Primary extra-nodal non-Hodgkin's lymphoma of gingiva: A diagnostic dilemma
Patient was a 50-year-old female of Indian origin who presented for evaluation of a slowly enlarging anterior mandibular mass, which she stated had been present for at least 12 months. She reported pain and swelling in association with paresthesia in the chin region for 12-14 months. Initially, her symptoms were thought by her dentist, to be a pyogenic granuloma and managed by excision and antibiotics. However, the lesion recurred after six months of excision and rapidly enlarged to the present size. Clinically, the lesion appeared as sessile, soft and friable mass, which bled on palpation []. The mass had displaced the teeth in the affected region and involved the mandibular labial sulcus. At the time of presentation, patient did not report any systemic symptoms and had no fever, weight loss or dysphasia. The patient's previous medical history was non-contributory. She was not on medications at the time of presentation and was a non-drinker and a non-smoker.\nExcisional biopsy was performed to determine the nature of the lesion. The H and E stained soft-tissue section [] revealed proliferation of lymphoblastic appearing cells that showed varying degrees of differentiation. Cells had round or oval nucleus with multi-lobed or cleaved nuclei. The section consisted of the population of monotonous proliferation of the lymphoblastic series with minimal cytoplasm. Lymphoblasts were scattered in diffuse pattern in the subepithelial connective tissue. At one area, the section was encapsulated and showed arteritis obliterans, extravasated red blood cells, collagen bundles, fibroblasts, adipocytes, chronic inflammatory cells mainly lymphocytes, calcifications, muscles fibers, eosinophilic material and bone. The epithelium was parakeratinized stratified squamous type, which was thin and atrophic at places.\nA diagnosis of primary extranodal non-Hodgkin's diffuse large B-cell type lymphoma of the gingiva with small cleaved nuclei type cells was made as CD20 marker was positive on immunohistochemistry [] and patient was then referred to the oncologist for definitive management. The oncologist confirmed that the lymphoma was localized to the anterior mandible only, without any diffuse disease or nodal involvement. She was categorized as stage IAE primary mandibular NHL. It was the recommendation of the oncologist that she should undergo four cycles of Cyclophosphamide hydroxydaunorubicin oncovin prednisolone-rituximab followed by radiotherapy. She attained a complete response and following therapy there appeared to be new healthy bone formation.