non hodgkin's lymphoma | Non Hodgkin of the cavum malignant lymphoma: prognostic factors and treatment protocols Non-Hodgkin lymphoma of the cavum: Prognosis factors and therapeutic protocols

Non Hodgkin of the cavum malignant lymphoma: prognostic factors and treatment protocols
Non-Hodgkin lymphoma of the cavum: Prognosis factors and therapeutic protocols



Summary
The malignant non Hodgkin lymphoma is a rare histological entity among the cavum, most of the tumors of nasopharyngeal cancers being undifferentiated carcinomas or Undifferencied Carcinoma of Nasopharyngeal Type (UCNT); It is often a problem of positive clinical and histological diagnosis. The symptomatology is generally little specific and the etiological approach is based on the biopsy of the cavum made the endoscopic examination with immuno-operational review. We report the case of lymphoma non-Hodgkin with achievement of the nasopharynx, pathological analysis is in favour of a malignant lymphoma non Hodgkin phenotype B. Clinical, radiological, histological and therapeutic aspects are described.

Keywords: Cavum, nasal obstruction, lymphoma, radio-chemotherapy

Introduction
Lymphomas are the third type of malignant tumor at the level of the head and neck (12%) after (46%) epidermoid carcinomas and thyroid carcinomas (33%). The incidence of non-Hodgkin lymphoma is increasing for several decades. They can occur in many places of the head and neck, as the ORL sphere is rich in lymphoid structures [1]. They represent a challenge of diagnosis and therapy [2]. Clinical detection occurs most often advanced due to the deep anatomic location. The diagnosis is based on the biopsy with Immunohistochemistry study. The treatment usually appealed to the chemo-radiation therapy association. We present here the case of a patient with lymphoma non Hodgkin type B of the cavum. His prognosis is similar to that of the lymphomas of other locations and remains generally good.

Patient and observation
Ms. A.K aged 57 years, no significant pathological history, introduced a bilateral nasal predominant right and running for 12 months with hypernasal voice, associated with an odynophagie for 3 months. Clinical examination ENT, including the fibroscopy Endonasal (Figure 1), showed a tumor purplish of the rhinopharyngee rear right median para which extends from the lower part of the tubal orifice right up to the oropharynx. This tumor is inflammatory and present on its surface a deposit pseudo-membraneux fibrinoide. Local samples by swabs were performed and analyzed in bacteriology. All samples were negative and the IDR tuberculin was measured at 10mm. Cervicofacial MRI (Figure 2) helped to objectify a diffuse thickening of the posterior wall of the nasopharynx, enhanced by injection of Gadolinium and extending down through a prevertebrale fusiform training that reduces the size of upper aero-digestive tract, with presence of Lymphadenopathy cervical Group II right circular measuring 17 mm. The thoracic scanner showed no lung fireplace, and the biological assessment was normal. Under general anesthesia, an endoscopy was carried out and several biopsies were conducted at the level of the rhinopharyngee tumor formation. These biopsies, sent without fixer, were investigated on the one hand a classic histological analysis, and on the other hand an analysis after immuno-marking. This anatomopathological analysis helped highlight a respiratory mucosa largely reworked by a polymorphous infiltrate of immune cells dense and diffuse without follicular structure with cells of large size in the outline irregular nuclear; Immunohistochemistry exploration found that fragments express the LCA, CD20 and CD79a and not EMA, CD3, CD15, CD30ni and CD45RO (Figure 3) facing the diagnosis of a malignant non Hodgkin Lymphoma large cell B. The malignant nature of the lesion is established, a Tomography by Emission of positrons in the 18F-Fluorodeoxyglucose (toe) was requested to determine the extension distance from lymphoma and regional (Figure 4). This review reported intense hyperfixations at the tumor site rhinopharynge (SUV max = 13.9) level but also at the level of the group right II (SUV max = 6.9) Lymphadenopathy, no other lesion has been highlighted). The tumor was classified so malignant non Hodgkin Lymphoma large cell B stage I E (cavum) according to the classification of Ann Arbor no prognostic factors unfavourable [3, 4]. The patient was able to benefit from specific treatment with chemotherapy with CHOP 3 cures (Cyclophasphamide: 750 mg/m2, ADRIAMYCIN: 50 mg/m m2, Vincristine: 1.4 mg/m m2, Prednisone) and irradiation of Waldeyer and areas ring lymph node neck 45 Gy in sprawl and split. The nasofibroscopie and the scanner of the cavum showed the disappearance of the tumor lesion at the end of the treatment. Radiological and endoscopic inspections after the end of treatment showed clinical and paraclinical remission. Hindsight is 8 years.

Discussion

No LMNH Hodgkin malignant lymphomas are the most frequent malignant hemopathies (15/100 000 people/year). This incidence has doubled in 20 years. It is the neoplasia that has increased the most in effect after the melanoma. Its primitive location at the level of the cavum is rare. It is about less than 10% of patients with Lymphoma of head and neck. This particular location of the lymphoma is more frequently seen in the far East and South America. Most of the published studies tended to include it with other lymphomas of the head and neck without making a difference; Lymphoma non-Hodgkin of the nasopharynx well has its own peculiarities in terms epidemiological, histological and prognostic. It can meet at any age but more often between the fifth and the sixth decade and more frequently in the male sex (sex ratio of 3.6) [5] the LMNH belong to lines B or T-natural killer (NK/T). They are part of the mature lymphoproliferative. The phenotype B predominates for lymphomas non Hodgkin of the cavum (60%) while the T/NK type predominates in the nasal cavity level. The Epstein-Barr virus was incriminated in the genesis of lymphoma not hodgkiniens the nasopharynx but only type T, since Immunohistochemistry or molecular biology reveals it almost constantly for lymphomas T but not for the B. The Immunohistochemistry study is necessary to confirm the polyposis of proliferation (expression of LCA) nature and reveal the phenotype of the tumor cells (expression of CD20 B phenotype and CD56 and CD45RO for phenotype T) [1, 3, [6]. calls of the malignant non Hodgkin Lymphoma clinical signs are nonspecific identical to those of all tumors of the cavum rhinologiques with United or bilateral nasal obstruction epistaxis, Otologic, on the other hand in relation to one Eustachian dysfunction, generally it may be otitis seromuqueuse [7]. The Lymphadenopathy are found usually in half of the cases, they are firm, mobile and painless. General signs are found in 20% of cases and the cranial pairs are extremely rare [7, 8]. Endoscopic examination may show a pale or purplish, soft, tumor limited to the cavum or extended to the tubal orifice or the choanae. Most often, the diagnosis is made early (80% in stages I and II) and the average time is 3 months [3, 7]. The MTR extension for these tumors has a radiological assessment. The superiority of MRI of the cavum compared to the scanner is established especially for the exploration of the deep spaces of the face. However, the TDM keeps his place for the study of the cortical bone of the base of the skull. Exploration of the neck to the sus-clavicular hollow is recommended looking for an extension. The PET scanner is more practiced for a regional extension and distance of lymphoma detection, the use of the PET scanner changed therapeutic support, detecting metastases to occult distance (8%), either by changing ganglionic classification (25%), but not for para - and retropharynge space, the base of the skull and the sphenoid sinuses where MRI keeps its superiority. MRI + PET scanner is desirable for the initial assessment of extension. The PET scanner is, moreover, of increasing use for the assessment of the response to treatment. Biologically, the blood and the dosage of Lacticodeshydrogenase (LDH), are made of principle for their prognostic value [9].

The LMNH present a certain number of factors (table 1) forecasts that predict the clinical behavior of the disease and leads to appropriate therapeutic indications [4, 7]. There is no standard therapy for lymphoma non-Hodgkin of the cavum. Their treatment is similar to that of other non-hodgkiniens Lymphoma [2]. For lymphomas located without risk factors, treatment Associates (by three courses of CHOP) chemotherapy with radiation therapy with good results also in terms of overall survival and the relapse rate. For lymphomas with factors of unfavourable prognosis in young patients, intensive chemotherapy are given either the ACVBP (doxorubicin, Cyclophosphamide, Vindesine, Bleomycin and Prednisone), the CHOEP (CHOP and Etoposide ), the mega-CHOEP or other. For older patients (61'70 years), type CHOP chemotherapy has become the treatment of choice because of its effectiveness and especially acceptable toxicity. For even older patients (over 70 years), the use of a less cardiotoxic Anthracycline, such as the Farmorubicine (at the dose of 35 mg/m2 for CEOP mini or the dose of 50 or 70 mg/m2 for the CEOP) has emerged in different protocols even If toxicity is more important particularly in patients in bad condition. The contribution of the therapeutic intensification and rituximab for patients in relapse chimiosensible situation is clearly demonstrated and represents an alternative for these patients [3, 7]. As for radiotherapy, the target volumes include the Waldeyer ring and bilateral cervical lymph node areas at a dose of 45 to 55Gy in sprawl and conventional fractionation. Currently, the radiotherapy should be minimalist (in terms of irradiated volume and dose) in order to avoid the late complications the use of conformational radiotherapy, with intensity modulation radiotherapy and radiotherapy image guided should minimize the dose to healthy organs of neighborhood [7, 10]. Treatments are performed in a curative purpose and there are many sequelae. The late toxicities are dominated by xerostomia, trismus, skin fibrosis, hearing toxicity and to lesser degree a neurocognitive deficit. Other much rarer complications can be lethal (carotid out particularly in situation of re-irradiation) [10].