSSION
Lymphomas are separated into two histopathologic
groups: Hodgkin’s disease and non-Hodgkin's
lymphomas. The cause of most of the non-Hodgkin’s
lymphoma is unknown. However, some occur with
increased frequency in patients with certain viral
infections, im m unoproliferative states, and
immunosupressed states. Rappaport system has
been the most widely used system for histologic
classification of non-Hodgkin's lymphomas. As our
knowledge has been improved about the immune
system and immune cells- each type of lymphoma

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Marmara Medical Journal Volume 9 No:2 April 1996

Fig. I : CT imaging showed a mass originating from left tonsillar fossa.

Fig. 2 : Histopathological analysis confirmed non-Hodgkin's lymphoma.

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has been better defined and the validity of the
Rappaport classification system has been
challenged. National Caner Institute developed a new
system: the Working Formulation. This system
divides lymphomas into three major subgroups: low-
grade, intermediate-grade and high-grade (6). Most
patients with head and neck lymphomas have
unfavorable subtypes, predom inantly diffuse
histiocyte and diffuse lym phocytic poorly
differentiated lymphoma (4,7-8).
The low-grade lymphomas have an inherent median
survival of 7 years, but in spite of a high response
rate to chemotherapy, they do not have improved
survival with aggresive therapy. The majority of the
intermediate-grade lymphomas, of the large cell type,
have a 30% cure rate with aggresive combination
chemotherapy (1,13). The highgrade lymphomas
have an inherent median survival of 1 year or less,
but a significant fraction can now be cured with
aggresive chemotherapy.

The incidence of non-Hodgkin's lymphoma rises with

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