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Oral manifestations of non-Hodgkin's lymphoma in HIV-infected patients
Medicine; pathology
0ral manifestations of nonHodgkin's lymphoma in HIVinfected patients
R. H. Groot 1, J. P. R. van M e r k e s t e y n ~, J. Bras 2 Departments of 1Oral and Maxillofacial Surgery and 2Pathology, Academic Medical Center, Amsterdam, The Netherlands
R. H. Groot, J. P. R. van Merkesteyn, 3". Bras: Oral manifestations of nonHodgkin's lymphoma in HIV-infected patients. Int. J. Oral Maxillofac. Surg. 1990; 19: 194-196. Abstract. The incidence o f n o n - H o d g k i n ' s lymphomas ( N H L ) in patients infected with human immunodeficiency virus (HIV) is relatively high. However, there have been few reports on the clinical and histopathological features of oral manifestations of N H L in these patients. The lesions reported so far were all tumorous swellings with or without ulceration, as in non-HIV-infected patients. In this report 3 cases are presented of HIV-infected patients with solitary, primary oral N H L . These lesions showed a striking resemblance to acute, necrotizing gingivitis, a c o m m o n finding in these patients, thus making the diagnosis more difficult.
Several reports on n o n - H o d g k i n ' s lymphomas ( N H L ) in the oral cavity have appeared in the literature 2'7'~7'18. In general, the oral lesions are characterized by a swelling that may grow rapidly and show ulceration ~4'~7. The most comm o n sites of oral involvement are the vestibular and buccal gingiva and the palatal mucosa 2'7. Primary involvement of the jawbones has also been reported 3,737. The occurrence of N H L in the oral cavity in patients with acquired immune deficiency syndrome (AIDS) has been reported by various authors 1'4'5'6'8'9'11'15'16'19.However, only 3 reports could be traced in which the oral manifestations o f N H L , in a total number of 4 patients with A I D S , are discussed in more detail 1's'9. The lesions in these 4 cases all exhibited the above described aspects of oral N H L . This report describes 3 cases (with different clinical appearance) of solitary, intra-oral N H L in HIV-infected patients. The initial lesions resembled acute gingival inflammations as seen often in these patients, thus making the diagnosis more difficult.
mandible. The lesion had been present for some weeks and appeared to be resistant to any local therapy. Intra-oral examination revealed both on the lingual and buccal side of the 1st and 2nd molar a painful lesion of the gingiva with a white necrotic surface and a hyperaemic margin (Fig. 1). These molars were slightly mobile. The radiograph showed a generalized periodontal bone loss (Fig. 2). The clinical diagnosis was: generalized periodontitis with ANUG in a patient with AIDS. During initial treatment, consisting of intensive irrigation with hydrogenperoxide 1.5% and chlorhexidine digluconate 0.2% mouthwash for 1 week, the size of the lesion appeared to have decreased. After 2 weeks; however, the lesion had enlarged again. On the lingual side of the 36 and 37 the alveolar bone was denuded over an area of 2 cm2, and the surrounding mucosa was hyperaemic, slightly indurated and detached from the underlying bone.
Case reports Case 1
Fig. 1. Case 1: Buccal
A 44-year-old man with AIDS was referred for an acute necrotizing ulcerating gingivitis (ANUG)-like lesion in the left part of the
aspect of the lesion, showing superficial necrosis of the marginal gingiva with a hyperaemic margin.
Key words: non-Hodgkin's lymphoma; HIV-infection; AIDS; necrotizing gingivitis. Accepted for publication 15 March 1990
On suspicion of malignancy, a biopsy was taken. The histologic diagnosis was malignant lymphoma, non-Hodgkin's, further classified according to LENNERT1° as diffuse centroblastie-centrocytic, according to the Working Formulation 12 as mixed small and large cell, and according to R A P P A P O R T 13 a s diffuse mixed. After staging of the disease no other localisations were found.
Case 2 A 35-year-old HIV-infected man was referred by his dentist for extraction of the 37 and 38 because of a local inflammation of the gingiva. The inflammation had been treated unsuccessfully with antibiotics elsewhere. Intra-oral examination revealed at the site of 37 and 38 a hyperaemic and slightly swollen gingiva. The gingiva distal to the 38 had
Oral non-Hodgkin's lymphoma in HIV-infected patients a white and somewhat verrucous aspect. The radiograph showed local resorption of the alveolar bone (Fig. 3). Under the clinical diagnosis of local parodontitis/peficoronitis, the 37 and 38 were extracted and a biopsy was taken from the abnormal gingiva distal to the 38. The histological diagnosis was malignant lymphoma, non-Hodgkin's, further classified according to LENNERTl° as immunoblastic, according to the Working Formulation ~2 as large-cell, immunoblastic, and according to RAPPAPORT 13 as diffuse histiocytic (Fig. 4). After staging o f the disease no other localisations were found.
Case 3
A 42-year-old man with AIDS was treated by his dentist for an ANUG-like lesion in the region of the 26-27. Treatment consisted of hydrogenperoxyde irrigation and, because o f persisting complaints of their severe mobility, the 26 and 27 were extracted. However, the extraction wounds did not heal and the region involved remained painful. The patient was, therefore, referred to our department. Intra-oral examination revealed at the site of the extracted 26 and 27 a large defect, with necrosis of gingiva and bone and an oroantra1 fistula. The adjacent gingiva was swol-
195
len and hyperaemic (Fig. 5). A biopsy was taken from the swollen gingiva. The histological diagnosis was malignant lymphoma, non-Hodgkin's, further classified according to LENNERT1° as diffuse centroblastic-centrocytic, according to the Working Formulation ~2as diffuse mixed small and large cell, and according to RAPPAPORT ~3 a s diffuse mixed. After staging of the disease no other lesions were found. Discussion
T h e l i t e r a t u r e o n oral m a n i f e s t a t i o n s o f H I V - a s s o c i a t e d N H L d e s c r i b e d a clin-
loss.
Fig. 3. Case 2: Radiograph showing local resorption of alveolar bone in the region of 37, 38.
Fig. 4. Case 2: N H L consisting o f cells with a large nucleus an
Fig. 5. Case 3: Appearance of the lesion after extraction of 26 and
prominent nueleoli. (H&E stain, original magnification 100 x ).
27. A defect is present with an oro-antral fistula and necrosis of bone and gingiva.
Fig. 2. Case 1: Radiograph showing generalized periodontal bone
196
Groot et al.
icat presentation similar to that of N H L in patients without a HIV-infection. In this paper 3 HIV-infected patients with a different clinical presentation o f a primary oral N H L are described. These intra-oral lymphomas showed a strong resemblance to acute, sometimes necrotizing, inflammations of the gingiva, that are fairly c o m m o n in this particular group of patients s. The clinical diagnosis may, therefore, be difficult to make, especially when it concerns primary and solitary (extranodal) manifestations of N H L . The above presented cases show that HIV-seropositive patients with acute or necrotizing gingival inflammations should be closely followed, and early biopsies taken in cases where the lesions do not react to normal therapy.
omas in HIV-infected patients: Association with Epstein-Barr virus DNA. Oral Surg 1989: 67: 437-42. 5. GREENSPAND, GREENSPANJS, PlNDBORG J J, SCHIODM. AIDS and the dental team. 1st. ed. Copenhagen: Munksgaard, 1986: 70-1. 6. HOMMELD J, BROWNML, KINZlEJJ. Response to radiotherapy of head and neck tumors in AIDS patients. Am J Surg 1987: 154: 443-6. 7. HOWELLRE, HANDLERSJP, ABRAMSAM, MELROSERJ. Extranodal oral lymphoma. Part 2. Relationships between clinical features and the Lukes-Collins classification of 34 cases. Oral Surg 1987: 64: 597602. 8. KAEGARSGE, BURNSJC. Non-Hodgkin's lymphoma of the oral cavity associated with AIDS. Oral Surg 1989: 67: 433-6. 9. LEESS FR, KESSLER DJ, MICKEL RA. Non-Hodgkin's lymphoma of the head and neck in patients with AIDS. Arch Otolaryngol Head Neck Surg 1987: 113: 1104-6.
References l. BRAHIM JS, KATZ RW, ROBERTS MW. Non-Hodgkin's lymphoma of the hard palate mucosa and buccal gingiva associated with AIDS. J Oral Maxillofac Surg 1988: 46: 328-30. 2. EISENBUD L, SCIUBBA J, M1R R, SACHS SA. Oral presentations in non-Hodgkin's lymphoma: A review of thirty-one cases. Part 1. Data analysis. Oral Surg 1983: 56: 151-6. 3. EISENBUDL, SCIUBBAJ, MIR R, SACHS SA. Oral presentations in non-Hodgkin's lymphoma: A review of thirty-one cases, Part 2. Fourteen cases arising in bone, Oral Surg 1984: 57: 272-80. 4. GREEN TL, EVERSOLELR. Oral lymph-
10. LENNERT K, MOHRI N. Histopathology and diagnosis of non-Hodgkin's lymphomas. In: Malignant lymphomas other than Hodgkin's disease. New York: Springer, 1978. 1l. LOZADA-NURF, SILVERMANJR S, MIGLIORATIC, et al. The diagnosis of AIDS and AIDS-related complex in the dental office: findings in 171 homosexual males. CDA J 1984: 12: 21-5. 12. The non-Hodgkin's lymphoma pathologic classification project. National Cancer Institute sponsered study of classification of non-Hodgkin's lymphomas: Summary and description of a working formulation for clinical usage. Cancer 1982: 49: 2112-35. 13. RAPPAPORTH. Tumors of the hematopo-
ietic system. In: Atlas of tumor pathology. US Armed Forces Institute of Pathology, Washington 1966, sect. III, fasc. 8. 14. SHAFER WG, HINE MK, LEVY BM. A textbook of oral pathology. 4th ed. Philadelphia: W. B. Saunders, 1983: 184-6. 15. SILVERMANJR S, MIGLIORATICA, LOZADA-NUR F, GREENSPAND, CONANT M. Oral findings in people with or at high risk for AIDS: a study of 375 homosexual males. JADA 1986: 112: 187-92. 16. SLANGEN MLBT, AKKER VAN DEN HP, LANGE JMA, SCHIPPER MEI, KESEN GJ.
Kaposisarcoom en andere orale manifestaties van AIDS. Ned Tijdschr Tandheelkd 1986: 93: 254-9. 17. SLOOTWEGPJ, WITTKAMPFARM, KLEIN PM, WILDE DE PCM, UNNIK VAN JAM. Extranodal non-Hodgkin's lymphoma of the oral tissues. An analysis of 20 cases. J Maxillofac Surg 1985: 13: 85-92. 18. WONG DS, FULLERLM, BUTLERJJ, SHULLENBERGER CC. Extranodal nonHodgkin's lymphomas of the head and neck. Am J Roentgenol 1975: 123: 471-81. 19. ZmGLER JL, BECKSTEADJA, et al. NonHodgkin's tymphoma in 90 homosexual men. Relation to generalized lymphadenopathy and the acquired immunodeficiency syndrome. New Engl J Med 1984: 311: 565-70.
Address: R. H. Groot, DMD Department of Oral and Maxillofacial Surgery Aeademiseh Mediseh Centrum Meibergdreef 9 1105 A Z Amsterdam The Netherlands
0ral manifestations of nonHodgkin's lymphoma in HIVinfected patients
R. H. Groot 1, J. P. R. van M e r k e s t e y n ~, J. Bras 2 Departments of 1Oral and Maxillofacial Surgery and 2Pathology, Academic Medical Center, Amsterdam, The Netherlands
R. H. Groot, J. P. R. van Merkesteyn, 3". Bras: Oral manifestations of nonHodgkin's lymphoma in HIV-infected patients. Int. J. Oral Maxillofac. Surg. 1990; 19: 194-196. Abstract. The incidence o f n o n - H o d g k i n ' s lymphomas ( N H L ) in patients infected with human immunodeficiency virus (HIV) is relatively high. However, there have been few reports on the clinical and histopathological features of oral manifestations of N H L in these patients. The lesions reported so far were all tumorous swellings with or without ulceration, as in non-HIV-infected patients. In this report 3 cases are presented of HIV-infected patients with solitary, primary oral N H L . These lesions showed a striking resemblance to acute, necrotizing gingivitis, a c o m m o n finding in these patients, thus making the diagnosis more difficult.
Several reports on n o n - H o d g k i n ' s lymphomas ( N H L ) in the oral cavity have appeared in the literature 2'7'~7'18. In general, the oral lesions are characterized by a swelling that may grow rapidly and show ulceration ~4'~7. The most comm o n sites of oral involvement are the vestibular and buccal gingiva and the palatal mucosa 2'7. Primary involvement of the jawbones has also been reported 3,737. The occurrence of N H L in the oral cavity in patients with acquired immune deficiency syndrome (AIDS) has been reported by various authors 1'4'5'6'8'9'11'15'16'19.However, only 3 reports could be traced in which the oral manifestations o f N H L , in a total number of 4 patients with A I D S , are discussed in more detail 1's'9. The lesions in these 4 cases all exhibited the above described aspects of oral N H L . This report describes 3 cases (with different clinical appearance) of solitary, intra-oral N H L in HIV-infected patients. The initial lesions resembled acute gingival inflammations as seen often in these patients, thus making the diagnosis more difficult.
mandible. The lesion had been present for some weeks and appeared to be resistant to any local therapy. Intra-oral examination revealed both on the lingual and buccal side of the 1st and 2nd molar a painful lesion of the gingiva with a white necrotic surface and a hyperaemic margin (Fig. 1). These molars were slightly mobile. The radiograph showed a generalized periodontal bone loss (Fig. 2). The clinical diagnosis was: generalized periodontitis with ANUG in a patient with AIDS. During initial treatment, consisting of intensive irrigation with hydrogenperoxide 1.5% and chlorhexidine digluconate 0.2% mouthwash for 1 week, the size of the lesion appeared to have decreased. After 2 weeks; however, the lesion had enlarged again. On the lingual side of the 36 and 37 the alveolar bone was denuded over an area of 2 cm2, and the surrounding mucosa was hyperaemic, slightly indurated and detached from the underlying bone.
Case reports Case 1
Fig. 1. Case 1: Buccal
A 44-year-old man with AIDS was referred for an acute necrotizing ulcerating gingivitis (ANUG)-like lesion in the left part of the
aspect of the lesion, showing superficial necrosis of the marginal gingiva with a hyperaemic margin.
Key words: non-Hodgkin's lymphoma; HIV-infection; AIDS; necrotizing gingivitis. Accepted for publication 15 March 1990
On suspicion of malignancy, a biopsy was taken. The histologic diagnosis was malignant lymphoma, non-Hodgkin's, further classified according to LENNERT1° as diffuse centroblastie-centrocytic, according to the Working Formulation 12 as mixed small and large cell, and according to R A P P A P O R T 13 a s diffuse mixed. After staging of the disease no other localisations were found.
Case 2 A 35-year-old HIV-infected man was referred by his dentist for extraction of the 37 and 38 because of a local inflammation of the gingiva. The inflammation had been treated unsuccessfully with antibiotics elsewhere. Intra-oral examination revealed at the site of 37 and 38 a hyperaemic and slightly swollen gingiva. The gingiva distal to the 38 had
Oral non-Hodgkin's lymphoma in HIV-infected patients a white and somewhat verrucous aspect. The radiograph showed local resorption of the alveolar bone (Fig. 3). Under the clinical diagnosis of local parodontitis/peficoronitis, the 37 and 38 were extracted and a biopsy was taken from the abnormal gingiva distal to the 38. The histological diagnosis was malignant lymphoma, non-Hodgkin's, further classified according to LENNERTl° as immunoblastic, according to the Working Formulation ~2 as large-cell, immunoblastic, and according to RAPPAPORT 13 as diffuse histiocytic (Fig. 4). After staging o f the disease no other localisations were found.
Case 3
A 42-year-old man with AIDS was treated by his dentist for an ANUG-like lesion in the region of the 26-27. Treatment consisted of hydrogenperoxyde irrigation and, because o f persisting complaints of their severe mobility, the 26 and 27 were extracted. However, the extraction wounds did not heal and the region involved remained painful. The patient was, therefore, referred to our department. Intra-oral examination revealed at the site of the extracted 26 and 27 a large defect, with necrosis of gingiva and bone and an oroantra1 fistula. The adjacent gingiva was swol-
195
len and hyperaemic (Fig. 5). A biopsy was taken from the swollen gingiva. The histological diagnosis was malignant lymphoma, non-Hodgkin's, further classified according to LENNERT1° as diffuse centroblastic-centrocytic, according to the Working Formulation ~2as diffuse mixed small and large cell, and according to RAPPAPORT ~3 a s diffuse mixed. After staging of the disease no other lesions were found. Discussion
T h e l i t e r a t u r e o n oral m a n i f e s t a t i o n s o f H I V - a s s o c i a t e d N H L d e s c r i b e d a clin-
loss.
Fig. 3. Case 2: Radiograph showing local resorption of alveolar bone in the region of 37, 38.
Fig. 4. Case 2: N H L consisting o f cells with a large nucleus an
Fig. 5. Case 3: Appearance of the lesion after extraction of 26 and
prominent nueleoli. (H&E stain, original magnification 100 x ).
27. A defect is present with an oro-antral fistula and necrosis of bone and gingiva.
Fig. 2. Case 1: Radiograph showing generalized periodontal bone
196
Groot et al.
icat presentation similar to that of N H L in patients without a HIV-infection. In this paper 3 HIV-infected patients with a different clinical presentation o f a primary oral N H L are described. These intra-oral lymphomas showed a strong resemblance to acute, sometimes necrotizing, inflammations of the gingiva, that are fairly c o m m o n in this particular group of patients s. The clinical diagnosis may, therefore, be difficult to make, especially when it concerns primary and solitary (extranodal) manifestations of N H L . The above presented cases show that HIV-seropositive patients with acute or necrotizing gingival inflammations should be closely followed, and early biopsies taken in cases where the lesions do not react to normal therapy.
omas in HIV-infected patients: Association with Epstein-Barr virus DNA. Oral Surg 1989: 67: 437-42. 5. GREENSPAND, GREENSPANJS, PlNDBORG J J, SCHIODM. AIDS and the dental team. 1st. ed. Copenhagen: Munksgaard, 1986: 70-1. 6. HOMMELD J, BROWNML, KINZlEJJ. Response to radiotherapy of head and neck tumors in AIDS patients. Am J Surg 1987: 154: 443-6. 7. HOWELLRE, HANDLERSJP, ABRAMSAM, MELROSERJ. Extranodal oral lymphoma. Part 2. Relationships between clinical features and the Lukes-Collins classification of 34 cases. Oral Surg 1987: 64: 597602. 8. KAEGARSGE, BURNSJC. Non-Hodgkin's lymphoma of the oral cavity associated with AIDS. Oral Surg 1989: 67: 433-6. 9. LEESS FR, KESSLER DJ, MICKEL RA. Non-Hodgkin's lymphoma of the head and neck in patients with AIDS. Arch Otolaryngol Head Neck Surg 1987: 113: 1104-6.
References l. BRAHIM JS, KATZ RW, ROBERTS MW. Non-Hodgkin's lymphoma of the hard palate mucosa and buccal gingiva associated with AIDS. J Oral Maxillofac Surg 1988: 46: 328-30. 2. EISENBUD L, SCIUBBA J, M1R R, SACHS SA. Oral presentations in non-Hodgkin's lymphoma: A review of thirty-one cases. Part 1. Data analysis. Oral Surg 1983: 56: 151-6. 3. EISENBUDL, SCIUBBAJ, MIR R, SACHS SA. Oral presentations in non-Hodgkin's lymphoma: A review of thirty-one cases, Part 2. Fourteen cases arising in bone, Oral Surg 1984: 57: 272-80. 4. GREEN TL, EVERSOLELR. Oral lymph-
10. LENNERT K, MOHRI N. Histopathology and diagnosis of non-Hodgkin's lymphomas. In: Malignant lymphomas other than Hodgkin's disease. New York: Springer, 1978. 1l. LOZADA-NURF, SILVERMANJR S, MIGLIORATIC, et al. The diagnosis of AIDS and AIDS-related complex in the dental office: findings in 171 homosexual males. CDA J 1984: 12: 21-5. 12. The non-Hodgkin's lymphoma pathologic classification project. National Cancer Institute sponsered study of classification of non-Hodgkin's lymphomas: Summary and description of a working formulation for clinical usage. Cancer 1982: 49: 2112-35. 13. RAPPAPORTH. Tumors of the hematopo-
ietic system. In: Atlas of tumor pathology. US Armed Forces Institute of Pathology, Washington 1966, sect. III, fasc. 8. 14. SHAFER WG, HINE MK, LEVY BM. A textbook of oral pathology. 4th ed. Philadelphia: W. B. Saunders, 1983: 184-6. 15. SILVERMANJR S, MIGLIORATICA, LOZADA-NUR F, GREENSPAND, CONANT M. Oral findings in people with or at high risk for AIDS: a study of 375 homosexual males. JADA 1986: 112: 187-92. 16. SLANGEN MLBT, AKKER VAN DEN HP, LANGE JMA, SCHIPPER MEI, KESEN GJ.
Kaposisarcoom en andere orale manifestaties van AIDS. Ned Tijdschr Tandheelkd 1986: 93: 254-9. 17. SLOOTWEGPJ, WITTKAMPFARM, KLEIN PM, WILDE DE PCM, UNNIK VAN JAM. Extranodal non-Hodgkin's lymphoma of the oral tissues. An analysis of 20 cases. J Maxillofac Surg 1985: 13: 85-92. 18. WONG DS, FULLERLM, BUTLERJJ, SHULLENBERGER CC. Extranodal nonHodgkin's lymphomas of the head and neck. Am J Roentgenol 1975: 123: 471-81. 19. ZmGLER JL, BECKSTEADJA, et al. NonHodgkin's tymphoma in 90 homosexual men. Relation to generalized lymphadenopathy and the acquired immunodeficiency syndrome. New Engl J Med 1984: 311: 565-70.
Address: R. H. Groot, DMD Department of Oral and Maxillofacial Surgery Aeademiseh Mediseh Centrum Meibergdreef 9 1105 A Z Amsterdam The Netherlands