Head and Neck Lymphomas: A Clinico- Pathologic Assesment of a Single Centre Study

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Head and Neck Lymphomas: A Clinico- Pathologic Assesment of a

Single Centre Study
1Mofoluwaso Abimbola Olajide., 2Olasunkanmi Funmilola Kuye., 3Olufemi Olagundoye., 4Olaoye

Olayiwola., 5Angela Omozele Okosun., 6Kehinde Adebiyi

1Senior Lecturer and Consultant, Department of Oral Pathology and Oral Medicine, Lagos State
University College of Medicine, Ikeja, Nigeria

2Senior Lecturer and Consultant, Department of Oral and Maxillofacial Surgery, Lagos State
University College of Medicine, Ikeja, Nigeria

3Senior Lecturer and Consultant, Department of Preventive Dentistry, Lagos State University College
of Medicine, Ikeja, Nigeria

4Houseofficer, Department of Preventive Dentistry, Lagos State University Teaching Hospital, Ikeja,
Nigeria

5Registrar, Department of Oral Pathology and Oral Medicine, Lagos State University Teaching
Hospital, Ikeja, Nigeria

6Professor and Consultant, Department of Oral Pathology and Oral Medicine, Lagos State University
College of Medicine, Ikeja, Nigeria

DOI: https://doi.org/10.51244/IJRSI.2025.120800407

Received: 13 Sep 2025; Accepted: 18 Sep 2025; Published: 22 October 2025

ABSTRACT

Lymphoma ranks as the third most common cancer globally, comprising approximately 3% of all malignant
tumors and 15% of childhood malignancy1–3. Lymphoma is said to be the most prevalent non-epithelial cancer
in the head and neck region, following squamous cell carcinoma, leukemia, and brain tumors. 1,2,4 The
occurrence of lymphoma varies significantly depending on factors such as histological subtype, age, gender,
ethnicity, geographic location, and socioeconomic status2,4.

The aim of this study was to retrospectively investigate the sites of occurrence and various histologic types of
lymphomas in the head and neck area, and to analyze the relationship between these and the age, sex, gender
and the duration of the lesions in patients who presented at our center.

Method: This is a retrospective cross-sectional study, utilizing socio-demographic information such as age,
sex, gender of clinically documented cases recorded during the designated study period, as well as their
clinico-pathologic characteristics. Differences in proportions across age groups, tumor sites, and lesion
categories, was assessed using chi-square test, supplemented by Fisher’s exact test where appropriate.
Statistical significance was determined at a threshold of p < 0.05.

Results: The mean age distribution in years, is 43.88 + 18.57 and the mean duration of lesion in weeks, is
67.72 + 151.74 Females had a slight predominance in the study (53.7%) compared to the males (46.7%) with
M: F of 1: 0.9. There is a broad age distribution, slightly skewed towards middle-aged participants.

Majority of the lymphoma cases (81.7%) are in cervical lymph nodes accounting for 98.51% of head and neck
nodal lesions. The remaining 18.3% were found in extra-nodal sites, most of which were found in the oral
cavity (66.67%). Non-Hodgkin’s Lymphoma made up 95.2% of all the Head and Neck Lymphomas. Of these,
diffuse lymphocytic lymphoma was the most prevalent histologic type (75.6%). Of the cases that had

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Immunochemistry records, 83.3% of the histologic types of NHL were of B cell origin. Hodgkin’s Lymphoma
accounted for 4.8% cases of the study.

There is no statistically significant relationship between sex and the type of lymphoma p=0.33. There was no
statistically significant association between Sex, the type of lymphoma, the site of the lymphoma and the
duration of lesions p= 0.29

Conclusion: Head and Neck Lymphoma is of almost equal gender predilection, slightly more predominant in
females and typically affect middle-aged individuals. HL is rare, less common in this study and NHL is more
predominant. Of all NHL, Small lymphocytic B cell lymphomas (SLL) is more prevalent in the study. There
is no significant relationship between, gender, duration of lesion and the site or type of lymphoma in the head
and neck.

INTRODUCTION

Lymphoma ranks as the third most common cancer globally, comprising approximately 3% of all malignant
tumors and 15% of childhood malignancy1–3. Lymphoma is the most prevalent non-epithelial cancer in the
head and neck region, following squamous cell carcinoma, leukemia, and brain tumors1,2,4. The incidence of
lymphoma increases with age, accounting for 3% of cancers in children under 5 and rising to 24% among
adolescent aged 15 to 195,6. The occurrence of lymphoma varies significantly depending on factors such as
histological subtype, age, gender, ethnicity, geographic location, and socioeconomic status2,4.
Hematolymphoid tumours in odontogenic and maxillofacial bones are exceedingly rare and also its true
incidence may be underreported due to the frequent absence of symptoms and the subtle nature of lymph node
enlargement7,8. It’s also important to note that Intra oral lymphomas can resemble dental abscesses, tumors or
other diseases such as osteonecrosis.9

Despite advances in treatment, lymphoma remains a leading cause of cancer-related deaths in adults and
children, particularly those between the ages of 1 and 10. A study by Lu et al analyzing data from the Cancer
Incidence in Five Continents database from 1988 to 2012, revealed a troubling rise in lymphomas across three
continents and predicted a rise in oral cancers in 5 nations over a period of 15 years10.

A significant proportion between 35% and 65% of head and neck lymphomas occur in Waldeyer’s ring, the
most common anatomical site for extranodal lymphoma in this region and is a lymphoid structure (Mucosa
Associated Lymphoid Tissues) not classified as a traditional nodal site.4,8 In addition, 6% to 25% of cases are
seen in the salivary glands4. Lymphomas often present with vague symptoms such as fever, weight loss, night
sweats, and lymphadenopathy11. These nonspecific signs can delay diagnosis, making early recognition
crucial. Clinicians should maintain a high level of suspicion when encountering such symptoms11.

Lymphomas are broadly categorized into Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL).
The subtype of the lymphomas is defined based on the cell of origin: B-cell lymphomas, T-cell and natural
killer-cell lymphomas (T/NK-NHL) and HL7. Over 20 different subtypes of NHL have been classified
according to the specific subtype of lymphoid cells involved. HL typically originates in lymph nodes, with
only about 3-5% of cases arising in extranodal locations. HL is more frequently seen in adolescents. In
contrast, NHL often presents in extranodal sites, with up to 20- 40% of cases involving regions outside the
lymph nodes, most commonly following (along) the gastrointestinal tract. In the head and neck, extranodal
NHL may affect areas such as the paranasal sinuses, nasal cavity, oral cavity, salivary glands, thyroid, and
orbit. Hodgkin lymphoma (HL) has a higher overall number of new cases annually compared to non-Hodgkin
lymphoma (NHL)5,6NHL is one of the more frequently diagnosed cancers in both children and adults. The
incidence of non-Hodgkin-lymphomas is rising in many regions and with variation in between different
countries, incidences increased up to 35 % in the last approximately 20 years. However, the survival has
improved during the last decades with nearly 30% to 50.8%, increase in the 5-year survival rate.

While improvements in treatment have significantly enhanced survival rates for patients with lymphomas, the
recent integration of targeted therapies offers promise for even better outcomes with reduced long-term side

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effects2. Risk factors for developing NHL include pre-existing immune diseases, medications, infections,
unhealthy lifestyles, ethnicity, genetics, heredity, certain occupations, prior radiation exposure, and viral
infections such as Epstein-Barr virus2. The incidence of NHL tends to increase with age, peaking during
adolescence and elderly age. While Hodgkin lymphoma (HL) has a higher overall number of new cases
annually compared to non-Hodgkin lymphoma (NHL)5,6, NHL is more prevalent in children under 10, whereas
HL is more frequently seen in adolescents. Both lymphomas HL and NHL encompass a variety of histologic
subtypes5,6. Hodgkin lymphomas (HLs) typically affect lymph nodes in the neck and mediastinum, with
extranodal involvement being rare—only about 5%, such as in the tonsils. In contrast, non-Hodgkin
lymphomas (NHLs) display extranodal involvement in roughly 30% of cases, often in diverse locations like
the major salivary glands, paranasal sinuses, mandible, maxilla, and Waldeyer’s ring7,8. These patterns are
often subtype-specific. Beyond the gastrointestinal tract, the head and neck region are a common extranodal
site in NHL, seen in 11–33% of patients. Current imaging modalities such as ultrasound, Computer
tomography, Magnetic resonance imaging and Positron Emission Tomography are unable to reliably
differentiate between Hodgkin and non-Hodgkin lymphomas or identify their specific subtypes, making
histopathological evaluation essential for diagnosis. However, certain clinical features and the anatomical
distribution within the head and neck region may offer clues, as each type tends to favor particular sites7,8.

METHODOLOGY

A retrospective cross-sectional study was conducted using medical records, surgical biopsy logs, surgical
procedure inventories and histopathology registers, from the Lagos State University Teaching hospital and its
affiliate, Lagos State University College of Medicine over a period of twelve years. Data obtained are from
the departments of Oral Pathology & Oral Medicine and Oral & Maxillofacial Surgery. The study utilized
socio-demographic information such as age, sex, gender and duration of clinically documented cases recorded
during the designated study period as well as, clinico-pathologic characteristics such as tumour sites and
histological type.

Analysis

Sociodemographic characteristics—including age, sex, and tumor duration—were summarized using
descriptive statistics. Categorical variables were expressed as frequencies, percentages, and tabulated formats,
while continuous variables were reported as means accompanied by standard deviations. To assess differences
in proportions across age groups, tumor sites, and lesion categories, the chi-square test was applied,
supplemented by Fisher’s exact test where appropriate. Statistical significance was determined at a threshold
of p < 0.05.

RESULT

Eighty-two patients were retrospectively enlisted for the study from records of a period of 12years. This
accounts for 3.9% of 2,152 oro-facial and head &neck lesions referred to our Oral pathology laboratory in the
study period.

From the study, the mean age distribution in years, is 43.88 + 18.57 and the mean duration of lesion in weeks,
is 67.72 + 151.74 indicating that most of the participants presented late . Females had a slight predominance
in the study (53.7%) compared to the males (46.7%) with M: F of 0.86. There is a broad age distribution,
slightly skewed towards middle-aged participants.

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Table 1: Sociodemographic characteristics

Variables Frequency (n=82) Percentages (%)

Mean Age± SD (Years) 43.88±18.57

Median Age (IQR) 46.00 (30.50)

Mean Duration± SD (weeks) 65.72±151.74

Gender

Male 38 46.30

Female 44 53.70

Fig:1

Majority of the lymphoma cases (81.7%) are sited in cervical lymph nodes accounting for 98.51% of head
and neck nodal lesions. The remaining 18.3% were found in extra-nodal sites, most of which were found in
the oral cavity (66.67%).

Fig: 2

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Table 2: Site of lesions

Variables Frequency (n=82) Percentages (%)

Nodal

Cervical lymph nodes 66 98.51

Parotid lymph nodes 1 1.49

Extra-nodal

Oral cavity (soft tissue) 10 66.67

Orofacial bony tissue 3 20.00

Oropharynx 1 6.67

Sino-nasal tissue 1 6.67

Non-Hodgkin’s Lymphoma made up 95.2% of all the Head and Neck Lymphomas. Of these, Diffuse
lymphocytic lymphoma was the most prevalent histologic type (75.6%), followed by Diffuse mixed cell
lymphoma (14.7%). Of the cases that had Immunochemistry records, 83.3% of the histologic types of NHL
were of B cell origin. Hodgkin’s Lymphoma accounted for 4.8% cases of the study.

Table 3: Histologic diagnosis and Immunohistochemistry

Variables Frequency

(n=82)

Percentages

(%)

1. Histologic

Hodgkin’s lymphomas Classical Hodgkin’s lymphoma 2 2.40

Nodular Lymphocyte-predominant

lymphoma

2 2.40

Non-Hodgkin’s lymphomas Diffuse small cell lymphoma 62 75.60

Diffused mixed cell lymphoma 12 14.70

Follicular lymphoma 2 2.40

Precursor B cell lymphoblastic 1 1.20

Anaplastic large T cell 1 1.20

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2. Immunohistochemisty

B cell Lymphoma 4 66.60

Precursor B-LBL 1 16.70

Anaplastic large T cell 1 16.70

Table 4: Relationship between sex and type of lymphoma

Sex Lymphoma type

Hodgkin’s (%) Non-Hodgkin’s (%) P-value

Male 3 (7.90) 35 (92.10) 0.33

Female 1 (2.30) 43 (97.70)

Neither age nor sex significantly influenced the type of lymphoma or duration of lesions, suggesting these
variables are not predictive in this cohort.

Table 5: Association between various variables and duration of the lesions

Variables Duration (weeks)

N Mean rank �� P value

SEX

Male 38 38.24 960.00 0.25

Female 44 44.32

LYMPHOMA TYPE

Hodgkin’s lymphoma 4 43.25 149.00 0.90

Non-Hodgkin’s lymphoma 78 41.41

SITE

Nodal 67 40.17 591.50 0.29

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Extra-nodal 15 47.43

Fig.:3

DISCUSSION

The incidence (3.9%) of head and neck lymphomas, predominantly NHL, among all oro-facial and head
&neck lesions in this study, is congruent with the submission that head and neck lesions lymphomas are rare,
or are under-reported as a result of frequent absence of significant symptoms in this region or the subtle nature
of lymph node enlargement.7,8 The age distribution of participants ranged widely from 12 to 85 years, with a
mean age of 43.88 years, indicating that lymphoma affects a broad age spectrum, though middle-aged
individuals were most represented in this study. The slight predominance of female participants (53.70%)
contrasts with some literature suggesting male dominance in lymphoma incidence5,9,12,13, and may reflect
regional or referral biases. Studies had documented an increasing trend of lymphomas (HL & NHL) among
the females2,14, children and the elderly individuals concurring with the outcome of this study2. The duration
of lesions varied significantly, with a median of 24 weeks and a mean of 65.72 weeks, suggesting that while
most cases are diagnosed within a few months, a subset of patients experience prolonged disease courses,
probably due to delayed presentation, diagnosis or the burden related with the out-of-pocket payment system
due to poorly implemented health insurance scheme in the national health insurance settings. Prolonged
disease course can also be attributable to the natural slow progression of the disease, and such Lymphomas are
described as indolent. Lymphomas presenting with vague symptoms and nonspecific signs had been
documented to make early diagnosis at times difficult, this also may be responsible for the long period seen
among the study patients4,13.

Nodal involvement was predominant, accounting for 81.7% of cases, with cervical lymph nodes comprising
nearly all nodal presentations (98.51%). This aligns with established patterns in lymphoma, where cervical
lymphadenopathy is a common initial finding1,12,15. Extra-nodal involvement was less frequent (18.3%), with
the oral cavity being the most affected site (66.67%)13. These findings in this study also underscore the
importance of thorough head and neck examinations in suspected lymphoma cases, particularly in most
patients and dental settings where extra-nodal lesions may be overlooked.

Non-Hodgkin’s lymphoma (NHL) was overwhelmingly more common than Hodgkin’s lymphoma (HL),
consistent with global epidemiological data2. Diffuse small cell lymphoma was the most prevalent subtype
(41.5%), followed by diffuse mixed cell lymphoma (34.1%). The incidence of NHL has increased rapidly in
the past decades.2 NHL ranked as the 11th most commonly

diagnosed cancer. The advent of novel targeted therapies, prognosis in NHL has significantly improved over
the past few decades2,9, with survival rates exceeding 80% in high-income countries2,12,16. However, high
mortality rate from this disease condition had been documented globally including North Africa (ASR, 3.7 per
100,000 people)9. Among the few cases tested, 80% were of B-cell origin, reinforcing the predominance of B-
cell lymphomas in this population.

Diffuse small cell (lymphocytic) lymphomaaccounts for approximately half of all B-cell lymphomas and the
indolent behavior of the small lymphocytic B-cell lymphomas (SLL) is reflected by a clinical course that is
usually protracted17,18. SLL is an aging-associated disease, with no apparent plateau in adjusted incidence
rates by age,

HL is rare, few cases were diagnosed in this study, compared to the NHL concurring with previously
established fact about HL.19 HL also is uncommon especially among young children ages 0-5years and
gradually increases among adolescents to the adults20. HL has a bimodal age distribution, with an early peak
among young adults (aged 20–24 years) and a second, smaller peak among older adults (aged 80–84
years)17,18

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The limited use of immunohistochemistry (performed in only 6.09% of cases) is notable in this study, and was
incurred by a resource-limited healthcare setting. However, molecular profiling is increasingly essential for
accurate classification (immuno-phenotyping) and targeted therapy. No statistically significant relationships
were found between age and lesion duration, sex and lymphoma type, or between lymphoma type and site of
involvement. Although females, patients with Hodgkin’s lymphoma, and those with extra-nodal lesions
tended to have longer lesion durations, these differences were not statistically significant. These trends may
probably be due to the underlying biological or healthcare access factors which may warrant further
exploration in larger cohorts.

The predominance of nodal lesions, particularly in the cervical region, and the high frequency of NHL
emphasize the need for clinicians to maintain a high index of suspicion when evaluating persistent
lymphadenopathy.20,21 The variability in lesion duration and the underutilization of immunohistochemistry
highlights potential gaps in diagnostic efficiency and resource availability. Enhancing access to molecular
diagnostics and promoting early recognition of atypical presentations could improve outcomes.

CONCLUSION

Head and Neck Lymphoma is of almost equal gender predilection, slightly more predominant in females and
typically affect middle-aged individuals. HL is rare, less common in the study and NHL is more predominant.
Of all NHL, Small lymphocytic B cell lymphomas (SLL) is more prevalent in the study. There is no
significant relationship between, gender, duration of lesion and the site or type of lymphoma in the head and
neck.

Limitations

The retrospective nature of the study and reliance on existing records may have introduced selection and
documentation biases. The small number of HL cases and limited immunohistochemical data restrict the
generalizability of some findings. Future prospective studies with broader diagnostic tools and larger sample
sizes are recommended.

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