Orbital lymphoma: imaging features and differential diagnosis

Ocular adnexal lymphoma - A single-center observational study of survival outcomes

PURPOSE

This study aims to comprehensively characterize the clinical, demographic, and histopathological features of ocular adnexal lymphoma (OAL) and assess their impact on patients' survival outcomes.

METHODS

A total of 123 patients were included in the study; of these, 93 patients were selected for survival analysis. Survival data were analyzed using the Kaplan-Meier test, and correlation was assessed through the log-rank test and Cox regression analysis.

RESULTS

The median age at presentation was 56 years. Furthermore, 98% of patients had primary OAL. The orbit was the most common site of involvement. The majority of patients were of B-cell origin (98%), and only 2% of patients had T-cell lymphoma. In addition, 83% of patients were treated with chemotherapy, and with a median follow-up of 38 months, complete remission was achieved in 48% of patients. The median progression-free survival was 26.4 months. The presence of disseminated disease was strongly linked to an unfavorable prognosis ( P < 0.001) and reduced survival ( P = 0.037).

CONCLUSION

The 5-year overall survival of the entire study cohort was 81%. The prognosis for OAL is found to be favorable, but the presence of dissemination serves as a notable predictor for poor prognosis.

Practical Approach to Orbital Lesions by Anatomic Compartments

A wide range of pathologic conditions can originate in the orbit. While it is common to approach the differential diagnosis based on disease categories, such as neoplastic and inflammatory, segmenting the orbit into anatomic compartments can direct the radiologist toward the most common pathologic conditions for each manifestation and space. The orbit can be divided into intraconal, conal, and extraconal compartments. Additionally, the optic nerve sheath complex and lacrimal apparatus can be partitioned into separate compartments due to their unique functions and pathologic features. By using this anatomic approach, the authors review the most common pathologic conditions affecting the orbit and discuss clinical and imaging findings that can guide the differential diagnosis for lesions with similar appearances. Published under a CC BY 4.0 license. Supplemental material is available for this article.

MR Imaging Characteristics of Solitary Fibrous Tumors of the Orbit : Case Series of 18 Patients

PURPOSE

Solitary fibrous tumor (SFT) of the orbit is a rare tumor that was first described in 1994. We aimed to investigate its imaging characteristics that may facilitate the differential diagnosis between SFT and other types of orbital tumors.

MATERIAL AND METHODS

Magnetic resonance imaging (MRI) data of patients with immunohistochemically confirmed orbital SFT from 2002 to 2022 at a tertiary care center were retrospectively analyzed. Tumor location, size, morphological characteristics, and contrast enhancement features were evaluated.

RESULTS

Of the 18 eligible patients 10 were female (56%) with a mean age of 52 years. Most of the SFTs were oval-shaped (67%) with a sharp margin (83%). The most frequent locations were the laterocranial quadrant (44%), the extraconal space (67%) and the dorsal half of the orbit (67%). A flow void phenomenon was observed in nearly all cases (94%). On the T1-weighted imaging, tumor signal intensity (SI) was significantly lower than that of the retrobulbar fat and appeared predominantly equivalent (82%) to the temporomesial brain cortex, while on T2-weighted imaging its SI remained equivalent (50%) or slightly hyperintense to that of brain cortex. More than half of the lesions showed a homogeneous contrast enhancement pattern with a median SI increase of 2.2-fold compared to baseline precontrast imaging.

CONCLUSION

The SFT represents a rare orbital tumor with several characteristic imaging features. It was mostly oval-shaped with a sharp margin and frequently localized in the extraconal space and dorsal half of the orbit. Flow voids indicating hypervascularization were the most common findings.

Ocular lymphoma: overcoming a diagnostic challenge with an endoscopic sinus approach

BACKGROUND

Ocular lymphomas are rare, indolent tumours that pose a diagnostic challenge. Patients may be asymptomatic or present with symptoms of increased orbital mass. An index of suspicion is required alongside an understanding of the diagnostics and staging required to facilitate expedited multi-disciplinary work-up and management.

METHODS

A comprehensive literature review was performed. We present a series of three cases, each presenting their own diagnostic challenge.

RESULTS

Although ocular lymphomas are notoriously difficult to diagnose histologically, our case series show procurement of a diagnostic histological sample using an image-guided endoscopic sinus approach.

CONCLUSIONS

Although not typically involved in the diagnosis or management, the otolaryngologist may encounter ocular lymphoma masquerading as sinus disease or with disseminated disease at other sites in the head and neck. Endoscopic sinus surgery is considered a safe, effective approach for achieving a histological diagnosis in these cases.

A rare case of orbital mantle cell lymphoma presenting as a well-demarcated mass on magnetic resonance imaging

A 71-year-old male presented with painless and slowly progressive proptosis of the right eye. The patient had no history of cancer and was in good health. Orbital magnetic resonance imaging showed a well-demarcated, slightly lobulated intraconal orbital mass hypo-isointense on T1- weighted and isointense on T2-weighted images, demonstrating contrast enhancement in the right orbit. The lesion had a central cavitary region. An anterior orbitotomy with lower lid crease incision was performed and the lesion was excised in toto. Histopathologic examination revealed diffuse infiltration of monomorphic population of small lymphoid cells. Immunohistochemical staining demonstrated diffuse and strong positivity for CD20, CD5, and cyclin D1. Histopathological and immunohistochemical findings were consistent with mantle cell lymphoma. Positron emission tomography-computed tomography did not show systemic involvement. The patient underwent orbital external beam radiotherapy (36 Gy). There was no recurrence and/or systemic involvement at 2.5 years follow-up.

Radiological analysis of orbital lymphoma histological subtypes

PURPOSE

To characterise the radiological features of orbital lymphoma subtypes.

METHODS

This was a multicentre, retrospective study to analyse radiological and clinical characteristics of orbital lymphoma by histological subtype across two sites within Australia and the United States.

RESULTS

A total of eighty-eight patients were included. The most common subtypes were extranodal marginal zone lymphoma [EMZL] (48, 54.5%), follicular lymphoma [FL] (16, 18.2%), and diffuse large B-cell lymphoma [DLBCL] (15, 17.0%). Clinically, significant associations were found between DLBCL and vision change (p < .01), pain (p < .01), extraocular movement limitation (p = .01), and optic neuropathy (p = .01). Radiologically, there was no significant difference between the individual histopathological sub-groups with respect to bone destruction (p = .30), optic nerve involvement (p = .30) and diffuse appearance (p = .84). However, if categorised as either aggressive or indolent, aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically than indolent subtypes (Odds Ratio = 5.5, 95% CI: 1.3, 23.3; p = .02).

CONCLUSIONS

DLBCL was significantly associated with vision change, pain, extraocular movement limitation and optic neuropathy clinically. Aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically. Otherwise, there were no significant differences between lymphoma subtypes and radiological findings on MRI and CT.

Cross-sectional imaging evaluation of atypical and uncommon extra-nodal head and neck Non-Hodgkin lymphoma: Case series

Extra-nodal Non-Hodgkin lymphoma (ENHL) of the head and neck is not uncommon and has variable clinical and imaging presentations. It represents about 25% of extra-nodal lymphomas. In addition, lymphoma is the third most common malignancy of the head and neck just after squamous cell carcinoma (SCC) and salivary gland neoplasms. Unlike SCC, ENHL usually presents as a well-defined mass in the oral cavity, along the pharyngeal mucosa, sinonasal cavity, orbit, and other different neck spaces. One of the common presentations of ENHL is the glandular type which can arise within the salivary or thyroid glands as marginal zone non-Hodgkin lymphoma. ENHL can infiltrate the bone resembling high grade osseous malignancies. Rarely, ENHL can present as perineural spread without definitive mass and manifest clinically with several neuropathies. In this case series, we presented different imaging features and presentation of ENHL of the head and neck. The knowledge of various presentations of ENHL of the head and neck can help early diagnosis and prompt management of these patients' population.

End-to-End Deep-Learning-Based Diagnosis of Benign and Malignant Orbital Tumors on Computed Tomography Images

Determining the nature of orbital tumors is challenging for current imaging interpretation methods, which hinders timely treatment. This study aimed to propose an end-to-end deep learning system to automatically diagnose orbital tumors. A multi-center dataset of 602 non-contrast-enhanced computed tomography (CT) images were prepared. After image annotation and preprocessing, the CT images were used to train and test the deep learning (DL) model for the following two stages: orbital tumor segmentation and classification. The performance on the testing set was compared with the assessment of three ophthalmologists. For tumor segmentation, the model achieved a satisfactory performance, with an average dice similarity coefficient of 0.89. The classification model had an accuracy of 86.96%, a sensitivity of 80.00%, and a specificity of 94.12%. The area under the receiver operating characteristics curve (AUC) of the 10-fold cross-validation ranged from 0.8439 to 0.9546. There was no significant difference on diagnostic performance of the DL-based system and three ophthalmologists (p > 0.05). The proposed end-to-end deep learning system could deliver accurate segmentation and diagnosis of orbital tumors based on noninvasive CT images. Its effectiveness and independence from human interaction allow the potential for tumor screening in the orbit and other parts of the body.

Orbital Muscle Enlargement: What if It’s Not Graves’ Disease?

Purpose of Review

To provide the radiologist with tools to recognize findings atypical for Graves’ ophthalmopathy and differentiate between the most important and common alternative causes of extraocular muscle enlargement on CT and MR imaging.

Recent findings

We introduce five ‘red flags’ representing features that are atypical for Graves’ ophthalmopathy: unilateral disease, atypical pattern of muscle involvement, adjacent structure involvement, restricted diffusion, and absence of pain.

Summary

About 95% of the cases with extraocular enlargement are due to Graves’ ophthalmopathy, other causes are less well known and recognized. The ‘red flags’ may aid in recognizing and suggesting alternative diagnoses.

Ocular adnexal mucosa-associated lymphoid tissue lymphoma: a narrative review

Lymphoma is the most common primary tumor of the orbit, accounting for 55% of all orbital malignancies. When divided into histopathological subtypes, extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) comprises the largest proportion. Clinical manifestations are unspecific, but in patients with slow-growing painless orbital mass, or red conjunctival lesion suggestive of 'salmon patch', ocular adnexa lymphoma (OAL) should be suspected. Although the pathogenetic mechanism of ocular adnexal MALT lymphoma (OAML) is not yet fully understood, the relationship between OAML and Chlamydia psittaci has been hypothesized recently, similar to that between gastric MALT lymphoma and Helicobacter pylori. This suggests a new treatment option for OAML; bacterial eradication therapy with systemic antibiotics. Several other treatment methods for OAML have been introduced, but no treatment guidelines have been established yet. In this article, we summarize the current knowledge on the clinical features, pathogenesis, diagnostic methods, therapeutic strategies, and prognosis of OAML.

[Differential diagnosis of intraorbital masses - a narrative review]

OBJECTIVE

Intraorbital masses represent a condition that is frequently threatening for the visual system. A rigorous differential diagnosis is essential to promptly initiate appropriate therapy and optimize prognosis.

MATERIALS/METHODS

Narrative review of current literature and expert recommendations. For further illustration we describe the case of a 71-year-old male admitted to our department three months after sinus surgery. Postoperative intraorbital hematoma of the right orbit had been treated conservatively with antibiotics/corticosteroids, leading to a near-complete unilateral visual loss. The immediate surgical intervention aimed at decompression of the orbit and the optical nerve. Due to the delay, the intervention could not prevent formation of a lipogranuloma. Inflammatory phases associated with the lipogranuloma are successfully managed by conservative treatment based on multidisciplinary recommendations.

RESULTS

In the case reported, delay of surgical therapy acted as a cause of intraorbital lipogranuloma formation. Literature supports our recommendation of immediate surgical intervention in case of acute retrobulbar hematoma. Besides acute conditions, intraorbital masses can be a sign of systemic disease. In every case, a multidisciplinary therapeutic approach is required for adequate management.

CONCLUSIONS

Intraorbital masses can occur as a complication of trauma or e.g. sinus surgery. On the other hand they can be a sign of systemic disease. Timely diagnosis and treatment prevents from visual loss. That is why rigorous differential diagnosis is essential for every discipline managing intraorbital lesions.

Low-Dose Radiotherapy Versus Moderate-Dose Radiotherapy for the Treatment of Indolent Orbital Adnexal Lymphomas

Purpose

Radiation therapy (RT) with doses ranging from 24 Gray (Gy) to 40 Gy is a proven treatment modality for indolent orbital adnexal lymphoma (IOAL), but recently the use of low dose RT (LDRT, defined as 2 Gy x 2 fractions) has become a notable alternative. However, limited data exists comparing outcomes following LDRT to moderate-dose RT (MDRT, RT dose 4 – 36 Gy). We present a single institution retrospective analysis comparing outcomes of patients with IOALs following LDRT or MDRT.

Methods

A total of 36 patients treated with 38 consecutive courses of RT were identified; LDRT was delivered for 14 courses and MDRT for 24 courses. Overall response rates (ORR) were recorded according to Deauville or RECIST criteria with a response characterized as a complete response (CR) or partial response. Local control (LC), orbital control (OC), and overall survival (OS) rates were estimated with the Kaplan-Meier method. RT toxicity was graded per CTCAEv5 and compared with the Fisher’s exact test.

Results

Median follow-up time was 29 months (m) (range, 4-129m), and median MDRT dose used was 24 Gy (range 21-36 Gy). Overall response rates (ORR) were 100% (CR 50%) and 87.5% (CR 58.3%) following LDRT and MDRT, respectively. OS at 2 years was 100% and 95% for the LDRT and MDRT groups, respectively (p=0.36). LC rates at 2 years was 100% for both LDRT and MDRT groups and at 4 years was 100% and 89% for the LDRT and MDRT groups, respectively (p=0.56). The 4-year OC rate (including both ipsilateral and contralateral relapses) was 80% and 85% for the LDRT and MDRT groups, respectively (p=0.79). No patient required treatment with RT to a previously irradiated orbit. Acute toxicities were reported following 6 LDRT courses compared to 20 MDRT courses (p=.014). No Grade 3 or higher acute toxicities occurred in either group. Late toxicities were reported following 2 LDRT courses compared to 10 MDRT courses (p=0.147).

Conclusions

LDRT produced similar ORR, LC, OC, and OS rates compared to MDRT with fewer acute and minimal late toxicities reported. Future multi-center studies with larger patient numbers are warranted to show significant associations.

Low-dose 'boom-boom' radiotherapy for ocular lymphoma arising from IgG4-related ophthalmic disease: Case report and literature review

Ocular adnexal extranodal marginal zone lymphoma (OA-EMZL) and immunoglobulin G4-related ophthalmic disease (IgG4-ROD) may exist on a continuum. Presence of immunoglobulin light-chain restriction and clonal gene rearrangement suggests presence of lymphoma; whereas bilateral, infraorbital nerve and systemic involvement accompanied by elevated serum IgG4 levels may indicate synchronous IgG4-ROD. Although steroids have been the mainstay for the treatment of IgG4-ROD, radiotherapy (RT) has been used occasionally. The reported RT doses range between 24 and 30 Gy, which can result in acute and late toxicities. A low-dose regimen of four Gy has not been previously described. We describe a patient with bilateral OA-EMZL arising from IgG4-ROD successfully treated with low dose 'boom-boom' radiotherapy. In addition, we review the literature for the association between these two conditions and the role of RT in their management.

A case report of secondary bilateral orbital lymphoma in a child

Lymphoma is one of the most common cancers of the orbital and lacrimal glands, after squamous cell carcinoma and melanoma. Based on cell origin, most lymphoma cases are classified as non-Hodgkin lymphoma. Orbital lymphoma can be either primary or secondary. The clinical manifestations of lymphoma are diverse, with the most common symptoms being bilateral or unilateral proptosis, limited eye motility, swelling, pain, changes in visual acuity, and diplopia. In this article, we describe the case of a 6-year-old male who presented with bilateral rapid orbital swelling for 10 days. This patient underwent surgical biopsy, and the final diagnosis was bilateral orbital secondary non-Hodgkin lymphoma.

To Explore MR Imaging Radiomics for the Differentiation of Orbital Lymphoma and IgG4-Related Ophthalmic Disease

Among orbital lymphoproliferative disorders, about 55% of diagnosed cancerous tumors are orbital lymphomas, and nearly 50% of benign cases are immunoglobulin G4-related ophthalmic disease (IgG4-ROD). However, due to nonspecific characteristics, the differentiation of the two diseases is challenging. In this study, conventional magnetic resonance imaging-based radiomics approaches were explored for clinical recognition of orbital lymphomas and IgG4-ROD. We investigated the value of radiomics features of axial T1- (T1WI-) and T2-weighted (T2WI), contrast-enhanced T1WI in axial (CE-T1WI) and coronal (CE-T1WI-cor) planes, and 78 patients (orbital lymphoma, 36; IgG4-ROD, 42) were retrospectively reviewed. The mass lesions were manually annotated and represented with 99 features. The performance of elastic net-based radiomics models using single or multiple modalities with or without feature selection was compared. The demographic features showed orbital lymphoma patients were significantly older than IgG4-ROD patients (p < 0.01), and most of the patients were male (72% in the orbital lymphoma group vs. 23% in the IgG4-ROD group; p = 0.03). The MR imaging findings revealed orbital lymphomas were mostly unilateral (81%, p = 0.02) and wrapped eyeballs or optic nerves frequently (78%, p = 0.02). In addition, orbital lymphomas showed isointense in T1WI (100%, p < 0.01), and IgG4-ROD was isointense (60%, p < 0.01) or hyperintense (40%, p < 0.01) in T1WI with well-defined shape (64%, p < 0.01). The experimental comparison indicated that using CE-T1WI radiomics features achieved superior results, and the features in combination with CE-T1WI-cor features and the feature preselection method could further improve the classification performance. In conclusion, this study comparatively analyzed orbital lymphoma and IgG4-ROD from demographic features, MR imaging findings, and radiomics features. It might deepen our understanding and benefit disease management.

Imaging of head and neck mucosa-associated lymphoid tissue lymphoma (MALToma)

Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALToma) arises in extranodal sites in the head and neck. Chronic inflammatory, infectious or autoimmune conditions are implicated in its pathogenesis. Within the head and neck, MALToma is often multifocal and indolent and the imaging appearances may be mistaken for non-malignant disease in the head and neck. The aim of this article is to illustrate the varied radiological and clinical features of MALToma in the head and neck, an awareness of which is needed for timely and correct diagnosis to guide subsequent disease management.

The utility of fine needle aspiration cytology in orbital haematolymphoid neoplasms

BACKGROUND

Orbital hematolymphoid lesions are rare and usually encountered in elderly patients. Orbital lesions are not easy to biopsy: hence fine needle aspiration cytology (FNAC) can be a very good diagnostic modality for these lesions.

MATERIALS AND METHODS

Cases of orbital masses subjected to FNAC dating from 2013 to 2020 were retrieved from our archives. A total of 16 cases with biopsy confirmation were included. All clinical details, the type of procedure, details of the immunocytochemistry (ICC) performed on smear, follow-up biopsy, and their haematological work-up were analysed in detail.

RESULTS

Sixteen biopsy-confirmed cases had been diagnosed as orbital haematolymphoid lesions on cytomorphology and further categorised with ancillary studies including ICC. In twelve instances, the cytology impression was congruent with the histopathological diagnosis and eight of the sixteen cases (50%) proved to be primary orbital lymphoma. Four were secondary orbital lymphomas and the remaining four included one case each of plasmacytoma, myeloid sarcoma, Rosai-Dorfman disease and angiolymphoid hyperplasia with eosinophilia.

CONCLUSION

FNAC is a minimally invasive procedure for diagnosing most of the haematolymphoid orbital lesions and it has a rapid turnaround time. The accuracy of cytomorphology combined with ICC on smears/cell blocks can be as good as a biopsy for exact categorisation. Additionally, aspirate smears are preferred samples for cytogenetics compared to formalin-fixed tissue blocks, as molecular cytogenetics techniques are frequently employed for diagnostic, prognostic, and therapeutic purposes.

Arterial spin labeling and diffusion-weighted MR imaging: Utility in differentiating idiopathic orbital inflammatory pseudotumor from orbital lymphoma

PURPOSE

To assess arterial spin-labeling (ASL) and diffusion-weighted imaging (DWI) and in combination for differentiating between idiopathic orbital inflammatory pseudotumor (IOIP) and orbital lymphoma.

MATERIAL AND METHODS

A retrospective study was done on 37 untreated patients with orbital masses, suspected to be IOIP or orbital lymphoma that underwent ASL and DWI of the orbit. Quantitative measurement of tumor blood flow (TBF) and apparent diffusion coefficient (ADC) of the orbital lesion was done.

RESULTS

There was a significant difference (P = 0.001) in TBF between patients with IOIP (n = 21) (38.1 ± 6.2, 40.3 ± 7.1 ml/100 g/min) and orbital lymphoma (n = 16) (55.5 ± 7.1, 56.8 ± 7.9 ml/100 g/min) for both observers respectively. Thresholds of TBF used for differentiating IOIP from orbital lymphoma were 48, 46 ml/100 g/min revealed area under the curve (AUC) of (0.958 and 0.921), and accuracy of (86% and 83%) for both observers respectively. There was a significant difference (P = 0.001) in ADC between patients with IOIP (1.04 ± 0.19, 1.12 ± 0.23 × 10^-3 mm²/s) and orbital lymphoma (0.69 ± 0.10, 0.72 ± 0.11 × 10^-3 mm²/s) for both observers respectively. Thresholds of ADC used for differentiating IOIP from orbital lymphoma were 0.84 and 0.86 × 10^-3 mm²/s with AUC of (0.933 and 0.920), and accuracy of 89% and 90% for both observers respectively. The combined TBF and ADC used for differentiating IOIP from orbital lymphoma had AUC of (0.973 and 0.970) and accuracy of (91% and 89%) for both observers respectively.

CONCLUSION

TBF and ADC alone and in combination are useful for differentiating IOIP from orbital lymphoma.

Primary Orbital Lymphoma – A Challenging Diagnosis

Background and purpose: The occurrence of primary orbital lymphoma comprises approximately 1% of non-Hodgkin’s lymphoma and 8% of extranodal lymphoma. The vast majority of orbital lymphomas are of B-cell origin, of which extranodal marginal zone B-cell lymphoma is the most common subtype. The purpose of this paper was to present the diagnostic challenges in a case of orbital lymphoma. Case presentation: An 84-year -old woman with orbital tumour was operated on after a long period of inappropriate treatment. It was later diagnosed as B-cell lymphoma.

Conclusion: Orbital lymphoma can be easily mistaken for another ocular disease due to the slowly progressing non-specific complaints of the patients. We should be alert to the possibility of this ocular diagnosis when we are presented with an elderly patient with proptosis.

Orbital solitary fibrous tumors: a multi-centered histopathological and immunohistochemical analysis with radiological description

BACKGROUND

Solitary fibrous tumors (SFT), formerly called hemangiopericytoma, are rare tumors derived from mesenchymal cells originally described in the pleura, but these tumors may affect extraserosal tissues including the lacrimal gland and orbit.

OBJECTIVE

Conduct a multi-centered clinical, radiological and histopathological analysis of 17 orbital SFT cases.

DESIGN

A retrospective case series.

SETTING

Three eye centers in two countries.

PATIENTS AND METHODS

The data collected from the charts of 17 adult patients presenting with tissue diagnosis of orbital hemangiopericytoma or SFT from January 2003 to December 2018 included demographics, clinical imaging and histopathological information including immunohistochemical (IHC) characteristics.

MAIN OUTCOME MEASURES

The demographic characteristics, clinical presentation, and histopathological patterns or variants of SFT were analyzed.

SAMPLE SIZE

17 adult patients.

RESULTS

Mean age was 45 years (range 23-80 years). Male to female ratio was 3:1. The right eye was affected in 12 (70.5%) patients. Commonest presentation was proptosis in 13/17 (76% of patients). Other symptoms were impaired motility (29%) and ptosis (11%). Lesions mostly affected the medial orbit (35%), then orbital apex in 11%. The histopathological classic pattern-less variant was the commonest. One case with aggressive behavior, multiple recurrences and atypical features was encountered. Immunohistochemical (IHC) markers used included CD34 expression in all cases, Bcl-2 expression in 10/11, CD99 in 9/9 and Vimentin in 4/4. STAT6 was used in 2 cases.

CONCLUSIONS

SFTs are rare tumors affecting the orbit in both genders equally in their mid-forties, but showed male predominance in our analysis with a predominant classic histopathological pattern. Tissue diagnosis is essential and requires IHC studies for confirmation.

LIMITATIONS

Sample size is relatively small owing to the rarity of this tumor in the orbit.

CONFLICT OF INTEREST

None.

A large primary orbital lymphoma with proptosis: A case report and review

Background:

Primary orbital lymphomas are a rare subset of tumors constituting 1–2% of non-Hodgkin's lymphoma. They are mostly indolent B-cell lymphomas presenting with gradual progressive proptosis, decreased visual acuity, restricted ocular mobility, and diplopia. The role of surgery is mainly for obtaining a biopsy. Most of these tumors require multimodality treatment including chemotherapy, radiation, or both, which have major role.

Case Description:

We report one such case of marginal zone lymphoma of the orbit in a female with significant proptosis who was treated with multimodality treatment, including surgical excision as a major treatment modality. Decompression of symptomatic proptosis was followed by chemotherapy and radiation.

Conclusion:

Primary orbital lymphoma is a rare clinical entity with diverse clinical outcomes. It can be successfully managed with surgical excision for decompression of mechanical proptosis followed by chemotherapy, radiation, or both.

[Clinical features of malignant orbital lymphoma]

INTRODUCTION

The occurrence of malignant lymphoma (ML) among patients with malignant orbital tumors ranges between 10 and 37.3% making early diagnosis clarification crucial for timely treatment.

PURPOSE

To study clinical features of ML with consideration of its morphological type and localization in the orbit.

MATERIAL AND METHODS

Clinical picture of primary malignant orbital lymphoma of 34 patients (36 orbits) was examined retrospectively with consideration of the tumor's morphotype. Median observation time was 6 years. Patients aged between 34 and 84 years, female to male ratio was 1.27:1.

RESULTS

The final diagnoses were: small cell MALT-type ML (23 patients), large cell B-lymphoma (5 patients), diffuse malignant lymphoma (5 patients), T-cell lymphoma (1 female patient). Systemic changes developed in 29.41% of cases after 6.7 years on average. 23.53% of patients has died. Clinical signs of MALT-type ML were described with consideration of tumor's localization in the orbit, and clinical features of B-cell, large cell, diffuse and T-cell lymphoma were shown. Signs helping differentiate ML from false tumor, composite tear gland tumor and malignant orbital tumor were established.

CONCLUSION

Despite the higher prevalence of malignant MALT-type lymphoma, primary malignant orbital lymphoma is characterized by unfavorable vital prognosis: in a third of all cases, signs of systemic lesion develop in 6.7 years on average. Clinical picture of MALT-type ML is defined by tumor's localization in the orbit. Recurrence of MALT-type ML after combined treatment (surgical, radiotherapy, polychemotherapy) happens in every fourth case among patients with tumor primarily localized in the orbital cellular tissues or in the tear gland. Describing clinical features of primary malignant orbital lymphoma allows faster diagnosis clarification reducing the number of orbital diseases that require differential diagnositcs.

Radiological-Pathological Correlation in Plasmablastic Lymphoma in an Immunocompromised Patient

Plasmablastic lymphoma (PBL) is a malignant, rare, and aggressive form of non-Hodgkin's lymphoma with poor response to treatment that most commonly involves the oral mucosa of immunodeficient patients. The orbit might be primarily or secondarily involved; on the other hand other pathological conditions, i.e., fungal infections, may localize in the orbit in both immunocompromised patients and drug user, which might have similar radiological features. We describe the clinical, radiological, and pathological features of an orbital plasmablastic lymphoma (PBL) in an immunocompromised HIV positive drug user patient.

Isolated superior oblique muscle extranodal marginal zone B cell lymphoma: case report

We describe a rare case of isolated extraocular muscle ocular adnexal lymphoma of a middle-aged female who presented with redness in the left eye associated with progressive proptosis over one year. Magnetic resonance imaging of the orbit indicated isolated enlargement of the left superior oblique (SO) muscle with an apparent diffusion coefficient (ADC) of (0.77 ± 0.11 × 10⁻³ mm²/s). Histopathology with immunohistochemical staining of the incisional biopsy from the SO muscle belly confirmed the diagnosis of extranodal marginal zone B cell lymphoma.

Retrospective chart review of the use of imaging and biopsy in the diagnosis of optic nerve sheath meningiomas and intra-conal orbital lymphomas at a single institution

Optic nerve sheath meningiomas (ONSM) and intra-conal orbital lymphomas are common entities on the differential of a retrobulbar optic nerve involving space-occupying lesion. In this study, we compare the pre-surgical diagnosis, based on clinical presentation and neuroimaging, to the surgical pathology results of intra-conal orbital lymphomas and ONSM. This is an IRB approved retrospective chart review of orbital lymphomas and optic nerve sheath meningiomas biopsied by a single surgeon over a 4-year period at a single institution. Pre-surgical diagnosis and surgical pathology were compared. Fifteen cases of orbital lymphoma were identified. Fourteen were excluded based on extra-conal location. The single histologically confirmed intra-conal orbital lymphoma had a pre-surgical diagnosis of ONSM. Four cases of optic nerve sheath meningioma were identified. Three of the 4 cases of histologically confirmed ONSM had a pre-surgical diagnosis of ONSM. One of the 4 had a pre-surgical diagnosis of lymphoma. Diagnosis based on surgical pathology differed from the pre-surgical diagnosis in 2 out of 5 cases showing that clinical diagnosis does not always correlate with histologic diagnosis. Although both diseases are typically managed with radiation therapy, the treatment dosage and systemic disease implications are very different. These findings emphasis the importance of biopsy in the diagnosis of orbital lesions surrounding the optic nerve.

Multimodality Imaging Spectrum of the Extranodal Lymphomas in the Head and Neck-A Pictorial Review

Lymphoma is the second most common malignant neoplasm of the head and neck region, involving the nodal and/or extranodal sites or both in a variable fashion. Lymphoma may mimic a variety of tumors in this region depending on the subsite involved. The usual presentation of lymphomatous disease is presence of multiple enlarged, often conglomerate, lymph nodes without significant necrosis. Extranodal lymphomas demonstrate more complex radiologic features, but careful evaluation can identify distinct imaging patterns to suggest extranodal lymphomatous disease from other more common lesions. Knowledge of these imaging features can help raise suspicion for lymphoma as a differential consideration. This can be of critical importance since further work-up and management can be vastly different between lymphomatous disease and other disease entities. The authors present a pictorial review of the spectrum of imaging findings in extranodal head and neck lymphomas.

Primary Ocular Adnexal Extranodal Marginal Zone Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma Presenting as Orbital Apex Syndrome

A 75-year-old female with a past medical history significant for prior stroke and atrial fibrillation presented with acute onset of orbital apex syndrome with chemosis and periorbital ecchymosis. Following initial treatment to relieve intraocular pressure, she began spontaneously haemorrhaging retro-orbitally. Preliminary investigation with neuroimaging demonstrated a left orbital mass with extension into the orbital apex. A provisional diagnosis of cavernous haemangioma was made. She was treated with transorbital resection of the orbital mass. Subsequent histopathology revealed a diagnosis of ocular adnexal non-Hodgkin lymphoma of histologic type extranodal marginal zone of mucosa-associated lymphoid tissue (MALT lymphoma). MALT lymphoma should be considered in cases of orbital apex syndrome.

Primary Orbital Follicular Lymphoma: A Case Report and Review

Orbital Lymphomas (OL) constitute a heterogeneous group of lymphoproliferative disorders of the orbit. They are predominantly of the Mucosa-Associated Lymphoid Tissue (MALT) subtype. Radiotherapy is the mainstay of treatment in localized orbital tumours, while chemotherapy is reserved for systemic disease. Authors report a case of a primary orbital lymphoma of follicular subtype (stage 1E) in a 54-year-old female managed by surgery and adjuvant radiotherapy.

Benign and malignant orbital lymphoproliferative disorders: Differentiating using multiparametric MRI at 3.0T

PURPOSE

To determine the optimal combination of parameters derived from 3T multiparametric (conventional magnetic resonance imaging [MRI], diffusion-weighted [DW] and dynamic contrast-enhanced [DCE]) MRI for differentiating malignant from benign orbital lymphoproliferative disorders (OLPDs).

MATERIALS AND METHODS

Forty patients with OLPDs (18 benign and 22 malignant) underwent conventional 3.0T MR, DW, and DCE-MRI examination for presurgery evaluation. Conventional MRI features (including tumor laterality, shape, number of involved quadrants, signal intensity on T₁ -weighted imaging (WI) and T₂ WI, flow void sign on T₂ WI, and findings suggestive of sinusitis) were reviewed, and multivariate logistic regression analysis was used to identify the most significant conventional MRI features. Apparent diffusion coefficient (ADC) and DCE-MRI derived parameters (area under curve [AUC], time to peak [TTP], maximum rise slope [Slope_max ]) were measured and compared between two groups. Receiver operating characteristic (ROC) curve analyses were used to determine the diagnostic ability of each combination that was established based on identified qualitative and quantitative parameters.

RESULTS

Multivariate logistic regression analysis showed that the presence of flow void sign on T₂ WI significantly associated with benign OLPDs (P = 0.034). Malignant OLPDs demonstrated significantly lower ADC (P = 0.001) and AUC (P = 0.002) than benign mimics. ROC analyses indicted that, ADC alone showed the optimal sensitivity (threshold value, 0.886 × 10^-3 mm² /s; sensitivity, 90.9%), while a combination of no presence of flow void sign on T₂ WI + ADC ≤ 0.886 × 10^-3 mm² /s + AUC ≤ 7.366 showed optimal specificity (88.9%) in differentiating benign from malignant OLPDs.

CONCLUSION

Multiparametric MRI can help to differentiate malignant from benign OLPDs. DWI offers optimal sensitivity, while the combination of conventional MRI, DWI, and DCE-MRI offers optimal specificity.

LEVEL OF EVIDENCE

3 J. Magn. Reson. Imaging 2017;45:167-176.

A case report of primary orbital non-Hodgkin's lymphoma causing complete vision loss

A 29-year-old male with acquired immunodeficiency syndrome presented with a week of left eye blurriness, which then progressed to complete vision loss. On exam, the left pupil was nonreactive to light, and fundoscopy showed significant optic nerve edema. CT and MRI of the left orbit showed a mass lesion compressing the posterior aspect of the sclera with diffuse thickening and contrast enhancement of the retrobulbar portion of the left optic nerve. The lesion demonstrated low T1 and intermediate T2 intensities and heterogeneous contrast enhancement and measured 17.4 mm x 15 mm x 10.6 mm. Anterior orbitotomy with exploration and biopsy were performed. Immunohistochemical studies confirmed diffuse large B-cell lymphoma and a workup showed no systemic involvement. Plans for treatment with chemotherapy and radiation were initiated.

Even though rare, primary orbital NHL should be in the differential for relatively acute blindness without other symptoms, especially in patients with AIDS.

An update on ocular adnexal lymphoma

Ocular adnexal lymphoma (OAL) is a relatively common lesion in the practice of ophthalmic oncology. Although OALs are usually primary tumors, secondary involvement of the ocular adnexae by systemic lymphoma is also possible. The clinical and radiological features of OAL are non-specific. Thorough morphological evaluation, aided by immunostaining, cytogenetic studies and molecular testing, are necessary for accurate diagnosis.

Bilateral orbital myeloid sarcoma preceding acute myeloid leukemia in an adult: a case report and review of the literature

Background

Acute myeloid leukemia is typically a disease of the older population and presents mostly in the fifth decade of life. Myeloid sarcoma is a rare initial presentation of acute myeloid leukemia. Previously it has only been documented in children and younger patients.

Case Presentation

We present an unusual case of retro-orbital myeloid sarcoma as an initial presentation of acute myeloid leukemia in a 43-year-old Caucasian man, with rearrangement of chromosome 11q23 involving the MLL gene.

Conclusions

We present an unusual case of retro-orbital myeloid sarcoma as an initial presentation of acute myeloid leukemia in a 43-year-old man, with rearrangement of chromosome 11q23 involving the MLL gene.

Orbital Indeterminate Lesions in Adults: Combined Magnetic Resonance Morphometry and Histogram Analysis of Apparent Diffusion Coefficient Maps for Predicting Malignancy

RATIONALE AND OBJECTIVES

The aim of this study was to evaluate the added value of histogram analysis of apparent diffusion coefficient (ADC) maps in differentiating indeterminate orbital malignant tumors from benign tumors, compared to using magnetic resonance (MR) morphological features alone.

MATERIALS AND METHODS

We retrospectively evaluated 54 patients with orbital tumors from March 2013 to February 2015. All the patients were assessed by both routine MR and diffusion-weighted imaging, and divided into benign group and malignant group. Routine MR imaging features and histogram parameters derived from ADC maps, including mean ADC (ADCmean), median ADC (ADCmedian), standard deviation, skewness, kurtosis, and 10th and 90th percentiles of ADC (ADC10 and ADC90), were compared between two groups. Univariate and multivariate logistic regression analyses were used to identify the most valuable variables in predicting malignancy. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic value of significant variables.

RESULTS

Multivariate logistic regression analysis indicated that two or more quadrants involved, iso-intense on T2-weighted imaging (T2WI), and ADC10 were significant predictors for orbital malignancy. By using model 2 (iso-intense on T2WI + two or more quadrants involved + ADC10 < 0.990) as the criterion, higher AUC and specificity could be achieved than by using model 1 (iso-intense on T2WI + two or more quadrants involved) alone, (model 2 vs model 1; area under curve (AUC), 0.827 vs 0.793; sensitivity, 65.4% vs 69.2%; specificity, 100% vs 89.3%).

CONCLUSIONS

Iso-intense on T2WI, two or more quadrants involved, and ADC10 are risk factors for orbital malignancy. Histogram analysis of ADC map might provide added value in predicting orbital malignancy.

Modern techniques of magnetic resonance in the evaluation of primary central nervous system lymphoma: contributions to the diagnosis and differential diagnosis

In addition to findings from conventional magnetic resonance imaging, modern magnetic resonance imaging techniques have provided important information about tumor metabolism, in vivo metabolite formation, water molecule diffusion, microvascular density, and blood-brain barrier permeability, all of which have improved the in vivo diagnostic accuracy of this method in the evaluation of primary central nervous system lymphoma. These nonconventional magnetic resonance techniques are useful in the clinical practice because they enhance conventional magnetic resonance imaging by reinforcing the possibility of a diagnosis and by allowing the early detection of disease recurrence.

This report is a review of the most relevant contributions of nonconventional magnetic resonance techniques to the imaging diagnosis of primary central nervous system lymphoma, the differential diagnosis of this disease, and the prognosis of patients. This paper aims to describe a wide range of presentations of primary central nervous system lymphoma, their appearance in imaging, and the differential diagnoses of this disease.

"Orbiting around" the orbital myositis: clinical features, differential diagnosis and therapy

Orbital myositis (OM) is a rare disease whose clinical heterogeneity and different treatment options represent a diagnostic and therapeutic challenge. We aim to review the state of knowledge on OM, also describing a cohort of patients diagnosed in our centre, to highlight some remarkable clinical features. A literature review was conducted in PubMed and Medline databases. The herein described cohort is composed of seven OM patients, diagnosed according to clinical, laboratory and neuroradiological features, whose clinical data were retrospectively analysed. OM is a non-infectious, inflammatory process primarily involving extraocular eye-muscles. It typically presents as an acute to sub-acute, painful ophthalmoplegia with signs of ocular inflammation, but atypical cases without pain or with a chronic progression have been described. The wide range of OM mimicking diseases make a prompt diagnosis challenging but orbit MRI provides valuable clues for differential diagnosis. Timely treatment is greatly important as OM promptly responds to steroids; nevertheless, partial recovery or relapses often occur. In refractory, recurrent or steroid-intolerant cases other therapeutic options (radiotherapy, immunosuppressants, immunoglobulins) can be adopted, but the most effective therapeutic management is yet to be established. In this review, we provide a detailed clinical description of OM, considering the main differential diagnoses and suggesting the most useful investigations. In light of the currently available data on therapy efficacy, we propose a therapeutic algorithm that may guide neurologists in OM patients' management.

The management of an orbital diffuse large B-cell lymphoma

BACKGROUND

The orbit represents a rare site of presentation of non-Hodgkin lymphoma. The diagnosis and management of orbital lymphomas may be challenging because these neoplasms present few specific features.

METHODS

A 69-year-old woman presented with painless swelling of the left lower eyelid of 5 years' duration. Magnetic resonance imaging and incisional biopsy were necessary to establish a diagnosis of orbital diffuse large B-cell lymphoma. Staging was completed, thanks to a computed tomographic study of the chest and abdomen.

RESULTS

The patient underwent systemic chemotherapy with 1 regimen (doxorubicin, vincristine, prednisone, 6-mercaptopurine, and methotrexate), followed by 1 R-COMP-14 regimen (rituximab, cyclophosphamide, nonpegylated liposome-encapsulated doxorubicin, vincristine, and prednisone). Complete resolution of the disease was obtained.

CONCLUSIONS

Although not typically performed by the head and neck surgeon, an understanding of the staging process is crucial for multidisciplinary management of orbital lymphomas.

Orbital lymphoproliferative disorders (OLPDs): value of MR imaging for differentiating orbital lymphoma from benign OPLDs

BACKGROUND AND PURPOSE

Accurate discrimination of orbital lymphoma from benign orbital lymphoproliferative disorders is crucial for treatment planning. We evaluated MR imaging including DWI and contrast-enhanced MR imaging for differentiating orbital lymphoma from benign orbital lymphoproliferative disorders.

MATERIALS AND METHODS

Forty-seven histopathologically proved orbital lymphoproliferative disorders (29 orbital lymphomas and 18 benign orbital lymphoproliferative disorders) were evaluated. Two board-certified radiologists reviewed visual features on T1-weighted, fat-suppressed T2-weighted, diffusion-weighted, and contrast-enhanced MR images. For quantitative evaluation, ADC and contrast-enhancement ratio of all lesions were measured and optimal cutoff thresholds and areas under curves for differentiating orbital lymphoma from benign orbital lymphoproliferative disorders were determined using receiver operative characteristic analysis; corresponding sensitivities and specificities were calculated.

RESULTS

Multivariate logistic regression analysis showed that ill-defined tumor margin (P = .003) had a significant association with orbital lymphoma whereas the "flow void sign" (P = .005) and radiologic evidence of sinusitis (P = .0002) were associated with benign orbital lymphoproliferative disorders. The mean ADC and contrast-enhancement ratio of orbital lymphomas were significantly lower than those of benign orbital lymphoproliferative disorders (P < .01). An ADC of less than 0.612 × 10(-3) mm(2)/s and a contrast-enhancement ratio of less than 1.88 yielded areas under curves of 0.980 and 0.770, sensitivity of 94.1% and 95.5%, and specificities of 93.3% and 80.0% for predicting orbital lymphoma, respectively.

CONCLUSIONS

Some characteristic MR imaging features and quantitative DWI and contrast-enhanced MR imaging are useful in further improving the accuracy of MR imaging for differentiation of orbital lymphoma from benign orbital lymphoproliferative disorders.

Marginal zone mucosa associated lymphoid tissue diffuse large B cell lymphoma

Context:

Non-Hodgkin's lymphomas (NHL) primarily involving the orbit, is relatively uncommon. Rarely two pathologically different NHL cell types have been found to be coexistent.

Case Report:

We report a case of orbital lymphoma in a 62-year-old male with rare histopathological findings secondary to transformation of once cell type into another. Tissue diagnosis and molecular studies led to revelation of diffuse large B cell lymphoma evolving from MALT lymphoma.

Conclusion:

Proliferation of two morphologically and phenotypically different B cells resulting in malignancy has not been found in the orbit so far. They are usually aggressive tumors and require chemo-immunotherapy.

Orbital lymphomas: clinical and radiological features

The purpose of this prospective study was to evaluate the clinical and radiological features of a consecutive series of orbital lymphomas in two Institutions in the North West of Italy. A prospective study was performed of all cases of diagnosed orbital lymphomas. Data on patient demographics, symptoms and clinical findings, histological type of lymphoma, site of lesion, imaging, and systemic involvement were recorded in each case. The mean age of the enrolled 20 patients was 63.65 years. Most orbital lymphomas were located in the superior-lateral quadrant. Superior rectus muscle was the most frequently involved orbital structure. Most patients were affected by extranodal marginal-zone lymphomas. The diagnosis of orbital lymphomas may be challenging, because these neoplasms present few specific features. Although not typically performed by the maxillofacial surgeon, an understanding of the staging process is crucial for multidisciplinary management of orbital lymphomas.