Maxillofacial lymphomas

Abstract

Lymphomas affecting the bones of the jaws, although less frequent than carcinomas, can both present radiologically as carcinomas in addition to the more frequent "periapical-radiolucencies-of-inflammatory-origin" (PRIOs). Certainly those lymphomas arising within the maxillary alveolus have a short period of prior awareness before presentation, denoting an aggressive process. Half are provisionally diagnosed as carcinomas and the other half as PRIOs. Failure of the latter to respond to appropriate treatment, compels prompt and appropriate investigation for a malignancy. Further distinction of the malignancy into carcinoma and lymphoma is necessary, because the treatment of carcinomas is radical, achieved mainly by resection plus radiotherapy, whereas treatment of lymphomas relies on chemotherapy and in some cases, radiotherapy. The few reported cases that have been subject to cross-sectional imaging and reporting by radiologists has only appeared relatively recently. These cases reveal roles for cone-beam computer tomography, computed tomography and magnetic resonance (MR). Ultimately the diagnosis is dependant on a biopsy from the most representative area/s and the treatment plan upon the diagnosis and extent of the disease defined by the imaging.

Figure 1.

A large field of view (FOV) of “cone-beam computed tomography” (CBCT) of a case of “non-Hodgkin lymphoma” (NHL) arising within the maxillary alveolus. (a) panoramic reconstruction of the CBCT exhibits the completely obturated right maxillary sinus. The roots of the adjacent teeth appear “floating” within the radiolucency. (b) axial reconstruction of the CBCT dataset, through the maxillary sinus, confirms the complete obturation of the maxillary sinus seen in (a). It reveals not only the erosion of all the walls of the sinus, but also extension of the NHL to the inferior turbinate. The NHL has also infiltrated the right ala of the nose displacing it and the adjacent cheek. The posterolateral wall is eroded and appears perforated in places. (c) coronal reconstruction displaying the lesion destroying the medial wall of the sinus. The adjacent hard palate is also eroded. (d) sagittal reconstruction through the dens and anterior arch of the atlas, revealing the extension of the lesion through-out the hard palate removing trabecular bone. The left maxillary sinus in (b) and (c) is hypoplastic.

Figure 2.

Computed tomography (CT) of two separate cases of “non-Hodgkin lymphoma” (NHL) (a) and (b) are of the case displayed in Figures 1, 3 and 8a, and (c) and (d) are of the case in Figure 8b. (a) bone window of a coronal CT, through the first molar teeth revealed that the right maxilla and sinus were replaced by a soft-tissue mass. The eroded floor-of the sinus was displaced upwardly. The medial wall of the maxillary sinus has been completed eroded leaving only the bone of the inferior turbinate intact. (b) soft-tissue window of a postcontrast axial CT, at a lower level than Figure 1b, displayed infiltration of the soft-tissue close the right ala of the nose. The lymphoma has perforated the posterolateral wall at the point already obvious in (Figure 1), to invade the fat space of the infratemporal fossa. There is no central necrosis. (c) soft-tissue window of a coronal CT reveals perforation of the palatal cortex and expansion into the palatal submucosa. The dome-shaped surface of the lesion is delineated by a well-defined uniformly thick cortex. (d) soft-tissue window of a coronal CT displays the expansion of the lesion buccally into the upper lip and adjacent cheek, filling out the left nasolabial fold, and also medially into the oral cavity.

Figure 3.

Magnetic resonance imaging (MRI) of the case imaged in and Figurers 1, 2 and 8a. (a) T1W sagittal MRI with contrast, reveals the complete obturation of the maxillary sinus up to the floor of the orbit. (b) T2W axial MRI exhibits a perforation of the anterior sinus wall and infiltration of the facial muscles. The posterolateral sinus wall is perforated and the medial wall and turbinate infiltrated and displaced. (c) T1W coronal MRI with contrast, reveals that the now-larger lesion has obturated the air-filled space between the inferior turbinate and the nasal septum. (d) T2W coronal MRI reveals perforation of the posterolateral sinus wall.

Figure 4.

A lymphoma arising within the lingual tonsil (on the dorsum of the tongue). (a, b) and (c) are postcontrast computed tomography (CT) displaying an almost spherical lymphoma in the left side of the dorsum of the tongue extending down to the body of the hyoid bone, substantially obturating the oral cavity and oropharynx on the left side, displacing the tongue forward. (a) coronal CT at the level of the left mandibular foramen. (b) a sagittal CT displaying the calcification of the thyroid cartilage. (c) axial CT through the forwardly-displaced tongue (see in (c) just above the anterior sextant of the mandible. (d) an axial positron emission tomography fused with CT through the lymphoma at a point similar to that in (c), displaying the hyperavidity of the lymphoma. Avidity is also observed in left level II lymph nodes suggestive of metastasis. The large white arrows indicate the involved lymph nodes

Figure 5.

(a). Schematic display of most of the lymph node groups. The spleen and Waldeyer’s ring are also included. (b) Schematic display of the ring of tonsils which traditionally constitute Waldeyer’s ring. Attention to brought to the lesser known “lateral pharyngeal band” of “mucosa-associated lymphoid tissue” (MALT). MALT is ubiquitously distributed throughout the alimentary system and body cavities.

Figure 6.

A DLBCL lymphoma arising within the dorsum of the tongue. It has ulcerated. (a) postcontrast axial computed tomography (CT and (b) axial positron emission tomography fused with CT. (a) displays the lesion an enhanced inverted u-shaped band lining the ulcer cavity (large white arrow). (b) level higher than (a) and displays a spray artefact caused by dental restorations.

Figure 7.

A DLBCL lymphoma arising within the maxillary alveolus. (a, b) are postcontrast computed tomography (CT). (a) coronal reconstruction through the apex of the orbit just behind the eyeballs. The lymphoma has arisen within the right maxillary alveolus, eroding it. It has also eroded the floor of the sinus and extending into its lumen. It has also extended substantially into the soft-tissues of the face causing a swelling of the right face. (b) axial reconstruction through the mandibular foramina. The buccal alveolus has been eroded and there is a substantial swelling of the right check. The lymphoma has infiltrated the skin anteriorly and filled out the right nasolabial fold.

Figure 8.

(a) periapical radiograph of a NHL discovered an incidental finding on an examination of previously root-filled-treated teeth, whose roots appeared to “floating” in the radiolucency (see Figures 1, 2(a, b), 3). (b) part of a panoramic radiograph displaying the roots of teeth in the posterior sextant “floating” within a radiolucency is enclosed by the radiopaque elevated floor (EF) of the maxillary sinus. It lies below the image of the hard palate (HP) (see Figure 2c, d).

Figure 9.

A DLBCL lymphoma arising within the right maxillary sinus. (a) is an axial reconstruction of a postcontrast computed tomograph (CT) displaying erosion and expansion through the anterior, posterolateral and medial walls to reach the right subcutaneous skin, the infratemporal fossa and obturates the nasal cavity. The right cheek is swollen. The right posterolateral and medical walls are also. (b) is an axial reconstruction of a positron emission tomograph fused with CT revealing the lymphoma and the aforementioned local extensions as hyperavid. (c) is a coronal reconstruction of a post contrast CT revealing the complete erosion of the floor of the orbit and infiltration of the orbit. The ethmoidal air cells are also obturated and the medial wall of the orbit displaced into the orbit. The medial wall of the sinus and the turbinate bones have been completely eroded and the right nasal cavity filled with lymphoma. The tissues lateral to the lateral wall of the sinus are infiltrated. (d) is a sagittal reconstruction of a postcontrast CT through the axis of the right orbit showing -proptosis. The erosions of the anterior and posterolateral sinus walls seen in (a) are noted. The floor of the orbit is almost completely eroded with substantial infiltration in the inferior orbit. (e) is a coronal reconstruction of positon emission tomography (PET) displaying the primary site of the lymphoma (small arrows in (d) and (e). The large white arrows in (d) and the large black arrows in (e) point to the involved submandibular and jugulodigastric nodes..

Figure 10.

A lymphoma affecting multiple air spaces and tissues around the nospharynx. (a) postcontrast axial computed tomography (CT). Although both maxillary sinuses and the posterior nasopharynx are involved, the main lesions is sited in the right sinus from where it has extended into the right face, causing substantial swelling and also extending posteriorly into the right infra-temporal space, having breached the anterior and posterolateral sinus walls, respectively. it has also obturated the right nasal cavity. (b) axial position emission tomography fused with CT passing oblliguely through the level in (a): anteriorly it is lower, in the oral cavity, and posteriorly it is higher, through the condylar head. Hyperavidity is observed in the aforementioned areas. (c) axial T₁-weighted magnetic resonance imaging (MRI) through the upper oral cavity and soft-palate. The main lesions displayed are the extensive infiltration of the right cheek and that of the posterior and right lateral pharynx, almost completely obsturating the nasopharynx. (d) coronal T₂-weighted MRI exhibiting complete obturation of both maxillary sinuses. The right lesion has also obturated the entire nasal cavity extending upwards into the ethmoid air cells. It has substantially infiltrated the right orbit from the medial and inferior (floor) orbital walls enveloping the medial and inferior rectus muscles. The left lymphoma has already begun to infiltrated the floor of the left orbit.

Figure 11.

A plasmablastic lymphoma arising within the right maxillary sinus extending medially into the nasal cavity and upwards into the ethmoid air-cell and downwards into the right alveolus. It has partially eroded the anterior wall of the sinus. (a) to (d) are axial reconstructions of (a) postcontrast. computed tomography (CT), (b) positron emission tomography fused with CT, (c) magnetic resonance Imaging (MRI) T₁-weighted and (d) MRI T₂-weighted and fat saturation.

Figure 12.

A plasmablastic lymphoma of the nasal cavity (a) postcontrast coronal computed tomography (CT) displaying obturation of the right maxillary sinus, nasal cavity and ethmoid air cells. The last has displaced the medial wall of the orbit inwards and the floor of the anterior cranial floor upwards, the lymphoma has extended into the maxillary alveolus. (b) coronal magnetic resonance imaging (MRI) T₂-weightred fat saturation reconstruction. The displacement into the orbital cavity and into the anterior cranial cavity is more pronounced. (c) . sagittal postcontrast CT displaying the the obturation of the maxillary sinus with erosions of its anterior wall and displacement of its posterior wall. The lateral expansion of the aforementioned ethmoidal lesion is also displayed. (d) sagittal MRI T₂ reveals the erosions of both the anterior and posterior walls of the maxillary sinus and the lymphoma's infiltration of the maxillary alveolus.