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ISSN: 2835-1568; CODEN: USA

DOI: http://dx.doi.org/10.51521/WJCRCI.2023.220122

CASE REPORT

Non-Hodgkin's Malignant Lymphomas of the

Palatine Tonsils: A Case Report
Z. El Hafi¹,3, W. Sidielmoctar Abdallahi¹,³, K. Hjaouj¹,³, R. Bencheikh¹,³,
M.A. Benbouzid¹,³, A. Oujilal¹,³, N. Cherradi²,³, H. EL Ouazzani²,³ & L.
Essakalli¹,³

1
ENT-HNS Department of Specialties Hospital – CHU Ibn Sina Rabat, Morocco
Received Date: 2
Pathology Department, of Specialties Hospital – CHU Ibn Sina Rabat, Morocco
31-10-2023 3
Mohammed V University in Rabat; Morocco
Revised Date:
05-11-2023
Accepted Date:
07-11-2023
Published Date
10-11-2023
Abstract
The palatine tonsils are the first extra-nodal localization of cervicofacial non-Hodgkin's
malignant lymphomas. It is a rare localization and most often a type B lymphoma. This
case highlights the difficulty of making an early diagnosis, given the non-specificity of
Corresponding Author: clinical and paraclinical signs, and the fact that only anatomopathological examination
Z. El Hafi, ENT-HNS Department of can confirm the diagnosis. Chemotherapy is the only treatment for chemo sensitive forms
Specialties Hospital – CHU Ibn Sina of the disease. Prognosis is generally good, depending on sensitivity to treatment and
Rabat, Morocco; Mohammed V stage of disease.
University in Rabat; Morocco
Citation:
Z. El Hafi, W. Sidielmoctar Abdallahi, K. Keywords:
Hjaouj, R. Bencheikh, M.A. Benbouzid, Non-Hodgkin's lymphoma
A. Oujilal, N. Cherradi, H. EL Ouazzani Palatine tonsil
& L. Essakalli (2023). Non-Hodgkin's Oral cavity
Radiotherapy
Malignant Lymphomas of the Palatine
Chemotherapy
Tonsils: A Case Report. World J Case
Homeopathy
Rep Clin Imag. 2023 October-November;
2(2)1-4.
Copyrights
© 2023, Z. El Hafi, et al. This article is
licensed under the Creative Commons
Attribution-Non Commercial-4.0-
International-License-(CCBY-NC) accounts for around 10% of all LMNH and more than a third of
(https://worldjournalofcasereports.org/bl extra-nodal localizations. LMNH present themselves as different
ogpage/copyright-policy). Usage and entities recognized within new classifications that incorporate data
distribution for commercial purposes from modern immunophenotyping [4]. Histological type is more
require written permission. decisive in therapeutic management than location.

Introduction Clinical Case

Malignant non-Hodgkin's lymphomas (MHNL) are malignant A 57-year-old female patient with type 2 diabetes on oral
proliferations of lymphoid tissue. They account for 5% of malignant antidiabetics and cardiac disease on platelet inhibitors presented
tumors of the head and neck, and develop preferentially from extra- with a 4-month history of ulcerative lesions of the left tonsil,
nodal lymphoid tissue [1,2]. Localization in Waldeyer's ring associated with bilateral cervical, axillary and inguinal adenopathy

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ISSN: 2835-1568; CODEN: USA

DOI: http://dx.doi.org/10.51521/WJCRCI.2023.220122

and hypertrophy of the contralateral tonsil. On CT scan, the localizations of the palatine tonsil. An increased risk of LMNH has
appearance was suggestive of a left tonsillar tumefaction with been observed in patients with autoimmune diseases, particularly
cervical adenopathy involving the entire cervical chain bilaterally. A dry syndrome, which increases this risk by a factor of 40 [6]. Other
biopsy performed at the level of the ulceration and whose anatomo- factors favour the occurrence of LMNH and explain the current
pathological examination came back in favour of a malignant non- increase in the incidence of this disease, such as AIDS, where B
Hodgkin's lymphoma of B phenotype. Biologically, the LDH level lymphoma constitutes an opportunistic neoplasm, and acquired
was elevated (over 3 mg/l). The blood count and sedimentation rate immune deficiencies following organ transplantation with
were without abnormalities. As part of the extension work-up, immunosuppressive treatment [6,7].
digestive fibroscopy and bone marrow biopsy were normal.
LMNH can occur at any age, but the average age of onset is around
Patient referred for further chemotherapy with: ACVBP 59. More than 80% of Waldeyer's ring NHLs occur after the age of
(Adreblastine, Endoxan, Oncovin, Bleomycin, Prednisone) and 50 [7,9]. Most series in the literature describe an even distribution
external radiotherapy. of the disease according to sex. Occasionally, there is a slight male
predominance [10].

LMNH of the tonsil is rapidly progressive, with nonspecific

presenting signs such as tonsillar asymmetry, odynophagia, upper
dysphagia and cervical swelling, as in the case of our patient. These
signs can lead to confusion with simple angina. In such cases, the
diagnosis is often overlooked and delayed [11]. It is the persistence
of the symptomatology, despite well-managed treatment, that
prompts the diagnosis. Bilateral tonsillar involvement is rare,
accounting for 10% of cases. Systemic signs, uncommon and present
in only 25% of cases, are helpful in diagnosis [7,12]. Associated
lymph node involvement is common, occurring in around 2/3 of
cases. It is often homolateral to the mobile, painless lesion, quite
different from lymph node metastases of squamous cell carcinoma
[4]. At the time of diagnosis, It is firm, evolving beneath a non-
ulcerated mucosa, contrasting with the absence of pain. This may
Figure 1: Oropharyngeal examination: bilateral suggest a peritonsillar phlegmon, but the absence of infectious signs,
tonsillar hypertrophy with ulcerated appearance on pain, trismus and uvula edema should alert the examiner.
left side Unfortunately, it is not uncommon for these lesions to be wrongly
incised in the first instance [4]. Imaging does not contribute to a
positive diagnosis, especially as a small asymmetry in size between
the two tonsils is considered normal. However, imaging can be
useful in assessing tumour volume and detecting non-palpable
adenopathies, particularly in the retro pharyngeal region. The
absence of invasion of adjacent structures of the tonsil, despite the
size of the tumor mass, is in favor of a lymphomatous localization
[12]. In cases of clinically suspected tonsillar lymphoma, the
diagnosis can only be confirmed by biopsy. Histological
examination includes: a simple morphological analysis of the
architecture of the tissue sampled (diffuse or follicular tumor
invasion); immunohistochemistry, which confirms the lymphoid
nature of the tumor mass and establishes its B or T phenotype,
looking for other markers specific to each sub-type; and finally,
cytogenetic analysis (looking for chromosomal abnormalities). The
Figure 2: Cervical CT axial section: Tumor of the left patient's workup includes myocardial function and, in addition to
palatine tonsil standard biology, HIV, HTLV-1, EBV and hepatitis C serologies, in
order to search for a viral context that may have favored the onset of
lymphoma. Lastly, a stomatological evaluation must be carried out
Discussion with a view to irradiation. At the end of this work-up, a number of
pejorative prognostic elements can be identified [14,15]: age over
Malignant tumors of the palatine tonsil are predominantly
60, site of involvement, volume greather than 5 cm3. Stage III or IV,
carcinomas, while primary LMNH occupy second place with a
involvement of the spinal cord or neurogical site, elevated LD or 2
frequency of 5 to 14% [3,5]. Among LMNH of Waldeyer's ring, the
microglobulin level, Abnormalities of chromosomes 6, 7 and 17,
palatine tonsil is the primary site (40 to 79% of primary lesions),
HIV infection.
followed by the nasopharynx (25 to 35%) and the lingual tonsil (3 to
10%) [3]. Multiple involvement is seen in almost 5% of cases of
The International Prognostic Index (IPI), which takes into account
tonsillar lymphoma. Bilateral involvement occurs in 10% of cases
five of these factors (age greater than 60 years, PS greater than 2,
[4]. Epitheliomas, plasmacytomas, adenocarcinomas, melanomas,
stage III or IV, high LDH level, presence of more than one extra-
Hodgkin's disease, sarcomas and metastases are rare tumor
nodal location), makes it possible to separate patients with a

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ISSN: 2835-1568; CODEN: USA

DOI: http://dx.doi.org/10.51521/WJCRCI.2023.220122

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ISSN: 2835-1568; CODEN: USA

DOI: http://dx.doi.org/10.51521/WJCRCI.2023.220122

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