Presentation
40 year-old male presenting with right submandibular mass that progressively enlarged over three to four months and also complaining of right nasal blockage that gradually progressed over a period of approximately one year. Clinical examination revealed polypoid lesion filling and occluding right nasal cavity, along with a large hard smooth submandibular mass.
Patient Data
MR images reveal large relatively homogeneous soft tissue mass lesion involving and occluding right nasal cavity and ethmoid air cells with right nasal turbinates being not delineated. Extension noted into right maxillary, frontal and sphenoid sinuses which also show retained secretions. Extensions also noted into nasopharynx and right pterygopalatine fossa with infiltration into right masticator space (more in pterygoid muscles) and right half of soft and hard palates. Extension is also noted into postero-inferior part of right orbit with involvement of inferior rectus muscle.This appears intermediate signal on T1WI and hyperintense on T2WI/STIR. Moderate enhancement is noted following contrast administration.
MR images also show large homogeneous right submandibular lymph node/mass showing moderate homogeneous enhancement. Also noted few discrete prominent right posterior triangle lymph nodes.
Case Discussion
Histopathological evaluation confirmed lymphoma (NHL). Serum LDH was also elevated (550U/l). There was no other lymphadenopathy in rest of body regions.
Lymphoma is neoplastic disease of nodal and extranodal lymphoid tissue, with spectrum ranging from low to high grade aggressive malignant pattern. Lymphomas have been categorized as Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Sinonasal lymphomas are usually of NHL type and prognosis is worse than lymphomas of other locations. Of these, B cell lymphomas are more common than T cell lymphomas. As far as geographical distribution is concerned, sinonasal lymphomas are more common in asian countries. Diagnosis of sinonasal lymphoma is delayed due to nonspecific symptoms in early stage disease (i.e. nasal discharge, obstruction, and epistaxis) mimicking sinonasal inflammatory conditions. Presence of clinical features such as persistent non-healing disease, destructive changes and associated lymphadenopathy in accessible regions prompt to search for neoplastic etiology and thus further evaluation accordingly.
On imaging studies, sinonasal lymphomas may be seen as diffusely infiltrating lesions along walls of paranasal sinuses and nasal cavity, or as discrete sinonasal soft tissue masses. On CT, lesions appear of soft tissue density (usually isodense to muscles). Associated bone destruction is better appreciated on CT. On T1WI lesions appear as intermediate signal pattern. On T2WI/STIR hyperintense (more hyperintense on STIR). MRI is optimal imaging modality for assessing complete locoregional extent of disease. Contrast enhancement of lymphomas is variable, however tend to be homogenous in pretreatment lymphomas. Correlation with LDH levels and histopathological results is necessary. Serum LDH levels are useful in assessing treatment response
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