Non-Hodgkin's lymphoma of maxillary sinus: An unusual presentation
A 65 year old man presented with a growth in the upper left alveolus with nasal obstruction for the past 6 months. He also complained of a mild intermittent pain associated with sudden ulcerated growth on the left maxillary alveolar ridge. He had undergone extraction of upper left posterior tooth 5 years back. He did not give any contributory medical and family history. He did not chew or smoke tobacco or use betel nut. On extraoral examination a non-tender, firm swelling involving the left side of face extending from infraorbital rim till 2 cms short of lower border of mandible superoinferiorly []. Intraorally the surface of the growth was covered with a yellowish necrotic material and it was slightly tender on palpation. It was extending to the buccal vestibule and the palatal side of alveolus in the region extending from tooth number 25 till left maxillary tuberosity region []. There were no palpable lymph nodes. The clinical differential diagnosis included the most common malignancies in the oral cavity such as squamous cell carcinoma (SCC), minor salivary gland tumor, and carcinoma of the maxillary sinus. Investigations revealed normal complete hemogram, blood sugar, and liver and kidney function tests. The patient's Enzyme- linked immunosorbent assay for Human immunodeficiency virus and Venereal Disease Research Laboratory were negative. Scrapings taken from the involved region to rule out fungal granulomas did not show any fungi. On radiographic examination in a Waters and Caldwell view, opacification was seen in left maxillary sinus with destruction of anterior and posterolateral wall of maxillary sinus. Computed tomography (CT) scan was performed and sections were taken in the axial, coronal, and sagittal planes. Axial section revealed a large soft tissue density lesion with its epicentre in the maxillary sinus, causing destruction of all walls of the maxillary sinus, extending medially into the lateral wall of the nasal septum, left nasal cavity involving the inferior and middle turbinates, laterally into the pterygopalatine fossa and inferiorly causing destruction of the hard palate and alveolar processes of the left maxilla in the molar region []. Next a biopsy was taken for histopathological evaluation, which was suggestive of peripheral reparative giant cell granuloma. In doubt, a repeat biopsy for immunohistochemistry findings was done. Immunohistochemistry reports were suggestive of non-Hodgkin's lymphoma diffuse large B cell type[] with tumor cells positive for CD20 []. The patient was staged IE according to the Ann Arbor Staging system. He received 6 cycles of standard (R-CHOP) regimen, Rituximab 375 mg/m2 d1 (Day 1),[] Cyclophosphamide 750 mg/m2 d1, Doxorubicine 50 mg/m2 d1, Vincristine 1.4 mg/m2 d1, and Prednisolone 100 mg (Day 1-5). The response to the treatment was successful []. Post treatment the patient is in follow up over past 1 year and no recurrence is seen till date [].