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CASE REPORT
Year : 2020  |  Volume : 65  |  Issue : 2  |  Page : 145-147
Lymphoma on the nasal dorsum: Report of a rare case


1 Department of Emergency, The First Hospital of Jilin University, Changchun, Jilin Province, China
2 Department of Otolaryngology-Head and Neck Surgery, The First Hospital of Jilin University, Changchun, Jilin Province, China

Date of Web Publication25-Feb-2020

Correspondence Address:
Jianmei Yin
Department of Otolaryngology-Head and Neck Surgery, The First Hospital of Jilin University, No. 3302, Jilin Road, Erdao District, Changchun City, Jilin Province - 130000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_559_18

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   Abstract 


Lymphoma over the nasal dorsum has never been reported. Herein, we report the case of a 74-year-old man who presented with a rapid swelling on the nasal dorsum. A physical examination revealed a firm, immobile, non-tender mass. Computed tomography revealed a space-occupying lesion in the subdermal layer of the nasal dorsum that was most likely a fibroma. An excisional biopsy was performed. Surprisingly, histopathological and immunohistochemical analyses identified a diffuse large B-cell lymphoma. The patient underwent seven cycles of chemotherapy comprising of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. He responded well to the regimen. No evidence of persistent or recurrent disease had been detected during the 9 months after his last chemotherapy session. Although never reported previously, lymphoma can mimic common midline nasal soft-tissue tumors and should be considered in the differential diagnosis.


Keywords: Biopsy, cutaneous, differential diagnosis, lymphoma, nasal dorsum


How to cite this article:
Zhu L, Liu H, Fu Z, Yin J. Lymphoma on the nasal dorsum: Report of a rare case. Indian J Dermatol 2020;65:145-7

How to cite this URL:
Zhu L, Liu H, Fu Z, Yin J. Lymphoma on the nasal dorsum: Report of a rare case. Indian J Dermatol [serial online] 2020 [cited 2020 Mar 29];65:145-7. Available from: http://www.e-ijd.org/text.asp?2020/65/2/145/279200





   Introduction Top


Lymphomas are a group of complex and diverse malignancies of the reticuloendothelial and lymphatic system that predominantly involve the lymph nodes, spleen, and other extranodal tissues. They comprise of 3% to 5% of all malignancies, and non-Hodgkin lymphoma accounts for 60% of all lymphoma cases.[1] The head and neck region is the second most common site of extranodal lymphomas, after the gastrointestinal tract. Lymphomas in the nose are extremely rare, representing only 1.5% of all lymphomas.[2] Nasal lymphomas usually involve the nasal cavity, paranasal sinuses, or aerodigestive tract.[2] To the best of our knowledge, there have been no case report of a primary lymphoma originating in the nasal dorsum.

In this paper, we present a case of early-stage lymphoma arising within the subcutaneous region of the nasal dorsum that was initially diagnosed as a fibroma.


   Case Report Top


A 74-year-old man was referred to the otorhinolaryngology department of our hospital who was suffering with a rapidly enlarging, painless mass over the nasal dorsum for the past 3 months. He had no history of facial trauma, fever, nasal obstruction, nasal discharge, neck pain, or unintentional weight loss. A physical examination revealed a mass overlying the dorsum of the nose. It measured approximately 3.0 × 1.5 cm, and was firm, immobile, and not tender. The overlying skin appeared normal, with no signs of ulceration [Figure 1]. There was no submandibular or cervical lymphadenopathy. Computed tomography (CT) revealed a space-occupying lesion in the subdermal layer of the nasal dorsum, very close to the nasal bone, without any evidence of bony erosion or destruction [Figure 2]. The lesion was suspected to be a fibroma. Routine preoperative laboratory investigations showed normal levels of leukocytes, erythrocytes, and thrombocytes.
Figure 1: Preoperative photograph reveals a 3.0 × 1.5 cm mass over the nasal dorsum in a 74-year-old man

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Figure 2: Preoperative computed tomographic scan of the head showing that the mass is located in the subdermal space

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The mass was removed by means of direct excision under general anesthesia. During the operation, we found that the lesion was located in the subcutaneous space and had adhered to a small part of the nasalis muscle [Figure 3]. Intraoperative frozen-section examination demonstrated a malignant tumor invading the muscle tissue. The mass along with the muscle it had attached to and some of the surrounding normal adipose tissue was separated from the underlying nasal bone. Unexpectedly, routine postoperative histopathological examination of paraffin-embedded sections of the tissue specimen revealed diffuse large B-cell lymphoma, with muscle and adipose tissue involvement [Figure 4]. Immunohistochemical staining of the lesion showed diffuse infiltration of large neoplastic cells that were CD20+, CD79a+, CD45RO+, BCL-6+, BCL-2+, OCT-2+, PAX-5+, MUM-1+, KI-67+ (55%), and C-MYC+ (40%). Epstein–Barr encoding region in situ hybridization yielded a negative result.
Figure 3: Intraoperative photograph showing that the mass is located in the subcutaneous region and is adhered to the nasalis muscle

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Figure 4: Histopathology shows diffuse infiltration by large tumor cells (H and E, ×200)

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With a confirmed pathological diagnosis, the patient was transferred to the hematology/oncology department of our hospital 2 weeks after the operation. Subsequently, bone-marrow biopsy showed no abnormalities, with no lymphoma infiltration. Systemic lymphoma involvement was not found on positron-emission tomography-CT. The tumor was staged as IE according to the Ann Arbor staging system, and the patient was advised to undergo seven cycles of chemotherapy comprising of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. The patient responded well to the treatment regimen. No evidence of persistent or recurrent disease was detected at 9 months after his last chemotherapy session. Regular follow-up was ongoing till reporting.


   Discussion Top


External nasal masses are uncommon; their exact incidence is not well known, but approximately 61% of these masses are diagnosed in children.[3] We created a rough classification of these lesions according to the otorhinolaryngological, neurosurgical, and pediatric literature: developmental masses, benign and malignant neoplasms, inflammatory lesions, post-traumatic deformities, vascular malformations, and others [Table 1]. Thus, the differential diagnosis should include these diseases. Radiological findings are indispensable to the investigation of lesions of the nasal dorsum,[3] and usually help in the exclusion of irrelevant entities. For example, they may provide direct or indirect evidence of soft-tissue tumor with or without intracranial communication, fluid-filled cyst, solid lesion, and involvement of deeper structures.[3]
Table 1: Classification of external nasal masses

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Regardless, misdiagnosis is still the norm rather than the exception in such cases, just as in our case, the detection of lymphoma on histopathological examination was unexpected. Excisional or fine-needle-aspiration biopsy is an alternative to remove the localized lesion and may establish the diagnosis.[4] An incisional biopsy is usually not recommended for diagnostic confirmation because of the potential risk of secondary intracranial infection and cerebrospinal fluid leak in the case of probable intracranial communication.[4]

In general, in patients with external nasal masses, a diagnosis of lymphoma should also be considered in addition to common soft-tissue tumors, especially when the lesion involves the nasal dorsum and is associated with rapid swelling. If necessary, excisional or fine-needle-aspiration biopsy may be performed. Referral to the hematology/oncology service is very helpful for the diagnosis and management of lymphoma.


   Conclusion Top


Through our review of the literature, we concluded that primary involvement of the nasal dorsum is an exceedingly rare manifestation of lymphoma. This case highlights the important role of a high index of suspicion for lymphoma and biopsy examination.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Quraishi MS, Bessell EM, Clark D, Jones NS, Bradley PJ. Non-Hodgkin's lymphoma of the sinonasal tract. Laryngoscope 2000;110:1489-92.  Back to cited text no. 1
    
2.
Peng KA, Kita AE, Suh JD, Bhuta SM, Wang MB. Sinonasal lymphoma: Case series and review of the literature. Int Forum Allergy Rhinol 2014;4:670-4.  Back to cited text no. 2
    
3.
Hanikeri M, Waterhouse N, Kirkpatrick N, Peterson D, Macleod I. The management of midline transcranial nasal dermoid sinus cysts. Br J Plast Surg 2005;58:1043-50.  Back to cited text no. 3
    
4.
Rickli J, Marchi M, Socher J. Subcutaneous cavernous hemangioma in the nasal dorsum: Report of case treated with endoscopic rhinoplasty. Int Arch Otorhinolaryngol 2013;18:213-6.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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    Abstract
   Introduction
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