07 March 2022

---

Facial lesion

Authors: Riccardo Bonacina, Umberto Mariani, Valeria Martini

---

A 78-year-old patient is examined at the Odontostomatology Clinic for onco-haematological patients USC Odontostomatologia HPG23 in Bergamo. The medical history reveals mild hypertension, prostatic hypertrophy treated with TUR-P in June 2015 and atrial fibrillation treated with ASA. The patient, who is a non-smoker, does not complain of symptoms but has a swelling at the level of the left zygomatic area (fig. 1). The skin does not show variations in color or temperature. On palpation, the swelling has an elastic consistency, is not painful and is not mobile. There are no appreciable lymphadenopathies. At the intra-oral level, the left fornix (fig. 2) presents a swelling with a parenchymatous consistency, fixed and painless. The mucosa covering the neoformation does not show significant alterations. There is a fixed prosthetic product anchored to osseointegrated implants. The gingiva has an adequate band of keratinized mucosa, small recessions are evident but the probes are less than 3 mm. There is no bleeding on probing and oral hygiene is good. An orthopantomography is performed that does not show significant pathologies. The patient has signed the informed consent for the treatment.

DIAGNOSIS AND CARE

The absence of inflammatory signs and symptoms and radiographic changes can exclude local infectious problems. As a further confirmation, a fine needle aspiration is performed without leaking purulent material. A biopsy is performed to discriminate both lesions of an onco-haematological nature, glandular, mesenchymal or chronic reactive pathologies.

The biopsy is carried out under local anesthesia with prior preparation of an envelope flap to access the neoformation. 2 fragments are taken for anatomo-pathological evaluation.

On the basis of the microscopic finding that showed a partly nodular infiltrate of lymphoid elements with a regular nucleus, a low grade follicular lymphoma was diagnosed (G1-2 sec. WHO2008)

The patient, referred to in Hematology, underwent general blood chemistry tests which did not show any alterations. A bone marrow biopsy was performed with negative results. CT and PET investigations (fig. 3) confirmed only the localization of the disease in the left hemimaxilla.

Confirmed the diagnosis of lymphoma and the localization only in the left upper jaw, the patient underwent radiotherapy (30 Gy in 15 fractions) with disappearance of the neoformation.

Lymphomas represent approximately 5% of cancers of the oral cavity. Follicular lymphoma is the second most common form of lymphoma (approximately 20%). It is a low-grade or indolent B lymphoma that originates from the B cells of the germinal centers of the lymph nodes or in extranodal sites. Typically affects adults (50-60 years with a slight prevalence for women). The patient is usually in good general condition. Sometimes it may present with fever, weight loss, night sweats, superficial and / or deep lymphadenomegaly, splenomegaly (present in about 1/3 of patients). Often the disease is diagnosed in well-being patients. Staging is fundamental for therapies and prognosis, which aims to define the extent and stage of the disease.

Medullary involvement is frequent. About 25% of cases have a stage I-II with a favorable prognosis.

Solution of the case
Based on the microscopic finding, low-grade follicular lymphoma was diagnosed