Oral lymphomas in HIV-infected patients: association with Epstein-Barr virus DNA

Clinicopathological analysis of oral plasmablastic lymphoma: A systematic review

BACKGROUND

Plasmablastic lymphoma (PBL) is a high-grade lymphoma that often affects the oral cavity of HIV-positive patients; however, its prognostic determinants remain unknown.

PURPOSE

To integrate the available data on oral PBL to determine its clinicopathological features and to identify potential prognostic factors.

METHODS

An electronic systematic review was performed using multiple databases with a specific search strategy in February 2018. Inclusion criteria comprised cases diagnosed as PBL affecting the oral cavity and gnathic bones with sufficient data to confirm the diagnoses.

RESULTS

A total of 70 publications were included, representing 153 cases. Oral PBL predominantly affected HIV-positive males (76.4%). EBV was observed in 63.4% of the cases. The gingiva was the most involved site and the lesion usually presented as an asymptomatic swelling. Most cases were classified as stage I (21.6%), and chemotherapy alone was applied in 28.8% of the cases. There was a significant association between HIV and EBV infections, and cases affecting HIV-negative patients were more common in older individuals. Cumulative survival of the patients achieved 42.4% and 33.5% after 2 and 5 years, respectively. Although there were no statistically significant clinicopathological parameters in the univariate analysis, the multivariate Cox regression model demonstrated that EBV-positive status, presence of B-symptoms, and chemotherapy alone were independent prognostic determinants of a poor prognosis.

CONCLUSION

Oral PBL is an aggressive neoplasm with low survival rates, which is influenced by the presence of EBV, presence of B-symptoms, and with the use of chemotherapy only.

EBV detection in HIV-related oral plasmablastic lymphoma

OBJECTIVES

Plasmablastic lymphoma (PBL) of the oral cavity is an aggressive neoplasm derived from B cell, considered to be the second more common among human immunodeficiency virus (HIV)-associated malignancies. As Epstein-Barr virus (EBV) infection has been associated with this neoplasm, the aim of the present study was to assess the presence of EBV in 11 cases of oral HIV-related PBL and investigate the controversial issue of the presence of Human herpesvirus-8 (HHV-8) in these tumors.

METHODS

DNA was extracted from nine cases of HIV-associated oral lymphomas, diagnosed as PBL, and genomic material was amplified by polymerase chain reaction to verify the presence of EBV. In situ hybridization (ISH) for EBV was performed in five cases. Immunohistochemical analysis was conducted to confirm previous diagnosis and verify HHV-8 infection.

RESULTS

The 11 cases had diagnosis confirmed by immunohistochemical analysis. Only nine cases presented an adequate amount of DNA for analysis, and EBV was detected in seven of them. The five cases tested for EBV viral infection by ISH showed positive signals. All 11 cases were negative for HHV-8.

CONCLUSION

The presence of EBV in all cases studied favors a direct role of this virus in the development of HIV-related PBL, and this finding could be considered when dealing with HIV patients.

siRNAs against the Epstein Barr virus latency replication factor, EBNA1, inhibit its function and growth of EBV-dependent tumor cells

The Epstein Barr virus (EBV) plays a role in maintenance of the tumor phenotype in a number of human cancers. The EBV latency replication factor, EBNA1, is required for persistence of the EBV episome, is anti-apoptotic, and is universally expressed in all EBV-associated tumors. Here, we show that EBNA1-specific siRNAs can inhibit EBNA1 expression and function. siRNAs were generated against three target sites in the EBNA1 messenger RNA, and two of these were found to inhibit EBNA1 expression from an ectopic EBNA1 expression cassette. EBNA1 siRNAs also inhibit endogenously expressed EBNA1 in EBV-positive epithelial and B-cell lines. Using a mini-EBV replication model, siRNA-mediated inhibition of EBNA1 expression suppressed the episomal maintenance function of EBNA1. Lastly, introduction of an EBNA1 siRNA into an EBV-positive tumor cell line inhibited tumor cell growth/survival. These data suggest that siRNAs against EBNA1 may have therapeutic value in EBV-associated diseases.

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.

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.

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.

Oral plasmablastic lymphoma in previously undiagnosed HIV disease

Non-Hodgkin's lymphoma is the second most common HIV-associated malignancy. This report details a case of the recently described entity plasmablastic lymphoma of the mouth in a patient who was later found to have severe HIV disease. The tumor manifested as a large ulcerated mass of the left maxillary alveolus, causing bony destruction and tooth mobility. Histologic examination of lesional tissue revealed a lymphoid tumor with a high proliferation rate containing lymphoplasmacytoid cells that were reactive to the plasma cell marker VS38c but not to CD20 or CD79a; these are features of the recently reported non-Hodgkin's lymphoma termed plasmablastic lymphoma. This is only the second report of an unusual tumor that has a predilection for the orofacial tissues.

AIDS-related plasmablastic lymphomas of the oral cavity and jaws: a diagnostic dilemma

Acquired immunodeficiency syndrome (AIDS)-related non-Hodgkin's lymphomas are highly pleomorphic in their clinical, pathological, and biological features. Recent investigations have led to the identification of a particular type of AIDS-related non-Hodgkin's lymphomas presenting in the oral cavity and jaws. This novel category of AIDS-related non-Hodgkin's lymphomas derives from B-cells and has been defined as plasmablastic lymphoma on the basis of its morphological and immunophenotypic features. Clinically, AIDS-related plasmablastic lymphoma is generally limited to the oral cavity at the time of diagnosis, although extension to distant sites frequently occurs at a later stage. Histologically, AIDS-related plasmablastic lymphoma is composed of a monomorphic and cohesive pattern of plasmablasts with basophilic cytoplasm. Phenotypically, AIDS-related plasmablastic lymphoma fails to express the most common B-cell-associated surface antigens, whereas it consistently expresses high levels of plasma cell-associated markers, including VS38c and CD138/syndecan-1. For the purpose of differential diagnosis, the morphological and immunophenotypic peculiarities of AIDS-related plasmablastic lymphoma clearly distinguish these lymphomas from other categories of AIDS-related non-Hodgkin's lymphomas, as well as from undifferentiated large cell carcinomas.

Plasmablastic lymphoma: a new subcategory of human immunodeficiency virus-related non-Hodgkin's lymphoma

A patient with human immunodeficiency virus-related non-Hodgkin's lymphoma arising in the oral cavity is reported. The tumour had an unusual immunohistochemical profile that was negative for leucocyte common antigen and the B-cell antigen CD20 but positive for the plasma cell-reactive antibody VS38c. The features of this type of tumour, which has recently been categorized, are presented and 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.

Oral manifestations of HIV disease: an update

More than 40 different oral diseases and conditions have been described in patients infected with human immunodeficiency virus (HIV). The recognition of the oral manifestations of HIV disease is of great significance because they may represent the first signs of the disease and have been shown to be highly predictive markers of severe immune deterioration and disease progression. Although some oral diseases and conditions have a weak association with HIV disease, others are strongly linked with the disorder, and a few are acquired immune deficiency syndrome (AIDS)-defining in nature. The spectrum of oral manifestations of HIV disease is reviewed with emphasis on clinical recognition, diagnosis, and treatment.

HIV-associated oral pleomorphic B-cell malignant lymphoma

A 48-year-old HIV-seropositive homosexual patient presented with an ulcerative lesion in the left side of the soft palate, extensively involving local soft tissue structures. On histologic evaluation the lesions appeared to be a large-cell high-grade B-cell pleomorphic lymphoma with anaplastic and plasmacytoid features harboring Epstein-Barr virus genome in the tumor cells. Although known to be associated with HIV infection, this is a rare subtype of a malignant lymphoma arising in a patient positive for HIV. Its meaning is yet unknown in biologic and prognostic terms.

Epstein-Barr virus: biology and disease

Epstein-Barr virus is a human herpes virus which, whilst found as a widespread asymptomatic infection, is also associated with certain tumours of lymphoid and epithelial origin including Burkitt's lymphoma (BL), immunoblastic lymphoma (IBL), Hodgkin's Disease (HD) and nasopharyngeal carcinoma (NPC). A unique characteristic of EBV is its ability to infect and transform primary resting B lymphocytes in vitro into permanently growing lymphoblastoid cell lines (LCLs); this effect is associated with constitutive expression of a limited set of viral genes. Interestingly, the pattern of EBV gene expression observed in LCLs in vitro is also a feature of IBLs, a tumour associated with immunosuppression. The other EBV associated tumours display a more restricted pattern of EBV latent protein expression. B cell lines can be activated in vitro into the virus replicative cycle, where a large number of viral genes associated with EBV DNA replication and virus assembly are synthesised. Whilst EBV can be detected in throat washings from seropositive individuals, the only in vivo situation where full virus replication can be reliably observed in hairy leukoplakia (HL), a benign lesion of lingual epithelium frequently found in AIDS patients. Thus, the relative contribution of lymphoid cells and epithelial cells to latent EBV infection/persistence vs replication in vivo remains controversial. Recent studies suggest that HL represents a focus of EBV replication in the absence of a truly latent infection and this supports the contention that EBV persistence resides in the lymphoid compartment. These aspects together with the role of EBV in oral diseases and the effect of certain EBV genes on the control of epithelial cell growth and differentiation will be discussed.

Plasmablastic Lymphomas of the Oral Cavity: A New Entity Associated With the Human Immunodeficiency Virus Infection

We report here a series of 16 highly malignant diffuse large B-cell lymphomas of the oral cavity with unique immunohistologic features. Fifteen of these developed in human immunodeficiency virus-positive patients. All cases displayed morphologic features of diffuse large-cell lymphomas but strikingly differed from them in that they showed a minimal or absent expression of the leukocyte common antigen as well as of the B-cell antigen CD20. Instead, the tumor cells showed a constant reaction with the plasma cell characteristic antibody VS38c and a frequent reaction with the CD79a antibody. This, in conjunction with a variable expression of cytoplasmic Ig and a monoclonal rearrangement of the Ig heavy chain gene in all of the three tested cases confirmed the B-cell nature, the clonal origin, and the plasmacellular differentiation of these neoplasms. The majority of these tumors were negative for the BCL-6 protein, with the remaining cases showing only a partial and weak expression of this antigen. An association with the Epstein-Barr virus (EBV) was found in 9 of 15 tested cases showing abundant EBV-encoded nuclear RNA transcripts in the absence of EBNA-2. Five of the EBV-positive cases variably expressed LMP-1. We propose to name these tumors plasmablastic lymphomas, in accordance with their morphologic and immunohistologic features. Knowledge of this lymphoma entity is important to avoid confusion with nonlymphoid malignancies due to the lack of commonly used lymphoid markers.

Cause of oral ulcers in HIV-infected patients: a study of 19 cases

OBJECTIVES

To study the cause and clinical aspects of oral ulcers in HIV-infected patients.

STUDY DESIGN

Forty-one consecutive HIV-positive patients with long-standing oral ulcers were examined; 19 were evaluated by biopsy. From these 19 cases, viral, bacterial, and fungal cultures and biopsies were taken in each patient. When indicated, special microbial stains were undertaken to identify bacteria or fungi. Ten cases without granulomatous bacterial fungal or lymphomatous features were available for in situ hybridization to detect viral DNA of herpes simplex virus 1 and 2, cytomegalovirus, varicella-zoster virus, and Epstein-Barr virus.

RESULTS

Most of the oral ulcers occurred in patients with severe immunodepression. Median CD4 T-lymphocyte count was 60 cell/mm3 (range, 3 to 335). It was ascertained that nine (47%) patients had nonspecific aphthous-like ulcers, and ulcers caused by herpes group viruses were identified in six (31.5%) patients. One (5%) person was diagnosed with non-Hodgkin's lymphoma; and in one (5%) patient, multiple ulcers were an expression of lues maligna. Two ulcers (10.5%) in the palate harbored mycotic granulomatous foci (cryptococcosis, histoplasmosis). In this population, almost all of these ulcers were found to be large, persistent, and painful.

CONCLUSIONS

Nontumefactive oral ulcers in HIV-positive patients may be a source of diagnostic difficulties because of the diverse array of underlying pathologic entities and multiplicity of etiologic agents. Biopsy should always be performed on long-standing ulcers because either infection or a neoplastic process may be extant. In the absence of infection or neoplasm, such lesions are then designated as ulcers not otherwise specified.

Intraoral non-Hodgkin's lymphoma in seven patients with acquired immunodeficiency syndrome

Since the appearance of AIDS, there has been a significant increase in the number of cases of oral non-Hodgkin's lymphoma. Rarely seen in the oral cavity before, non-Hodgkin's lymphoma is now seen with some frequency in HIV-positive patients. Oral HIV-related lymphomas exhibit an aggressive course and can mimic other oral tumors and infections, which makes early recognition and diagnosis important and difficult. We report on the clinical findings in seven homosexual men in whom the oral cavity was the first site in which non-Hodgkin's lymphoma appeared and the only site involved at the time of diagnosis. Treatment consisted of chemotherapy with or without radiation therapy. The relatively short survival in these patients averaged 8 months. All patients died of complications from their tumor.

Morphologic patterns and molecular pathways of AIDS-related head and neck and other systemic lymphomas

Head and neck manifestations of human immunodeficiency virus (HIV) infection include lymph nodal and extranodal localization of non-Hodgkin's lymphoma (NHL). A histopathologic characteristic common to head and neck NHLs and to all the other systemic lymphomas in HIV patients is the frequent occurrence of cases displaying pleomorphic features and some overlap between established histologic subtypes. This article highlights the difficulties in defining HIV-related NHLs correctly, and proposes a specific pathologic categorization of these disorders accounting for their pathogenic aspects as gathered from molecular data.

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.

Intraoral squamous cell carcinoma in human immunodeficiency virus infection. A clinicopathologic study

The purpose of this study was to characterize the clinical and histological features of intraoral squamous cell carcinoma in men who were seropositive for the human immunodeficiency virus and to evaluate viral cofactors (human papillomavirus, herpes simplex virus, Epstein-Barr virus), proliferative index (proliferating cell nuclear antigen), a factor associated with invasion (cathepsin D), and mutated tumor suppressor gene and proto-oncogene products (mutated p53, c-erbB-2). Four men who were seropositive for the human immunodeficiency virus and had acquired immunodeficiency syndrome presented with painful oral lesions of variable duration. Oral cancer risk factors included heavy tobacco use (four of four), heavy alcohol use (three of four), and previous radiotherapy (one of four). The lesions consisted of ulcers (two of four), a fungating mass (one of four), and papillary erythroplakia (one of four). Incisional biopsy specimens were obtained. High-stringency in situ hybridization was performed with DNA probes to the human papillomavirus (types 6/11; 16/18; 31/33/35) and Epstein-Barr virus: Immunocytochemical studies for the herpes simplex virus, proliferating cell nuclear antigen, cathepsin D, mutated p53, and c-erbB-2 were performed. Two lesions were moderately differentiated squamous cell carcinoma, one lesion was a basaloid squamous cell carcinoma, and one was carcinoma in situ. Stage of disease at diagnosis was II (one of four), III (two of four), and IV (one of four). Three cases were positive for the human papillomavirus, one case was positive for Epstein-Barr virus, and three cases were positive for the herpes simplex virus. C-erbB-2 was focally positive in one case, and mutated p53 was positive in a separate case.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV-related tumors of the oral cavity

In HIV-infected patients with AIDS the most frequent malignancies are Kaposi's sarcoma and non-Hodgkin's lymphoma. In these patients, the natural history of these tumors is quite different from those of HIV-negative subjects. These tumors may present atypical clinical aspects, may be very aggressive, and the coexistence of immunosuppression and opportunistic infections may render their treatment more difficult. The aim of this article is to provide updated information on the epidemiology, pathogenesis, natural history, and management of tumors that develop in the oral cavity of patients with AIDS.

Unusual clinical aspects of oral non-Hodgkin lymphomas in patients with HIV infection

Patients with HIV infection are at greater risk of developing malignancies. We report two HIV-seropositive patients with primary oral manifestation of a B-cell non-Hodgkin lymphoma (NHL). Localisations of tumours were the palate, with an unusual bifocal origin, and the tongue which is rarely the primary site of NHL. Ulcerations and extensive tissue necrosis were observed. Histologically both cases were high grade malignant lymphomas, immunoblastic. Epstein-Barr virus DNA was detected with in situ hybridisation in 1 patient.

Oral manifestations in HIV-infected patients: diagnosis and management

Oral lesions have been observed since the beginning of the AIDS epidemic. The number of HIV-infected patients is still increasing, especially in the heterosexual population. Oral diseases in HIV-infected patients are often more difficult to diagnose because the clinical presentations may differ from the same diseases in HIV-negative patients. HIV-associated oral lesions have diagnostic, prognostic, and therapeutic impact. Approximately 10% of the HIV-infected population will have oral manifestations as a first sign of their disease. In HIV-infected men oral hairy leukoplakia and oral candidiasis are useful markers for disease progression. This article summarizes the oral manifestations and the management of oral health in persons with HIV infection.

Intraoral presentation of anaplastic large-cell Ki-1 lymphoma in association with HIV infection

Persons infected with human immunodeficiency virus have an increased risk for development of high-grade, non-Hodgkin's lymphomas. Anaplastic large-cell Ki-1 lymphoma is a recently described lymphoid neoplasm characterized by cellular pleomorphism, a sinusoidal growth pattern, and Ki-1 epitope reactivity. This type of lymphoma is often mistaken for metastatic carcinoma, melanoma, or malignant histiocytosis. Although persons with acquired immunodeficiency syndrome frequently have non-Hodgkin's lymphoma at extranodal sites, the oral cavity and mandible, in particular, are unusual locations. We report two cases of anaplastic large-cell Ki-1 lymphoma that occurred in persons with the human immunodeficiency virus and with initial presentation as soft tissue masses of the posterior mandible. Immunocytochemical studies were positive for Ki-1 (CD30) in both cases. In situ hybridization for Epstein-Barr virus-deoxyribonucleic acid was positive with tumor cells in both cases. Flow cytometry on paraffin, formalin-fixed tissue revealed tetraploidy and high proliferative fractions that are characteristic of high-grade lymphomas. Intraoral presentation of rapidly enlarging, soft tissue masses may represent a high-grade non-Hodgkin's lymphoma in persons with the human immunodeficiency virus. Although rare, anaplastic large-cell Ki-1 lymphoma should be considered and requires immunocytochemical study to eliminate the possibility of other malignant conditions associated with the acquired immunodeficiency syndrome.

T-cell lymphoma associated with periodontal disease and HIV infection. A case report

A case is described of gingival non-Hodgkins lymphoma presenting in a site previously diagnosed as HIV-periodontitis. The lymphoma presented along with other signs of HIV infection and AIDS, which taken together were compatible with increased immunosuppression and reactivation of Epstein-Barr virus. The implications of these findings are discussed, and it is suggested that areas of gingiva which show rapid localised recession, associated with HIV seropositivity, should be monitored closely and considered for biopsy if abnormal signs are detected.

Oral findings in Mexican AIDS patients with cancer

Oral findings of 42 Mexican AIDS patients with cancer were reviewed. Kaposi's sarcoma (KS) was the most frequent malignancy (81%) followed by non-Hodgkin's lymphoma (NHL) (12%). All cases of NHL were of high or intermediate grade and most of them were extranodal. Out of the 34 individuals with KS, 22 (65%) showed oral KS and in 21 of them the palate was involved. The clinical features of oral KS including site, appearance and size are described. Pseudomembranous candidosis (PC), hairy leukoplakia (HL) and exfoliative cheilitis (ECh) were also found in these patients. There was no association of these lesions with any type of cancer. A strong association of oral candidosis and history of this infection was found, RR = 7.0 (1.3-4.1). There was evidence of severe immunosuppression in most patients, with mean average CD4 counts of 116 mm3 (range 4-841/mm3). Oral KS, ECh, PC and HL were more common in patients with lower CD4 counts. Our findings illustrate the most frequent oral lesions associated with HIV-1 infection in patients with AIDS and cancer, and further support the importance of oral examination in HIV infected patients.

Head and neck manifestations during HIV infection

The ENT manifestations of HIV infection are well known and the findings in AIDS patients have been described, nevertheless there are no reports of the frequency of head and neck involvement during the various stages of the disease. From 1987 to 1991, 210 HIV positive patients had ENT evaluation without symptoms-related selection. The majority of them were men and intravenous drug users. The frequency of enlarged neck nodes, neck mass, nasopharyngeal lymphatic tissue hypertrophy, extranodal localization of non-Hodgkin's lymphomas, Kaposi's sarcoma, oral hairy leukoplakia, candidiasis and other less common findings is reported, in relation to the stage of the disease. Overall 84 per cent of the observed patients had head and neck manifestations. An ENT evaluation in every HIV infected patient is suggested.

Epstein-Barr virus DNA detection in gingival tissues of patients undergoing surgical extractions

The main oral manifestation of Epstein-Barr virus (EBV) infection is hairy leukoplakia, a lesion associated with the acquired immunodeficiency syndrome (AIDS) and occasionally in other immunocompromised patients. However, the recent literature describes the presence of viral genome in clinically normal oral tissues. The purpose of this work was to investigate these occult EBV infections in gingival epithelium. The Southern blot method with 32P-radiolabelled DNA probes under stringent conditions was applied to 20 interproximal gingival papillae specimens and revealed homologous EBV sequences in 4 of 10 AIDS patients as well as in 4 of 10 HIV negative patients. In order to determine whether EBV has a predilection for the gingival tissues, samples of nasal, laryngeal and oral mucosa, other than gingival mucosa, were collected from 10 HIV-negative patients undergoing surgical treatment for a variety of clinical conditions. None of these extra-periodontal mucosal specimens contained homologous EBV DNAs, except an edentulous palatal gingival specimen. With the present detection of EBV DNAs in the gingival tissues of patients undergoing surgical extractions, it would be of interest to investigate more systematically these subclinical infections in order to determine their exact implications in oral disease.

Neoplastic disease in the head and neck of patients with AIDS

Immunosuppression increases the risk of developing malignancies. In immunosuppression due to human immunodeficiency virus (HIV) disease the common head and neck tumors are Kaposi's sarcoma and non-Hodgkin's lymphoma. Squamous cell carcinoma has also been reported. Kaposi's sarcoma is the commonest neoplastic disease in AIDS. The incidence of lymphoma is rapidly increasing. This article reviews the incidence, clinical presentation and management of these diseases in the head and neck in AIDS patients.

Simultaneous assay of adenosine deaminase and purine nucleoside phosphorylase activity as possible biochemical means to detect non-Hodgkin lymphomas of the oral cavity

BACKGROUND AND METHODS

This study proposes the usefulness of simultaneous assay of adenosine deaminase (enzyme code [EC] 3.5.4.4; ADA) and purine nucleoside phosphorylase (EC 2.4.2.1; PNP) activities in a biopsy specimen as a biochemical test adjunctive to the histologic diagnosis of oral non-Hodgkin lymphomas (NHL).

RESULTS

NHL tissues showed an ADA activity of more than 1428 nmol/h/mg of protein, and more than 3451 nmol/h/mg of protein was the sum of ADA and PNP activity. In contrast to this finding, all the 106 lesional tissues affected by various carcinomas, various benign tumors, various cysts, ameloblastomas, osteosarcomas, gingival hyperplasia, and inflammation showed an ADA activity of less than 1000 nmol/h/mg of protein, except for 2. The sum of ADA and PNP activity was less than 2249 nmol/h/mg of protein in these diseases, except for squamous carcinoma. Different control tissues of the oral cavity showed less than 766 nmol/h/mg of protein in ADA activity, and the highest sum of ADA and PNP activity in these was only 1384 nmol/h/mg of protein.

CONCLUSIONS

These findings suggest that a strong suspicion of oral NHL is justified when the sum of ADA and PNP activity in a biopsy specimen exceeds 3000 nmol/h/mg of protein and ADA activity is greater than 1000 nmol/h/mg of protein.

Hodgkin's disease involving the gingiva in AIDS

Non-Hodgkin lymphomas are a recognised complication of AIDS and may involve the oral cavity. However, no case of Hodgkin's disease affecting the oral cavity in AIDS appears to have been recorded. We report a male homosexual with AIDS and Hodgkin's lymphoma, who presented with gingival involvement.

Epstein-Barr virus (EBV) genomes and c-myc oncogene in oral Burkitt's lymphomas

In addition to Burkitt's lymphomas, tentative evidence suggests the involvement of Epstein-Barr virus (EBV) in malignant lymphomas of T-cell origin. The c-myc proto-oncogene is strongly associated with the development of lymphoid neoplasias. In the present study, a series of 38 biopsies of oral lymphomas (29 Burkitt's lymphomas, 9 malignant lymphomas of other type) obtained from patients in Tanzania were studied using in situ hybridization (ISH) and polymerase chain reaction (PCR) for detection of EBV DNA and c-myc oncogene. In ISH applied on formalin-fixed, paraffin wax-embedded biopsies, the Bam HI W fragment of EBV DNA was used as the probe. Amplification of c-myc oncogene was studied by PCR with a primer set from Exon II area. As an internal standard beta-globin gene was simultaneously amplified. EBV DNA was disclosed by ISH in five Burkitt's lymphomas only. Using the PCR, 20 of the 29 cases (70%) of Burkitt's lymphomas showed amplification for EBV DNA. Of the other EBV-positive lymphomas, two were of the lymphocytic type (large non-cleaved cell), one histiocytic and one Burkitt's-like lymphoma. All EBV-positive cases found on the agarose gel were positive also with the dot blot, when hybridized with the 32P-labeled EBV Bam HI W-fragment probe. All lymphomas showed similar bands on the gel for c-myc and beta-globin indicating that no amplification of c-myc was present.

Unusual oral presentation of non-Hodgkin's lymphoma in association with HIV infection

In 4.4% of human immunodeficiency virus-associated non-Hodgkin's lymphoma the presenting lesion is seen in the mouth. Often the lesion may clinically resemble a less sinister process, and a definitive diagnosis of lymphoma may be delayed. We describe three unusual cases of non-Hodgkin's lymphoma, appearing intraorally in association with other oral lesions, in HIV-positive homosexual men. The three patients reported here were all diagnosed as having diffuse, large-cell malignant non-Hodgkin's lymphoma. We performed Epstein-Barr virus DNA in-situ hybridization on our cases and Epstein-Barr virus DNA sequences were not seen. We review the pertinent literature and stress the importance of including non-Hodgkin's lymphoma in the differential diagnosis of oral lesions in patients at risk of HIV infection.

Head and neck malignancies associated with HIV infection

Immunosuppressed persons are at greater risk of developing malignancies. In human immunodeficiency virus (HIV) immunosuppression the most common oral cancers are Kaposi's sarcoma and non-Hodgkin's lymphoma. Squamous cell carcinoma has also been reported to be associated with HIV disease. Kaposi's sarcoma is the most frequent neoplastic disease in acquired immunodeficiency syndrome and is by far the most common in the head and neck area. This article reviews the prevalence, clinical features, and management of these diseases in HIV infection.

Viral infections of the head and neck among HIV-seropositive patients

Many viruses cause opportunistic infections in HIV-positive patients. Those that cause oral lesions include herpes simplex, varicella zoster, Epstein-Barr virus, cytomegalovirus, and papillomavirus. Importantly, many of the herpes-group viruses are able to augment immunosuppression and some actually transactivate HIV replication-inducing genetic sequences. This article reviews the role of viral agents in the activation of HIV replication and details the features of the reported oral lesions that represent viral opportunistic infections.

Non-Hodgkin's lymphomas in patients with human immunodeficiency virus infection. Presence of Epstein-Barr virus by in situ hybridization, clinical presentation, and follow-up

The authors studied all patients with serologic evidence of human immunodeficiency virus (HIV) infection and malignant non-Hodgkin's lymphoma (NHL) that presented at a single hospital from 1982 to 1989. Sixteen patients were identified, all white homosexual men with a mean age of 38.2 years. Lymphoma was the initial presentation of HIV infection in 37.5%. Sixty-two percent of the cases had a high-grade NHL, 31% had intermediate-grade, and 6% (one patient) had a low-grade lymphoplasmacytoid lymphoma. Extranodal involvement was present in 43.7%, with the gastrointestinal tract and liver being the most common sites. Actuarial survival was increased by treatment with methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B). Colorimetric in situ hybridization identified Epstein-Barr virus (EBV) in nine of the 14 cases hybridized. A statistically significant association of EBV with diffuse small noncleaved type (i.e., Burkitt's-like) (six of six) compared with other morphologic types (three of eight) was found (P = 0.025).

Viruses and chronic disorders involving the human oral mucosa

Viruses have been implicated in the etiology of several chronic disorders of the oral mucosa. Most of these associations have been with DNA viruses, particularly certain herpesviruses, which are associated, for example, with some cases of erythema multiforme and with hairy leukoplakia. Papillomaviruses are associated with various papillomatous lesions, focal epithelial hyperplasia, and possibly with some carcinomas. Viruses may possibly be associated with recurrent aphthae, Behçet's syndrome, and some dermatoses. The literature concerning these possible associations is reviewed. However, much more research needs to be done before the full story of viral associations with oral mucosal disorders can be written.

Lymphoma of the maxillary sinus in a patient infected with human immunodeficiency virus type 1

A 27-year-old woman with a history of intravenous drug abuse presented with a stage IE, diffuse, large cell lymphoma of the right maxillary sinus. A test for antibodies to the human immunodeficiency virus was positive. The patient was treated with systemic chemotherapy and local maxillary sinus irradiation which resulted in complete regression of the disease. Therapy was complicated by mucositis, neutropenia, and opportunistic infections. This is the first case report to discuss the presentation and treatment of acquired immunodeficiency syndrome (AIDS)-related lymphoma of the maxillary sinus.

Non-Hodgkin's lymphoma presenting at the site of a recent dental extraction: a report of two cases

Two cases of non-Hodgkin's lymphoma (NHL) are reported. The lesions presented as swellings at the site of recent dental extractions. The natural history of the lymphomas in these two patients was markedly contrasted, demonstrating the heterogeneity of NHL. The importance of establishing an early diagnosis and treatment of such lesions is stressed.

Oral manifestations of HIV infection and their management. II. Less common lesions

This second of two articles reviews the many uncommon and rare oral lesions that have arisen in persons infected with human immunodeficiency virus (HIV). The various drug-related oral disorders of HIV disease are also considered.

AIDS-related lymphoma of the oral cavity

Six new cases of non-Hodgkin's lymphoma (NHL), primarily located in the oral cavity, in patients infected by the human immunodeficiency virus (HIV), are presented. They all had a voluminous fungous tumoral mass, that extended from the gingiva to the buccal vestibule or palate. All were intravenous drug abusers. The diagnosis of AIDS was known in one patient, 2 patients presented with AIDS-related complex symptomatology, and in 3 cases NHL was the first manifestation of the HIV infection. All presented advanced stages (IV). Histologically, all were considered high grade NHL. It is recommended to determine the HIV status in all young patients affected with oral NHL. All intraoral lesions in AIDS patients or in patients that belong to a risk group should have a biopsy to rule out NHL or any other manifestations of AIDS.