Diagnostic challenges in a diffuse large B-cell lymphoma of the maxilla presenting as exposed necrotic bone

Abstract

Lymphoma is the second most common malignancy in the head and neck area, affecting both nodal and extranodal sites, including oral soft and hard tissues, usually in the form of non-Hodgkin's lymphoma (NHL). However, lymphomas of the jaws, including diffuse large B-cell lymphoma (DLBCL), the most common type of NHL, are very rare and may cause significant diagnostic challenges resembling common jaw pathologies, such as periapical lesions, osteomyelitis and osteonecrosis. The aim of this paper is to present a rare case of DLBCL in an 84-years-old diabetic male patient on methylprednisolone treatment for autoimmune hemolytic anemia. The lesion appeared clinically as exposed necrotic bone of the maxilla with surrounding soft tissue ulceration and radiographically as an extensive osteolytic lesion with ill-defined borders. Despite the resemblance of the lesion with osteonecrosis or osteomyelitis that could be theoretically related to diabetes and/or systemic use of corticosteroids, histopathologic examination, necessitating a repeat biopsy in order to acquire sufficient tissue, revealed the final diagnosis of lymphoma. The need for increased clinical awareness and vigilance of this possible diagnostic conundrum is emphasized. Key words:Diffuse large B-cell lymphoma, exposed bone, oral, malignancy, maxilla, jaw osteonecrosis, differential diagnosis.

Figure 1

Clinical examination. Exposed bone in the left maxilla, partially covered by a greenish pseudomembrane with surrounding soft tissue ulceration.

Figure 2

Imaging examination. Cone beam computed tomography scan showing osteolytic lesion with ill-defined borders and buccal and palatal perforation in the left maxillary alveolar bone between central incisor and second premolar.

Figure 3

(A,B): Histopathologic examination (original magnification [A] ×100 and [B] ×400). Hematoxylin and eosin staining showing diffuse and dense infiltration of the connective tissue by large neoplastic lymphoid cells with anaplastic features, prominent nucleolus, and abundant cytoplasm.

Figure 4

Immunohistochemical analysis (magnification x400) demonstrating diffuse and intense positivity of tumor cells for BCL-6 and MUM1 and a high Ki-67 index; CD10 was negative.