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摘要: 目的 分析头颈部弥漫大B细胞淋巴瘤(DLBCL)的临床特征。方法 选取2011年7月—2021年9月在西安交通大学第二附属医院住院的头颈部DLBCL患者为研究对象，进行回顾性研究，分析患者的发病部位及临床表现、诊断、治疗及预后。结果 63例头颈部DLBCL的累及部位包括口咽部(27例，其中扁桃体25例)、颈部(29例)、鼻腔鼻咽(7例)等，发生于口咽部者多表现为咽痛、咽部异物感及吞咽不利，而鼻腔鼻咽部发病者以鼻塞、流涕、嗅觉减退为初始表现。34例发生于鼻腔鼻咽、口咽的DLBCL患者其电子喉镜检查可见局部隆起新生物，表面黏膜粗糙，其中16例(47.1%)患者肿物表面有黄白色、片状分布的假膜覆盖，5例患者(14.7%)NBI内镜下于假膜边缘检见异常新生血管，包括扁桃体3例，舌根部1例，鼻咽部1例。29例颈部DLBCL多表现为局部肿物渐进性增大，其电子喉镜和NBI内镜检查均未见明显异常。无痛性进行性淋巴结肿大是头颈部DLBCL的共同表现，且DLBCL患者病灶同侧颈部淋巴结最大直径[(21.3±6.7) mm]显著大于对侧淋巴结最大直径[(16.0±7.2) mm](P=0.009)。63例DLBCL患者中，生发中心型(GCB)27例，非生发中心型(non-GCB)33例，未分型3例，确诊方式包括穿刺活检(33例，52.4%)和手术切除(30例，47.6%)。头颈部DLBCL的影像学表现多为局部软组织肿块，均匀等密度，并呈不均匀强化，周围结构常受压移位。在采用标准R-CHOP化疗方案的基础上，LDH正常患者总生存期长，IPI评分低危者较中高危、高危患者总生存期长(PLDH=0.011，PIPI=0.022，P < 0.05)。结论 头颈部DLBCL多好发于口咽部，尤其是单侧扁桃体。当内镜下检见肿物表面片状黄白色假膜附着或异常新生血管，超声提示颈部多发肿大淋巴结且病灶同侧淋巴结较大时，应考虑DLBCL的可能，必要时可行手术切除活检，及早诊断预后较优。Abstract: Objective To investigate the clinical features of diffuse large B-cell lymphoma (DLBCL) of head and neck.Methods A retrospective study was conducted among patients with DLBCL in the Department of otolaryngology and head and neck surgery of the Second Affiliated Hospital of Xi'an Jiaotong University from July 2011 to September 2021. The disease location, clinical manifestations, diagnosis, treatment and prognosis of DLBCL patients in head and neck were analyzed retrospectively.Results Oropharynx(27 cases, including 25 cases in tonsil), neck(29 cases), nasopharynx and nasal cavity (7 cases)were included in 63 cases of DLBCL in head and neck. Pharyngalgia, pharyngeal foreign body sensation and dysphagia were the most common manifestations of oropharyngeal DLBCL, while nasal obstruction, runny nose and hyposmia were the initial manifestations of nasal and nasopharyngeal DLBCL.Under the NBI endoscopy, locally uplifted neoplasm with rough surface mucosa was observed in 34 cases DLBCL patients of oropharynx, nasopharynx and nasal cavity. Among them, 16 cases were covered with yellow-white and patchy pseudomembrane on the surface of the neoplasm, and 5 cases were detected with abnormal new vessels, including 3 cases of tonsils, 1 case of root of tongue, and 1 case of nasopharynx. Painless progressive lymphadenectasis was the common manifestation of DLBCL in head and neck, and the maximum diameter([21.3±6.7]mm) of neck lymph nodes in the same side of DLBCL was significantly larger than that in the opposite side([16.0±7.2]mm, P=0.009). Sixty-three cases of DLBCL in head and neck, including 27 cases of germinal center type(GCB), 33 cases of nongerminal center type(non-GCB), and 3 cases of non-specific DLBCL, were confirmed the diagnosis by needle biopsy(33 cases, 52.4%) and surgical resection(30 cases, 47.6%). The imaging features of DLBCL in head and neck were mostly showed as local soft tissue masses with uniform density and uneven enhancement, and the surrounding structures were often compressed and displaced. All the patients were treated with standard R-CHOP chemotherapy regimens, and overall survival was longer in normal LDH, and overall survival of the patients at low risk of IPI was longer than those at medium-high or high risk of IPI(PLDH=0.011, PIPI=0.022, P < 0.05).Conclusion DLBCL mainly occurs in oropharynx, especially the unilateral tonsil. When flake yellow-white pseudomembrane adhesion and abnormal neovessels on the surface of the mass are detected under endoscopy, and the ultrasound suggested multiple enlarged lymph nodes in the neck with large iplateral lymph nodes, the possibility of DLBCL should be considered. Surgical resection could be performed for diagnosis if necessary, and early diagnosis would have a better prognosis.
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Key words:
- head and neck neoplasms /
- diffuse large B-cell lymphoma /
- NBI endoscopy
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表 1 63例DLBCL患者的临床特征分析
例(%) 项目 例数(%) Ann Arbor分期 P值 Ⅰ~Ⅱ期(45例) Ⅲ~Ⅳ期(18例) 总数 63(100.0) 45(71.4) 18(28.6) 年龄/岁 0.867 18~ < 60 22(34.9) 16(35.6) 6(33.3) 60~87 41(65.1) 29(64.4) 12(66.7) 性别 0.524 男 31(49.2) 21(46.7) 10(55.6) 女 32(50.8) 24(53.3) 8(44.4) 职业 农民 23(36.5) 16(35.6) 7(38.9) 0.804 非农民 40(63.5) 29(64.4) 11(61.1) 发病部位 0.760 口咽 27(42.9) 20(44.4) 7(38.9) 鼻咽 3(4.8) 2(4.4) 1(5.6) 鼻腔鼻窦 4(6.3) 2(4.4) 2(11.1) 颈部 29(46.0) 21(46.7) 8(44.4) 头颈部肿大淋巴结 0.495 双侧 32(50.8) 22(48.9) 10(55.6) 单侧 18(28.6) 14(31.1) 4(22.2) 无 13(20.6) 9(20.0) 4(22.2) LDH 0.005 正常 47(74.6) 38(84.4) 9(50.0) 升高 16(25.4) 7(15.6) 9(50.0) HIV(-) 63(100.0) 45(100.0) 18(100.0) B症状 5(7.9) 2(4.4) 3(16.7) 0.105 IPI评分 < 0.001 0~1 28(44.4) 25(55.6) 3(16.7) 2 15(23.8) 12(26.7) 3(16.7) 3 11(17.5) 7(15.6) 4(22.2) 4~5 9(14.3) 1(2.2) 8(44.4) 
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表 2 可分型的60例DLBCL患者主要分子表型分布
免疫组织化学分子表型 Han's分型 总数(%) GCB/例 non-GCB/例 总数 27 33 60(100.0) Ki67 26 33 59(98.3) PAX-5 17 26 43(71.7) CD3 20 21 41(68.3) CD79a 19 21 40(66.7) LCA 15 20 35(58.3) VIM 14 19 33(55.0) C-MYC 11 22 33(55.0) BCL-2 6 25 31(51.7) CD5 9 13 22(36.7) P53 9 13 22(36.7)
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