Hodgkin lymphoma of the maxillary sinus: an unusual occurrence

Sinonasal lymphoma: A primer for otolaryngologists

Objective

Sinonasal lymphomas are a rare entity that commonly present with nonspecific sinonasal symptoms and are often recognized immediately. Through this review, we aim to summarize important principles in diagnosis and treatment of sinonasal lymphomas, with the goal of disseminating the current knowledge of this under-recognized malignancy to otolaryngologists.

Methods

Systemic review using PRISMA guidelines of foundational scholarly articles, guidelines, and trials were reviewed focusing on clinical characteristics of key sinonasal lymphoma subtypes, along with available treatments in the otolaryngology, medical oncology, and radiation oncology literature.

Results

Sinonasal lymphoma are derived from clonal proliferation of lymphocytes at various stages of differentiation, of which diffuse large B-cell lymphoma (DLBCL) and extranodal natural killer/T-cell lymphoma (ENKTL) are the most common. Diagnosis and staging require biopsy with immunohistochemistry in conjunction with imaging and laboratory studies. Treatment is ever evolving and currently includes multi-agent chemotherapy and/or radiation therapy.

Conclusion

Otolaryngologists may be the first to recognize sinonasal lymphoma, which requires a comprehensive workup and a multidisciplinary team for treatment. Symptoms are nonspecific and similar to many sinonasal pathologies, and it is crucial for otolaryngologists to keep a broad differential.

Level of Evidence

5.

A Rare Case of Hodgkin Lymphoma of the Maxillary Sinus

Hodgkin lymphoma (HL) is an uncommon B-cell malignant disease. It usually presents with mediastinal and/or laterocervical lymph node localization, while primary extranodal HL is a rare entity giving rise to diagnostic and therapeutic challenges. It rarely presents as just extranodal localization, so its presence within the maxillary sinus without any lymphadenopathy is exceptional. Given the rarity of this localization, there is no standard treatment for maxillary sinus HL. We present a case of a patient with extranodal HL of the right maxillary sinus treated with primary surgery followed by adjuvant sequential chemoradiation therapy.

Epstein-Barr virus (EBV)-associated lymphoid lesions of the head and neck

Epstein Barr virus (EBV)-related lymphoproliferative processes occur in the head and neck ranging from reactive processes such as infectious mononucleosis to high grade malignant lymphomas. EBV is a ubiquitous herpes virus that infects more than 90% of adults worldwide, and is generally transferred though saliva. Primary infection can occur throughout life. EBV is the first virus linked to malignancies, both epithelial and lymphoid. Both T and B cell lymphomas can be associated with EBV and evidence shows that an individual's response to the acute EBV infection may be critical in the development of subsequent lymphoma. Currently, in situ hybridization for EBER is the most sensitive available test to detect EBV and should be routinely performed in lymphoproliferative lesions of the head and neck. Immunohistochemistry for EBV related proteins, such as LMP1, is much less sensitive than EBER in situ hybridization, but can help determine latency patterns of EBV infection. Although relatively rare, primary EBV-related lymphomas must be considered in the differential of atypical lymphoid proliferations in the head and neck. We present selected EBV-related disorders of the head and neck discussing etiology as well as differential diagnosis.

A rare case of breast cancer metastasising to the nasopharynx and paranasal sinuses

INTRODUCTION

Metastatic spread from non-head and neck tumours to the sinonasal region is exceedingly rare. We present a case of breast cancer metastasis to the nasopharynx, ethmoid and sphenoid sinuses. To date there have been only two similar cases in the literature. We discuss the diagnosis and management of such cases and propose how they may be staged.

PRESENTATION OF CASE

A 75-year-old woman with past medical history of breast carcinoma, presented clinically as having a primary sinonasal malignancy. Magnetic resonance imaging (MRI) demonstrated a lesion involving the spenoid and ethmoid sinuses, nasendoscopy revealed a mass in the nasopharynx. Biopsy from clinic pointed to inverted sinonasal papilloma, however this did not fit with the MRI or the clinical picture. Repeat biopsy under image guidance revealed the lesion to be a breast cancer metastasis.

DISCUSSION

An extensive literature review revealed few cases of spread to the sinonasal region from distant primary malignancy. When such cases do arise, most are from renal tumours. Breast cancer metastases usually present with signs and symptoms of disseminated disease, however our case represents a true isolated metastasis. We discuss the management of our case and suggest the use of the tumour-node-metastasis (TNM) system, in order to stage these rare isolated occurrences.

CONCLUSION

If discovered early, this rare manifestation may be managed by primary surgical resection. Metastases to the region may be more common than previously thought. A high index of suspicion should be employed, especially where there is past medical history of malignancy.