Primary malignant lymphoma of the anorectum in homosexual men

Rectal burkitt lymphoma in childhood

Lymphomas are the third most common cancer in children and Burkitt lymphoma (BL) accounts for about 40% of them. The rectum is extremely seldom involved in BL: 91 children were treated at our institution for BL between 1987 and June 2006, but none of them had involved the rectum. We report here on a 9-year-old boy who presented with bowel bleeding and subocclusion, which proved due to a BL of the rectum. The role of surgery for this tumor is limited nowadays, except for surgical emergencies, biopsies, and second-look surgery in selected cases.

Anorectal and gastric peripheral T-cell lymphoma, unspecified in a non-AIDS patient

Anorectum is a rare location for malignant lymphoma. Involvement of is rare even for the lynphoma associated with acquired immune deficiency syndrome (AIDS), and AIDS has a relatively increased frequency of anorectal lymphoma. Most lymphomas in AIDS patients are of a B-cell origin, and T-cell lymphoma of the gastrointestinal tract is extremely rare. We report here on a case of anorectal and gastric peripheral T-cell lymphoma, unspecified (PTCLu) in a non-AIDS patient. A previously healthy 29-year-old man presented with hematochezia and tenesmus that he had suffered with for the previous 2 months. Sigmoidoscopy showed anal and rectal submucosal tumor. Multiple round-shaped, flat and elevated lesions were noted on the gastric antrum and body as well. He underwent excisional biopsy for the anal mass and the diagnosis was PTCLu. Biopsies of the gastric lesions gave the same diagnosis. There was no lymphoma involved in the bone marrow. At admission, no antibodies against human immunodeficiency virus were detected. He underwent systemic chemotherapy and upfront autologous stem cell transplantation.

HIV-related and Epstein-Barr virus-associated anal Burkitt's lymphoma: report of a case

PURPOSE

This article describes and discusses primary Burkitt's lymphoma of the anus which is an extremely rare site of origin.

METHODS AND RESULTS

A 38-year-old HIV+ Rwandan farmer had an 8-cm x 13-cm anal tumor. Histopathology and immunohistology provided evidence of an Epstein-Barr virus-associated Burkitt's lymphoma. Chemotherapy in combination of virostatic therapy is the gold standard for treatment, but because of economic constraints surgical treatment was the only practicable intervention and an abdominoperineal resection of the anorectum was performed.

CONCLUSIONS

Because of the AIDS epidemic and the increase of anal malignant pathologies, anal Burkitt's lymphoma may appear more frequently. Adequate treatment is available for only a small percentage of patients.

Anorectal manifestations of sexually transmitted infections

Sexually transmitted infections have a wide range of clinical presentations, including involvement of the anal verge, anal canal and rectum. This review focuses on anorectal sexually transmitted infections which may cause diagnostic difficulty when encountered by the coloproctologist. An approach to the diagnosis of a variety of sexually transmitted infections is set out, with a discussion of the role of biopsy and a summary of relevant histopathological findings. The value of early antibiotic treatment is discussed. Problems related to HIV/AIDS are highlighted, as clinical presentation may be atypical in immunosuppressed individuals. Sexually transmitted oncogenic viruses and their role in anal neoplasia are also briefly summarized.

Anorectal lymphoma and AIDS: an outcome analysis

BACKGROUND AND OBJECTIVE

Primary lymphoma of the anus is an extremely rare problem. In patients with the Acquired Immune Deficiency Syndrome (AIDS), there is a marked increase in gastrointestinal non-Hodgkin's lymphomas (NHL). The aim of this study was to evaluate the outcome of patients with anorectal NHL and AIDS.

METHODS

Over an 18-year period, we identified 6 patients with AIDS and primary anorectal NHL. Five were male. All were high-grade B-cell lymphomas and half showed systemic "B" symptoms. Patient's mean CD4 count was 93 (range 8 to 201).

RESULTS

The average life span for those with "B" symptoms was 6.7 months and 16 months for those without symptoms. No benefit was shown from radiation or chemotherapy in those with "B" symptoms. Younger patients and those without systemic constitutional symptoms of lymphoma do better. One patient without "B" symptoms was able to tolerate his radiation and chemotherapy and is disease free at 10 months.

CONCLUSION

Despite traditional non-Hodgkin's lymphoma treatment regimens, our AIDS patients (and those examined in a review of the pertinent literature) with anorectal NHL and "B" symptoms have a poor prognosis. For those without "B" symptoms and who can tolerate the therapy, NHL remission may be obtained.

Perianal lymphoma in a heterosexual and nonimmunocompromised patient: report of a case and review of the literature

PURPOSE

This study was conducted to report a rare case of anorectal pathology.

METHODS

We report a case of perianal lymphoma in a nonimmunocompromised, heterosexual patient and review the literature.

RESULTS

A 67-year-old white male was found to have an ulcerated posterior anal mass. Biopsy revealed large cell lymphoma, B cell type, immunoblastic. There was no disseminated disease. The patient denied any homosexual activity and was HIV negative. There was complete resolution with chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone), and he remained disease free for six years.

CONCLUSIONS

Rare anorectal pathology may mimic common conditions. Biopsies should be taken to rule out malignancy.

EBV-associated anorectal lymphomas in patients with acquired immune deficiency syndrome

Primary lymphomas of the gastrointestinal tract represent 9% of all non-Hodgkin lymphomas, and of these only 3% arise in the rectum or anus. In contrast to their rare occurrence in the general population, the incidence of anorectal lymphomas in patients with acquired immune deficiency syndrome (AIDS), particularly homosexual patients, may be as high as 26% as reported in our own series of AIDS-associated lymphomas. To determine the characteristics of this entity, we studied 15 cases of primary anorectal lymphoma in AIDS patients and compared them with four cases of anorectal lymphoma unrelated to AIDS. The cases in our study were also compared with the reports of rectal lymphoma in the medical literature over the past 30 years. In the present series, the AIDS patients were all male with a median age of 34 years, human immunodeficiency virus (HIV)-positive, with homosexuality as the main risk factor. The four non-AIDS patients included a woman and had a median age of 66.5 years. Histologically, the anorectal lymphomas in AIDS patients were all high grade, predominantly immunoblastic, and polymorphous. In the non-AIDS patients, only two of four lymphomas were high grade, including one Burkitt type. All tumors were of B-cell phenotype. In the AIDS-associated anorectal lymphomas, the presence of Epstein-Barr virus (EBV) in a latent form was demonstrated by an abundance of Epstein-Barr-encoded RNA (EBER) in 14 of 15 cases and latent membrane protein (LMP) in four cases. All anorectal lymphomas unrelated to AIDS were negative for EBV. The unusual anorectal location of AIDS-associated lymphomas is explainable by the high incidence of preceding traumatic lesions and chronic infections in the area. As a result, EBV-carrying B cells may be attracted to the field providing the cell population that, under the conditions of immune deficiency, is able to give rise to high-grade lymphomas.

Anorectal surgery in patients infected with human immunodeficiency virus: factors associated with delayed wound healing

OBJECTIVE

A review of all anorectal operations in patients infected with human immunodeficiency virus (HIV) was performed to assess the incidence, variety, and clinical course of anorectal disease in these patients and to identify factors influencing wound healing.

SUMMARY BACKGROUND DATA

Anorectal disease is the most common indication for surgical intervention in patients infected with HIV. The cause and management of HIV-related anorectal conditions, which differ significantly from non-HIV-related diseases, are not clear. There also is considerable variation in the reported results of surgical procedures, including wound healing. St. Vincent's Hospital, Sydney, is situated in an area with the highest concentration of individuals infected with HIV in Australia.

METHODS

The medical records of all identified patients infected with HIV who had an anorectal operation at St. Vincent's General Hospital between January 1, 1988, and January 31, 1995, were reviewed retrospectively. Logistic regression, Mann-Whitney U test, and Fisher's exact tests were used for analysis.

RESULTS

One thousand five hundred two patients with acquired immune deficiency syndrome (AIDS), equivalent to 26.8% of all known patients with AIDS in Australia at this time, were admitted to this hospital during the 7-year period. One hundred one patients infected with HIV underwent 161 anorectal operations. All patients were male homosexuals (98 patients, 97%) or bisexuals (3 patients, 3%), with intravenous drug use an additional risk factor in 5 patients (5%). Thirty-seven percent of patients had more than one operation. Seventy-two percent of patients were Centers for Disease Control (CDC) group 4 (AIDS) at operation, 27% were group 2, 1% was group 3, and none were group 1. Accurate information about wound healing was available for 74% of first operations, and univariate and multivariate logistic analyses of these showed that when the CD4+ T-lymphocyte count was <50 cells/ microL, healing was significantly retarded (p = 0.016). The Centers for Disease Control group, patient age, and serum albumin were not significant predictors of wound healing. The interval between HIV diagnosis and operation was not associated with impaired wound healing, but recognition of AIDS more than 1 year before operation was associated with significantly better wound healing compared with those in whom AIDS developed within the year before operation (p = 0.025). In the patients for whom accurate wound healing information was available, only 40% had healed their wounds by 3 months after operation. Wound healing was worst for patients with chronic fissures, only 16% of whom had healed their wounds at 3 months. The wound healing rate was worse for repeat operations than for first operations. Ten percent of patients had anorectal malignancies, none of which were diagnosed clinically before or during operation.

CONCLUSIONS

Wound healing is a significant problem after anorectal operations in patients infected with HIV, especially when the CD4 count is <50/microL. Although there seems to be little or no benefit from more invasive operations in some cases, thorough examination with adequate biopsies is required in all cases. The best management of anorectal disease in patients infected with HIV still is unclear.

Etiology and pathogenesis of AIDS-related non--Hodgkin's lymphoma

The incidence of NHL is greatly increased in HIV-infected individuals. The vast majority are clinically aggressive B cell-derived neoplasms exhibiting BL, IBL, or LCL histology. Approximately 80% arise systemically (nodal and/or extranodal), and the remaining 20% arise as primary CNS lymphomas. A small proportion are body cavity-based lymphomas associated with KSHV infection. Possible factors contributing to lymphoma development include HIV-induced immunosuppression, chronic antigenic stimulation, and cytokine overproduction. These alterations are associated with the development of oligoclonal B-cell expansions. The appearance of NHL is characterized by the presence of a monoclonal B-cell population displaying a variety of genetic lesions, including EBV infection, c-myc gene rearrangement, bcl-6 gene rearrangement, ras gene mutations, and p53 mutations/deletions. The number and type of genetic lesions varies according to the anatomic site and histopathology. In the case of BL, virtually 100% exhibit c-myc gene rearrangements, two thirds display p53 gene mutations, one third contain EBV, and none exhibit bcl-6 gene rearrangements. In contrast, in the case of IBL, virtually 100% contain EBV, 25% display c-myc gene rearrangements, 20% display bcl-6 gene rearrangements, and very few exhibit p53 gene mutations. These findings suggest that more than one pathogenetic mechanism is operational in the development and progression of AIDS-related NHLs. Further work will be necessary to develop a complete understanding of the etiology and pathogenesis of NHL in the setting of HIV infection. AIDS-related NHL remains an important biologic model for investigating the development and progression of high-grade NHLs as well as NHLs that develop in immune-deficient hosts.

Colitis ulcerosa complicated by malignant lymphoma: case report and analysis of published works

A 51 year old woman with a two year history of ulcerative colitis developed a wide spread gastrointestinal non-Hodgkin's lymphoma of low grade malignancy (MALT-lymphoma) involving upper and lower gastrointestinal tract, spleen, and bone marrow. After chemotherapy, clinical symptoms improved and lymphocytic infiltrates disappeared. Thirty nine cases of ulcerative colitis and 22 cases of Crohn's disease complicated by gastrointestinal lymphomas reported in published works are reviewed. In inflammatory bowel diseases any dense lymphocytic infiltrates seen in biopsy specimens obtained from ulcerative colitis or Crohn's disease should be assessed to exclude gastrointestinal lymphoma.

Multiple lymphomatous polyposis and the role of fine needle aspiration cytology

Multiple lymphomatous polyposis is an uncommon but distinctive form of gastrointestinal lymphoma. Clinical symptoms may closely resemble those of colorectal carcinoma and diagnostic confusion may result. The condition has a characteristic pathological appearance and immunophenotype which is important in allowing distinction from other less aggressive forms of gastrointestinal lymphoma. We report a case of this unusual condition in which the diagnosis was aided by fine needle aspiration cytology.

Acquired immunodeficiency syndrome-associated lymphomas: clinical, pathologic, immunologic, and viral characteristics of 111 cases

The incidence of lymphomas in individuals infected with the human immunodeficiency virus has increased progressively since the beginning of the acquired immunodeficiency syndrome (AIDS) epidemic. The present series includes 111 patients, all diagnosed and studied at one hospital in New York City. There were 108 men and three women; the average age was 39 years and male homosexuality was the predominant risk factor. The materials examined originated from 138 surgical specimens and 24 autopsies. There were 11 cases of Hodgkin's lymphoma and 100 cases of non-Hodgkin's lymphomas (NHL), a proportion strongly skewed in favor of the latter. Hodgkin's lymphoma in AIDS patients was characterized by advanced clinical stage, high histologic grade, and frequent bone marrow involvement. Non-Hodgkin's lymphoma in AIDS patients, in contrast to the general population, originated predominantly in extranodal locations (61 cases) versus locations in which the lymph nodes were the site of the primary tumors (39 cases). In the digestive tract, the unusual oral and anal primary locations were often noted and were possibly related to specific risk factors. There were 15 cases of NHL of the central nervous system, an incidence 14 times greater than that recorded in the general population. The majority of NHLs were of high histologic grade, Burkitt's and large cell immunoblastic, representing most of the cerebral and gastrointestinal tumors. All NHLs were of B-cell immunophenotype. Lymphadenopathies with the histologic features of human immunodeficiency virus infection, particularly of the late stage (type C), often preceded NHL. Probing for Epstein-Barr virus genome was more frequently positive in Hodgkin's lymphoma than in NHL. Immunologic evaluations showed severely depressed T cell counts and CD4 to CD8 cell ratios as well as markedly increased levels of antilymphocyte antibodies. Reflecting the background of profound immune deficiency, the AIDS-associated lymphomas were characterized by high aggressiveness, early tendency to generalization, frequent post-treatment relapse, and short periods of survival.

Surgical management of anorectal disease in HIV-positive homosexuals

One thousand and ninety human immunodeficiency virus (HIV)-positive homosexual or bisexual males were seen in one hospital for management of HIV disease over a 9-year period. One hundred and fifty-five patients were referred by acquired immunodeficiency syndrome (AIDS) physicians for general surgical management. The most frequent reason for surgical referral (64 patients) was anorectal disease which occurred in 5.9 per cent of all HIV-positive patients. One or more diagnoses were reached in 61 of the 64 patients referred with anorectal disease: warts (38 per cent of diagnoses), anorectal ulceration (26 per cent), perianal sepsis (15 per cent), neoplasia (14 per cent) and haemorrhoidal disease (8 per cent). Anorectal symptoms were relieved in 68 per cent of patients and the median survival of those treated was 17.5 months from the time of surgical referral. Both warts and perianal sepsis were associated with in situ neoplasia, but no case of progression from in situ to invasive anal squamous carcinoma was detected. The aetiology of anorectal ulcers was not clear, but surgical excision of anal ulcers and skin tags can produce healing. Palliation of anorectal symptoms in HIV-positive homosexual patients is possible but some conditions are unusual and surgeons should be familiar with their presentation and management.

Kaposi's sarcoma and lymphoma of the gut in AIDS

KS and non-Hodgkin's lymphomas frequently involve the gut in patients with AIDS. These neoplasms establish the diagnosis of AIDS in an HIV-positive patient. KS is a spindle-cell tumour derived from lymphatic endothelia which is associated with luminal lesions in at least 40% of patients. Gastrointestinal KS is usually asymptomatic but may rarely bleed or obstruct. Treatment of KS with either interferon-alpha, radiation or chemotherapy can reduce tumour bulk, but does not alter overall survival in AIDS. Non-Hodgkin's lymphomas in AIDS are B cell neoplasms with many genotypic and phenotypic similarities to Burkitt's lymphoma. The tumours are usually highly aggressive, and present in extranodal sites in the majority of cases. Of these extranodal sites, gastrointestinal involvement is most common. Gastrointestinal lymphomas are usually symptomatic and almost always require treatment. Obstruction, perforation and bleeding may occur in patients with luminal involvement, whereas hepatic or biliary disease may lead to jaundice. Several chemotherapeutic regimens for lymphoma have been successfully used to achieve partial remission, although no prolongation of survival has been demonstrated. There appears to be an increased incidence of Hodgkin's disease in patients with AIDS, which is generally of advanced stage. This tumour does not meet the CDC criteria for AIDS as yet. Hepatic and/or splenic involvement in this setting are common.

Male homosexuality, HIV infection and colorectal surgery

The sexual practices of male homosexuals may lead to the development of a wide variety of colorectal and perianal diseases. This review describes the pathogenesis of these conditions, their management, and the influence of HIV infection on these conditions.

The gastrointestinal manifestations of AIDS

Gastrointestinal disease in AIDS is common and is due to opportunistic infections, aggressive malignancy and possible direct HIV enteropathy. Disabling gastrointestinal symptoms are prominent both in patients with established AIDS and in patients with earlier stages of HIV infection. We report the cases of 160 patients with AIDS who underwent gastroenterological investigations at St Vincent's Hospital, Sydney, between November 1983 to October 1987. Of these, 127 had the diagnosis of AIDS established prior to referral and 33 patients had the diagnosis of AIDS established as a result of gastroenterological investigations. Diarrhoea and weight loss (88%) were the most frequent reasons for undertaking gastroenterological investigations. Swallowing disorders (47%), abdominal pain (20%), oral and perianal disease (74%) and evidence of hepatobiliary disease were the other major indications for investigation. In 90% of cases there was evidence of concurrent and active gastrointestinal disease at two or more sites within the alimentary tract. Results from this series reveal a wide range of infectious pathogens: viral (Cytomegalovirus, Herpes simplex), bacterial (Mycobacterium avium intracellulare) and parasitic (Cryptosporidium, Isospora belli). Kaposi's sarcoma and non-Hodgkin's lymphoma were the only malignancies detected in this series. Gastrointestinal disease associated with HIV infection is common, and contributes significantly to its overall morbidity and mortality. Moreover, chronic diarrhoea, weight loss and malnutrition may also contribute to the overall immunodeficiency.

Primary rectal lymphoma and malignant lymphomatous polyposis. Two cases illustrating current methods in diagnosis and management

Two cases of colorectal lymphoma are presented. Preoperative histologic diagnosis is difficult and examination of the fresh specimen using immunocytochemical and gene rearrangement techniques are necessary to establish the precise nature of the lesion. Surgical excision is the mainstay of treatment for localized lymphoma of the colorectum and chemotherapy for malignant lymphomatous polyposis.

Perianal lymphoma as a manifestation of the acquired immune deficiency syndrome. Report of a case

A case of nonHodgkin's lymphoma of the perianal region in a patient with AIDS is reported. The unusual features of AIDS-related lymphoma and the possible role of immunodeficiency increasing susceptibility to oncogenic viruses are discussed.

Primary malignant lymphoma of the colon and rectum. A histopathological and immunohistochemical analysis of 45 cases with clinicopathological correlations

Primary colorectal lymphoma accounts for only about 0.2% of large intestinal malignancies. Management difficulties are compounded by a lack of consistent pathological reporting and by the use of numerous different classifications. Forty-five cases of primary colorectal lymphoma are included in this study. The presenting features are indistinguishable from those of colorectal cancer. Seven patients had a history of chronic ulcerative colitis but no other predisposing factors were identified. Immunohistochemical studies showed that all tumours were of B-cell phenotype. Most tumours were difficult to characterize using standard pathological classifications such as Kiel, except for the 11 cases of malignant (multiple) lymphomatous polyposis, which were morphologically diffuse centrocytic lymphomas. Twenty-nine lymphomas showed the morphological and immunohistochemical features associated with tumours arising in mucosa-associated lymphoid tissue. These tumours showed variable but often marked polymorphism and we have used the term polymorphic B-cell lymphoma to describe them. Consistency was achieved between three observers as to whether these tumours were low or high grade, and grade was found to be prognostically important. A modified Dukes staging system was adopted and there was a trend for early stage to give prognostic advantage. This study supports the view that surgery should be the primary treatment for localized lymphoma of the gastrointestinal tract with radiotherapy and/or chemotherapy for advanced cases and for malignant lymphomatous polyposis.

Primary anorectal lymphoma. A new manifestation of the acquired immune deficiency syndrome (AIDS)

Non-Hodgkin's lymphomas with particular clinicopathologic features occur with a high incidence in homosexual men affected by AIDS. More frequently than in the general population, these lymphomas have an extranodal location including the gastrointestinal tract. We have recently observed four cases of AIDS-associated lymphomas whose primary location is in the lower rectum and anus. The patients were 27 to 44 years of age, had greatly depressed helper-suppressor T-cell ratios, and antibodies to human immunodeficiency virus (HIV). All four presented with anorectal symptoms and originally had surgery for anorectal fistulas or tumor masses. When staged, three patients had no other organ involvement, the fourth only had lymphoma in an axillary lymph node, and all four had large tumor masses confined within the rectum. In terms of histology, the lymphomas were of undifferentiated or of large cell type and of B-cell phenotype. Lymphomas with primary or major location in the rectum are a rare occurrence in the general population, and until recently, are rare even among the lymphomas associated with the immune deficiency syndrome. At the Lenox Hill Hospital in New York City, no rectal lymphoma among the 58 cases of AIDS-related lymphoma diagnosed during the past 4 years was recorded until 10 months ago. The recognition of the new feature in presentation, a neoplasm associated with AIDS, is obviously important for its early diagnosis and treatment. Its unusual occurrence at the suspected portal of entry of the HIV infection is of interest because it may provide new clues to the association between AIDS and neoplasia.