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Abstract
Primary intraocular lymphoma (PIOL) is a type of primary central nervous system lymphoma (PCNSL). It is the most common neoplastic masquerade syndrome involving the eye. Its protean ocular manifestations, plus in many cases the initial positive response to corticosteroid therapy for presumed uveitis, delay accurate diagnosis. A high index of suspicion is essential, followed by tissue biopsy with cytology and ancillary studies. Current treatment is based on chemotherapy featuring high-dose methotrexate and radiation therapy. Prognosis is poor due to CNS involvement, but newer therapies have had some success in prolonging survival.
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Affiliation(s)
- John Y Choi
- Retina Specialists of Boston, Cambridge, MA, USA
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52
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Augsburger and JJ, Tsiaras WG. Lymphoma and Leukemia. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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54
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Suh MH, Yu HG. Clinical Manifestations of Intraocular Lymphoma. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2009. [DOI: 10.3341/jkos.2009.50.1.78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Min Hee Suh
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Hyeong Gon Yu
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
- Institute of Sensory Organs, Medical Research Center, Seoul National University, Seoul, Korea
- Institute of Rheumatology, Medical Research Center, Seoul National University, Seoul, Korea
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Hideyama T, Tanaka H, Uesaka Y, Kunimoto M, Miwa A. [Case of primary intraocular central nervous system lymphoma with high interleukin 10 level and positive cytology in cerebrospinal fluid]. Rinsho Shinkeigaku 2008; 48:415-8. [PMID: 18616153 DOI: 10.5692/clinicalneurol.48.415] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 73-year-old woman was admitted to the surgical department of our hospital for endoscopic resection of a colonic polyp. The day after endoscopic resection, she became drowsy and dysphasic. Two days later, left hemiparesis and gait difficulty developed. The next day, hemiparesis progressed bilaterally and dyspnea developed due to upper airway stenosis. The most prominent signs were those of bulbar palsy. Blood analysis revealed mild inflammatory responses and hyponatremia. T2-weighted magnetic resonance imaging showed high-intensity lesions in the swollen medulla and cervical spinal cord. Those areas and the meninges of the posterior fossa were enhanced by gadolinium. Steroid pulse therapy was administered, resulting in rapid recovery of bulbar and paretic symptoms with decreased enhanced area. At this point, concentration of cerebrospinal fluid interleukin (IL)-10 was markedly elevated at 146 pg/ml (normal,< 5 pg/ml), suggesting malignant lymphoma. Cytology of the cerebrospinal fluid was repeatedly examined, eventually revealing atypical lymphocytes with hyperlobulated nuclei and clear nucleoli. Lymphocytes stained with anti-CD20 antibody. These findings strongly suggested a diagnosis of primary intraocular and central nervous system lymphoma. In the present case, repeated cytology of cerebrospinal fluid was highly important for diagnosis in this case of high IL-10 level in cerebrospinal fluid.
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Affiliation(s)
- Takuto Hideyama
- Department of Neurology, International Medical Center of Japan
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57
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Haque S, Law M, Abrey LE, Young RJ. Imaging of Lymphoma of the Central Nervous System, Spine, and Orbit. Radiol Clin North Am 2008; 46:339-61, ix. [DOI: 10.1016/j.rcl.2008.04.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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58
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Abstract
Primary intraocular lymphoma (PIOL) is a subset of primary central nervous system lymphoma (PCNSL) in which malignant lymphoid cells invade the retina, vitreous body, or optic nerve head. It is usually a large B-cell non-Hodgkin's lymphoma. PIOL typically presents as a vitritis that is unresponsive to corticosteroid therapy. Diagnosis of PIOL requires pathologic confirmation of malignant cells in specimens of the cerebrospinal fluid, vitreous, or chorioretinal biopsies. The optimal therapy for PIOL has yet to be determined. It is generally believed that PIOL should be treated with a combination of systemic chemotherapy, including high-dose methotrexate and radiotherapy. However, several new developments for PIOL with central nervous system involvement have been reported, including intrathecal therapy and autologous stem-cell transplantation. In addition, intravitreal methotrexate has been successful in the treatment of isolated recurrent ocular disease. This article provides an overview of treatment modalities for initial, recurrent, and relapsed PIOL.
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Affiliation(s)
- Stella K Kim
- University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, #443, Houston, TX 77030, USA.
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59
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Abstract
BACKGROUND Primary intraocular lymphoma (PIOL) is a subset of primary central nervous system lymphoma (PCNSL) in which lymphoma cells initially invade the retina, vitreous, or optic nerve head, with or without concomitant CNS involvement. The incidence of this previously rare condition has increased dramatically. Given its nonspecific presentation and aggressive course, PIOL provides a diagnostic and therapeutic challenge. METHODS We review the current strategies for diagnosis and treatment of PIOL and present our own experience with PIOL. RESULTS Recent developments in the diagnosis of PIOL include immunohistochemistry, flow cytometry, cytokine evaluation, and molecular analysis. However, definitive diagnosis still requires harvesting of tissue for histopathology. Optimal treatment for PIOL remains unclear. Initial therapeutic regimens should include methotrexate-based chemotherapy and radiotherapy to the brain and eye. In addition, promising results have been seen with intravitreal methotrexate and autologous stem cell transplantation for recurrent and refractory disease. CONCLUSIONS Efforts to further determine the immunophenotype and molecular characteristics of PIOL will continue to assist in the diagnosis of PIOL. Future studies are required to determine the role of radiotherapy and optimal local and systemic chemotherapeutic regimens.
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Affiliation(s)
- Chi-Chao Chan
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, MD 20892, USA.
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60
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Intzedy L, Teoh SCB, Hogan A, Mangwana S, Mayer EJ, Dick AD, Pawade J. Cytopathological analysis of vitreous in intraocular lymphoma. Eye (Lond) 2007; 22:289-93. [PMID: 17767143 DOI: 10.1038/sj.eye.6702965] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To describe the cytopathological method used in the analysis of vitreous samples in the diagnosis of primary intraocular lymphoma (PIOL). PARTICIPANTS Seven patients with refractory posterior uveitis referred to a regional ocular inflammatory service were diagnosed as having PIOL between 1999 and 2006. METHODS Clinical features of the uveitis and cytopathological preparation of the samples were described. All patients underwent vitrectomy and samples were placed in formal saline or prepared fresh. Following paraffin embedding generating a cell block, immunostaining, and polymerase chain reactions were performed. RESULTS Five women (71.4%) and two men (28.6%) (mean age 67.7 years) were included. Five patients had diagnostic vitrectomy performed within 6 months of presentation, but in two patients diagnosis was delayed up to 2 years. Uveitis was bilateral in two patients. Cytologic and immunohistochemical staining prepared from the vitreous specimens showed PIOL in all patients, and PCR displayed single band of immunoglobulin heavy chain rearrangement in five out of six samples tested. CONCLUSIONS Diagnosis of PIOL is difficult due to small volume of sample with low number of malignant cells and inadequate preparation of samples. Our method of analysis with fresh samples together with immunohistochemistry and PCR analysis demonstrates a high yield of diagnosis reducing diagnostic delay.
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Affiliation(s)
- L Intzedy
- Department of Pathology, Bristol Royal Infirmary, Bristol, UK
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61
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Browning DJ, Fraser CM. Primary intraocular lymphoma mimicking multifocal choroiditis and panuveitis. Eye (Lond) 2007; 21:880-1. [PMID: 17304253 DOI: 10.1038/sj.eye.6702756] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Affiliation(s)
- Robin Ray
- Neuro-ophthalmology Service, Baylor College of Medicine, 6565 Fannin NC-205, Houston, TX 77030, USA
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Gündüz K, Pulido JS, McCannel CA, O'Neill BP. Ocular manifestations and treatment of central nervous system lymphomas. Neurosurg Focus 2006; 21:E9. [PMID: 17134125 DOI: 10.3171/foc.2006.21.5.10] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
✓ Intraocular primary central nervous system lymphoma (PCNSL), also called primary intraocular lymphoma (PIOL), is a subset of PCNSL in which lymphoma cells invade the subretinal pigment epithelial space and vitreous cavity with or without central nervous system involvement at the time of ocular diagnosis. The frequency of this rare condition has increased over the past years in immunosuppressed as well as immunocompetent patients. The authors review the current status of PIOL and elaborate on their group's experience with its diagnosis and treatment.
The incidence of PIOL is increasing. There is evidence that chronic antigenic stimulation may result in the development of PIOL. Recent advancements in the diagnosis of PIOL include better handling of vitreous specimens for cytological studies, immunocytological investigation for lymphoid cells, flow cytometry, cytokine evaluation, and molecular analysis. Because PIOL has a nonspecific presentation, the differential diagnosis should include infectious and noninfectious causes presenting with vitreitis and/or subepithelial infiltration as well as paraneoplastic syndromes including CRMP-5 optic neuropathies. Given that therapy is long-term and has significant systemic and ocular complications, tissue diagnosis is important. Treatment of PIOL may include systemic chemotherapy in which high-dose methotrexate-based regimens are used as well as intraocular injections of methotrexate and rituximab (anti-CD20 antibody). Cranial and ocular external-beam radiotherapy is being used less often today.
Further studies are needed to prevent the tumor formation in terms of eliminating antigenic load and inhibiting B-cell chemokines as well as to determine the optimal local and systemic chemotherapy and immunotherapy options in the management of PIOL.
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Affiliation(s)
- Kaan Gündüz
- Retina and Vitreous Surgery Service, Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
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64
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Saatci AO, Arikan G, Ozcan MA, Ozkal S, Kargi A, Undar B. Indocyanine green angiographic features of systemic non-Hodgkin's lymphoma and bilateral choroidal involvement. Ophthalmic Surg Lasers Imaging Retina 2006; 37:236-9. [PMID: 16749262 DOI: 10.3928/15428877-20060501-10] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 35-year-old man with systemic non-Hodgkin's lymphoma and bilateral choroidal involvement is described. Indocyanine green angiography depicts choroidal involvement much better than fluorescein angiography and seems to be superior in diagnosing and monitoring patients with systemic non-Hodgkin's lymphoma and choroidal involvement.
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Affiliation(s)
- A Osman Saatci
- Ophthalmology Department Dokuz Eylül University Izmir, Turkey
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65
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Affiliation(s)
- Mark R Melson
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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66
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Sbeity ZH, Coupland S, Loeffler KU. High-grade malignant B-cell lymphoma of the retina in a patient with concomitant gastric MALT lymphoma. Graefes Arch Clin Exp Ophthalmol 2006; 245:448-50. [PMID: 16775720 DOI: 10.1007/s00417-006-0364-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 02/23/2006] [Accepted: 05/01/2006] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To report the unexpected finding of a primary retinal B-cell lymphoma in a patient with previous breast carcinoma and subsequent lymphoma of the stomach. METHODS Histopathologic and immunohistochemical findings in the enucleated eye are described in conjunction with clinical features and investigations. RESULTS An 80-year-old woman with previous breast cancer presented with moderate loss of vision associated with vitreous opacities, circumpapillary retinal haemorrhages, and attenuated retinal vessels in her left eye. Treatment with systemic steroids and oral immunosuppressive drugs was initiated on suspicion of carcinoma-associated retinopathy. Two years later, the patient was diagnosed with MALT lymphoma of the stomach. Unfortunately, the ocular symptoms did not improve, and the patient developed neovascular glaucoma, for which the eye was eventually enucleated. Histopathology and immunohistochemistry as well as a molecular analysis revealed a primary B-cell lymphoma of the retina. CONCLUSION Non-Hodgkin B-cell lymphoma of the retina should be considered as a differential diagnosis in cases of non-specific retinopathies even in the presence of other primary neoplastic co-morbidities.
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MESH Headings
- Aged, 80 and over
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/pathology
- Female
- Glucocorticoids/therapeutic use
- Humans
- Immunohistochemistry
- Immunosuppressive Agents/therapeutic use
- Lymphoma, B-Cell/metabolism
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell, Marginal Zone/metabolism
- Lymphoma, B-Cell, Marginal Zone/pathology
- Neoplasm Proteins/metabolism
- Neoplasms, Second Primary/metabolism
- Neoplasms, Second Primary/pathology
- Retinal Neoplasms/metabolism
- Retinal Neoplasms/pathology
- Stomach Neoplasms/metabolism
- Stomach Neoplasms/pathology
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Affiliation(s)
- Zaher H Sbeity
- Department of Ophthalmology, Division of Ocular Pathology, University of Bonn, Ernst-Abbe-Strasse 2, 53127, Bonn, Germany
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67
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Coutinho AB, Muccioli C, Martins MC, Belfort R, Sant'Anna AE, Burnier MN. Extranodal B-cell lymphoma of the uvea: a case report. Can J Ophthalmol 2005; 40:623-6. [PMID: 16391629 DOI: 10.1016/s0008-4182(05)80058-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
CASE REPORT Ocular involvement by non-Hodgkin's lymphoma is a rare condition that can result from a primary intraocular lymphoma of the retina or an intraocular manifestation of systemic lymphoma. Uveal involvement is seldom the initial manifestation of extranodal lymphoma. We describe an 80-year-old patient with a blind and painful left eye and a history of recurrent uveitis. After ultrasound evaluation, the eye was enucleated and histopathologic examination revealed a malignant B-cell lymphoma of the uveal tract. The patient has been followed for 8 years after surgery, but she has had no further systemic manifestations of lymphoma and has not required subsequent treatment. COMMENTS Primary extranodal lymphoma can be easily mistaken for recurrent uveitis or primary intraocular lymphoma of the retina and central nervous system; it is a differential diagnosis to be considered in cases of recurrent uveitis-like symptoms evolving to blind painful eye.
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Affiliation(s)
- Anamaria B Coutinho
- The Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil.
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68
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Abstract
A 58-year-old woman with an initial diagnosis of multiple evanescent white dot syndrome OU experienced deteriorating vision despite corticosteroid treatment. Reevaluation disclosed retinal and subretinal infiltrates and pigmentary alterations, prompting a suspicion of primary intraocular lymphoma (PIOL). Diagnostic vitrectomy yielded inconclusive cytology, but flow cytometry demonstrated small monoclonal B cells less suggestive of PIOL than of small lymphocytic lymphoma originating outside the eye or central nervous system. Brain magnetic resonance imaging, chest/abdomen/pelvis computed tomography, lumbar puncture, and laboratory studies failed to disclose lymphoma elsewhere. There was insufficient evidence to recommend radiation therapy. Vision deteriorated rapidly, prompting a diagnostic retinal biopsy and aspiration of the subretinal infiltrate, revealing unequivocal evidence of PIOL. After 40 Gy orbital x-irradiation, visual function improved dramatically. This case emphasizes the unusual ocular manifestations of PIOL and the difficulty of obtaining a definitive diagnosis by sampling vitreous, particularly after corticosteroid treatment. In such cases, subretinal aspiration or retinal biopsy may be necessary. Timely diagnosis is critical because treatment can reverse visual loss if it is not severe.
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Affiliation(s)
- Daniel K Fahim
- Kellogg Eye Center and Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, MI 48105, USA
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69
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Neudorfer M, Kessler A, Anteby I, Goldenberg D, Barak A. Co-existence of intraocular and orbital lymphoma. ACTA ACUST UNITED AC 2005; 82:754-61. [PMID: 15606477 DOI: 10.1111/j.1600-0420.2004.00354.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The concomitant occurrence of both intraocular and periocular lymphomas is extremely rare. Periocular involvement by lymphoproliferative disease ranges from benign lymphoid hyperplasia to malignant lymphoma. Intraocular lymphomas usually appear in conjunction with primary central nervous system lymphoma. CASE REPORTS We describe clinical characteristics, standardized A- and B-scan ultrasonography, colour Doppler, computerized tomographic and magnetic resonance imaging, and immunohistological findings in three cases of concurrent choroidal and periocular involvement of lymphoma. DISCUSSION The clinical presentation of diffuse choroidal tumours may be variable, making diagnosis of intraocular lymphoma troublesome on clinical grounds alone. The high accuracy of colour Doppler imaging is known to be effective in differentiating the benign from the malignant and adds valuable information in the differential diagnosis of a low reflective lesion. We suggest the use of auxiliary examinations such as ultrasonography and colour Doppler imaging to help in the differential diagnosis of choroidal and orbital tumours.
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Affiliation(s)
- Meira Neudorfer
- Department of Ophthalmology, Tel Aviv Medical Centre, Tel Aviv, Israel.
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70
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Coupland SE, Anastassiou G, Bornfeld N, Hummel M, Stein H. Primary intraocular lymphoma of T-cell type: report of a case and review of the literature. Graefes Arch Clin Exp Ophthalmol 2004; 243:189-97. [PMID: 15806372 DOI: 10.1007/s00417-004-0890-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2004] [Revised: 02/03/2004] [Accepted: 02/09/2004] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Primary intraocular lymphoma (PIOL) is an uncommon non-Hodgkin lymphoma and is usually of B-cell type. Intraocular T-cell or T/NK-cell lymphomas are extremely rare and mostly represent a secondary manifestation of either a cutaneous or a systemic lymphoma. The aim of the current paper is to report the clinical, histopathological and molecular biological findings of a PIOL of T-cell type. METHODS Conventional cytological and immunocytological examination of vitrectomy specimens. Conventional histology, immunohistochemistry and polymerase chain reaction (PCR) for the detection of immunoglobulin heavy chain (IgH) and T-cell-receptor gamma (TCR-gamma) gene rearrangement, GeneScan analysis, and DNA sequencing were performed on the chorioretinal biopsy. RESULTS Cytology of the right vitreous aspirate revealed a moderate cellular infiltrate consisting of medium-sized T-cells with pleomorphic nuclei. Similar atypical lymphocytes were seen in the partially necrotic chorioretinal biopsy. These lymphocytes expressed CD3, CD4, betaF1 and CD30, with a growth fraction of 90%. TCR-gamma-PCR, GeneScan analysis and DNA sequencing demonstrated a monoclonal amplification product within the expected range. In contrast, IgH-PCR revealed oligoclonal amplificates. The patient was treated with low-dose radiotherapy (total 45 Gy), and was in complete remission at final follow-up. CONCLUSION A rare PIOL of T-cell type was diagnosed on the basis of vitreous aspiration and chorioretinal biopsy. In addition to conventional cytology and immunocytology, the utilisation of gene rearrangement studies on vitreous or chorioretinal biopsies increases the chances of diagnosing or excluding a PIOL of either B-cell or T-cell type. Despite its rarity, ophthalmic pathologists should always consider the diagnosis of T-PIOL when reviewing vitreous samples.
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Affiliation(s)
- Sarah E Coupland
- Department of Pathology, Charité-Medical Faculty Berlin, Campus Benjamin Franklin, Germany.
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71
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Coupland SE, Heimann H, Bechrakis NE. Primary intraocular lymphoma: a review of the clinical, histopathological and molecular biological features. Graefes Arch Clin Exp Ophthalmol 2004; 242:901-13. [PMID: 15565454 DOI: 10.1007/s00417-004-0973-0] [Citation(s) in RCA: 152] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Revised: 05/04/2004] [Accepted: 06/11/2004] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Primary intraocular lymphoma (PIOL) is a rare non-Hodgkin lymphoma which arises in the retina or the vitreous. It can occur either together with or independently of primary cerebral nervous system lymphoma (PCNSL); the incidence of the latter has significantly increased over the past three decades. PIOL remains one of the most difficult diagnoses to establish, particularly due to its ability to mimic other diseases in the eye and to the limited material which is often available for examination. METHODS The article reviews the clinical, histopathological, molecular biological and biochemical approaches to the diagnosis of PIOL. The differential diagnoses, including other lymphomatous manifestations in the eye, e.g. primary uveal lymphoma, as well as non-neoplastic uveal diseases are addressed. Furthermore, the treatment strategies for PIOL are summarised. RESULTS Diagnostic progress has been made in various fields, including flow cytometry and immunocytology, cytokine analysis, and as well as molecular biological analysis of the immunoglobulin heavy and light chains using polymerase chain reaction on both fixed and non-fixed material. The optimal therapy of PIOL remains to be determined: the current trends suggest that combined radiotherapy and chemotherapy, as well as intravitreal chemotherapy, are of value. Novel therapies which may have a role in the future include oral trofosfamide. CONCLUSION Our understanding of the pathogenesis of PIOL/PCNSL remains far from complete. Intensified efforts must be made to determine the cell of origin of PIOL, as well as to establish "molecular signatures", which could be used to decrease diagnostic delay. Further studies, possibly prospective ones, are required to establish the optimal therapy for initial and recurrent disease.
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Affiliation(s)
- Sarah E Coupland
- Department of Pathology, Charité--University Medicine, Campus Benjamin Franklin, Hindenburgdamm 30, Berlin, 12200, Germany.
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Hormigo A, Abrey L, Heinemann MH, DeAngelis LM. Ocular presentation of primary central nervous system lymphoma: diagnosis and treatment. Br J Haematol 2004; 126:202-8. [PMID: 15238140 DOI: 10.1111/j.1365-2141.2004.05028.x] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Primary ocular lymphoma (POL), a lymphoma of the globe, is a restricted form of primary central nervous system lymphoma (PCNSL) that often progresses to the brain and meninges; frequently it is misdiagnosed until central nervous system (CNS) lymphoma develops. The optimal treatment has not yet been identified. We retrospectively reviewed the course and the treatment of POL in 31 patients. Seventeen patients were treated for isolated POL (group A) and 14 were treated only after CNS disease was diagnosed (group B). The treatment in both groups consisted of systemic chemotherapy, chemotherapy plus radiotherapy (RT) or RT alone. In group A, nine patients (53%) developed CNS progression and five (29%) had ocular recurrence. In group B, seven (50%) had CNS progression and three (21%) ocular relapse. To control for diagnostic lead time, median survival was calculated from initial ocular symptoms and was 60 months in group A and 35 months in group B (P < 0.05). Ocular lymphoma responds to a variety of therapies but treatment with chemotherapy and/or ocular radiotherapy (ORT) failed to prevent CNS progression. Patients whose ocular disease was identified and treated before CNS progression had a significantly improved survival.
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Affiliation(s)
- Adília Hormigo
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Higashide T, Takahira M, Okumura H, Torisaki M, Sakurai M, Shirao Y, Sugiyama K. Bilaterally identical monoclonality in a case of primary intraocular lymphoma. Am J Ophthalmol 2004; 138:306-8. [PMID: 15289150 DOI: 10.1016/j.ajo.2004.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2004] [Indexed: 10/26/2022]
Abstract
PURPOSE To report a case of primary intraocular lymphoma possessing bilaterally identical monoclonal rearrangements of the immunoglobulin heavy chain (IgH) gene. DESIGN Observational case report. METHODS A 78-year-old woman with bilateral vitritis, subretinal infiltrates in the right eye, and no involvement of the central nervous system (CNS) was diagnosed histologically with diffuse large B-cell lymphoma by a transvitreal subretinal biopsy of the right eye. One month later, vitrectomy was performed on the left eye due to increased vitreous opacity. DNA was extracted from a vitrectomy specimen from each eye, and the third complementarity-determining region of IgH gene was analyzed by polymerase chain reaction and direct sequencing. RESULTS Monoclonal rearrangements of IgH gene with identical DNA sequence were detected in both eyes. CONCLUSIONS Bilaterally identical monoclonality was detected in a case of primary intraocular lymphoma with no CNS involvement.
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MESH Headings
- Aged
- DNA, Neoplasm/analysis
- Female
- Gene Rearrangement, B-Lymphocyte, Heavy Chain/genetics
- Genes, Immunoglobulin
- Humans
- Immunoglobulin Heavy Chains/genetics
- Lymphoma, B-Cell/genetics
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/radiotherapy
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/radiotherapy
- Polymerase Chain Reaction
- Retinal Neoplasms/genetics
- Retinal Neoplasms/pathology
- Retinal Neoplasms/radiotherapy
- Sequence Analysis, DNA
- Vitrectomy
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Affiliation(s)
- Tomomi Higashide
- Department of Ophthalmology, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
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74
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Adán A, Baget M, De Llobet JM, Segura A, Marieges MT, Casaroli-Marano R. Uveítis como manifestación inicial de sarcoidosis: estudio de 31 pacientes. Med Clin (Barc) 2004; 122:748-52. [PMID: 15171910 DOI: 10.1016/s0025-7753(04)74374-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Our goal was to analyze the epidemiological and clinical findings, as well as the diagnostic approach in a group of patients in whom uveitis was the first manifestation of sarcoidosis. PATIENTS AND METHOD Retrospective study (between March 1998 and July 2002) including 31 patients diagnosed with sarcoidosis after an episode of uveitis. The group consisted of 19 females (61%) and 12 males (39%). Mean follow-up was 34.5 months. Age, sex, ocular and systemic clinical findings were recorded. Angiotensin converting enzyme (ACE) levels were measured and radiological studies of the thorax were conducted including simple radiography (Rx), computerized axial tomography (CT) and gallium scan (67Ga). Biopsy was carried out in 14 patients. RESULTS Mean age was 59.6 years. Six different clinical presentations of uveitic sarcoidosis were observed, the most common being bilateral panuveitis in 13 patients (42%) and chronic anterior bilateral uveitis in 11 (35%). Gallium scan, thoracic CT and chest radiography were positive in 88%, 77% and 33% cases, respectively. ACE levels were raised in 7 of the 27 patients analyzed (26%). Histological confirmation of disease was obtained in all 14 patients biopsied with a specificity and sensitivity of 100%. CONCLUSIONS Uveitis may be the presenting manifestation of sarcoidosis, especially in women over 60 years of age. Bilateral panuveitis and chronic bilateral anterior uveitis are the most common clinical presentations. The sensitivity of gallium scan and thoracic CT is greater than simple chest radiography in diagnosing pulmonary and mediastinal lesions of sarcoidosis. The need for biopsy should be individualized in each case depending on complementary exams, age and potential morbidity of the procedure.
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Affiliation(s)
- Alfredo Adán
- Servicio de Oftalmología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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75
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Coupland SE, Bechrakis NE, Anastassiou G, Foerster AMH, Heiligenhaus A, Pleyer U, Hummel M, Stein H. Evaluation of vitrectomy specimens and chorioretinal biopsies in the diagnosis of primary intraocular lymphoma in patients with Masquerade syndrome. Graefes Arch Clin Exp Ophthalmol 2003; 241:860-70. [PMID: 14605902 DOI: 10.1007/s00417-003-0749-y] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2003] [Revised: 06/25/2003] [Accepted: 06/26/2003] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To correlate the histopathological diagnoses established by diagnostic vitrectomy and chorioretinal biopsy in patients with clinically suspected primary intraocular lymphoma (PIOL) or chronic idiopathic uveitis, and the clinical follow-up data. METHODS Eighty-four consecutive pars plana vitrectomy (PPV) specimens, three chorioretinal biopsies and two enucleated eyes taken from 80 patients were evaluated. All PPV specimens were unfixed; these were centrifuged, the "cytospins" being stained conventionally (May-Grünwald-Giemsa) and using immunocytology (CD79a, CD3, CD68, immunoglobulin (Ig) light chains). An extended immunohistochemical panel, as well as polymerase chain reaction (PCR) for rearrangements of the Ig heavy chain gene (IgH-PCR), were used to investigate the chorioretinal biopsies and the enucleated eyes. Diagnoses, made on the basis of morphology and immunophenotype, included "reactive cellular infiltrate", "malignant lymphoma", "suspicious of neoplastic disease", and "insufficient for diagnosis". The corresponding clinical data were collected and compared with the diagnosis. RESULTS The 80 patients consisted of 46 women and 34 men. The patients' age range varied from 21 to 100 years (mean age 62 years). Sixty-two (74%) of the 84 vitrectomy specimens were diagnosed as "reactive cellular infiltrate", 12 (14%) as definite "malignant lymphoma", 5 (6%) as "suspicious of neoplastic disease" and 5 (6%) specimens were considered "insufficient for diagnosis". An additional chorioretinal biopsy enabled an unequivocal diagnosis of PIOL to be reached in 3 patients. All PIOL were diffuse large cell B-cell lymphoma (DLBCL), with the immunophenotype CD79+, CD20+, BCL-2+, BCL-6+, MUM1+ and monotypical expression for IgM+. A monoclonal IgH-PCR amplification product was obtained in four vitrectomy specimens, two chorioretinal biopsies and one of the enucleated eyes. Comparison of the diagnoses with long-term follow-up clinical data resulted in concordance in 77 (96%) cases and discrepancies ("false-negative" diagnoses) in 3 patients (4%). The patients diagnosed with lymphoma were treated with either radiotherapy, chemotherapy or both. At final follow-up (mean 35 months), 5 patients (6%) had developed cerebral lymphomatous manifestation, and 7 (9%) had succumbed to their disease. CONCLUSION The diagnosis of PIOL is often extremely difficult, requiring sufficient rapidly transported good-quality material, and experienced interpretation. Although cytological examination of vitreal aspirates remains the gold standard in diagnosis, examination of chorioretinal biopsies increase the reliability of diagnosing or excluding a PIOL that involves the retina or choroid. Most PIOL are DLBCL with an immunophenotype suggesting a cellular origin from germinal centre cells.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biomarkers, Tumor/analysis
- Biopsy
- Choroid Neoplasms/diagnosis
- Choroid Neoplasms/drug therapy
- Choroid Neoplasms/radiotherapy
- Combined Modality Therapy
- Diagnosis, Differential
- Female
- Gene Rearrangement, B-Lymphocyte, Heavy Chain/genetics
- Humans
- Immunoglobulin Heavy Chains/genetics
- Lymphoma, B-Cell/diagnosis
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/radiotherapy
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/radiotherapy
- Male
- Middle Aged
- Polymerase Chain Reaction
- Retinal Neoplasms/diagnosis
- Retinal Neoplasms/drug therapy
- Retinal Neoplasms/radiotherapy
- Retrospective Studies
- Uveitis/diagnosis
- Vitrectomy
- Vitreous Body/pathology
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Affiliation(s)
- Sarah E Coupland
- Department of Pathology, University Hospital Benjamin Franklin, Free University, Hindenburgdamm 30, 12200 Berlin, Germany.
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76
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Cross SA, Salomao DR, Parisi JE, Kryzer TJ, Bradley EA, Mines JA, Lam BL, Lennon VA. Paraneoplastic autoimmune optic neuritis with retinitis defined by CRMP-5-IgG. Ann Neurol 2003; 54:38-50. [PMID: 12838519 DOI: 10.1002/ana.10587] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Autoantibodies have defined two paraneoplastic visual disorders related to small-cell lung carcinoma: retinopathy ("CAR"-IgG [23kDa, recoverin]) and optic neuritis collapsin response-mediated protein 5 (CRMP-5-IgG [62kDa]). Among 16 patients with CRMP-5-IgG and optic neuritis (aged 52-74 years; all smokers, 9 women), we documented coexisting retinitis in 5. None had CAR-IgG. Fifteen had subacute vision loss, swollen optic discs, and field defects. Vascular leakage was evident at and remote from the disc; 5/5 tested had abnormal electroretinograms. Nine had striking vitreous cells. Vitrectomy showed reactive lymphocytosis (4/4), predominantly CD4(+) (1/1). Most patients had multifocal neurological accompaniments. Cerebrospinal fluid contained lymphocytes (7-32), elevated protein, multiple oligoclonal immunoglobulin bands, and CRMP-5-IgG. Three patients superficially resembled Devic's disease at presentation. One autopsied patient had predominantly CD8(+) T lymphocytes infiltrating optic nerve and spinal cord. Eleven patients had confirmed small-cell carcinoma; 1 had imaging evidence of lung cancer; 3 had renal or thyroid carcinoma. Full-length CRMP-5 protein was identified in normal retina and optic nerve by Western blot analyses. Photoreceptor cells, retinal ganglion cells, and nerve fibers exhibited CRMP-5-specific immunoreactivity. In summary, CRMP-5-IgG defines a paraneoplastic ophthalmological entity of combined optic neuritis and retinitis with vitreous inflammatory cells. Positive serology obviates the need for vitreous biopsy and expedites the search for cancer.
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Affiliation(s)
- Shelley A Cross
- Department of Neurology, Mayo Graduate and Medical Schools, Mayo Clinic, Rochester, MN 55905, USA
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77
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Chan CC. Primary intraocular lymphoma: clinical features, diagnosis, and treatment. CLINICAL LYMPHOMA 2003; 4:30-1. [PMID: 12837151 DOI: 10.1016/s1526-9655(11)70005-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Chi-Chao Chan
- Section of Immunopathology Laboratory of Immunology National Eye Institute National Institutes of Health Bethesda, MD, USA
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78
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Hormigo A, DeAngelis LM. Primary ocular lymphoma: clinical features, diagnosis, and treatment. CLINICAL LYMPHOMA 2003; 4:22-9. [PMID: 12837150 DOI: 10.3816/clm.2003.n.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Primary ocular lymphoma involves the globe in the absence of any systemic or central nervous system lymphoma. Diagnosis is frequently delayed and often made only after the tumor has progressed to the brain and meninges. Clinical features, cues in ancillary tests, and immunologic and molecular advances that support the diagnosis are reviewed. The current treatment options are discussed. Although advances have been made, the optimal treatment for primary ocular lymphoma remains to be identified
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Affiliation(s)
- Adilia Hormigo
- Department of Neurology, New York Presbyterian Hospital and Weill College of Medicine of Cornell University, New York, USA
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79
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Chan CC, Shen D, Hackett JJ, Buggage RR, Tuaillon N. Expression of chemokine receptors, CXCR4 and CXCR5, and chemokines, BLC and SDF-1, in the eyes of patients with primary intraocular lymphoma. Ophthalmology 2003; 110:421-6. [PMID: 12578791 DOI: 10.1016/s0161-6420(02)01737-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE Chemokines have a range of biologic activities, including regulation of leukocyte trafficking, modulation of hematopoietic cell proliferation, and adhesion to extracellular matrix molecules. Specifically, B-lymphocyte chemoattractant (BLC); BCA-1; CXCL13, SCYB13) and stromal cell-derived factor-1 (SDF-1, CXCL12, SCYB12) are chemotactic for human B cells, and their ligands CXCR4 and CXCR5 are differentially expressed on B cells, including malignant B cells. We investigated the expression of these chemokine/chemokine receptors in eyes with primary intraocular B-cell lymphoma (PIOL). DESIGN Observational case series (human tissue study). METHODS Three freshly enucleated eyes with PIOL and a normal autopsied eye were frozen and sectioned. The sections were evaluated using immunohistochemistry (avidin-biotin-complex immunoperoxidase technique) for CXCR4, CXCR5, BLC, and SDF-1 to detect the expression and location. Reverse transcriptase-polymerase chain reaction was used to detect chemokine transcripts of CXCR4, CXCR5, BLC, and SDF-1 in PIOL and retinal pigment epithelium (RPE) cells after microdissection-either by laser capture (Arcturus) or by manual dissection-from frozen sections. MAIN OUTCOME MEASURES AND RESULTS The three PIOL eyes showed similar pathology, with typical diffuse large B-lymphoma cells subjacent to the RPE. The eyes also demonstrated a similar chemokine profile. High expression levels of CXCR4 and CXCR5 were found limited to the lymphoma cells. In contrast, BLC protein was expressed in the RPE but not located in other ocular resident cells. SDF-1 was barely detected in a few RPE cells. CXCR4 and CXCR5 transcripts were detected abundantly in lymphoma cells, whereas BLC and SDF-1 transcripts were detected only in the RPE and not the malignant cells. No chemokine expression was detected on the RPE cells in the normal control eye. CONCLUSIONS Chemokines and chemokine receptors selective for B cells were identified in RPE and malignant B cells, respectively. BLC, and possibly SDF-1, attracts both normal and malignant B-cells while promoting migration of only small numbers of T cells and macrophages. We propose that B-cell chemokines may be involved in the pathogenesis of PIOL by selectively attracting lymphoma cells to the RPE from the choroidal circulation. Our data suggest that inhibition of B-cell chemoattractants could be a future strategy for the treatment of PIOL.
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MESH Headings
- B-Lymphocytes/metabolism
- Chemokine CXCL12
- Chemokine CXCL13
- Chemokines, CXC/genetics
- Chemokines, CXC/metabolism
- Eye Enucleation
- Female
- Humans
- Immunoenzyme Techniques
- Lymphoma, B-Cell/genetics
- Lymphoma, B-Cell/metabolism
- Lymphoma, B-Cell/pathology
- Middle Aged
- Neoplasm Proteins/metabolism
- Pigment Epithelium of Eye/metabolism
- RNA, Messenger/metabolism
- Receptors, CXCR5
- Receptors, Chemokine
- Receptors, Cytokine/genetics
- Receptors, Cytokine/metabolism
- Retinal Neoplasms/genetics
- Retinal Neoplasms/metabolism
- Retinal Neoplasms/pathology
- Reverse Transcriptase Polymerase Chain Reaction
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Affiliation(s)
- Chi-Chao Chan
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg. 10, Rm. 10N103, 90 Center Drive, Bethesda, MD 20892-1857, USA
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Abstract
Primary central nervous system lymphoma (PCNSL) is an aggressive non-Hodgkin's lymphoma associated with a poor prognosis without treatment. The incidence in immunocompetent patients appears to be increasing. Patients present with nonspecific neurologic symptoms or visual symptoms and contrast-enhancing lesions that abut a cerebrospinal fluid (CSF) space. A subset of patients have positive CSF cytology or ocular involvement. Tissue diagnosis is accomplished by stereotactic biopsy, CSF cytology, or vitreous aspirate. Corticosteroids may obscure the results of tissue specimens and are best avoided prior to tissue diagnosis. PCNSL has emerged as a treatment- sensitive tumor responsive to corticosteroids, radiotherapy, and methotrexate-based chemotherapy. The most effective treatment program has not yet been identified, but it is clear that regimens containing high-dose methotrexate improve survival over radiotherapy alone. Because combined chemo-radiotherapy has been associated with late neurologic toxicities, especially in patients over the age of 60 years, chemotherapy without radiotherapy is being explored further. Significant progress in the treatment of PCNSL has been made in the past 10 years. Further progress will depend heavily on improved understanding of lymphoma biology, and future trials need to focus on improving survival rates while avoiding late neurologic toxicity.
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Affiliation(s)
- Leslie D McAllister
- Legacy Brain and Spinal Cord Tumor Service, Legacy Cancer Services, Legacy Hospital System, 1040 NW 22nd Avenue, Portland, OR 97210, USA.
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