[Angiocentric T/NK cell lymphoma: a special clinical-pathological entity of lethal midline granuloma. A case report]

The term "midline granuloma syndrome" (MGS) is a clinical description of a broad spectrum of diseases, which are characterised by aggressive and progressive destruction of mucosa and adjacent structures of the midface and upper aerodigestive tract. After exclusion of granulomatous infections, rare granulomatous diseases and epithelial neoplasias, the differential diagnosis includes the following entities: Wegener's granulomatosis (WG), malignant lymphoma and idiopathic midline destructive disease (IMDD). Today there are doubts about the existence of IMDD. After exclusion of WG nearly all remaining cases presenting as MGS are peripheral sinonasal angiocentric T- and/or NK-cell lymphomas, which show a close association to Epstein-Barr virus infection and now are recognised as a special clinicopathological entity. The natural history of these lymphomas is characterised through a rapidly progressive course with a poor prognosis.

A case of a 35-year-old male patient with an angiocentric nasal T/NK-cell lymphoma, which involved the left lacrimal cyst, the left maxillar and ethmoid sinus as well as the soft and hard palates, is presented. First clinical signs and symptoms were similar to chronic-recurrent sinusitis. For almost two years the patient was treated with systemic corticoids for suspected limited Wegener's granulomatosis. The patient underwent sinus surgery for pansinusitis three times. After development of midline destructive disease the diagnosis of angiocentric lymphoma was established.

Soon after the diagnosis a combination high-dose radiochemotherapy was performed. The patient died only 3 months later because of multiorgan failure.

Because of its poor prognosis the angiocentric nasal NK/T-cell lymphoma should included early into the differential diagnosis of the midline granuloma syndrome. Correct biopsy technic and in situ hybridization of EBV can be important for an early diagnosis. Therapy should be aggressive and consists of high-dose radiotherapy, which is most important to reach local tumor control, and combination chemotherapy, the use of which is presently in discussion.