Hematolymphoid Tumors of the Oral Cavity

Non-Hodgkin lymphoma (NHL) is the second most common malignancy to arise in the oral cavity after squamous cell carcinoma, yet only accounts for 3.5% of all oral cavity malignancies. Among all lymphomas, oral cavity NHLs are rare, representing approximately 2% of all extranodal lymphomas. Most patients are older although immunosuppressed patients may be of a younger age. Patients often have presenting symptoms clinically of a discrete mass, sometimes ulcerated, with loosening of teeth, and pain, dysesthesia, or paresthesia. The most commonly affected sites are the palatal mucosa, gingiva, tongue, buccal mucosa, and floor of mouth; many cases (almost half in some studies) exhibit underlying bone involvement ( Fig. 18.1 ). Diffuse large B-cell lymphoma is the most common subtype with frequencies ranging from 50% to 68%. Immunosuppressed patients, particularly patients with HIV infection, often develop a distinctive type of this lymphoma known as plasmablastic lymphoma, which was first described in the oral cavity. The majority of other oral cavity NHLs fall into the category of mature B-cell NHLs such as follicular lymphoma and marginal zone lymphoma; T-cell NHLs are infrequent and only extranodal NK/T-cell lymphoma, nasal type will be discussed briefly. In certain geographic locations, Burkitt lymphoma shows a predilection for facial structures, including the jaw.

FIG 18.1
(A) Lymphoma of the palatal mucosa presenting as a diffuse swelling. (B) Lymphoma of the right mandible presenting as a poorly demarcated radiolucency extending from the left mandibular canine to the right molars; a nonhealing socket developed after extraction of the loose right first molar.

The term “plasma cell neoplasm” refers to clonal expansions of malignant plasma cells and includes diseases primarily affecting the bone marrow such as multiple myeloma, solitary plasmacytoma in bone, or plasmacytoma arising in extramedullary sites, which may or may not subsequently develop into systemic multiple myeloma. Approximately 14% of patients with multiple myeloma have an oral manifestation. The head and neck region is the most common site of involvement of extramedullary plasmacytomas, including oral cavity lesions.

Finally, acute myeloid leukemia may infrequently manifest as diffuse gingival infiltrates of blasts or discrete tumor masses within the oral cavity. This may be the presenting manifestation of the leukemia, may occur during the course of disease or at relapse, or may represent the first sign of transformation from an underlying myelodysplastic or myeloproliferative neoplasm. This phenomenon is most commonly associated with acute myeloid leukemia exhibiting monocytic or myelomonocyticdifferentiation.

Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) comprises 30% to 40% of adult NHL in Western countries and a higher percentage in developing countries. Up to 40% of DLBCLs present in extranodal sites, and it is the most common type of oral cavity NHL. It usually represents a de novo process but can transform from an underlying low-grade lymphoma. Gene expression profiling has identified two distinct molecular subtypes termed germinal center B-cell (GCB) and activated B-cell (ABC) types with different prognoses. Many of the oral DLBCLs tend to be the non-GCB type.

Clinical Findings

  • This occurs in the sixth and seventh decades, but may also be seen in younger adults.

  • Lesions present as an enlarging painless mass, frequently occur on the palatal mucosa, and may be ulcerated and painful.

  • B symptoms (fever, weight loss, and night sweats) are uncommon.

Histopathologic Features

  • There is a diffuse proliferation of large lymphoid cells effacing underlying tissue architecture; multiple morphologic variants may be seen, including centroblastic (large cells with moderate amounts of cytoplasm, and large, open nuclei with multiple peripheral nucleoli), immunoblastic (large cells with abundant amphophilic cytoplasm, and large nuclei with large central nucleoli), and anaplastic; areas of frank necrosis may be present ( Fig. 18.2A–B ).

    FIG 18.2
    Diffuse large B-cell lymphoma (DLBCL). (A) The infiltrate exhibits a diffuse pattern of growth with effacement of underlying tissue architecture. (B) Higher magnification reveals that the tumor cells are large in size with round nuclei and variably distinct nucleoli. (C) The lymphoid cells are shown to be of B-cell origin by diffuse reactivity for CD20. (D) BCL6 may be strongly positive in tumor cell nuclei, as in this case. (E) The Ki67 proliferation index is variable among different cases of DLBCL; in this example, approximately 40% of tumor cell nuclei are reactive.
  • Lesional cells express B-cell markers CD19, CD20, and PAX5 ( Fig. 18.2C ); monotypic surface immunoglobulin light chain expression may be detected by flow cytometry.

  • The expression of CD10, BCL6, and MUM1 varies depending on subtype (GCB versus ABC) ( Fig. 18.2D ); several immunohistochemistry-based algorithms have been developed as a tool for assigning subtype.

  • In situ hybridization for Epstein-Barr virus (EBV)–encoded RNA (EBER) may be positive in some cases, particularly in older patients; however, EBER reactivity is not common and should prompt evaluation for lesions outlined in the Differential Diagnosis section later.

  • The proliferation index is variable and may be moderate to as high as 90% ( Fig. 18.2E ).

Differential Diagnosis

  • Burkitt lymphoma: There is a monotonous infiltrate of intermediate-sized B cells in a background of numerous macrophages containing cytoplasmic particles of cellular debris (“tingible-body macrophages”), which imparts a moth-eaten appearance at low-power known as a “starry-sky” pattern; cells express CD10 and lack BCL2; the proliferation index is greater than 95%; endemic cases in particular may show reactivity for EBER; MYC translocation is detected (typically t(8;14)(q24;q32)) without concurrent BCL2 or BCL6 translocation.

  • Plasmablastic lymphoma: Cells are uniformly positive for CD138 and EBER and negative for CD20; oral lesions are most commonly seen in the setting of immunosuppression such as HIV/AIDS.

  • EBV-positive mucocutaneous ulcer: This ulcer contains cells that exhibit Hodgkin-like features in a polymorphous inflammatory background with strong expression of CD30 and EBER, and weak expression of CD20; it typically occurs in older patients, is self-limited, and runs an indolent course (see Chapter 4 ).

  • Myeloid sarcoma (acute myeloid leukemia): Given the morphologic overlap between the two entities, immunophenotyping is essential to confirm the B-cell origin of the infiltrate.

  • Extranodal NK/T-cell lymphoma, nasal type: This lymphoma tends to occur in those living in East Asia and South and Central America; a presenting symptom is an ulcerated, necrotic mass in the nasal and nasopharyngeal mucosa, and oral sites include Waldeyer ring and the palatal mucosa presenting as midline destructive disease; there is an infiltrate of large, irregular lymphoid cells with angiodestruction and abundant necrosis/apoptosis, and there is a high proliferation index; cells are typically positive for CD3 in a cytoplasmic pattern (but negative for surface CD3 by flow cytometry), CD2, CD56, and EBER, and negative for T-cell antigens CD5, CD4, and CD8; cells are also often positive for granzyme B and/or TIA-1.

Management and Prognosis

  • High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements: Cases falling into this category are also known as “double-” or “triple-hit” lymphomas because they show a MYC rearrangement as well as BCL2 and/or BCL6 rearrangements. Cases that morphologically resemble DLBCL but show these genetic changes are placed into this category.

  • DLBCLs are aggressive but potentially curable with multiagent chemotherapy.

  • Multivariable analysis of patients with oral and maxillofacial DLBCL show age, clinical stage, and performance status to be significant prognostic factors.

References

  • Alizadeh AA, Eisen MB, Davis RE, et. al.: Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling. Nature 2000; 403: pp. 503-511.
  • Bhattacharyya I, Chehal HK, Cohen DM, Al-Quran SZ: Primary diffuse large B-cell lymphoma of the oral cavity: Germinal center classification. Head Neck Pathol 2010; 4: pp. 181-191.
  • Dojcinov SD, Venkataraman G, Pittaluga S, et. al.: Age-related EBV-associated lymphoproliferative disorders in the western population: A spectrum of reactive lymphoid hyperplasia and lymphoma. Blood 2011; 117: pp. 4726-4735.
  • Dojcinov SD, Venkataraman G, Raffeld M, et. al.: EBV positive mucocutaneous ulcer–a study of 26 cases associated with various sources of immunosuppression. Am J Surg Pathol 2010; 34: pp. 405-417.
  • Freeman C, Berg JW, Cutler SJ: Occurrence and prognosis of extranodal lymphomas. Cancer 1972; 29: pp. 252-260.
  • Friedberg JW: Double-hit diffuse large B-cell lymphoma. J Clin Oncol 2012; 30: pp. 3439-3443.
  • Guevara-Canales JO, Morales-Vadillo R, Cava-Vergiu CE, et. al.: Survival in patients with oral and maxillofacial diffuse large B-cell lymphoma. Braz Oral Res 2013; 27: pp. 349-355.
  • Guevara-Canales JO, Morales-Vadillo R, Sacsaquispe-Contreras SJ, et. al.: Malignant lymphoma of the oral cavity and the maxillofacial region: overall survival prognostic factors. Med Oral Patol Oral Cir Bucal 2013; 18: pp. e619-e626.
  • Hans CP, Weisenburger DD, Greiner TC, et. al.: Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray. Blood 2004; 103: pp. 275-282.
  • Kolokotronis A, Konstantinou N, Christakis I, et. al.: Localized B-cell non-Hodgkin’s lymphoma of oral cavity and maxillofacial region: a clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: pp. 303-310.
  • Owosho AA, Bilodeau EA, Surti U, Craig FE: Large B-cell lymphoma of the base of the tongue and oral cavity: A practical approach to identifying prognostically important subtypes. Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 118: pp. 338-347.
  • Sehn LH, Gascoyne RD: Diffuse large B-cell lymphoma: Optimizing outcome in the context of clinical and biologic heterogeneity. Blood 2015; 125: pp. 22-32.
  • Clinical Findings

    • This occurs in the sixth and seventh decades, but may also be seen in younger adults.

    • Lesions present as an enlarging painless mass, frequently occur on the palatal mucosa, and may be ulcerated and painful.

    • B symptoms (fever, weight loss, and night sweats) are uncommon.

    Histopathologic Features

    • There is a diffuse proliferation of large lymphoid cells effacing underlying tissue architecture; multiple morphologic variants may be seen, including centroblastic (large cells with moderate amounts of cytoplasm, and large, open nuclei with multiple peripheral nucleoli), immunoblastic (large cells with abundant amphophilic cytoplasm, and large nuclei with large central nucleoli), and anaplastic; areas of frank necrosis may be present ( Fig. 18.2A–B ).

      FIG 18.2
      Diffuse large B-cell lymphoma (DLBCL). (A) The infiltrate exhibits a diffuse pattern of growth with effacement of underlying tissue architecture. (B) Higher magnification reveals that the tumor cells are large in size with round nuclei and variably distinct nucleoli. (C) The lymphoid cells are shown to be of B-cell origin by diffuse reactivity for CD20. (D) BCL6 may be strongly positive in tumor cell nuclei, as in this case. (E) The Ki67 proliferation index is variable among different cases of DLBCL; in this example, approximately 40% of tumor cell nuclei are reactive.
    • Lesional cells express B-cell markers CD19, CD20, and PAX5 ( Fig. 18.2C ); monotypic surface immunoglobulin light chain expression may be detected by flow cytometry.

    • The expression of CD10, BCL6, and MUM1 varies depending on subtype (GCB versus ABC) ( Fig. 18.2D ); several immunohistochemistry-based algorithms have been developed as a tool for assigning subtype.

    • In situ hybridization for Epstein-Barr virus (EBV)–encoded RNA (EBER) may be positive in some cases, particularly in older patients; however, EBER reactivity is not common and should prompt evaluation for lesions outlined in the Differential Diagnosis section later.

    • The proliferation index is variable and may be moderate to as high as 90% ( Fig. 18.2E ).

    Differential Diagnosis

    • Burkitt lymphoma: There is a monotonous infiltrate of intermediate-sized B cells in a background of numerous macrophages containing cytoplasmic particles of cellular debris (“tingible-body macrophages”), which imparts a moth-eaten appearance at low-power known as a “starry-sky” pattern; cells express CD10 and lack BCL2; the proliferation index is greater than 95%; endemic cases in particular may show reactivity for EBER; MYC translocation is detected (typically t(8;14)(q24;q32)) without concurrent BCL2 or BCL6 translocation.

    • Plasmablastic lymphoma: Cells are uniformly positive for CD138 and EBER and negative for CD20; oral lesions are most commonly seen in the setting of immunosuppression such as HIV/AIDS.

    • EBV-positive mucocutaneous ulcer: This ulcer contains cells that exhibit Hodgkin-like features in a polymorphous inflammatory background with strong expression of CD30 and EBER, and weak expression of CD20; it typically occurs in older patients, is self-limited, and runs an indolent course (see Chapter 4 ).

    • Myeloid sarcoma (acute myeloid leukemia): Given the morphologic overlap between the two entities, immunophenotyping is essential to confirm the B-cell origin of the infiltrate.

    • Extranodal NK/T-cell lymphoma, nasal type: This lymphoma tends to occur in those living in East Asia and South and Central America; a presenting symptom is an ulcerated, necrotic mass in the nasal and nasopharyngeal mucosa, and oral sites include Waldeyer ring and the palatal mucosa presenting as midline destructive disease; there is an infiltrate of large, irregular lymphoid cells with angiodestruction and abundant necrosis/apoptosis, and there is a high proliferation index; cells are typically positive for CD3 in a cytoplasmic pattern (but negative for surface CD3 by flow cytometry), CD2, CD56, and EBER, and negative for T-cell antigens CD5, CD4, and CD8; cells are also often positive for granzyme B and/or TIA-1.

    Management and Prognosis

    • High-grade B-cell lymphoma, with MYC and BCL2 and/or BCL6 rearrangements: Cases falling into this category are also known as “double-” or “triple-hit” lymphomas because they show a MYC rearrangement as well as BCL2 and/or BCL6 rearrangements. Cases that morphologically resemble DLBCL but show these genetic changes are placed into this category.

    • DLBCLs are aggressive but potentially curable with multiagent chemotherapy.

    • Multivariable analysis of patients with oral and maxillofacial DLBCL show age, clinical stage, and performance status to be significant prognostic factors.

    References

  • Alizadeh AA, Eisen MB, Davis RE, et. al.: Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling.Nature 2000; 403: pp. 503-511.
  • Bhattacharyya I, Chehal HK, Cohen DM, Al-Quran SZ: Primary diffuse large B-cell lymphoma of the oral cavity: Germinal center classification.Head Neck Pathol 2010; 4: pp. 181-191.
  • Dojcinov SD, Venkataraman G, Pittaluga S, et. al.: Age-related EBV-associated lymphoproliferative disorders in the western population: A spectrum of reactive lymphoid hyperplasia and lymphoma.Blood 2011; 117: pp. 4726-4735.
  • Dojcinov SD, Venkataraman G, Raffeld M, et. al.: EBV positive mucocutaneous ulcer–a study of 26 cases associated with various sources of immunosuppression.Am J Surg Pathol 2010; 34: pp. 405-417.
  • Freeman C, Berg JW, Cutler SJ: Occurrence and prognosis of extranodal lymphomas.Cancer 1972; 29: pp. 252-260.
  • Friedberg JW: Double-hit diffuse large B-cell lymphoma.J Clin Oncol 2012; 30: pp. 3439-3443.
  • Guevara-Canales JO, Morales-Vadillo R, Cava-Vergiu CE, et. al.: Survival in patients with oral and maxillofacial diffuse large B-cell lymphoma.Braz Oral Res 2013; 27: pp. 349-355.
  • Guevara-Canales JO, Morales-Vadillo R, Sacsaquispe-Contreras SJ, et. al.: Malignant lymphoma of the oral cavity and the maxillofacial region: overall survival prognostic factors.Med Oral Patol Oral Cir Bucal 2013; 18: pp. e619-e626.
  • Hans CP, Weisenburger DD, Greiner TC, et. al.: Confirmation of the molecular classification of diffuse large B-cell lymphoma by immunohistochemistry using a tissue microarray.Blood 2004; 103: pp. 275-282.
  • Kolokotronis A, Konstantinou N, Christakis I, et. al.: Localized B-cell non-Hodgkin’s lymphoma of oral cavity and maxillofacial region: a clinical study.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: pp. 303-310.
  • Owosho AA, Bilodeau EA, Surti U, Craig FE: Large B-cell lymphoma of the base of the tongue and oral cavity: A practical approach to identifying prognostically important subtypes.Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 118: pp. 338-347.
  • Sehn LH, Gascoyne RD: Diffuse large B-cell lymphoma: Optimizing outcome in the context of clinical and biologic heterogeneity.Blood 2015; 125: pp. 22-32.
  • Plasmablastic Lymphoma

    Plasmablastic lymphoma (PBL) is an aggressive variant of DLBCL originally described in the HIV-positive population. In initial reports, the majority of the patients presented with oral lesions. Subsequent reports have demonstrated that PBL can also rarely occur in the HIV-negative population, most commonly in the setting of immunosuppression such as posttransplantation. In the HIV-negative setting, PBL frequently arises in an extraoral location.

    Clinical Findings

    • PBL involving the oral cavity typically presents as a lesion of the gingiva or palatal mucosa, similar to other oral lymphomas; secondary bony involvement is uncommon.

    • Approximately 50% of patients present with advanced stage disease, although only a third demonstrate bone marrow involvement.

    • The presence of B symptoms is variable.

    Histopathologic Features

    • There is a diffuse proliferation of large lymphoid cells with variable appearance; some show typical immunoblastic features with prominent central nucleoli, whereas others resemble mature plasma cells or exhibit plasmablastic features (namely vesicular chromatin, prominent nucleoli, and eccentrically placed nuclei) ( Figs. 18.3A–C ); there is a background of numerous apoptotic bodies and tingible-body macrophages.

      FIG 18.3
      Plasmablastic lymphoma (PBL). (A) Low-power view shows diffuse infiltration with near-complete destruction of the underlying tissue. (B) Some cases of PBL show plasmacytic features including eccentrically placed nuclei, variably prominent nucleoli, and abundant cytoplasm. Frequent mitotic figures are seen in this highly proliferative tumor. (C) Other cases of PBL do not show plasmacytic features but instead consist of diffuse sheets of large-sized cells with irregular nuclei, distinct nucleoli, and a high nuclear : cytoplasmic ratio. (D) EBER in situ hybridization is positive in most cases of HIV-associated PBL.
    • Lesional cells express plasma cell markers including CD138, CD38, and MUM1; CD30 and EMA are frequently positive; cells are mostly negative for, or show weak expression of, CD45 and B-cell markers such as CD20 and PAX5; monotypic cytoplasmic immunoglobulin light chain is detected in 50% to 70% of cases; Ki67 proliferation index is usually very high (>90%); HHV8 and BCL6 are negative.

    • EBER is positive in almost all of the HIV-associated oral lesions, and in approximately 50% of the lesions occurring in the HIV-negative setting ( Fig. 18.3D ).

    • CD56 expression is more common in cases associated with HIV than in HIV-negative cases.

    Differential Diagnosis

    • Anaplastic (plasmablastic) plasmacytoma: Correlation with clinical findings is essential; EBER-positivity favors PBL, although rare cases of EBV-positive plasmacytoma in immunocompetent patients have been reported.

    • Burkitt lymphoma: Shared features include EBER-positivity, high proliferation index, and tingible-body macrophages; unlike PBL, BL cells are intermediate in size without plasmacytoid features and are strongly positive for CD45, CD20, and BCL6.

    • Diffuse large B-cell lymphoma: Unlike PBL, DLBCL will show strong expression of CD45 and CD20 and typically a lower proliferation index.

    Management and Prognosis

    • Most are treated with multiagent chemotherapy, but PBL is an aggressive tumor and many patients die within the first year.

    • In one study, univariate analysis showed older age (60 years or older), advanced stage/bone marrow involvement, high Ki67 proliferation index (>80%), and HIV-negative status were associated with worse overall survival.

    References

  • Boy SC, van Heerden MB, Raubenheimer EJ, van Heerden WF: Plasmablastic lymphomas with light chain restriction – plasmablastic extramedullary plasmacytomas?.J Oral Pathol Med 2010; 39: pp. 435-439.
  • Castillo JJ, Winer ES, Stachurski D, et. al.: Clinical and pathological differences between human immunodeficiency virus-positive and human immunodeficiency virus-negative patients with plasmablastic lymphoma.Leuk Lymphoma 2010; 51: pp. 2047-2053.
  • Castillo J, Pantanowitz L, Dezube BJ: HIV-associated plasmablastic lymphoma: lessons learned from 112 published cases.Am J Hematol 2008; 83: pp. 804-809.
  • Delecluse HJ, Anagnostopoulos I, Dallenbach F, et. al.: Plasmablastic lymphomas of the oral cavity: A new entity associated with the human immunodeficiency virus infection.Blood 1997; 89: pp. 1413-1420.
  • Gaidano G, Cerri M, Capello D, et. al.: Molecular histogenesis of plasmablastic lymphoma of the oral cavity.Br J Haematol 2002; 119: pp. 622-628.
  • Guan B, Zhang X, Hu W, et. al.: Plasmablastic lymphoma of the oral cavity in an HIV-negative patient.Ann Diagn Pathol 2011; 15: pp. 436-440.
  • Hansra D, Montague N, Stefanovic A, et. al.: Oral and extraoral plasmablastic lymphoma: similarities and differences in clinicopathologic characteristics.Am J Clin Pathol 2010; 134: pp. 710-719.
  • Loghavi S, Khoury JD, Medeiros LJ: Epstein-Barr virus-positive plasmacytoma in immunocompetent patients.Histopathology 2015; 67: pp. 225-234.
  • Kane S, Khurana A, Parulkar G, et. al.: Minimum diagnostic criteria for plasmablastic lymphoma of oral/sinonasal region encountered in a tertiary cancer hospital of a developing country.J Oral Pathol Med 2009; 38: pp. 138-144.
  • Rafaniello Raviele P, Pruneri G, Maiorano E: Plasmablastic lymphoma: A review.Oral Dis 2009; 15: pp. 38-45.
  • Tsachouridou O, Christoforidou A, Metallidis S, et. al.: Plasmablastic lymphoma of the oral cavity, a B cell-derived lymphoma associated with HIV infection: a case series.Eur Arch Otorhinolaryngol 2012; 269: pp. 1713-1719.
  • Vega F, Chang CC, Medeiros LJ, et. al.: Plasmablastic lymphomas and plasmablastic plasma cell myelomas have nearly identical immunophenotypic profiles.Mod Pathol 2005; 18: pp. 806-815.
  • Clinical Findings

    • PBL involving the oral cavity typically presents as a lesion of the gingiva or palatal mucosa, similar to other oral lymphomas; secondary bony involvement is uncommon.

    • Approximately 50% of patients present with advanced stage disease, although only a third demonstrate bone marrow involvement.

    • The presence of B symptoms is variable.

    Histopathologic Features

    • There is a diffuse proliferation of large lymphoid cells with variable appearance; some show typical immunoblastic features with prominent central nucleoli, whereas others resemble mature plasma cells or exhibit plasmablastic features (namely vesicular chromatin, prominent nucleoli, and eccentrically placed nuclei) ( Figs. 18.3A–C ); there is a background of numerous apoptotic bodies and tingible-body macrophages.

      FIG 18.3
      Plasmablastic lymphoma (PBL). (A) Low-power view shows diffuse infiltration with near-complete destruction of the underlying tissue. (B) Some cases of PBL show plasmacytic features including eccentrically placed nuclei, variably prominent nucleoli, and abundant cytoplasm. Frequent mitotic figures are seen in this highly proliferative tumor. (C) Other cases of PBL do not show plasmacytic features but instead consist of diffuse sheets of large-sized cells with irregular nuclei, distinct nucleoli, and a high nuclear : cytoplasmic ratio. (D) EBER in situ hybridization is positive in most cases of HIV-associated PBL.
    • Lesional cells express plasma cell markers including CD138, CD38, and MUM1; CD30 and EMA are frequently positive; cells are mostly negative for, or show weak expression of, CD45 and B-cell markers such as CD20 and PAX5; monotypic cytoplasmic immunoglobulin light chain is detected in 50% to 70% of cases; Ki67 proliferation index is usually very high (>90%); HHV8 and BCL6 are negative.

    • EBER is positive in almost all of the HIV-associated oral lesions, and in approximately 50% of the lesions occurring in the HIV-negative setting ( Fig. 18.3D ).

    • CD56 expression is more common in cases associated with HIV than in HIV-negative cases.

    Differential Diagnosis

    • Anaplastic (plasmablastic) plasmacytoma: Correlation with clinical findings is essential; EBER-positivity favors PBL, although rare cases of EBV-positive plasmacytoma in immunocompetent patients have been reported.

    • Burkitt lymphoma: Shared features include EBER-positivity, high proliferation index, and tingible-body macrophages; unlike PBL, BL cells are intermediate in size without plasmacytoid features and are strongly positive for CD45, CD20, and BCL6.

    • Diffuse large B-cell lymphoma: Unlike PBL, DLBCL will show strong expression of CD45 and CD20 and typically a lower proliferation index.

    Management and Prognosis

    • Most are treated with multiagent chemotherapy, but PBL is an aggressive tumor and many patients die within the first year.

    • In one study, univariate analysis showed older age (60 years or older), advanced stage/bone marrow involvement, high Ki67 proliferation index (>80%), and HIV-negative status were associated with worse overall survival.

    References

  • Boy SC, van Heerden MB, Raubenheimer EJ, van Heerden WF: Plasmablastic lymphomas with light chain restriction – plasmablastic extramedullary plasmacytomas?.J Oral Pathol Med 2010; 39: pp. 435-439.
  • Castillo JJ, Winer ES, Stachurski D, et. al.: Clinical and pathological differences between human immunodeficiency virus-positive and human immunodeficiency virus-negative patients with plasmablastic lymphoma.Leuk Lymphoma 2010; 51: pp. 2047-2053.
  • Castillo J, Pantanowitz L, Dezube BJ: HIV-associated plasmablastic lymphoma: lessons learned from 112 published cases.Am J Hematol 2008; 83: pp. 804-809.
  • Delecluse HJ, Anagnostopoulos I, Dallenbach F, et. al.: Plasmablastic lymphomas of the oral cavity: A new entity associated with the human immunodeficiency virus infection.Blood 1997; 89: pp. 1413-1420.
  • Gaidano G, Cerri M, Capello D, et. al.: Molecular histogenesis of plasmablastic lymphoma of the oral cavity.Br J Haematol 2002; 119: pp. 622-628.
  • Guan B, Zhang X, Hu W, et. al.: Plasmablastic lymphoma of the oral cavity in an HIV-negative patient.Ann Diagn Pathol 2011; 15: pp. 436-440.
  • Hansra D, Montague N, Stefanovic A, et. al.: Oral and extraoral plasmablastic lymphoma: similarities and differences in clinicopathologic characteristics.Am J Clin Pathol 2010; 134: pp. 710-719.
  • Loghavi S, Khoury JD, Medeiros LJ: Epstein-Barr virus-positive plasmacytoma in immunocompetent patients.Histopathology 2015; 67: pp. 225-234.
  • Kane S, Khurana A, Parulkar G, et. al.: Minimum diagnostic criteria for plasmablastic lymphoma of oral/sinonasal region encountered in a tertiary cancer hospital of a developing country.J Oral Pathol Med 2009; 38: pp. 138-144.
  • Rafaniello Raviele P, Pruneri G, Maiorano E: Plasmablastic lymphoma: A review.Oral Dis 2009; 15: pp. 38-45.
  • Tsachouridou O, Christoforidou A, Metallidis S, et. al.: Plasmablastic lymphoma of the oral cavity, a B cell-derived lymphoma associated with HIV infection: a case series.Eur Arch Otorhinolaryngol 2012; 269: pp. 1713-1719.
  • Vega F, Chang CC, Medeiros LJ, et. al.: Plasmablastic lymphomas and plasmablastic plasma cell myelomas have nearly identical immunophenotypic profiles.Mod Pathol 2005; 18: pp. 806-815.
  • Follicular Lymphoma

    Follicular lymphoma (FL) accounts for 20% of all lymphomas and predominantly occurs in adults with a median age greater than 50 years. Most adults show symptoms of widespread disease but 10% to 20% have a localized stage I or II disease at initial diagnosis. FL primarily involves lymph nodes, although the spleen and bone marrow may also be involved. Fewer than 10% of all FLs show extranodal involvement with common sites including gastrointestinal tract, skin, head and neck, breast, and testis. Oral cavity involvement is rare, and FL is estimated to account for 8.7% to 15% of all oral NHL.

    Clinical Findings

    • In the oral cavity, the mean age of presentation is in the eighth decade with a 3 : 1 male predominance; most cases involve the palatal mucosa (75% of cases).

    • Most lesions are low-grade at presentation.

    Histopathologic Features

    • Most cases of FL have a predominantly follicular pattern with back-to-back follicles that replace the nodal architecture ( Fig. 18.4A ); the abnormal follicles exhibit attenuated mantle zones and are composed of a mixture of centrocytes (lymphoid cells with cleaved nuclei and condensed chromatin) and centroblasts.

      FIG 18.4
      Follicular lymphoma (FL). (A) Low-power view shows the well-circumscribed nodules characteristic of FL. (B) CD21 highlights the follicular dendritic cell meshworks underlying the nodules in this case, revealing a follicular growth pattern; an absence of CD21 reactivity in an area with lesional B-cells would signify a diffuse pattern of growth. (C) The nodules of low-grade FL are composed of cleaved centrocytes in contrast to the small round lymphocytes in the surrounding mantle zone. (D) Centrocytes are cleaved (elongated) cells with condensed chromatin. (E) High-grade FL is diagnosed when there are greater than 15 centroblasts per high-powered field, as seen in this case. (F) Centroblasts are larger cells with round to ovoid nuclei, open chromatin, and distinct nucleoli.
    • CD21 highlights the follicular dendritic cell (FDC) meshwork underlying neoplastic follicles ( Fig. 18.4B ); diffuse areas demonstrate an absence of CD21 expression.

    • Grading of follicular lymphoma is based on the number of centroblasts present in neoplastic follicles: grade 1 = 0–5 centroblasts/high-powered field (hpf) ( Fig. 18.4C–D ); grade 2 = 6–15 centroblasts/hpf; grade 3 = greater than 15 centroblasts/hpf ( Fig. 18.4E–F ); grade 3 is subdivided into grade 3A (admixed centrocytes and centroblasts) and grade 3B (sheets of centroblasts); diffuse areas may be present as defined by an absence of underlying FDC meshworks; if grade 3 cytology is present in an architecturally diffuse area, this should be classified as DLBCL.

    • Lesional B cells express the B-cell markers CD19, CD20, and PAX5, and show coexpression of BCL2, BCL6, and CD10.

    • Grade 3 FL can be CD10− and lack BCL2 expression.

    • Monotypic surface immunoglobulin light chain expression is detected by flow cytometry.

    • The majority of FLs show a characteristic IGH-BCL2 translocation: t(14;18)(q32;q21).

    Differential Diagnosis

    • Reactive follicular hyperplasia: Reactive follicles will show well-defined mantle zones and admixed tingible-body macrophages; germinal center cells will not coexpress BCL2, and molecular analysis will show a polyclonal pattern of immunoglobulin heavy chain gene rearrangements.

    • Marginal zone lymphoma: May show reactive follicles reminiscent of FL nodules, but the follicles in marginal zone lymphoma demonstrate reactive features as described above and are usually a minor component of the lesion; the majority of the marginal zone lymphoma infiltrate consists of neoplastic B cells in the interfollicular space.

    Management and Prognosis

    • Prognosis of FL is related to the extent of disease present at diagnosis; histologic grade also correlates with grade 1–2 cases being more indolent (but not curable), whereas grade 3 shows a more aggressive course.

    • Localized lesions may be treated with radiation, systemic disease may warrant chemotherapy, and these regimens will differ depending on grade.

    References

  • Argyris PP, Dolan M, Piperi E, et. al.: Oral follicular lymphomas. A short report of 8 cases with assessment of the IGH/BCL2 gene fusion with fluorescence in situ hybridization.Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116: pp. 343-347.
  • Bosga-Bouwer AG, van den Berg A, Haralambieva E, et. al.: Molecular, cytogenetic, and immunophenotypic characterization of follicular lymphoma grade 3B; a separate entity or part of the spectrum of diffuse large B-cell lymphoma or follicular lymphoma?.Hum Pathol 2006; 37: pp. 528-533.
  • Freedman A: Follicular lymphoma: 2014 update on diagnosis and management.Am J Hematol 2014; 89: pp. 429-436.
  • Kemp S, Gallagher G, Kabani S, et. al.: Oral non-Hodgkin’s lymphoma: review of the literature and World Health Organization classification with reference to 40 cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: pp. 194-201.
  • Weinberg OK, Ma L, Seo K, et. al.: Low stage follicular lymphoma: Biologic and clinical characterization according to nodal or extranodal primary origin.Am J Surg Pathol 2009; 33: pp. 591-598.
  • Clinical Findings

    • In the oral cavity, the mean age of presentation is in the eighth decade with a 3 : 1 male predominance; most cases involve the palatal mucosa (75% of cases).

    • Most lesions are low-grade at presentation.

    Histopathologic Features

    • Most cases of FL have a predominantly follicular pattern with back-to-back follicles that replace the nodal architecture ( Fig. 18.4A ); the abnormal follicles exhibit attenuated mantle zones and are composed of a mixture of centrocytes (lymphoid cells with cleaved nuclei and condensed chromatin) and centroblasts.

      FIG 18.4
      Follicular lymphoma (FL). (A) Low-power view shows the well-circumscribed nodules characteristic of FL. (B) CD21 highlights the follicular dendritic cell meshworks underlying the nodules in this case, revealing a follicular growth pattern; an absence of CD21 reactivity in an area with lesional B-cells would signify a diffuse pattern of growth. (C) The nodules of low-grade FL are composed of cleaved centrocytes in contrast to the small round lymphocytes in the surrounding mantle zone. (D) Centrocytes are cleaved (elongated) cells with condensed chromatin. (E) High-grade FL is diagnosed when there are greater than 15 centroblasts per high-powered field, as seen in this case. (F) Centroblasts are larger cells with round to ovoid nuclei, open chromatin, and distinct nucleoli.
    • CD21 highlights the follicular dendritic cell (FDC) meshwork underlying neoplastic follicles ( Fig. 18.4B ); diffuse areas demonstrate an absence of CD21 expression.

    • Grading of follicular lymphoma is based on the number of centroblasts present in neoplastic follicles: grade 1 = 0–5 centroblasts/high-powered field (hpf) ( Fig. 18.4C–D ); grade 2 = 6–15 centroblasts/hpf; grade 3 = greater than 15 centroblasts/hpf ( Fig. 18.4E–F ); grade 3 is subdivided into grade 3A (admixed centrocytes and centroblasts) and grade 3B (sheets of centroblasts); diffuse areas may be present as defined by an absence of underlying FDC meshworks; if grade 3 cytology is present in an architecturally diffuse area, this should be classified as DLBCL.

    • Lesional B cells express the B-cell markers CD19, CD20, and PAX5, and show coexpression of BCL2, BCL6, and CD10.

    • Grade 3 FL can be CD10− and lack BCL2 expression.

    • Monotypic surface immunoglobulin light chain expression is detected by flow cytometry.

    • The majority of FLs show a characteristic IGH-BCL2 translocation: t(14;18)(q32;q21).

    Differential Diagnosis

    • Reactive follicular hyperplasia: Reactive follicles will show well-defined mantle zones and admixed tingible-body macrophages; germinal center cells will not coexpress BCL2, and molecular analysis will show a polyclonal pattern of immunoglobulin heavy chain gene rearrangements.

    • Marginal zone lymphoma: May show reactive follicles reminiscent of FL nodules, but the follicles in marginal zone lymphoma demonstrate reactive features as described above and are usually a minor component of the lesion; the majority of the marginal zone lymphoma infiltrate consists of neoplastic B cells in the interfollicular space.

    Management and Prognosis

    • Prognosis of FL is related to the extent of disease present at diagnosis; histologic grade also correlates with grade 1–2 cases being more indolent (but not curable), whereas grade 3 shows a more aggressive course.

    • Localized lesions may be treated with radiation, systemic disease may warrant chemotherapy, and these regimens will differ depending on grade.

    References

  • Argyris PP, Dolan M, Piperi E, et. al.: Oral follicular lymphomas. A short report of 8 cases with assessment of the IGH/BCL2 gene fusion with fluorescence in situ hybridization.Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 116: pp. 343-347.
  • Bosga-Bouwer AG, van den Berg A, Haralambieva E, et. al.: Molecular, cytogenetic, and immunophenotypic characterization of follicular lymphoma grade 3B; a separate entity or part of the spectrum of diffuse large B-cell lymphoma or follicular lymphoma?.Hum Pathol 2006; 37: pp. 528-533.
  • Freedman A: Follicular lymphoma: 2014 update on diagnosis and management.Am J Hematol 2014; 89: pp. 429-436.
  • Kemp S, Gallagher G, Kabani S, et. al.: Oral non-Hodgkin’s lymphoma: review of the literature and World Health Organization classification with reference to 40 cases.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: pp. 194-201.
  • Weinberg OK, Ma L, Seo K, et. al.: Low stage follicular lymphoma: Biologic and clinical characterization according to nodal or extranodal primary origin.Am J Surg Pathol 2009; 33: pp. 591-598.
  • Extranodal Marginal Zone Lymphoma of Mucosa-Associated Lymphoid Tissue (MALT Lymphoma)

    MALT lymphomas comprise approximately 8% of all B-cell NHL. Presentation is usually at stage I or II disease. These lymphomas arise from a wide variety of extranodal sites, most commonly the gastrointestinal tract, often in the setting of chronic inflammatory or autoimmune disorders. Other locations where MALT lymphomas frequently occur include the thyroid, salivary glands, ocular adnexa, trachea, larynx, lung, skin, breast, thymus, liver, and dura mater. MALT lymphomas arising in the oral cavity are very rare, with fewer than 20 cases reported in the literature, and in a large series of 108 cases of MALT lymphoma, all 10 reported head and neck cases were located outside of the oral cavity.

    Clinical Findings

    • Most cases occur with a median age in the seventh decade with a slight female predominance; presents as a painless mass on the palatal mucosa, lip, sublingual gland, and buccal mucosa.

    • There is a frequent association with Sjögren syndrome.

    Histopathologic Features

    • The characteristic marginal zone B cells are small to medium in size with slightly irregular nuclei, moderately dispersed chromatin and inconspicuous nucleoli, and frequently display abundant pale cytoplasm (imparting a monocytoid appearance) ( Fig. 18.5A ); plasmacytic differentiation is frequently seen ( Fig. 18.5B ).

      FIG 18.5
      Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT). (A) The infiltrate consists of predominantly small-sized lymphoid cells surrounding and focally invading glandular structures. (B) The tumor cells in MALT lymphoma often exhibit plasmacytic differentiation. (C) The lymphoid cells are shown to be of B-cell origin by diffuse reactivity for CD20. (D) An immunostain for IgG demonstrates heavy chain restriction within this infiltrate. (E) In situ hybridization for immunoglobulin kappa light chain exhibits dark cytoplasmic reactivity in the plasma cells, and weaker (blush) reactivity in the lymphoid cells, confirming plasmacytic differentiation in this case.
    • In glandular tissues, lymphocytes often invade epithelium to form lymphoepithelial lesions.

    • Lymphoma cells may colonize reactive germinal centers, imparting a nodular appearance at low power.

    • Lesional B cells express B cell markers CD19, CD20, and PAX5 ( Fig. 18.5C ); they may express CD79a and may exhibit aberrant coexpression of CD43; they are negative for CD5 and CD10.

    • If plasmacytic differentiation is present, immunohistochemical and/or in situ hybridization often shows monotypic heavy and light chain restriction supporting the clonal (neoplastic) nature of the infiltrate ( Fig. 18.5D–E ).

    Differential Diagnosis

    • Reactive follicular hyperplasia: Because reactive follicles can be seen in both entities, features favoring a diagnosis of MALT include monocytoid B cells surrounding the follicles, the presence of plasmacytic differentiation showing heavy and light chain restriction, and lymphoepithelial lesions.

    • Follicular lymphoma: The follicles in FL are often present in a back-to-back architectural arrangement and lack reactive features such as tingible-body macrophages; follicles will show aberrant BCL2 expression.

    Management and Prognosis

    • MALT lymphomas are usually indolent and sensitive to radiation therapy.

    • Recurrences can occur in other extranodal sites.

    References

  • Benson-Mitchell R, Warwick-Brown N, Chappell ME: Non-Hodgkin’s lymphoma presenting as an isolated temporal soft tissue swelling.J Laryngol Otol 1996; 110: pp. 161-162.
  • Ferry JA: Extranodal lymphoma.Arch Pathol Lab Med 2008; 132: pp. 565-578.
  • Isaacson PG, Spencer J: Malignant lymphoma of mucosa-associated lymphoid tissue.Histopathology 1987; 11: pp. 445-462.
  • McLellan M, Hasserjian R, Emerick K: Marginal zone B-cell lymphoma of the head and neck: A rare case and review.Laryngoscope 2010; 120: pp. S165.
  • Thieblemont C, Bastion Y, Berger F, et. al.: Mucosa-associated lymphoid tissue gastrointestinal and nongastrointestinal lymphoma behavior: Analysis of 108 patients.J Clin Oncol 1997; 15: pp. 1624-1630.
  • Thieblemont C, Berger F, Dumontet C, et. al.: Mucosa-associated lymphoid tissue lymphoma is a disseminated disease in one third of 158 patients analyzed.Blood 2000; 95: pp. 802-806.
  • Yamagata K, Onizawa K, Kojima H, Yoshida H: Treatment of localized oral MALT lymphoma by rituximab: A case report.Oral Maxillofac Surg 2008; 12: pp. 227-230.
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    Oct 3, 2019 | Posted by in Oral and Maxillofacial Pathology | Comments Off on Hematolymphoid Tumors of the Oral Cavity

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