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mantle cell lymphoma ( mcl ) is a b - cell malignant lymphoid tumor which is defined as a separate entity and included in lymphoma classification by world health organization ( who ) .
mcl includes small - medium sized lymphoid cells and accounts for 610% of all b - cell lymphomas .
mcl patients are predominantly older males and usually present as stage iv ( ann arbor ) disease .
the prognosis of mcl is reported to be poor with a mean survival of 3 years . in most of the cases
however , extra - nodal sites of involvement such as oral cavity , gastrointestinal tract , waldeyer 's ring , peripheral blood are well documented .
palatal mcl is mostly seen in elderly people and may be masked with the presence of prosthesis . in this study , a case of palatal mcl is presented with treatment outcome and a literature analysis was performed to analyze the importance of dental examination in the primary diagnosis of the disease .
a 71-year - old male patient was referred to eskiehir osmangazi university , faculty of dentistry , department of oral and maxillofacial surgery with a complaint of ill - fitting dentures .
an intra - oral examination was performed and symmetric mucosal enlargements were observed on hard palate [ figure 1 ] .
patient was uncomfortable about the mobility of his dentures and had tried to fix them by sticking dish rags or other foreign materials into the prosthesis .
therefore , a provisional diagnosis of reactive mucosal lesion was made and incisional biopsy was performed under local anesthesia .
ulcerated palatal symmetric mucosal swelling responsible for the mobility of maxillary dentures microscopic examination revealed diffuse abundant small cells with hyperchromatic nuclei in the subepithelial region [ figure 2 ] .
glandular structures can be seen at the upper - right quadrant ( h&e stain , 100 ) nuclei of small cells have distinct hyperchromatism .
mild nuclear pleomorphism is also evident ( h&e stain , 400 ) after the immunohistochemistry , tumoral cells showed strong positive staining with cd20 ( l26 , ventana , tucson ) [ figure 4 ] , pax-5 ( sp34 , ventana , tucson ) , cd5 ( sp19 , ventana , tucson ) , cyclin d1 ( sp4-r , ventana , tucson ) [ figure 5 ] , bcl-2 ( 124 , ventana , tucson ) and igm ( poliklnal , ventana , tucson ) .
cd21 ( sp104 , ventana , tucson ) and cd23 ( sp23 , ventana , tucson ) immunostaining showed follicular dendritic cells .
cd10 ( sp67 , ventana , tucson ) and igd ( policlonal , ventana , tucson ) were negative .
patient was referred to hematology department of eskiehir osmangazi university , faculty of medicine for further evaluation and treatment .
tumoral cells stained diffusely positive with cd20 ( ihc stain , 200 ) tumoral cells showed nuclear positivity with cyclin d1 staining ( ihc stain , 200 ) ultrasonography of abdomen revealed multiple lymphoadenopathies at mesenteric and para - aortic regions . after informed consent was taken , patient underwent cyclophosphamide , oncovin , prednol ( cop ) chemotherapy regimen .
english dental and medical literature search was conducted using the combination of terms such as hard palate , mcl , lymphoma and extra - nodal lymphoma in pubmed .
cases which were reported under the strict diagnosis of mcl and primarily located on the hard palate were extracted and data regarding treatment , follow - up and demographics was reviewed .
nine publications with 14 cases defining primary hard palate mcls published between 1990 and 2014 were identified .
mcl is a counterpart of non - hodgkin lymphoma family and was first included in lymphoma classification in 2001 .
although mcl is mainly located in the lymph nodes , involvement of extra - nodal sites such as waldeyer 's ring , peripheral blood , bone marrow and gastrointestinal tract are also reported .
definite diagnosis of mcl is achieved with immunohistochemical staining with or without the assistance of molecular techniques .
mcl tumoral cells commonly express cd20 , cd5 , cd43 antigens and bcl2 and cyclin d1 protein .
however , they are cd10 and bcl6 negative and show negativity / weak positivity for cd23 antigen expression .
histologic examination reveals abundant monomorphic small - medium sized lymphoid cells with slightly / markedly irregular nuclear contours .
blastoid and pleomorphic subtypes of mcl have been defined by who and it is suggested that blastoid or pleomorphic morphology are aggressive variants ; similar histology may be seen in some cases at relapse .
hard palate is an unusual site for primary mcl and this has been reported in the english literature several times .
reported that long term use of maxillary prosthesis might have provoked the lymphoid tissue accumulation and proliferation leading to a mass of mcl in the submucosal region of the hard palate .
guggisberg and jordan reported that most oral mcls occur in an elderly male population and have a predilection for the palate .
the duration of the prosthesis usage of mcl patients could not be analyzed in the current literature review due to the unavailable data in the case reports . in the current case
, patient was using total prosthesis for 10 years and the only complaint of the patient was the mobility of his dentures .
the clinical appearance of the tumor suggested that the palatal accumulation of lymphoid mass might have been initiated by the long term use of the total prosthesis .
milgrom and yahalom reported nine cases of primary indolent lymphomas of the hard palate including mcl , follicular lymphoma and marginal zone lymphoma .
there were two cases of mcl in their series and it is suggested that mcl cases showed more aggressive behavior compared to other lymphomas of the hard palate .
( chop ; cyclophosphamide , doxorubicin , vincristine , prednisolone ) chang et al . reported a polychemotherapy regimen consisting of cytoxan , doxorubicin , vincristine and prednisone , in conjunction with
meusers et al . reported that the chop regimen did not show superiority to cop regimen in the treatment of mcl .
although chop - like antracycline containing chemotherapeutic combinations do not have distinct advantage on survival , they are currently chosen for standard therapuetic approach .
radiation therapy is still a therapeutic option in low - stage disease ( ann - arbor stage 1,2 ) in advance stage disease , the combination of radiotherapy and chemotherapy can be used , however , the efficacy of this combination have not been proven yet .
primary mcl of the hard palate is a rare entity which is mostly seen in elder people . in this study ,
a case of palatal primary mcl which presents with ill - fitting total prosthesis is reported with clinical and histopathological features .
dental total prosthesis may mask the existing lesion on the hard palate , therefore , dental practitioner should be alert at the time of the clinical examination of patients with total or partial prosthesis .
mantle cell lymphoma ( mcl ) is a subtype of b - cell non - hodgkin 's lymphoma seen predominantly in males . 
 common extra - nodal sites of involvement of mcl are waldeyer 's ring , gastrointestinal tract , bone marrow and peripheral blood . 
 the extra - nodal palatal localization of mcl is quite uncommon . 
 mcl is seen in predominantly older patients , therefore undiagnosed mcl patients are likely to have total prosthesis . in this study , 
 a case of mcl , initially presenting as palatal swelling was reported with relevant literature review and the possible role of dental professionals in the diagnosis of this rare entity was discussed .