Extranodal oral lymphomas: histologic subtypes and immunophenotypes (in routinely processed tissue)

Adult T-cell leukemia/lymphoma with predominant bone involvement, initially diagnosed by its oral manifestation: A case report

Adult T-cell leukemia/lymphoma (ATL/L) is a rare malignant neoplasm linked to human T-cell lymphotropic virus type 1 (HTLV-1). This virus has been identified in Japan, the Caribbean, and, more recently, Brazil. We report a case of ATL/L (lymphoma-type) affecting a 30-year-old Brazilian woman. She presented a painful and ulcerated lesion on her hard palate mucosa. Conventional radiographs and computed tomography revealed the involvement of several bones plus the lung and axillary lymph nodes. Histopathological and immunohistochemical analyses of oral biopsy confirmed a T-cell non-Hodgkin's lymphoma. Final diagnosis of ATL/L was made based on HTLV-1 positivity. She underwent multiple cycles of chemotherapy, which produced some improvement, but she died as a consequence of pulmonary and hepatic complications 4 months after the initial diagnosis. Besides the process of diagnosing and typing a malignant lymphoma, this article outlines the value of computed tomography and the necessity of performing HTVL-1 investigation in patients with a diagnosis of lymphoma of T-cell lineage.

Localized B-cell non-Hodgkin's lymphoma of oral cavity and maxillofacial region: a clinical study

OBJECTIVE

Non-Hodgkin's lymphomas (NHL) are the third most common group of malignant lesions in the oral cavity and maxillofacial region. Most such lymphomas have been shown to be predominantly of B-lineage. The purpose of the present study is to analyze the clinical signs and symptoms and the clinical staging of B-cell NHL of this region.

STUDY DESIGN

Eighteen adults, with B-cell NHL manifestations of the oral cavity and maxillofacial region, were available for this study. The clinical stage according to the Ann Arbor system was assessed by history, physical, and laboratory examination. Hematoxylin and eosin--stained slides and paraffin blocks were available for all cases. Histologic diagnosis was based on the WHO classification of tumors.

RESULTS

The mean age of patients at the time of biopsy was 64 years. At the time of the disease presentation, according to the Ann Arbor system, 11 patients were in stage IE, 2 patients in stage IIE, 2 patients in stage IIIE, 1 patient in stage IVE, and 2 patients in stage IV. The typical clinical appearance was a painless local mass lateral or bilateral. Often there is a superficial ulceration of the tumor mass. Tonsillar NHL was the most frequent site occurring in 8 patients followed by NHL of the oral cavity, of the salivary glands, and of the mandible. Grading revealed that most cases were high grade (11 cases), followed by the cases of low grade (5 cases) and intermediate grade (2 cases). All the different histologic types may be observed, but the most frequently encountered is the diffuse large type.

CONCLUSIONS

The B-cell NHL may involve both osseous and soft tissues of the oral cavity and maxillofacial region. The favored sites are tonsils, palatal mucosa and parotid glands. The typical clinical appearance is a painless local mass lateral or bilateral. Often there is a superficial ulceration of the tumor mass. According to the Ann Arbor system, the majority of the cases at the time of diagnosis are in stage I or II. Most patients have high grade disease. All the different histologic types may be observed, but the most frequently encountered is the diffuse large type.

Primary extranodal malignant lymphoma affecting the periodontium

BACKGROUND

Non-Hodgkin's lymphoma may arise in extranodal tissues within the head and neck region. These lesions may occur in the oral cavity, but rarely appear on the gingiva. Due to their malignant nature, rapid identification, diagnosis, and treatment of non-Hodgkin's lymphomas are essential to patient survival.

METHODS

An unusual case of primary extranodal non-Hodgkin's lymphoma is described. The small lesion arose on the gingiva and alveolar mucosa. Upon excision, the tissue was submitted for microscopic examination, with the expectation that the lesion would be benign and excision would constitute the entirety of treatment. However, a diagnosis of primary extranodal large B-cell lymphoma was returned.

RESULTS

In addition to excision of the lesion, the patient underwent a complete work-up to rule out other systemic lesions. Chemotherapy and radiation therapy were performed. The patient has remained healthy, without recurrence of lymphoma for 3 years.

CONCLUSIONS

This case reinforces the importance of submitting excised tissues for microscopic examination even when the lesion appears totally benign. In addition, it highlights the need for complete excision of suspected lesions, with generous borders of normal tissue. With current periodontal plastic surgical techniques, most defects remaining after soft tissue biopsy can be managed with good esthetic results.

Lymphomas of the oral cavity: histology, immunologic type, and incidence of Epstein-Barr virus infection

The purpose of this study was to determine the histologic class and immunologic phenotype of lymphomas presenting initially in the oral cavity and whether this correlated to a high incidence of Epstein-Barr virus (EBV) infection as has been reported with lymphomas in the nasal cavity. Seventy-one cases of oral lymphomas from the oral pathology referral service were analyzed retrospectively. They were classified according to the Revised European American Lymphoma (REAL) classification system using routine immunohistochemistry. EBV infection was determined by detection of early viral RNA sequences (EBER) and latent membrane protein (LMP-1) expression. Only non-Hodgkin's lymphomas were observed, with a female predominance of 2:1. They were primarily of B-cell origin and histologically classified mainly as large B-cell type (68%); T-cell lymphomas were rare (8%). EBV infection was observed in 14% of the B-cell lymphomas, an incidence rate higher than that reported in studies of B-cell lymphomas not located in the oral cavity but not as high as that observed in pleomorphic T-cell lymphomas (all sites, 36%) or nasal cavity T-cell lymphomas (nearly 100%). Interestingly, EBV proliferation did not correlate with expression of either Bcl-2 or p53.

Advanced diagnostic methods in oral and maxillofacial pathology. Part II: immunohistochemical and immunofluorescent methods

The practice of pathology is currently undergoing significant change, in large part due to advances in the analysis of DNA, RNA, and proteins in tissues. These advances have permitted improved biologic insights into many developmental, inflammatory, metabolic, infectious, and neoplastic diseases. Moreover, molecular analysis has also led to improvements in the accuracy of disease diagnosis and classification. It is likely that, in the future, these methods will increasingly enter into the day-to-day diagnosis and management of patients. The pathologist will continue to play a fundamental role in diagnosis and will likely be in a pivotal position to guide the implementation and interpretation of these tests as they move from the research laboratory into diagnostic pathology. The purpose of this 2-part series is to provide an overview of the principles and applications of current molecular biologic and immunologic tests. In Part I, the biologic fundamentals of DNA, RNA, and proteins and methods that are currently available or likely to become available to the pathologist in the next several years for their isolation and analysis in tissue biopsies were discussed. In Part II, advances in immunohistochemistry and immunofluorescence methods and their application to modern diagnostic pathology are reviewed.

Epstein-Barr virus detection in non-Hodgkin's lymphoma of the oral cavity: an immunocytochemical and in situ hybridization study

OBJECTIVE

The purpose of this study was to histologically characterize a series of oral non-Hodgkin's lymphomas (NHLs) and to investigate latent and lytic Epstein-Barr virus (EBV) infection in these.

STUDY DESIGN

The revised European-American Lymphoma classification system (41) was used to categorize 58 cases of oral NHL, which included 9 immunosuppression-related NHLs. EBV infection was determined by in situ hybridization for Epstein-Barr virus-encoded RNA and by immunohistochemistry for the EBV antigens latency membrane protein, Epstein-Barr nuclear antigen-2 (EBNA2) and Z EBV replication activator protein.

RESULTS

Most tumors were B-cell lymphomas (78%), but the proportion of T-cell lymphomas was surprisingly high (22%). The most common histologic subtypes were diffuse large B-cell lymphomas (45%), peripheral T-cell lymphomas (19%), and follicle center lymphomas (14%). Two thirds of the known immunosuppression-related NHLs were T-cell lymphomas. All of the immunosuppression-related tumors were EBV-infected, whereas the EBV infection rate in the NHLs of the remaining patients presumed to be immunocompetent was only 9%. Most EBV-positive tumors expressed neither of the latent antigens (ie, latency membrane protein and Epstein-Barr nuclear antigen-2), and coexpression of the 2 was observed only in immunosuppressed patients. Z EBV replication activator protein expression, which is indicative of replicative infection, occurred only in immunosuppressed individuals.

CONCLUSIONS

Diffuse large B-cell lymphomas were the most common histologic subtype of oral NHLs, but T-cell lymphomas were relatively common and frequently occurred in states of immunosuppression. EBV may play a limited role in the initiation of lymphoma in the immunocompetent patient, but the virus may be of importance in progression of the disease in those patients with more aggressive tumors, as immunosuppression occurs.

Primary non-Hodgkin's lymphoma of the jaws: immunohistochemical and genetic review of 10 cases

PURPOSE

Non-Hodgkin's lymphoma (NHL) comprises a group of malignant lymphoproliferative diseases characterized by clonal expansion of lymphocytes at various levels of ontogenetic development. The aim of this study was to review the immunohistochemical and cytogenetic features of 10 cases of NLH of the jaws to determine their respective derivation.

PATIENTS AND METHODS

Histopathologic and immunohistochemical review of 10 cases of large-cell lymphomas of the jaws, together with Southern blot analysis of 2 of the cases, was performed and results compared with the findings in the literature.

RESULTS

In the 10 cases studied, the average age of onset of the NHL was 51 years, with a male-to-female ratio of 3:2. Tumefaction was the first clinical sign of disease. Eight of 10 cases were high-grade, large-cell NHLs, centroblastic type. Two cases were high-grade, large-cell NHL, immunoblastic type.

CONCLUSION

The immunohistochemical and Southern blot data remain the principal laboratory aids in the diagnosis and characterization of NHL, and they provide critical information for guiding clinicians to the appropriate treatment protocol for these malignancies.

Radiotherapy for primary localized (stage I and II) non-Hodgkin's lymphoma of the oral cavity

PURPOSE

To assess the role of radiation therapy in the treatment of primary localized (Stage I: 24 cases and Stage II: 13 cases) non-Hodgkin's Lymphoma (NHL) of the oral cavity.

METHODS AND MATERIALS

In total, 37 patients (27 male, 10 female) with primary localized NHL of the oral cavity have been treated with radiotherapy alone (23 cases) or radiation with chemotherapy (14 cases). The age range was 29 to 86 years (median: 65). Clinical and treatment variables with potential prognostic significance for survival were evaluated by univariate and multivariate analysis. Of the 37 patients, 31 (84%) had intermediate-grade lymphomas and six (14%) had high-grade lymphomas. Four patients showed necrotic ulcer in the central portion of the hard palate.

RESULTS

The 5-year actuarial survival rate for all cases was 73%. The 5-year survival rates for intermediate-grade and high-grade lymphoma were 85% and 14%, respectively. Significant prognostic factors identified by the multivariate analysis were histologic grade of malignancy (p = 0.02) and central necrotic ulcer in the tumor (p = 0.02). Chemotherapy did not improve survival (p = 0.41).

CONCLUSIONS

Our analysis suggests that radiotherapy alone may be approved as the treatment for localized oral NHL with no ulceration and intermediate histology. However, patients with high-grade lymphoma and/or necrotic ulcer are difficult to cure with radiation alone and aggressive treatment should be advocated to improve survival.

Sinonasal lymphoma

The clinical course of 49 patients with the diagnosis of non-Hodgkin's lymphoma were studied in the Department of Otolaryngology of the Hospital General de Mexico between December 1986 and March 1997. The most frequent clinical symptoms in these patients were: nasal obstruction, rhinorrhea, fever, weight loss, cervical lymph adenopathy, rhinopharyngeal tumor, ulceration on the palate and periorbital cellulitis. In 73% of the patients in this series the primary presentation was nasal. Sixty-six percent of the patients were classified as intermediate grade lymphoma according to the New Working Formulation, and 33% were in a I B state according to the Ann Arbor predominant immunotype was B cell in 63% of the cases. An extensive review of the literature is also presented.

Gastric and gingival localization of mucosa-associated lymphoid tissue (MALT) lymphoma. An immunohistochemical, virological and clinical case report

Non-Hodgkin's lymphomas (NHL) of the mucosa-associated lymphoid tissue (MALT) are characterized by their mucosal and glandular tissue localization. The case described here falls into the European-American classification of a low-grade B-cell lymphoma of the MALT type, with a gingival lesion 2 years after a gastric lesion. The pathogenetic mechanisms of NHL in oral MALT and the diagnosis and treatment are discussed.

Apoptosis-associated proteins in oral lymphomas from HIV-positive patients

Extranodal oral lymphomas, seen with increasing frequency in HIV infection, may have dysfunctional apoptotic mechanisms that favor tumor progression. The purpose of this study was to evaluate extranodal lymphomas from HIV-positive patients for expression of apoptosis-associated proteins. Correlations were made with 10 histologically comparable extranodal lymphomas from HIV-negative patients and 6 hyperplastic lymph nodes from otherwise healthy young adults. Formalin-fixed tissue sections were immunohistochemically stained for apoptosis-associated proteins (Bcl-2, Bcl-x, Bax, Bak, p53, MDM2, BHRF). In situ hybridization was also done on deparaffinized sections for Epstein-Barr virus EBER mRNA. Eighteen consecutive oral lymphomas were studied in HIV/AIDS-positive patients. Four of 5 intermediate-grade lymphomas expressed Bcl-2 to a greater degree than did high-grade lymphomas (4 of 13). Most lymphomas were positive for Bcl-x and Bax, and few expressed Bak. The staining patterns for these proteins were similar to those seen in HIV-negative patients. Staining patterns were relatively consistent in the hyperplastic lymph nodes, whereas such patterns were irregular in lymphomas. Positive p53 staining was seen in 11 of 18 HIV-positive cases; 9 of these were also MDM2-positive. Double stains suggested that both p53 and MDM2 proteins were expressed in the same cells in these nine cases. Epstein-Barr virus-EBER mRNA was detected in 14 of 18 cases and in 3 of 10 cases from HIV-negative patients. BHRF staining was evident in only a few cells of three HIV-positive lymphomas. The irregular expression of Bcl-2, Bcl-x, Bax, and Bak in oral lymphomas indicates dysfunctional apoptotic mechanisms in these tumors. Bcl-2 staining differs with tumor grade. Positive staining for p53 and MDM2 proteins is a notable feature of lymphomas in HIV-positive patients and may relate to binding of MDM2 to wild-type p53. Epstein-Barr virus is more commonly associated with oral lymphomas in HIV-positive patients, although the Epstein-Barr virus-produced protein BHRF, which has Bcl-2-like activity, is minimally expressed.

Comparison between submucosal (extra-nodal) and nodal non-Hodgkin's lymphoma (NHL) in the oral and maxillofacial region

Fifty-two cases of non-Hodgkin's lymphoma (NHL) in the oral and maxillofacial region, comprising 31 submucosal (extra-nodal) and 21 cervical node NHLs, were investigated. The patients' ages ranged from 5 to 86 years, with a bimodal age distribution among young people below 12 years of age (average 8 years) and in those aged 30 years or older (average 60.3 years). The male-to-female gender difference ratio was 1.3:1. Patients presented with swelling as the major symptom. Histologically, diffuse, large cell malignant lymphoma was the most frequent type and 67.9% of lymphomas were of intermediate malignancy as defined by the Working Formulation for Clinical Usage. All submucosal lymphomas showed diffuse proliferation patterns, although follicular proliferation was identified in 5 of the 21 nodal lymphomas. Immunohistochemistry showed that the B-cell type was predominant, especially in nodal lymphomas.

Lymphomas of the oral soft tissues are not preferentially associated with latent or replicative Epstein-Barr virus

OBJECTIVES

Epstein-Barr virus is periodically shed in the saliva of persons infected by the virus. Epstein-Barr virus has been implicated in the pathogenesis of certain subtypes of lymphoma, particularly high-grade lymphomas. Because high-grade subtypes represent the majority of lymphomas that arise in oral soft tissues, we hypothesized that Epstein-Barr virus might be preferentially associated with oral lymphomas.

STUDY DESIGN

A series of 34 oral lymphomas were diagnosed according to the revised European-American classification scheme. They were examined for the presence of latent Epstein-Barr virus by EBER1 in situ hybridization and for expression of the Epstein-Barr virus replicative protein, BZLF1, by immunohistochemistry.

RESULTS

Epstein-Barr virus EBER1 transcripts were detected in 11 of 31 oral lymphomas including 7 of 10 AIDS-related lymphomas and only 4 of 21 lymphomas that occurred in nonimmunocompromised persons. The Epstein-Barr virus-containing lymphomas were all high-grade histologic subtypes, that is, diffuse large cell, immunoblastic, or Burkitt's lymphomas. In contrast, Epstein-Barr virus was not detected in any of five low-grade oral lymphomas. In the single case of T-cell lymphoma in this study, EBER1 was expressed in the tumor cells. A switch from viral latency to replication, as measured by EBV BZLF1 expression, was identified in rare lymphoma cells in only four cases. This rate of viral replication was not higher than what has been reported in lymphomas arising at other anatomic sites. Although one of our lymphomas arose at a site of previous oral hairy leukoplakia, there was no other evidence that Epstein-Barr virus replication predisposed to development or persistence of oral lymphomas.

CONCLUSIONS

These data suggest that even though Epstein-Barr virus is frequently found in oral secretions, neither latent nor replicative Epstein-Barr virus is present more commonly in oral lymphomas than in lymphomas arising in other anatomic sites, when controlling for immunodeficiency status.

Subclasses of extranodal oral B-cell lymphomas express cIgM, plasmacytoid, and monocytoid differentiation. A study of 10 cases

Light microscopic and immunohistochemical findings in 10 extranodal oral B-cell lymphoproliferations are described. Three lymphomas were of the small lymphocytic/plasmacytoid type that also contained immunoblasts. Five lymphomas were monocytoid type with folded nuclei and pale-staining cytoplasm. Two lymphomas were of the large-cell type and contained multilobated blast cells, a low-grade neoplastic lymphoid component, and tumor plasma cells. All lymphomas were reactive with B-cell specific 4KB5, LN-2, L26, and LN-1 antibodies. There was a variable expression of intracytoplasmic mu heavy chain and monotypic kappa or lambda light chains with neoplastic lymphoplasmacytoid cells and plasma cells. These subclasses of primary oral lymphomas express the histologic and immunophenotypic likeness as well as the immunoreactive spectrum of parafollicular B cells. They may have an intimate morphogenetic association with that of the mucosa-associated lymphoid tissue lymphoma.

Primary extranodal non-Hodgkin lymphoma of the oral cavity. An analysis of 34 cases

34 patients with primary extranodal non-Hodgkin lymphoma (PE-NHL) of the oral cavity have been studied with reference to age, sex, clinical symptoms, location of primary tumour, histological subtype, grade of malignancy according to the Working Formulation, stage of disease, treatment and follow-up. The clinicopathological features of these oral PE-NHL correspond with those of PE-NHL in general. Survival was influenced by stage of disease and grade of malignancy.