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Pseudolymphoma of the palate: A rare cause of dysphagia and odynophagia.

A 51-year-old woman with a history significant for systemic lupus erythematosis presented to clinic for evaluation of a lesion of the palate. She reported that the lesion had been present for more than 1 year and described symptoms of odynophagia, dysphagia, and globus sensation. Her physical examination revealed a lesion of the soft palate that was erythematous and papular in nature (figure 1).

Because we suspected malignancy, she was taken to the operating room for further examination and biopsy of the lesion. The lesion was friable, exophytic in nature, spanning the soft palate, and approximately 1.5 x 0.5 cm in size. An additional small (0.5 cm) ulceration on the hard palate was also noted. The lesion was biopsied and sent for pathologic analysis.

Histopathologic examination revealed a diffuse infiltrate composed of lymphocytes, plasma cells, neutrophils, and a few eosinophils (figure 2, A). Immunohistochemistry studies demonstrated B cells that were positive for CD79a and CD20 (figure 2, B). A few scattered T cells were positive for CD3, CD5, and Bcl-2. Kappa and lambda light chains were expressed in the infiltrate, with no restriction and no monoclonality. These results were consistent with pseudolymphoma of the palate.

Pseudolymphoma, also known as benign lymphoid hyperplasia, of the palate is a rare, benign process encountered in clinical practice that results in a distinct-appearing lesion of the palate. There are fewer than 30 published cases describing this pathology in available literature, and it is most commonly described in women and the elderly. (1) The disease is characterized by its slow growth, its usually painless nature, and the lack of ulceration seen on examination. It is typically located in the hard palate and, less commonly, the soft palate. (1,2)

Important in diagnosis is differentiating pseudolymphoma from malignant lymphoid entities that appear similar in clinical and morphologic presentation. Pseudolymphoma also has been shown to transform into malignant lymphoid entities in rare instances, requiring close and frequent follow-up. These two entities are primarily distinguished with immunologic and genetic analysis. (1) Histopathology can reveal only subtle distinctions, making discerning the correct diagnosis challenging, and it alone is many times insufficient for making an accurate diagnosis. (2,3)

In summary, pseudolymphoma is a rare, benign lesion that must be carefully distinguished from similar appearing malignant entities. It is characterized pathologically by prominent lymphoid infiltrate that appears reactive in nature and lacks clonality on immunogenic analysis. (3-5) Clinically, it is virtually impossible to appreciate differences between pseudolymphoma and various low-grade lymphomas. Its similarities on histopathology also pose a diagnostic challenge, and one must rely on immunohistochemistry to distinguish the two lesions. Differentiation is crucial in management planning. Pseudolymphoma has almost universally resolved with surgical excision alone or, in some cases, observation.

From the Department of Otolaryngology-Head and Neck Surgery (Dr. Melancon and Dr. Madden) and the Department of Pathology (Dr. Onajin), Wake Forest Baptist Medical Center, Winston Salem, N.C.

References

(1.) Jham BC, Binmadi NO, Scheper MA, et al. Follicular lymphoid hyperplasia of the palate: Case report and literature review. J Craniomaxillofac Surg 2009;37(2):79-82.

(2.) Menasce LP, Shanks JH, Banerjee SS, Harris M. Follicular lymphoid hyperplasia of the hard palate and oral mucosa: Report of three cases and a review of the literature. Histopathology 2001;39(4):353-8.

(3.) Manveen JK, Subramanyam R, Harshaminder G, et al. Primary B-cell MALT lymphoma of the palate: A case report and distinction from benign lymphoid hyperplasia (pseudolymphoma). J Oral Maxillofac Pathol 2012;16(1):97-102.

(4.) Kolokotronis A, Dimitrakopoulos I, Asimaki A. Follicular lymphoid hyperplasia of the palate: Report of a case and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;96(2):172-5.

(5.) Napier SS, Newlands C. Benign lymphoid hyperplasia of the palate: Report of two cases and immunohistochemical profile. J Oral Pathol Med 1990;19(5):221-5.

Caption: Figure 1. Endoscopic image depicts the patient's soft and hard palate lesions, consistent with pseudolymphoma.

Caption: Figure 2. A: Histopathology reveals a diffuse, mixed infiltrate composed predominantly of lymphocytes with scattered plasma cells, neutrophils, and eosinophils (hematoxylin and eosin, original magnification x40). B: CD79a immunostain highlights the B cells within the infiltrate (original magnification x40).
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Title Annotation:DYSPHAGIA CLINIC
Author:Melancon, C. Claire; Onajin, Oluwakemi; Madden, Lyndsay L.
Publication:Ear, Nose and Throat Journal
Geographic Code:1USA
Date:Jul 1, 2018
Words:695
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