Lymphomas of the Head and Neck

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Practice Essentials

A quarter of all extranodal lymphomas occur in the head and neck, and 8% of findings on supraclavicular fine-needle aspirate biopsy yield a diagnosis of lymphoma. Lymphoma is the second most common primary malignancy occurring in the head and neck. Nasopharyngeal laryngoscopy, fine-needle aspiration cytology, excision lymph-node biopsy (in Hodgkin lymphoma [HL] and non-Hodgkin lymphoma [NHL]), and bone marrow aspiration and biopsy are essential in the workup of patients with head and neck lymphomas. ABVD, a regimen of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine, is considered the standard of care in HL.

See the image below.



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CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

Signs and symptoms

Lymphoma may be nodal or extranodal. Common symptoms include the following:

Full otorhinolaryngologic and neck examination including fiberoptic examination, in addition to complete physical examination, is indicated. Physical findings that may be noted include the following:

See Presentation for more detail. See also 10 Patients with Neck Masses: Identifying Malignant versus Benign, a Critical Images slideshow, to help identify several types of masses.

Diagnosis

The following laboratory studies may be warranted:

The following imaging studies may be warranted:

Other tests to be considered include the following:

The following procedures may be helpful:

A lymphoma specialist should perform staging and treatment. The Ann Arbor staging system is used to stage lymphomas.

See Workup for more detail.

Management

Initial therapy for HL typically includes the following:

Therapy for relapsing or refractory HL typically involves the following:

Therapy for NHL may include the following:

Therapy for T-cell lymphomas may include the following:

Surgery for treatment of lymphomas of the head and neck is only performed in select cases.

See Treatment and Medication for more detail.

Background

Otolaryngologists are frequently involved in the diagnosis of lymphoma. A quarter of all extranodal lymphomas occur in the head and neck, and 8% of findings on supraclavicular fine-needle aspirate biopsy yield a diagnosis of lymphoma. In white populations, lymphoma is a more common cause of cervical lymphadenopathy than metastatic disease. Lymphoma is the second most common primary malignancy occurring in the head and neck and importantly, the incidence of aggressive non-Hodgkin lymphoma has risen steadily over recent decades.

The image below depicts a lymphoma of the head and neck.



View Image

CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

Pathophysiology

Although a variety of histologic classification schemes have been used for lymphoma in the past, the World Health Organization (WHO) classification is currently used.

The WHO classification of lymphomas is as follows:

HL is characterized by the presence of Reed-Sternberg (RS) cells, and the subtype diagnosis depends on the cytoarchitectural milieu in which the RS cells or their variants are found. Nodular sclerosis, mixed cellularity, lymphocyte-rich and lymphocyte-depleted subtypes are collectively termed classic HL. Nodular sclerosis is the most common subtype, especially in patients younger than 40 years, followed by mixed cellularity. Lymphocyte-predominant HL, more common in young men than in others, behaves more like a low-grade B-cell lymphoma than other tumors. In general, patients who are elderly, those who live in developing countries, and those infected with HIV are most likely to have widespread disease with systemic symptoms at diagnosis.

Approximately 85% of NHLs are B-cell lymphomas. The most common indolent NHL is follicular lymphoma, which is derived from germinal center B cells. Other indolent histologies are lymphoplasmacytoid lymphoma, which has characteristics of B cells differentiating toward plasma cells, and marginal-zone lymphoma derived from the memory B-cell compartment, which includes MALT lymphomas. DLBCL is the most common aggressive NHL. On the basis of messenger RNA microarrays, most cases have profiles that indicate an origin from a germinal center B cell or a postgerminal-center activated B cell. Mantle-cell lymphoma and Burkitt lymphoma are aggressive NHLs that have the characteristics of normal B cells residing in the mantle zone or in the germinal center of a lymphoid follicle, respectively.

Cutaneous T-cell lymphomas, such as mycosis fungoides, can be indolent. However, many T-cell NHLs are aggressive malignancies.

Mortality/Morbidity

For HL, overall 5-year survival rates in the United States are 83% for whites and 77% for African Americans. For NHL, the 5-year survival rate is 53% for whites and 42% for African Americans.

A study by Han et al using the Surveillance, Epidemiology, and End Results (SEER) database found overall survival rates in the United States for nasopharyngeal lymphoma to be 70%, 57%, and 45% at 2, 5, and 10 years, respectively, and determined median overall survival to be 8.2 years. Multivariate analysis indicated that overall and disease-specific survival rates are worse in patients with advanced age or NK/T-cell NHL and are improved in association with radiation therapy.[1]

A study by Anderson et al found that in adolescents and young adults aged 15-39 years, noncancer-related deaths rates were higher in NHL, HL, and head and neck cancer than in the general US population, with the standardized mortality ratios for these rates being 6.33, 3.12, and 2.09, respectively. The ratio was high for certain other cancers as well.[2]

Epidemiology

Frequency

United States

Lymphoma is the fifth most common cancer in the United States, with an annual incidence of 74,490 estimated cases. Approximately 88% of these cancers are NHLs. The incidence of NHL has doubled over the last 20 years because of the increase in AIDS-related lymphoma (ARL)[3] ; an increase in the detection of lymphoma; an increase in the elderly population; and for other, poorly understood reasons.

International

The different histologic subtypes of NHL have various distributions and geographic predilections. The frequency of NK/T-cell lymphoma is increased in China, in Taiwan, in Southeast Asia and in parts of Africa where Burkitt lymphoma is endemic.

Race

HL and, to a lesser extent, NHL are more common in whites than in African Americans or Hispanics. Other races such as Asian/Pacific islanders or American Indians have the lowest incidence and mortality rates.

Sex

The incidence of both HL and NHL is higher in men than in women, especially among older patients.

Age

In the United States, HL has a bimodal age distribution, with a peak incidence in people aged 20-34 years and a second peak in whites aged 75-79 years and in African Americans aged 55-64 years. In Japan, the early peak is absent, and in some developing countries, the early peak shifts into childhood.

The mortality rate increases with age. For example, incidence and mortality rates for NHL increase with age. In addition, Burkitt lymphoma represents 40-50% of all pediatric lymphomas but is uncommon in adults without AIDS.

Lymphoblastic lymphoma most commonly affects men aged 20-40 years who have lymphadenopathy and/or a mediastinal mass.

History

Lymphoma may be nodal or extranodal. Extranodal lymphoma is usually NHL and worsens the patient's prognosis. HL extends by means of contiguous nodal spread; therefore, it is often localized and frequently occurs in the mediastinum. NHL tends to spread hematogenously and is often systemic at diagnosis.

Physical

Full otorhinolaryngologic and neck examination including fiberoptic examination, in addition to complete physical examination, is indicated.

Causes

Incidence of HL is increased 10-fold in same-sex siblings and by as much as 100-fold in identical twins. This observation implies genetic factors in the etiology.

Infectious agents implicated in the pathogenesis of some lymphomas include Epstein-Barr virus, HIV-1 (aggressive NHL occurs in 10-30% of patients with AIDS), Helicobacter pylori, human t-cell lymphotropic virus-1 (HTLV-1), hepatitis B and C viruses, human herpes virus 8, Borrelia burgdorferi, Chlamydia psittaci, and Campylobacter jejuni.

Chronic inflammation increases the risk of lymphoma, such as a MALT lymphoma arising in the salivary gland in a patient with Sjögren syndrome.

Immunosuppressive medications, for example those used following organ allotransplantation, increase the risk of Epstein-Barr virus–associated NHL. A percentage of these lymphomas regress spontaneously when the immunosuppressive medication is discontinued.

Farming, welding, and work in the lumber industry are associated with an increased risk of lymphoma.

Laboratory Studies

Laboratory studies of the following are indicated:

Imaging Studies

Chest radiography is essential.

CT scanning of the chest, abdomen, and/or pelvis is necessary for the evaluation of mediastinal, retroperitoneal, and mesenteric adenopathy. CT scans miss splenic involvement in 20-30% of cases of limited stage HL.

CT scanning of the head and/or neck is mandatory for patients with a head and neck presentation; localized disease; or symptoms such as cranial neuropathies, hearing loss, vertigo, or visual changes. The images below depict CT scan changes.



View Image

CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.



View Image

CT scan 6 months after treatment with 4 cycles of DA-EPOCH (ie, infused etoposide, doxorubicin, and vincristine with bolus cyclophosphamide and predni....



View Image

CT scan of a patient with a recurrence of stage I-AE angiocentric lymphoma of the left maxillary sinus, treated 7 years earlier with 4 cycles of ProMA....



View Image

CT scan 2 years after salvage therapy.

MRI is used as indicated for evaluation of the brain and/or spinal cord. Positron emission tomography (PET) scanning should also be ordered as indicated.

Other Tests

Immunohistochemical analysis of the tumor is essential for diagnosis and may aid in identifying monoclonal antibody targets such as CD20 (rituximab) or CD52 (alemtuzumab). Cytogenetic analysis may be useful in select cases.

Polymerase chain reaction analysis helps in evaluating for B- or T-cell clonality or for minimal residual disease, eg, t(14;18).

In diffuse large B-cell lymphoma, fluorescent in-situ hybridization (FISH) for t(8;14)/MYC translocation should be considered. Up to 10% of DLBCLs have a MYC translocation and have a poor outcome with standard therapy.[4]

Procedures

Nasopharyngeal laryngoscopy

Nasopharyngeal laryngoscopy is essential. Perform this as the initial investigation to evaluate for a neoplasm of the upper aerodigestive tract that is accessible for biopsy.

Fine-needle aspiration cytology

Fine-needle aspiration cytology is also essential. This test is useful for the initial investigation of neck lymphadenopathy for differentiating squamous cell carcinoma from lymphomas, thyroid tumors, and salivary gland tumors.

A study by Crous et al found the combination of fine-needle aspiration cytology and flow cytometry to be effective in diagnosing NHL but less so in detecting HL. According to the investigators, in NHL the combined diagnostic means had a sensitivity of 95.5%, a specificity of 99.9%, a positive predictive value of 99.5%, and a negative predictive value of 99.2%, being 99.3% accurate. However, fine-needle aspiration cytology/flow cytometry missed 6 out of 13 HL cases (46.2%).[5]

Excisional lymph-node biopsy

Excisional lymph-node biopsy is essential in HL and NHL. Needle aspiration and/or biopsy are not adequate for the primary histologic diagnosis because the architectural features of the tissue are important. A biopsy sample should be obtained from the lump through an incision that can itself be excised and incorporated into a radical neck dissection if the histology indicates squamous cell carcinoma. In most cases, the unfixed node should be sent immediately to the laboratory for analysis.

Bone marrow aspiration and biopsy

Bone marrow aspiration and biopsy are also essential. Results are positive in as many as 70% of patients with indolent NHL. In disseminated disease, malignant cells may be found in the bone marrow, spinal fluid, ascites fluid, or pleural fluid.

Lumbar puncture

Lumbar puncture may be indicated. This should be performed routinely in all patients with HIV infection in addition to patients with specific histologic subtypes such as Burkitt lymphoma and lymphoblastic lymphoma. Lumbar puncture is also used when possible symptoms of CNS disease are present after head CT or MRI shows no evidence of mass effect. In addition to cytology, the CSF should be evaluated with flow cytometry, as evidence has demonstrated that cytology may not help in detecting some cases with positive results on flow cytometry.

Staging laparotomy or laparoscopy

Staging laparotomy or laparoscopy for HL may be needed. CT and other imaging modalities are not reliable in diagnosing occult splenic and nodal disease.

Historically, staging laparotomy was often included in the initial evaluation of patients with HL, as this was the only way to detect occult splenic disease. Because chemotherapy is usually incorporated into the initial treatment of HL, it is rarely done now, and really indicated only in patients in whom the assessment is required to optimize treatment.

Staging laparotomy includes biopsy of selected lymph nodes in the retroperitoneum, splenectomy, and several needle and wedge biopsy procedures in the liver. Laparoscopy with laparoscopic sonographic probes can be used to detect small intrahepatic and lymph-node metastases, with a sensitivity and specificity that approaches those of laparotomy.

In the past, the initial clinical stage changed in nearly one third of all patients with HL because of staging laparotomy. About one third of normal-sized spleens were found to be infiltrated with tumor, and 35% of patients with clinical splenomegaly had no histologic evidence of disease. However, a randomized study did not demonstrate a survival advantage in patients with surgically staged disease compared with those with clinically staged disease.

The use of prognostic factors is replacing staging laparotomy in identifying HL patients suitable for radiotherapy alone.

Diagnostic tonsillectomy

Diagnostic tonsillectomy may be indicated if lymphoma of the tonsils is suspected. Risk factors for malignancy in the tonsils are tonsillar asymmetry, a history of cancer, palpable firmness or a visible lesion of the tonsil, neck mass, unexplained weight loss, and constitutional symptoms.

In a study of 476 consecutive adults undergoing tonsillectomy, no patient without at least one of the risk factors listed above had malignancy on pathologic evaluation of the tonsils.

Histologic Findings

Accurate histologic diagnosis is the main guide for the modality of treatment to be used in NHL. A pathologist experienced in lymphoma diagnosis uses immunophenotyping by immunocytochemistry and/or flow cytometry to aid diagnosis. Special stains can be used, such as staining for follicular dendritic cells to highlight residual architecture in differentiating MALT from non-MALT lymphoma. Of interest, 80% of lymph-node infarctions are associated with a final diagnosis of lymphoma.

Staging

A lymphoma specialist should perform staging and treatment.

Medical Care

In the past, the standard chemotherapeutic regimen used for HL was mechlorethamine (nitrogen mustard), vincristine, procarbazine, and prednisolone (MOPP). However, this regimen was associated with infertility, a 2% incidence of myelodysplasia/acute leukemia at 4-6 years after treatment, and a 3% incidence of fatal febrile neutropenia. ABVD is a regimen of doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine. ABVD is superior to MOPP alone and now considered the standard of care in HL. The incidence of infertility is lower with ABVD than with MOPP, but fatal pulmonary toxicity can occur with bleomycin.

In advanced HL, intensified regimens such as the escalated BEACOPP (ie, cyclophosphamide, doxorubicin, etoposide, procarbazine, prednisolone, vincristine, and bleomycin with granulocyte colony-stimulating factor) are being investigated. However, ABVD remains the standard of care.

Surgical Care

Surgery is only performed in select cases.

Medication Summary

For a general discussion of chemotherapeutic regimens, see Treatment. See also the following articles: For adults, see Lymphoma, Non-Hodgkin and Lymphoma, B-Cell, and for children, please see Non-Hodgkin Lymphoma and Hodgkin Disease.

Further Outpatient Care

Otolaryngologists are required to perform regular nasopharyngeal laryngoscopy in patients whose initial presentation involved findings in the nasopharyngeal cavity, mouth, or sinuses.

In addition, otolaryngologists may be required to perform biopsy when suspicious lesions are present in these areas. They may also need to perform biopsy for suspicious neck nodes during follow-up to obtain a histopathologic specimen to examine for recurrence.

Deterrence/Prevention

For patients with HL anticipating mantle irradiation, abstinence from smoking is essential to minimize their risk of lung carcinoma.

In addition, patients who receive bleomycin are at risk for lung toxicity.

When possible, mantle irradiation should be avoided in people who smoke and in young women because of the risks of lung and breast cancer, respectively, as secondary neoplasia is the most common cause of long-term treatment-related mortality.

Complications

Because of the high cure rates with lymphoma, particularly in HL, the long-term adverse effects of therapy are important considerations and these effects have recently been realized in long-term follow-up of patients with HL.[11, 12] Mortality from causes other than HL overtakes HL deaths at 15 years after diagnosis, and because the median age at diagnosis is 44 years, most are treatment-related deaths. Deaths from second malignancies become the most important cause of death other than HL itself.

Other complications of radiation therapy are hypothyroidism (after mantle irradiation), xerostomia, pharyngitis, fatigue, and weight loss.

Patients treated for NHL can have late relapses at 7-10 years.

A study by Seland et al indicated that in patients with NHL treated with radiation of the head and neck, those with untreated hormone dysfunction are at greater risk of subsequently developing chronic fatigue. The study’s results also suggested that patients whose dysfunction has been treated with hormone substitution are at no greater risk of chronic fatigue than are patients with normal hormone status. The study included 98 NHL survivors who had been treated with radiation to the head and neck region, 29% of whom had chronic fatigue.[13]

Common toxicity-related effects of chemotherapy are nausea and vomiting, marrow suppression, alopecia, mucositis, pneumonitis, and neuropathy. Delayed effects of chemotherapy can include a risk of premature menopause and infertility and a small risk of anthracycline-induced cardiac toxicity.

After autologous stem-cell transplantation, late, nonrelapse mortality is primarily due to chronic lung damage, infection, and secondary malignancies. Late pulmonary fibrosis occurs in up to 6% of patients, and late fatal infections occur in 1-2%. The incidence of leukemia in patients receiving transplantation is similar to the incidence in those receiving conventional chemotherapy, but the risk of secondary solid tumors is higher than with chemotherapy alone.

Prognosis

In early-stage HL, factors associated with adverse outcomes are large mediastinal involvement, age older than 40 years, B symptoms, involvement at multiple sites, high ESR, high beta2-microglobulin, mixed-cellularity and lymphocyte-depleted histologies, and treatment with involved-field radiation.

For advanced HL, the International Prognostic Factors Project for Advanced Hodgkin's Lymphoma identified 7 adverse factors at diagnosis: initial hemoglobin level of less than 10.5 g/dL, albumin value less than 4 g/dL, stage IV disease, male sex, WBC count greater than 15,000 cells/mm3, absolute lymphocyte count of less than 600 cells/mm3, and age older than 45 years. Each of these factors decreases the 5-year progression-free survival rate by 7-8%.

In patients with aggressive B-cell NHL (eg, DLBCL), the prognosis depends on age (< 60 or >60 y), serum LDH levels, performance status, stage, and extranodal involvement. Response to treatment is also an important prognostic indicator.

A study by Teckie et al indicated that in patients with early stage extranodal marginal-zone lymphoma, those with lymphoma of the stomach or the head and neck have the highest likelihood of relapse-free survival following treatment with curative-intent radiation therapy alone. The study utilized the records of 490 patients (median follow-up 5.2 y) with stage IE or IIE marginal-zone lymphoma, located most frequently in the stomach, orbit, skin, breast, or nonthyroid head and neck.[14]

Patient Education

For patient education resources, see the Cancer and Tumors Center, as well as Brain Cancer and Cancer of the Mouth and Throat.

Author

Kieron M Dunleavy, MD, Professor of Medicine, Director of Lymphoma Program, Co-Director of Microbial Oncology Program, Division of Hematology and Oncology, GWU Cancer Center

Disclosure: Nothing to disclose.

Coauthor(s)

Erik Kass, MD, Chief, Department of Clinical Otolaryngology, Associates in Otolaryngology of Northern Virginia

Disclosure: Nothing to disclose.

Wyndham Wilson, MD, PhD, Senior Investigator, Division of Clinical Sciences, National Institutes of Health National Cancer Institute

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Karen H Calhoun, MD, FACS, FAAOA, Professor, Department of Otolaryngology-Head and Neck Surgery, Ohio State University College of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .

Additional Contributors

Daniel J Kelley, MD, Consulting Staff, Eastern Shore ENT and Allergy Associates and Peninsula Regional Medical Center

Disclosure: Nothing to disclose.

References

  1. Han AY, Kuan EC, Alonso JE, Badran KW, St John MA. Epidemiology of Nasopharyngeal Lymphoma in the United States: A Population-Based Analysis of 1119 Cases. Otolaryngol Head Neck Surg. 2017 May. 156 (5):870-6. [View Abstract]
  2. Anderson C, Lund JL, Weaver MA, Wood WA, Olshan AF, Nichols HB. Noncancer mortality among adolescents and young adults with cancer. Cancer. 2019 Mar 20. [View Abstract]
  3. Sissolak G, Sissolak D, Jacobs P. Human immunodeficiency and Hodgkin lymphoma. Transfus Apher Sci. 2010 Feb 3. [View Abstract]
  4. Savage KJ, Johnson NA, Ben-Neriah S, Connors JM, Sehn LH, Farinha P, et al. MYC gene rearrangements are associated with a poor prognosis in diffuse large B-cell lymphoma patients treated with R-CHOP chemotherapy. Blood. 2009 Oct 22. 114(17):3533-7. [View Abstract]
  5. Crous H, Gillam A, Kalokerinos MA, et al. Investigation of lymphoid lesions of the head and neck using combined fine needle aspiration cytology and flow cytometry: Accuracy and pitfalls. Cytopathology. 2019 Apr 15. [View Abstract]
  6. Meyer RM, Gospodarowicz MK, Connors JM, Pearcey RG, Wells WA, Winter JN, et al. ABVD alone versus radiation-based therapy in limited-stage Hodgkin's lymphoma. N Engl J Med. 2012 Feb 2. 366(5):399-408. [View Abstract]
  7. Younes A, Gopal AK, Smith SE, Ansell SM, Rosenblatt JD, Savage KJ, et al. Results of a Pivotal Phase II Study of Brentuximab Vedotin for Patients With Relapsed or Refractory Hodgkin's Lymphoma. J Clin Oncol. 2012 Jun 20. 30(18):2183-9. [View Abstract]
  8. Feugier P, Van Hoof A, Sebban C, Solal-Celigny P, Bouabdallah R, Fermé C. Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: a study by the Groupe d'Etude des Lymphomes de l'Adulte. J Clin Oncol. 2005 Jun 20. 23(18):4117-26. [View Abstract]
  9. Witzig TE, Flinn IW, Gordon LI, Emmanouilides C, Czuczman MS, Saleh MN. Treatment with ibritumomab tiuxetan radioimmunotherapy in patients with rituximab-refractory follicular non-Hodgkin's lymphoma. J Clin Oncol. 2002 Aug 1. 20(15):3262-9. [View Abstract]
  10. Dunleavy K, Little RF, Pittaluga S, Grant N, Wayne AS, Carrasquillo JA, et al. The role of tumor histogenesis, FDG-PET, and short course EPOCH with dose-dense rituximab (SC-EPOCH-RR) in HIV-associated diffuse large B-cell lymphoma. Blood. 2010 Feb 3. [View Abstract]
  11. Dunleavy K, Bollard CM. Sobering realities of surviving Hodgkin lymphoma. Blood. 2011 Feb 10. 117(6):1772-3. [View Abstract]
  12. Castellino SM, Geiger AM, Mertens AC, Leisenring WM, Tooze JA, Goodman P, et al. Morbidity and mortality in long-term survivors of Hodgkin lymphoma: a report from the Childhood Cancer Survivor Study. Blood. 2011 Feb 10. 117(6):1806-16. [View Abstract]
  13. Seland M, Holte H, Bjoro T, et al. Chronic fatigue is prevalent and associated with hormonal dysfunction in long-term non-Hodgkin lymphoma survivors treated with radiotherapy to the head and neck region. Leuk Lymphoma. 2015 May 18. 1-9. [View Abstract]
  14. Teckie S, Qi S, Lovie S, et al. Long-term outcomes and patterns of relapse of early-stage extranodal marginal zone lymphoma treated with radiation therapy with curative intent. Int J Radiat Oncol Biol Phys. 2015 May 1. 92 (1):130-7. [View Abstract]

CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

Fiberoptic nasal examination of a patient with natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

CT scan 6 months after treatment with 4 cycles of DA-EPOCH (ie, infused etoposide, doxorubicin, and vincristine with bolus cyclophosphamide and prednisone).

CT scan of a patient with a recurrence of stage I-AE angiocentric lymphoma of the left maxillary sinus, treated 7 years earlier with 4 cycles of ProMACE-MOPP (ie, prednisone, methotrexate, Adriamycin, cyclophosphamide, etoposide–mechlorethamine [nitrogen mustard], vincristine, procarbazine, and prednisone) and 3960 cGy of radiation.

CT scan 2 years after salvage therapy.

CT scan of a patient with a natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.

CT scan 6 months after treatment with 4 cycles of DA-EPOCH (ie, infused etoposide, doxorubicin, and vincristine with bolus cyclophosphamide and prednisone).

CT scan of a patient with a recurrence of stage I-AE angiocentric lymphoma of the left maxillary sinus, treated 7 years earlier with 4 cycles of ProMACE-MOPP (ie, prednisone, methotrexate, Adriamycin, cyclophosphamide, etoposide–mechlorethamine [nitrogen mustard], vincristine, procarbazine, and prednisone) and 3960 cGy of radiation.

CT scan 2 years after salvage therapy.

Fiberoptic nasal examination of a patient with natural killer (NK)/T-cell lymphoma of the right nasal cavity and maxillary sinus.