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Diffuse Palatal Swelling in a Woman in Her 60s

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A healthy woman in her 60s was referred by her dentist to an oral surgeon for evaluation of a palatal swelling of unknown duration. The patient first presented to her dentist with a complaint of “it feels like there is something on the roof of [her] mouth.” She was never aware of the palatal lesion before her initial presentation. She denied any pain or discomfort from the site, and stated that the increasing size of the mass was what first alerted her to its presence.

The extraoral examination results were within normal limits, with no evidence of swelling, expansion, trismus, or lymphadenopathy. Intraoral examination revealed a focally ulcerated, fluctuant 2.5 × 2 × 1-cm pink-red submucosal swelling in the right palatal mucosa (Figure, A). The lesion involved almost the entire right side of the hard palatal mucosa and soft palate and terminated at the palatal midline. Imaging studies were unremarkable.

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C. Diffuse large B-cell lymphoma

Non-Hodgkin lymphoma represents a broad spectrum of hematologic malignant neoplasms that may present either with nodal or extranodal sites. The majority of non-Hodgkin lymphoma of the oral cavity present as an extranodal mass. In addition, diffuse large B-cell lymphoma (DLBCL) is the most common type and accounts for 60% of oral cavity lymphomas.1,2 It is defined by the presence of characteristic malignant lymphoid cells that have nuclei equal to or larger than a macrophage nucleus or more than double that of a standard lymphocyte nucleus.3 Although DLBCLs may affect patients of any age, most cases are reported in patients in their sixth to seventh decade of life.3 The cause of DLBCL remains unknown, and it occurs either de novo or represents an aggressive transformation of an indolent lymphoma.3

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Article Information

Corresponding Author: Scott M. Peters, DDS, Division of Oral and Maxillofacial Pathology, Department of Oral and Maxillofacial Surgery, Columbia University Irving Medical Center, 630 W 168th St, PH15-1562W, New York, NY 10032 (smp2140@columbia.edu).

Published Online: January 2, 2020. doi:10.1001/jamaoto.2019.3993

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Shindoh  M, Takami  T, Arisue  M,  et al.  Comparison between submucosal (extra-nodal) and nodal non-Hodgkin’s lymphoma (NHL) in the oral and maxillofacial region.  J Oral Pathol Med. 1997;26(6):283-289. doi:10.1111/j.1600-0714.1997.tb01238.xPubMedGoogle ScholarCrossref
2.
Epstein  JB, Epstein  JD, Le  ND, Gorsky  M.  Characteristics of oral and paraoral malignant lymphoma: a population-based review of 361 cases.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(5):519-525. doi:10.1067/moe.2001.116062PubMedGoogle ScholarCrossref
3.
Martelli  M, Ferreri  AJ, Agostinelli  C, Di Rocco  A, Pfreundschuh  M, Pileri  SA.  Diffuse large B-cell lymphoma.  Crit Rev Oncol Hematol. 2013;87(2):146-171. doi:10.1016/j.critrevonc.2012.12.009PubMedGoogle ScholarCrossref
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Noonan  V, Lerman  MA, Woo  SB, Kabani  S.  Non-Hodgkin’s lymphoma presenting as palatal swelling.  J Mass Dent Soc. 2012;61(3):57.PubMedGoogle Scholar
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Dominis  M, Dzebro  S, Gasparov  S, Pesut  A, Kusec  R.  Diffuse large B-cell lymphoma and its variants.  Croat Med J. 2002;43(5):535-540.PubMedGoogle Scholar
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Alizadeh  AA, Eisen  MB, Davis  RE,  et al.  Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling.  Nature. 2000;403(6769):503-511. doi:10.1038/35000501PubMedGoogle ScholarCrossref
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Li  JM, Hou  J, Li  L, Wang  Y.  Immunohistochemical subtypes of diffuse large B-cell lymphoma in the head and neck region.  Genet Mol Res. 2015;14(2):3889-3896. doi:10.4238/2015.April.27.3PubMedGoogle ScholarCrossref
8.
Zhou  Z, Sehn  LH, Rademaker  AW,  et al.  An enhanced International Prognostic Index (NCCN-IPI) for patients with diffuse large B-cell lymphoma treated in the rituximab era.  Blood. 2014;123(6):837-842. doi:10.1182/blood-2013-09-524108PubMedGoogle ScholarCrossref
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Flowers  CR, Sinha  R, Vose  JM.  Improving outcomes for patients with diffuse large B-cell lymphoma.  CA Cancer J Clin. 2010;60(6):393-408. doi:10.3322/caac.20087PubMedGoogle Scholar
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