Brief chemotherapy, involved field radiation therapy, and central nervous system prophylaxis for paranasal sinus lymphoma

Pediatric Diffuse Large B-Cell Lymphoma of the Frontal Sinus: A Case Report

An 11-year-old male presented with right proptosis, bulbar conjunctivitis, and diplopia. Computerized tomography (CT) and magnetic resonance imaging revealed an enhancing mass involving the superio-medial orbit, ethmoids, frontal sinus, and anterior cranial fossa with skull base destruction. Diffuse large B-cell lymphoma was diagnosed via CT-guided biopsy. As a component of multidisciplinary care, the patient underwent frontal sinus cranialization, with orbital and skull base reconstruction. Trauma reconstructive principles guided recreation of orbital, frontal sinus, and anterior skull base anatomy. This rare primary location is undescribed in the pediatric literature.

Diffuse Large B-Cell Lymphoma of the Frontal Sinus Presenting as a Pott Puffy Tumor: Case Report

Objective Sinonasal non-Hodgkin lymphoma (NHL) is a very rare condition. NHL located specifically in the frontal sinus is even rarer with only 14 cases in the literature reported to date. A unique case of diffuse large B-cell lymphoma of the frontal sinus that presented first and was treated as suspected Pott puffy tumor is presented along with a review of the literature. Case Report A 69-year-old white man with a history of sinusitis and two recent endoscopic sinus surgeries presented with enlargement of his right forehead. Computed tomography and magnetic resonance images revealed a dense opacification of the frontal sinus bilaterally, thickening and enhancement of the dura mater behind the right frontal sinus, and local osteomyelitis-like lytic bone changes. A bifrontal craniotomy was performed. Radical exoneration of the frontal sinus, copious antibiotic-impregnated irrigation after culture swabs, and resection of presumed granulation tissue was performed. Culture swabs remained negative, but histopathology revealed diffuse large B-cell lymphoma. Subsequent chemotherapy was administered. Conclusion Sinonasal NHL is very rare but can occur in the frontal sinus and may present as a suspected Pott puffy tumor. A high clinical suspicion is necessary for early diagnosis and treatment.

The role of radiotherapy and intrathecal CNS prophylaxis in extralymphatic craniofacial aggressive B-cell lymphomas

The results of this retrospective analysis do not support intrathecal prophylaxis or radiotherapy to ECFI patients in complete remission/unconfirmed complete remission.

Frontal sinus lymphoma presenting as progressive multiple cranial nerve palsy

Primary frontal sinus lymphoma is a very uncommon disease. In all the previously reported cases, the presenting symptoms have been due to the tumor mass effect. We present an unusual case report of an immunocompetent patient who presented with facial palsy, and then progressively developed other cranial nerve palsies over several months. He was later diagnosed with diffuse large B cell lymphoma originating from the frontal sinus. The patient underwent chemotherapy, but eventually had to receive autologous peripheral blood stem cell transplantation. He is currently disease-free. The clinical course, diagnostic workup, and therapeutic outcome are described.

Primary paranasal sinus lymphoma: natural history and improved outcome with central nervous system chemoprophylaxis

Non-Hodgkin's lymphoma of the paranasal sinus is an uncommon presentation of extranodal lymphoma. Its natural history, treatment and prognosis have been infrequently characterized in the medical literature; however, a tendency to involve the central nervous system (CNS) has been noted. In British Columbia (population 4 million), a central database for lymphomas has allowed us to accurately track cases of paranasal sinus lymphoma diagnosed since 1980. A retrospective review was performed on the 44 patients who presented with primary paranasal sinus lymphoma (stage I or II) between 1980 and 1999. Histologic features were identified and immunophenotypic classification performed. Complete diagnostic and follow-up data including stage, treatment, response rates, sites of relapse and survival data were available for all patients. There were 26 men and 18 women. The types of lymphoma found were: diffuse large B cell (including immunoblastic), n = 37 (84%); T/NK nasal type, n = 3 (8%); peripheral T cell, not otherwise classified, n = 2 (4%); and others, n = 2 (4%). The median age at presentation was 66 years (range 27-97 years). The median follow-up for living patients was 114 months. For all 44 patients, the 5- and 10-year overall survivals were 48% and 41% and the disease-specific survivals 62% and 62%, respectively. Beginning in May 1985, intrathecal chemotherapy was added to our standard treatment plan of multi-agent chemotherapy and local irradiation. Before 1985, 2 of 5 patients developed leptomeningeal metastasis. Following the institution of intrathecal chemotherapy, only 8% (3 of 39) of patients have developed CNS disease. Introduction of intrathecal chemoprophylaxis was also associated with an improvement in overall survival from 20% to 51% and disease-specific survival from 40% to 65%. Primary paranasal sinus lymphoma is an uncommon presentation of lymphoma that carries the potential risk of spreading to the leptomeninges. Treatment with combined modality chemotherapy and irradiation can cure many patients and the addition of intrathecal chemotherapy may reduce the risk of CNS relapse.

MALT lymphoma of the paranasal sinuses and the hard palate: report of two cases and review of the literature

Extra-nodal low-grade B-cell lymphomas arising in the gastrointestinal tract recapitulate the structure and features of mucosa-associated lymphoid tissue, called "MALT lymphomas." In the head and neck region except for the salivary glands the occurrence of this neoplasm is very rare. The authors report on two such cases of MALT lymphoma, one of the hard palate in a 71-year-old woman and the other of the paranasal sinuses in a 69-year-old woman with the history of chronic sinusitis. Such chronic inflammatory conditions can induce the development of MALT lymphoma. Clinical elaboration should include computerized tomography (CT) and magnetic resonance imaging (MRI) for the assessment of tumor extension, bone destruction, lymph node involvement and differentiation of mucosal thickening from tumor mass. Biopsy for histopathological diagnosis is mandatory. Treatment should be surgery, irradiation or combined radio-chemotherapy depending on the stage of the disease.

Aggressive sino-nasal non-Hodgkin's lymphoma diagnosed in Nottinghamshire, UK, between 1987 and 1996

In the 10-year period 1987 to 1996, 24 patients were diagnosed with aggressive non-Hodgkin's lymphoma of the nasal cavities or paranasal sinuses. The disease occurred in a relatively elderly population of median age 72 years (range 42 to 96) with a male predominance (male 15; female nine). The histology on review was mostly of the large B-cell subtype (21 patients); peripheral T-cell subtype (one), anaplastic large cell of T-cell type (one) and T/natural killer cell nasal lymphoma (one). The disease was localized in 20 patients (Stage IEA). The overall survival at 5 years was 40% (95% confidence interval (CI) 19-61); at 10 years it was 33% (95% CI 12-54). The cause-specific survival (excluding deaths from causes other than lymphoma) at 5 years and 10 years was 62% (95% CI 39-86).

Sinonasal lymphoma: a clinicopathologic analysis of 58 cases from the Massachusetts General Hospital

Few large series compare lymphomas of the nasal cavity with those of the paranasal sinuses. We studied the cases of 58 patients, 34 males and 24 females, aged 7 to 92 years (mean, 57 years), who had lymphoma involving the nasal cavity or paranasal sinuses. Thirty-three patients had diffuse large B-cell lymphoma (DLBCL). Twenty-three were male and 10 were female, with an age range of 7 to 91 years (mean, 63 years); two were HIV-positive. Only 2 of 11 cases tested (one in an HIV-positive patient and one of lymphomatoid granulomatosis type) were Epstein-Barr virus (EBV)-positive. Thirty (91%) involved paranasal sinuses, 10 with nasal involvement, whereas three cases had nasal, but not sinus, involvement. At last follow-up, 16 (67%) were free of disease 7 to 169 months later (mean, 65 months), and 8 (33%) had died of disease 2 to 166 months later (mean, 45 months). Seventeen patients had nasal-type natural killer (NK)/T-cell lymphoma. There were 10 women and 7 men, aged 27 to 78 years (mean, 48 years). Thirteen of 14 were EBV-positive. Sixteen patients had nasal involvement, eight with sinus involvement. Eleven (73%) of 15 were alive and well 6 to 321 months later (mean, 139 months), three (20%) died of lymphoma 1, 11, and 12 months later, and one (7%) is alive with disease. There was one case each of marginal zone B-cell lymphoma, Burkitt's lymphoma, Burkitt-like lymphoma, peripheral T-cell lymphoma of unspecified type, and adult T-cell lymphoma/leukemia. In an additional three cases, the lymphomas were composed predominantly of large cells, but no immunophenotyping could be performed for subclassification. In 19 cases (17 DLBCLs, 1 Burkitt-like lymphoma, and 1 lymphoma of uncertain lineage), presenting symptoms included complaints related to the eyes. In 16 cases (13 DLBCLs, 1 Burkitt-like lymphoma, 1 nasal NK/T-cell lymphoma, and 1 lymphoma of uncertain lineage), the orbit was invaded by lymphoma. In our series, the most common lymphoma to arise in the sinonasal area is DLBCL, followed by nasal NK/T-cell lymphoma. Comparison of these two types of lymphoma showed that lymphomas involving sinuses without nasal involvement were predominantly DLBCLs (20 of 21), whereas nasal cavity lymphomas without sinus involvement were usually NK/T-cell type (8 of 11) (p = 0.000125). Compared with patients with DLBCL, patients with nasal NK/T-cell lymphoma were overall younger, with a lower male-to-female ratio. Lymphomas of B-cell lineage were more likely to be associated with symptoms related to the eyes (p < 0.0005) and to have extension to the orbit (p < 0.01) than were lymphomas of T- or NK-cell lineage. In contrast to results of Asian studies in which nasal NK/T-cell lymphoma has a very poor prognosis, our nasal NK/T-cell lymphomas had an outcome similar to that of DLBCL.

Lymphoma of the nasal cavity and paranasal sinuses: improved outcome and altered prognostic factors with combined modality therapy

BACKGROUND

Lymphoma of the nasal cavity and paranasal sinuses is a rare presentation of extranodal lymphoma with a natural history that is not well characterized in this era of combination chemotherapy. The goals of this retrospective study were 1) to define the natural history of sinonasal lymphomas; 2) to compare the results of radiation therapy (XRT) alone with those of combined modality therapy (CMT) in the treatment of patients with lymphoma of the nasal cavity and paranasal sinuses; and 3) to define prognostic factors for each treatment.

METHODS

Between 1947 and 1993, 70 patients with newly diagnosed lymphoma of the nasal cavity and paranasal sinuses were treated. The Ann Arbor stages were: Stage IE: 42 patients; Stage IIE: 14 patients; Stage IIIE: 2 patients; and Stage IV: 12 patients. The distribution of T classifications of the primary tumors was as follows: T1: 2 patients; T2: 16; T3: 18; and T4: 34. Greater than 90% of the patients had intermediate grade lymphoma (Working Formulation), and none had follicular lymphoma. Twenty-eight patients received XRT alone, and 42 received CMT.

RESULTS

The actuarial 5-year freedom from progression (FFP) and overall survival (OS) rates for the entire group were 57% and 52%, respectively. For patients with localized disease (Stages IE and IIE) receiving CMT, the actuarial 5-year FFP and OS were 83% and 67%, respectively. In multivariate analysis, treatment with CMT (P = 0.0005) and stage (IE vs. IIIE-IV) (P = 0.0001) were associated with improved FFP. In the group of patients receiving XRT, extent of disease (Stage IE, T1-3 vs. Stage IE, T4 vs. Stage IIE-IV) (P = 0.0001) was the only clinical characteristic associated with improved FFP in multivariate analysis. For patients receiving CMT, International Index (0 vs. 1-3 vs. 4, 5) (P = 0.0001) was the only significant factor predictive of improved FFP in multivariate analysis. One patient failed in the central nervous system (CNS) after initial therapy as a result of a radiation therapy marginal miss.

CONCLUSIONS

In a Western population, patients with localized lymphoma of the nasal cavity and paranasal sinuses have a favorable prognosis when treated with CMT. FFP is significantly improved by treatment with CMT. For patients treated with XRT, extent of disease is the strongest predictor of outcome. International Index is the most significant prognostic factor for patients receiving CMT. Failure in the CNS is rare after initial therapy and is associated with local failure.

Combined therapy for angioimmunoproliferative lesions

43 patients with a diagnosis of angioimmunoproliferative lesions (AIL) entered onto a prospective clinical trial to evaluate the use of combined therapy as a primary therapeutic approach. Patients were treated initially with involved field radiotherapy 40-55 Gy (40 patients received 45 Gy) followed by six cycles of chemotherapy which consisted of CEOP-Bleo (cyclophosphamide, epirubin, vincristine, prednisone and bleomycin). Complete response was achieved in 41 cases (95%). At a median follow-up of 40 months, 40 patients (91%) remain in first complete remission. 2 patients died during radiotherapy secondary to sepsis and tumour progression. Treatment was well tolerated. The treatment of AIL remains controversial. Our results show that combined therapy appears to be the best therapeutic approach in patients with this type of malignant lymphoma. More studies are necessary to define the role of combined therapy in patients with AIL.