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

Treatment for NHL is based on the type of disease and involves combination therapy or targeted therapies derived from the immunohistochemistry of the tumor. Radiation is frequently used in the treatment of HL and NHL.

Risk factors for HL include immunodeficiency and Epstein-Barr virus (EBV) exposure. Risk factors for NHL include immunodeficiency, exposures to chemicals such as glyphosate (eg, Roundup weed killer),[1] radiation treatment or chemotherapy, and infections with EBV, human immunodeficiency virus (HIV), hepatitis C virus, Helicobacter pylori, human T-lymphotropic virus 1, or human herpesvirus 8. Patients with HL have a bimodal age distribution, whereas patients with NHL are usually older than 60 years. 

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 details. 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 selected 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 aspiration 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, with the incidence of aggressive non-Hodgkin lymphoma having risen steadily over recent decades.

The image below shows 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 2016 World Health Organization (WHO) classification update is currently used and is as follows[3] :

HL is characterized by the presence of Reed-Sternberg (RS) cells, and the subtype diagnosis depends on the cytoarchitectural milieu in which the Reed-Sternberg 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 low-income 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 lymphoplasmacytic 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 White patients 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.[5]

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.[6]

Epidemiology

Frequency

United States

Lymphoma is the fifth most common cancer in the United States, with an estimated annual incidence of 74,490 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)[7] ; 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 and 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 low-income countries, the early peak is seen in 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 EBV, HIV-1 (aggressive NHL occurs in 10-30% of patients with AIDS), H 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, such as those used following organ allotransplantation, increase the risk of EBV-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

The following laboratory studies 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 vision 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....



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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....



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CT scan 2 years after salvage therapy.

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

A literature review by Baba et al indicated that the apparent diffusion coefficient (ADC) may be useful in differentiating extranodal lymphoma from squamous cell carcinoma (SCC), in the head and neck. Using diffusion-weighted imaging, the report found that SCC has a mean ADC of 0.88 x 10-3 mm2/s, compared with a significantly lower mean ADC of 0.64 x 10-3 mm2/s for extranodal lymphoma. The investigators cautioned, however, that heterogeneity in the data used in the review means that the study’s results “should be interpreted with caution.”[26]

Other Tests

Immunohistochemical analysis of the tumor is essential for diagnosis and may aid in identifying monoclonal antibody targets such as CD20 (rituximab), CD52 (alemtuzumab), PD-1 (nivolumab, pembrolizumab), or CD30 (brentuximab). Cytogenetic analysis may be useful in select cases.

PCR assay analysis helps in evaluating for B- or T-cell clonality or for minimal residual disease, such as t(14;18).

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

Triple-hit lymphomas (MYC/BCL2/BCL6 translocations) and double-hit lymphomas (MYC/BCL2 vs MYC/BCL6 translocations) have a worse prognosis, particularly if they overexpress p53.[11]

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%).[12]

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 specimen should be obtained from the lump through an incision that can itself be excised and incorporated into a radical neck dissection if the histologic findings indicate 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, as well as in 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 cerebrospinal fluid (CSF) should be evaluated with flow cytometry, as evidence has indicated that cytology may not help in detecting some cases with positive results on flow cytometry.

Staging laparotomy or laparoscopy

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. This is now being replaced by PET/CT scanning. 

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. However, a retrospective study including 740 patients (170 adults and 570 children) undergoing tonsillectomy with pathologic evaluation had an incidence of 0.67% (1.2% adult) for occult malignancy. One case of Burkitt lymphoma, one case of follicular lymphoma, one case of DLBCL, and two cases of Mantle cell lymphoma were described. Two of the five patients with occult malignancies discovered on routine tonsillectomy did not have any features suggestive of malignancy.[8]

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 is 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 [Adriamycin], 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 performed only in select cases. Surgical intervention may be pivotal in obtaining biopsy specimens for histopathologic and immunophenotypic characterization of the lymphoproliferative disorder.

Consultations

Medical oncologists work closely with radiation oncologists, head and neck oncologic surgeons, and pathologists to establish diagnoses and treatment courses and to provide follow-up care by means of multidisciplinary conferences. 

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 a 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 for patients with lymphoma, particularly those with 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.[20, 21] 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.[22]

A study by Chelius et al found that in patients with indolent NHL of the head and neck, toxicities tend to be minimal for treatment with either very low–dose radiation (4 Gy) or higher-dose radiation (>4 Gy, median dose in this study being 30 Gy). However, patients in the 4 Gy group had lower rates of toxicity, with, for example, early toxicity of the orbit having an incidence of 42%, versus 96% in the higher-dose patients.[23]

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 undergoing 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 seven 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, white blood cell 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 lactate dehydrogenase (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.[24]

A study by Eismann et al indicated that following systemic therapy, image-guided intensity-modulated radiotherapy (IG-IMRT) offers some benefit over three-dimensional conventional radiotherapy (3DCRT), in patients with aggressive head and neck extranodal NHL. Patients who received IG-IMRT had an overall response rate of 85%, compared with 73% in individuals who underwent 3DCRT. Moreover, there were fewer acute or chronic adverse events associated with IG-IMRT.[25]

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

Jordan W Rawl, MD, Fellow in Head and Neck Oncological Surgery and Microvascular Reconstruction, Nebraska Methodist Estabrook Cancer Center, Creighton University School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Aru Panwar, MD, Head and Neck Surgical Oncologist, Methodist Estabrook Cancer Center, Nebraska Methodist Hospital; Associate Professor, Department of Surgery, Creighton University School of Medicine

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, Emeritus 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; Neosoma; MI10;Invitrocaptal,Medtechsyndicates<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX);MI10;Invitrocaptal;MTS<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10 advisor.

Additional Contributors

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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.

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

Disclosure: Nothing to disclose.

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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.

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.