Original Article

Lymphomas of the head‑and‑neck region

 ABSTRACT Bartlomiej
Background: Lymphomas of the head and neck are always a challenge for an ENT specialist whose goal is to make a quick diagnosis. Kamiński
Aim: Accordingly, clinical and epidemiological analysis of head‑and‑neck lymphoma was performed to approximate diagnostic  Otolaryngology Ward,
difficulties. Maria
Materials and Methods: The diagnosed patients with head‑and‑neck lymphoma in our center were assessed in 2012–2019. Skłodowska‑Curie
District Hospital,
Results: The study group included 22 patients with head‑and‑neck lymphoma including 20 non‑Hodgkin’s lymphoma (NHL) and 2 Skarżysko‑Kamienna,
Hodgkin’s lymphoma (HL). NHL showed symptoms in the lymph nodes of the neck, tonsils, parotid gland, and the orbit. HL showed Poland
exclusive manifestation in the lymph nodes of the neck and tonsils.
For correspondence:
Conclusions: Uncharacteristic symptoms of lymphoma are always a challenge for the ENT specialist whose task is to quickly Dr. Bartlomiej
determine the diagnosis that forms the basis for further treatment. Interview, physical examination, imaging, and laboratory tests Kamiński,
can only be suggestions for the diagnosis or exclusion of lymphoma; always, the decisive test is histopathological examination of Otolaryngology Ward,
Maria
the lymph node or a fragment of the affected organ.
Skłodowska‑Curie
District Hospital,
Szpitalna Street 1,
KEY WORDS: Enlarged neck lymph nodes, head‑and‑neck lymphomas, palatine tonsils 26‑110
Skarżysko‑Kamienna,
Poland.
INTRODUCTION mostly B‑cell hyperplasia (86%) and less often E‑mail: bartl.
kaminski@gmail.com
T‑lymphocytes (12%), while lymphomas derived
T‑ and B‑lymphocytes are the main ceflls of the from natural cytotoxicity cells account for 2%.[ 5,6]
immune system. In healthy people, they are found The incidence rate is constantly increasing by 3%–
mainly in the lymph organs (lymph nodes and 4% per year. The reasons for the increase in the
spleen) and in the lymphatic tissue associated incidence of lymphomas are unknown, as there are
with the mucosa (MALT). The head‑and‑neck no unequivocal data on etiological factors.  Most
area is rich in lymphatic tissue, especially the lymphoma patients go to doctor due to the swollen
Waldeyer’s ring, thyroid gland, salivary glands, lymph nodes and/or the presence of a tumor in
and oral cavity. Around 200–300 lymph nodes the extranode area, as well as the presence of
are found around the head and neck, which is general symptoms of the disease such as fever,
why the head and neck are favorable anatomical night sweats, or weight loss.  Data from medical
sites for the development of lymphoproliferative history, physical examination, and laboratory
diseases.[1,2] tests can only be suggestions for the diagnosis or
exclusion of lymphoma. The decisive examination
Within the head and neck, malignant lymphomas is histopathological examination in each case.[7] Submitted: 23-Feb-2020
account for 5% of all malignancies.[3,4] Malignant For this purpose, the entire lymph node or part of Revised: 30-May-2020
lymphomas constitute a histopathologically the organ involved should be removed. The lymph Accepted: 22-Jun-2020
and clinically diverse group of malignant node should be taken completely along with the Published: 14-Dec-2021
tumors originating in the lymphatic system. pouch. Classical histopathological evaluation
They arise as a result of the proliferation after hematoxylin and eosin staining should be
of immune cells. Tumor transformation is extended to include immunophenotypic testing
characterized by clonal proliferation of lymphoid using monoclonal antibodies. Access this article online
cells corresponding to different stages of Website: www.cancerjournal.net
differentiation of normal B‑cells, T‑cells, or This is an open access journal, and articles are distributed under the terms of the DOI: 10.4103/jcrt.JCRT_213_20
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which
natural cytotoxicity cells. The WHO classification Quick Response Code:
allows others to remix, tweak, and build upon the work non‑commercially, as
based on genetic–immunohistochemical criteria long as appropriate credit is given and the new creations are licensed under the
divides lymphoma into Hodgkin’s lymphoma (HL) identical terms.
and non‑Hodgkin’s lymphoma (NHL).  They are For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

Cite this article as: Kamiński B. Lymphomas of the head-and-neck region. J Can Res Ther 2021;17:1347-50.

© 2021 Journal of Cancer Research and Therapeutics | Published by Wolters Kluwer - Medknow 1347
 Kamiński: Lymphomas of the head-and-neck region

Table 1: Immunohistochemical panel

DLBCL T‑cell lymphoma Mantel cell lymphoma Small lympocytic lymphoma HL
CD20 + ‑ + +
MUM 1 +
bcl6 ‑/+ ‑ ‑
bcl2 + +
CD3 ‑ + ‑
CD5 ‑ + +
CD10 + ‑ ‑
CD30 ‑ + +
CycD1 ‑ + ‑
C‑myc ‑
Ki 67 + + + +
CD15 +
LCA + + +
CD4 ‑
CD8 ‑
CKAE1/AE3 ‑
Synaptophysin ‑
CD23 ‑ +
DLBCL=Diffuse large B‑cell lymphoma, HL=Hodgkin’s lymphoma

Table 2: Primary lymphoma symptom in the analyzed group
Symptom Number of patients
Cervical lymphadenopathy 15
Feeling of pharyngeal obstruction 5 DISCUSSION
Orbital syndrome 1
Asymmetry of face 1
Aim
The aim of the study is the epidemiological and clinical
analysis of cancer incidence from lymphoid tissue in the
head‑and‑neck region based on the patient history diagnosis
in the department of otolaryngology in 2012–2019.
MATERIALS AND METHODS
A retrospective analysis included data from subjective
and physical examinations and results of imaging and
histopathological examinations of 22 patients aged 19–
88 years (mean age 63.68 years). There were 12 men and 10
women in this group.
RESULTS
Of the 22 lymphoid neoplasms, 20 patients (90%) were
diagnosed with NHL while two patients were diagnosed
with 10% of HL.  In 11 patients with NHL, diffuse large B‑cell
lymphoma (DLBCL, 55%) was diagnosed, 3 cases (15%)
found T‑cell lymphoma, mantel cell lymphoma, and small
lymphocytic lymphoma. In each case, the diagnosis is made
on the basis of histopathological examination using an
immunohistochemical panel [Table 1].
The dominant symptoms with which the patients reported
were enlarged lymph nodes in the neck – 15 patients (68.18%)
[Table 2], while another symptom reported by five
patients (27.72%) was a feeling of obstruction in the throat
[Table 3]. Two of the youngest patients aged 19 and 28 years
reported very severe pain for HL in the neck as the leading
symptoms and for sore throat for DLBCL.
Most patients with malignant growths from the
lymphoproliferative system report to the ENT doctor because
of enlarged lymph nodes (60%) and/or the presence of a
tumor in the extranode area (40%), enlarged lymph nodes are
usually painless, the skin above them remains unchanged,
and the dimensions exceed 2 cm and tend to fuse into
packets. Differentiating from other causes for pathological
lymphadenopathy due to infectious diseases Cytomegalovirus
(CMV) and Epstein - Barr virus (EBV) or metastatic squamous
cell carcinoma with head‑and‑neck area is crucial and often
difficult. Certain differences including alcohol and/or tobacco
consumption history, patient age, ENT clinical abnormalities,
general symptoms, and systemic lymphadenopathy may
suggest a diagnosis of lymphoproliferative disease. Some
patients may report general symptoms in the form of fever,
night sweats, and weight loss. Due to high clinical significance
of the presence of general symptoms, it is important to exclude
other causes. This is a difficult diagnostic and differential
problem as a significant percentage of the patients with
lymphomas show immunodeficiency, which predisposes
them to an increased incidence of infections of various, often
complex, and atypical etiologies. Lymphomas in addition to
the nodal location can quite often be located in the Waldeyer’s
throat ring.[8] Further, in our study, the most common location
was the lymph nodes of the neck and then the Waldeyer’s
ring. In one patient, the original location was the parotid
gland. Salivary glands are also a place of the development of
lymphomas in patients with Sjogren’s syndrome (SS).[9,10] It is
assumed that patients with SS have a higher risk of developing
NHL than the general population; this risk is estimated at
44 times. The incidence of lymphomas in SS ranges from 5% to
10%. In most cases, they are extranode B‑lymphocytes with low

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 Kamiński: Lymphomas of the head-and-neck region

Table 3: Location of primary lesion and histological type of lymphoma in the analyzed group
Histological type of the Location of the primary lesion
lymphomas
Nodal Tonsil Orbit Parotid gland Total
Diffuse large B‑cell lymphoma 5 5 1 11
T‑cell lymphoma 3 3
Mantle cell lymphoma 2 1 3
Small lymphocytic lymphoma 3 3
HL 2 2
Total 15 5 1 1 22
HL=Hodgkin’s lymphoma

malignancy and mucosal‑associated lymphoma (MALT).[11,12] In patients with diagnosed lymphoma, it is necessary to

The current SS diagnostic criteria, approved in 2016 by the
American College of Rheumatology and the European League
Against Rheumatism, are based on a total of five elements,
one of which is the assessment of lymphocytic infiltrates
in a 4 mm2 salivary gland taken from the lower lip labial
salivary gland biopsy ( LSGB). Focal lymphocytic salivary
gland inflammation should be differentiated from other
types of inflammation, such as nonspecific salivary gland
inflammation, hardening chronic salivary gland inflammation,
granulomatous inflammation, and lymphomas precisely.[13,14]
Specific extranode lymphoma locations include testicles, orbit,
paranasal sinuses, and spine.[15] One of our patients presented
such special locations, who came to us because of eye
widening.  In most cases, it can be expected that recognition
of a single outbreak lymphoma is just one of the symptoms’
generalizations of the disease, if after careful diagnosis will be
made diagnosed isolated lymphoma – the disease is classified
as seizure single nonlymphatic organ. The probability of an
isolated occurrence lymphoma in the head‑and‑neck region
compared with one possible next location of the generalized
disease does not exceed 20%–30%. The basis for the diagnosis
of lymphoma is only a histopathological examination, to which
the entire lymph node along with the capsule or a fragment of
the involved organ should be taken. Of all the head‑and‑neck
malignancies, lymphomas are the third most common
malignancies after squamous cell carcinoma and thyroid
cancer,[16,17] and therefore, lymphoproliferative hyperplasia
should always be considered for a tumor in the neck or mouth.
Misinterpretation of clinical appearance and radiological
results (ultrasound, computed tomography, and magnetic
resonance imaging [MRI]) can lead to delayed diagnosis,
delayed treatment initiation, and worsening of patient
prognosis. In the current study, we analyzed the clinical and
epidemiological data of lymphomas diagnosed over 8 years in
our ENT department to highlight specific clinical symptoms
that allow early diagnosis of lymphomas. We did not notice
significant differences in the gender distribution of M12:K10.
In our study, we found 20 NHL and 2 HL. Among NHL, DLBCL
was the most common lymphoma in the head‑and‑neck region
in 55% of cases. Enlarged lymph nodes on the neck are the
most common sites for both NHL and HL in the head‑and‑neck
area.[18,19] In our study, we found 15 (68.18%) patients with
cervical lymphadenopathy. Another symptom found in our
group of patients was an obstacle in the throat (5, 22.72%).
accurately determine the degree of advanced disease to select
the optimal treatment method. Positron emission tomography
is the test of choice for both diagnosis and monitoring of the
disease. MRI is the test of choice for orbital lymphoma or
suspected central nervous system involvement.[20] Lymphoma
treatment is based on chemotherapy and radiation therapy in
various schemes developed for specific types of disease. HLs
are characterized by the highest recovery rate.
CONCLUSIONS
Malignant lymphomas should always be considered when
diagnosing head‑and‑neck tumors. Due to the uncharacteristic
clinical picture, anamnesis including no alcohol or smoking
may only suggest a diagnosis or exclusion of lymphoma. The
decisive examination is in each case the histopathological
examination of the entire lymph node or a fragment of the
involved organ.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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