COM March 2010

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Large swelling, left soft palate and tonsillar area

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Dr. Guillermo Chacon
Oral & Maxillofacial Surgery; Puyallup, WA

Case Summary and Diagnostic Information

This is an 88-year-old white female whose chief complaint was a progressively enlarging swelling of the left soft palate and tonsil.  It was large, around 5 x 5 cm in size; pink-to-red in color; and focally ulcerated (Figure 1).  She complained of pain and difficulty swallowing.  The lesion is of six months’ duration.

Diagnostic Information Available

History of present Illness

This is an 88-year-old white female whose chief complaint was a progressively enlarging swelling of the left soft palate and tonsil. It was large, around 5 x 5 cm in size; pink-to-red in color; and focally ulcerated (Figure 1). She complained of pain and difficulty swallowing. The lesion is of six months’ duration.

Figure 1 This photograph was taken at the first clinical presentation; note the large ulcerated swelling involving most of the left soft palate and left tonsil.

Medical History

Her PMH is significant for hypertension, atrial fibrillation, gastroesophageal reflux disease, insomnia, and rheumatoid arthritis. She is currently taking Digoxin, Lisinopril, Metoprolol, Omeprazole, Aspirin EC, Citalopram, and Acetaminophen with Hydrocodone. The patient reports an allergy to sulfa-based antibiotics. Her past surgical history is significant for a hysterectomy at age 60 and bladder resuspension at age 67. She also underwent placement of a pacemaker/defibrillator at age 75. She reports no tobacco or alcohol use.

Clinical and Radiographic Findings

At presentation, the patient complained of pain and difficulty swallowing. Clinical examination revealed a large and diffuse swelling affecting the soft palate and the left tonsil. It was pink-to-red in color and was focally ulcerated. The overlying mucosa was stretched and the blood vessels were prominent in the area of the swelling but indistinct in the surrounding areas (Figure 1). The swelling was described to be 5 x 5 cm in size and was soft.

Figure 1 Photograph is taken at clinical presentation demonstrating a diffuse, mostly superficial red and white lesion on the left ventral and lateral tongue.

Excisional Biopsy

Treatment

Due to the large size of the mass, and given the differential diagnosis, a decision was made to obtain a tissue sample under local anesthesia for histopathologic analysis. A 1 cm X 0.5 cm wedge of tissue was obtained from the lateral aspect of the mass, in the vicinity of the left maxillary tuberosity. Care was taken to incise deep into mass to avoid missing its core. Of interest, there was minimal bleeding and the tissue had the consistency of cutting through a soft rubber ball. Local measures were applied to obtain hemostasis and no sutures were placed over the surgical defect. A gauze pressure dressing was also applied to the area.

Incisional Biopsy

The histologic diagnosis of this case was rendered by Drs. Thomas Morton (Oral Pathology Service) and Sindhu Cherian (Hematopathology Service) from the University of Washington.

Histologic examination reveals a hemisected piece of soft tissue composed of surface epithelium with underlying fibrous connective tissue intensely infiltrated by sheets of medium-to-large-size blue cells consistent with B-lymphocytes (Figures 2 & 3. These cells have large nuclei with vesicular chromatin pattern and multiple nucleoli arranged haphazardly (Figure 3). A few cells with large nuclei and prominent centrally located nucleoli are also present. A few macrophages with tangible bodies are also present. This neoplasm shows high mitotic activity as demonstrated by the H & E histology and by the Ki-67 antibody stain (approximately 90% mitosis) (Figure 4). The immunohistochemistry staining was positive for PAX5, CD20 (Figure 5) and Ki-67 (Figure 4).

Figure 2 Low power (x40) H & E histology demonstrates a piece of mucosa infiltrated by diffuse sheets of monotonous medium to large size blue cells. The nuclei are large, most with multiple nucleoli and some with centrally located prominent nucleoli. Scattered macrophages with tangible bodies are also present.

Figure 3 Higher power (x400) H & E histology demonstrates closer look at the atypical medium size to large round cells with large oval to round nuclei and high mitotic activity.

Figure 4 Low power (x40) Immunohistochemistry stain demonstrate that the neoplastic cells are uniformly positive with Ki-67 with approximately 90% mitotic rate.

Figure 5 Low power (x400) Immunohistochemistry stain demonstrate that the neoplastic cells are variably positive with CD-20.

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