Immunologic characterization of ocular adnexal lymphoid neoplasms

Interferon Alpha in the Therapy of Conjunctival Lymphoma in An Hiv+ Patient

The authors evaluated the efficacy of interferon-alpha used intralesionally in the therapy of low-grade conjunctival non-Hodgkin lymphoma in an HIV-positive patient. The patient received one intralesional injection of 1,000,000 U of interferon-alpha three times a week for a total of twelve doses. The remission of conjunctival involvement was seen three months from the end of therapy. The intralesional use of interferon-alpha can be considered an efficacious therapy for low-grade conjunctival non-Hodgkin lymphoma.

Ocular adnexal lymphoid tumors: progress in need of clarification

PURPOSE

To evaluate recent ophthalmic publications on ocular adnexal lymphomas (OALs) according to histopathologic and immunophenotypic criteria used in the diagnosis of systemic lymphomas (World Health Organization classification).

DESIGN

Summary and critical analysis of recent clinical and pathologic studies.

METHODS

Literature review and interpretation.

RESULTS

In the largest study of 353 cases of OALs published in the pathology literature, extranodal marginal zone lymphoma (EMZL) constituted 52%, follicular lymphoma 23%, mantle cell lymphoma 5%, and small cell lymphocytic and chronic lymphocytic leukemia 4%-plus a residuum of arcane entities. In smaller series of less intensively studied OALs in the ophthalmic literature, EMZLs had a higher preponderance and also were associated with a favorable prognosis. Many EMZLs seemed to arise primarily in the ocular adnexa (mucosa-associated lymphoid tissue [MALT] lymphoma should be restricted for EMZLs involving epithelial tissues).

CONCLUSIONS

Rigorous diagnostic criteria and a proposal for a prospective multicenter study may bring further clarification to the emerging order in this set of tumors.

Immunohistochemical profile of lymphoid lesions of the orbit

BACKGROUND

Orbital idiopathic inflammation, lymphoid hyperplasia, and lymphoma may all present clinically in the same manner. Histopathology and especially immunohistochemistry play a major role in the differential diagnosis. The purpose of this study was to determine the immunophenotypic features of these lesions.

METHODS

Fifty-five orbital lymphoid lesions were retrieved from the ophthalmic pathology registries at McGill University, Montreal, Canada, and the Federal University of São Paulo, São Paulo, Brazil. Formalin-fixed, paraffin-embedded, histopathologic sections were stained with hematoxylin and eosin and periodic acid-Schiff. The sections were also immunostained for B-cell (CD20) and T-cell (CD43) markers and for immunoglobulin light chains kappa and lambda. Two pathologists determined the histopathologic and immunohistochemical pattern of each lesion in a masked fashion.

RESULTS

Of the 55 lesions, 11 (20%) were idiopathic chronic inflammations, 22 (40%) were lymphoid hyperplasias and 22 (40%) were lymphomas. Idiopathic inflammation displayed a predominance of T cells and all lesions expressed polyclonal light chains. Lymphoid hyperplasia displayed a mixture of B cells and T cells, with a slight predominance of the former and all lesions expressed polyclonal light chains. Lymphoma showed a striking predominance of B cells and all lesions expressed monoclonal light chains, usually kappa (63.7%). The differences in the mean percentages of B cells among the orbital lymphoid lesions (inflammation, 35%; hyperplasia, 65.9%; lymphoma, 87.3%) were statistically significant (p < 0.001).

INTERPRETATION

Orbital lymphoid lesions can be differentiated based on the percentages of B cells and T cells and the monoclonal or polyclonal expression of immunoglobulin light chains.

Surgical treatment of obstructive palpebral tumors in d'emblee variant of cutaneous T-cell lymphoma

BACKGROUND

Our patient presented with an unusual case of rapidly growing palpebral tumors, which obstructed his vision and caused professional and social impairment.

OBJECTIVES

The objective was to report the role of surgical management in a case of the d'emblee variant of cutaneous T-cell lymphoma and to provide a literature review.

METHODS

Tumors of the eyelids previously treated with topical and oral retinoids, indomethacin, dapsone, systemic chemotherapy, and high-dose systemic corticosteroids respond finally to conservative excision and second intention healing.

RESULTS

Surgical debulking of palpebral tumors achieved remission of a locally aggressive form of cutaneous T-cell lymphoma and significant restoration of the sight, eyelid function, and social/professional function.

CONCLUSION

In selected cases, surgical excision of tumor tissue may be of significant assistance in managing d'emblee variant cutaneous T-cell lymphoma.

Role of curcumin in idiopathic inflammatory orbital pseudotumours

The present report, describes for the first time the clinical efficacy of curcumin, the active constituent of rhizomes of Curcuma longa, in the treatment of patients suffering from idiopathic inflammatory orbital pseudotumours. Curcumin was administered orally at a dose of 375 mg/3 times/day orally for a period of 6-22 months in eight patients. They were followed up for a period of 2 years at 3 monthly intervals. Five patients completed the study, out of which four recovered completely and in one patient the swelling regressed completely but some limitation of movement persisted. No side effect was noted in any patient and there was no recurrence. It is suggested that curcumin could be used as a safe and effective drug in the treatment of idiopathic inflammatory orbital pseudotumours.

Lacrimal gland tumors and simulating lesions. Clinicopathologic and MR imaging features

The lacrimal gland region can be involved in a wide spectrum of orbital pathology, including inflammatory, lymphoproliferative, and epithelial tumors. This article focuses on benign and malignant epithelial tumors of lacrimal gland and simulating lesions. The clinical presentations, MR imaging, and pathologic findings of lacrimal gland tumors are reviewed.

What is orbital pseudotumor?

We have reviewed the literature in order to delineate the clinicopathologic definition of orbital pseudotumor, also called idiopathic nonspecific orbital inflammation. The clinical picture of orbital pseudotumor varies widely, with signs of mass effect, inflammation and/or infiltration. On computed tomography, orbital pseudotumor presents as a unilateral focal or diffuse mass. The histopathologic hallmark of orbital pseudotumor is a mixed inflammatory infiltrate with fibrosis of varying degree. Contrary to an old belief, orbital pseudotumor is not related to orbital reactive lymphoid hyperplasia (pseudolymphoma) and is not a lymphoid tumor. Atypical histopathologic findings of orbital pseudotumor include dominant sclerosis, granulomatous inflammation, vasculitis, and tissue eosinophilia. In the absence of systemic fibroinflammatory, granulomatous, and vasculitic disease, these atypical histopathologic patterns can be considered to represent subclasses of orbital pseudotumors rather then distinct entities. Clinical and prognostic characteristics of both histopathologically classical and atypical orbital pseudotumors appear to be heterogeneous. The etiology of orbital pseudotumor is unknown, but infection, autoimmune disorder, and aberrant wound healing have all been put forward as possibilities. In conclusion, orbital pseudotumor is one distinct disease albeit with many clinical and histopathologic guises.

Ocular adnexal lymphoproliferative lesions

Ocular adnexal lymphoproliferative lesions consist of a spectrum of disease entities, including reactive lymphoid hyperplasia, atypical lymphoid hyperplasia, and lymphoma. No clinical or radiologic criteria facilitate a distinction among these lymphoproliferative lesions. The two hyperplastic processes may evolve to localized or systemic lymphoma. A similar pattern is evident in other mucosa-associated lymphoid tumors elsewhere in the body. Most ocular adnexal lymphomas are small lymphocytic non-Hodgkin's tumors with an indolent course; frequently, they remain localized to the ocular adnexa. In comparison, intermediate- and high-grade lymphomas are less common in the ocular adnexa but more aggressive. An approach to the diagnosis and treatment of these complex entities is suggested. Despite new pathologic classification schemes, immunophenotypic labeling, and molecular genetic analysis, the prognosis for patients with small-cell lymphoma in the ocular adnexa is difficult to predict.

Molecular-genetic analysis of ocular adnexal benign lymphoid hyperplasias by a two-step polymerase-chain-reaction

Twelve biopsied ocular adnexal benign lymphoid hyperplasias (OABLH) satisfying benign histological criteria were investigated for clonal immunoglobulin (Ig) heavy-chain gene rearrangement by means of a two-step polymerase chain reaction (PCR) method using formalin-fixed and paraffin-embedded tissue. Of the 12, 4 (33%) demonstrated clear single bands of the rearranged gene for the Ig heavy-chain, of between 100 and 150 base pairs. The selected cases were all free of malignant lymphoma and all of the lesions were small (2 x 2-22 x 6 mm; median 4.5 x 3 mm). Histopathological and cytological features were not essentially different between monoclonal and non-monoclonal examples. Immunohistochemistry was of little benefit in separating the two. It is concluded that OABLH demonstrating a benign clinical course frequently contain monoclonal B cell populations suggesting a continuous progressive spectrum of lesions in B cell neoplasia. In addition, the significance of molecular-genetic analysis for OABLH and the utility of the two-step PCR method should be emphasized.

Primary orbital malignant lymphoma: a clinicopathology study of 17 cases

We investigated the clinicopathologic characteristics of 17 patients (13 men and 4 women) with primary orbital malignant lymphoma using the Working Formulation. Most of the cases belonged to the low-grade malignancy group, and more women than men were in the histologically high-grade malignancy group. The phenotype of the tumor cells was investigated immunohistochemically. All cases showed the monoclonal feature of a B-cell lineage. All patients received chemotherapy with or without radiotherapy. Of 16 subjects, 15 achieved a complete remission; none of these patients has had a recurrence since the completion of the initial therapy (range of follow-up from 16 months to 10 years). One patient died.

Report of a primary lymphoma of the conjunctiva. A lymphoma of MALT origin?

A case of primary conjunctival lymphoma is reported herein. A 47-year-old woman presented with an indolent salmon-coloured tumour of the lower epibulbar conjunctiva. Histologically, we found a lymphoid infiltrate in the epithelium and subepithelium consisting of two components. One component was characterized by centrocytic-like cells and the other by lymphocytic, plasmacytoid and plasma cells. An immunohistological study demonstrated a light chain restricted immunoglobulin expression of the tumour cells as well as some residual polytypic follicles exhibiting reticular dendritic cells. Tumour cell proliferation was associated with a T cell reactive population. A comprehensive investigation (in particular an orbital scan) did not demonstrate any other localization of this lymphoma. Such a lesion raised the question of a possible MALT origin, by analog with MALT-lymphomas of the gastrointestinal tract described by Isaacson and colleagues.

Lymphoid hyperplasia and malignant lymphoma occurring in the ocular adnexa (orbit, conjunctiva, and eyelids): a prospective multiparametric analysis of 108 cases during 1977 to 1987

We performed a prospective multiparametric correlative clinical, histopathologic, and immunologic analysis of 117 ocular adnexal lymphoid proliferations developing in 108 patients between October 1977 and July 1987. The ocular adnexal lymphoid proliferations were distributed among the 108 patients as follows: orbit 69 (64%), conjunctiva 30 (28%), and eyelids nine (8%). The 117 ocular adnexal lymphoid proliferations were classified as follows: polyclonal lymphoid hyperplasia, 32 (22 orbit, nine conjunctiva, one eyelid) (27%); monoclonal B cell lymphoma, 81 (48 orbit, 25 conjunctiva, eight eyelid) (69%); null cell lymphoma, one (orbit) (1%); and histologically indeterminate, three (one each: orbit, conjunctiva, eyelid) (3%). Patients presenting with ocular adnexal polyclonal lymphoid hyperplasia and monoclonal B cell lymphoma, and patients developing unilateral and bilateral ocular adnexal lymphoid proliferations did not differ significantly with respect to age, sex, presenting complaints, duration of symptoms, or ophthalmic findings. Classifying ocular adnexal lymphoid proliferations into benign and malignant categories by histopathologic criteria and into polyclonal and monoclonal B cell categories by immunophenotypic criteria was not useful in predicting eventual outcome, including the occurrence of extraocular lymphoma. However, the clinicopathologic characteristics did differ according to the anatomic site of involvement and histopathology of the ocular adnexal lymphoid proliferations. Lymphoid infiltrates of the conjunctiva were associated with a lower incidence of extra-ocular lymphoma (20%) than were those of the orbit and eyelid, 35% and 67%, respectively (statistically significant, P less than .03). Ocular adnexal small lymphocytic and intermediate lymphocytic lymphomas were less often associated with extra-ocular lymphoma than were ocular adnexal lymphomas of all other histologic types, 27% and 46%, respectively (P less than .09). However, the single most important and statistically significant prognostic factor in these patients was the extent of disease at the time of presentation with an ocular adnexal lymphoid proliferation (P less than .001). Eighty-six percent of patients presenting with a unilateral or bilateral clinical stage lE ocular adnexal lymphoid proliferation, regardless of the histopathology or the immunophenotype, had a benign indolent clinical course and failed to develop ocular or extra-ocular lymphoma during a median follow-up period of 51 months. The results of this study substantially improve our understanding of extranodal small lymphocytic proliferations in general, and those of the ocular adnexa in particular.

Clinical course and pathologic features of conjunctival non-Hodgkin's lymphoma. A report of six cases

Six patients with conjunctival non-Hodgkin's lymphoma (NHL) were evaluated. In all six cases the conjunctiva was the primary site of clinical presentation; four cases involved low-grade malignancy and two, intermediate-grade malignancy, according to the International Working Formulation. The disease developed within a short period of time to stage IV. The poor response to therapy revealed a worse prognosis than would be expected according to the histopathologic classification. Four of the six patients died of NHL, three of them within 15 months. Comparison of these 6 cases with a group of 15 patients with orbital NHL revealed a much better prognosis in the latter patients. In spite of the fact that 4 of the 15 orbital cases showed NHL of high-grade malignancy, only 2 of them died of the lymphoma. Therefore, conjunctival NHL requires a fast and adequate diagnostic and therapeutic approach.

Primary orbital lymphomas

Between 1950 and 1982, seventeen patients with primary orbital lymphoma were treated at the University of Kansas Medical Center. There were 10 males and 7 females with a median age of 61 years. Four patients had bilateral disease, seven patients had disease involving the conjunctiva, and in ten patients, the disease involved paraocular structures. Fourteen patients received radiation with a median dose of 3500 cGy (range 2250 cGy to 4250 cGy) given in about 3 1/2 to 5 weeks. Median follow-up was 10 years (range 5 to 31 years). Local control was 100% and 5-year survival was 76%. Three patients are living with no evidence of lymphoma; three patients died from progression of the disease, and others died from unrelated causes. Radiation treatment for localized primary orbital lymphomas appears to be the primary treatment of choice.

Immunological responses in the eyelid and orbit

Immunological responses in the eyelid and the orbit are reviewed: (1) A local immune response is dependent on the presence of lymphoid tissue in an organ. Lymphoid tissue is found in the conjunctival fornices and in the lacrimal gland but not in the orbit. The eyelids also have lymphatic drainage into the local lymph nodes. A local immune response is found in the palpebral conjunctiva and in the lacrimal gland, measureable both as immunoglobulin or specific antibody levels in tears or as immunoglobulin producing cells within the tissue. No local immunity has been demonstrated in the orbit. (2) The other type of immune response found in the eyelids, the lacrimal gland and the orbit is the involvement of these tissues in systemic diseases. Systemic diseases with an immunological basis, which affect the above mentioned tissues are: atopic diseases of the skin, autoimmune diseases, immunodeficiency diseases and lymphoproliferative diseases. (3) Finally, it is possible that the extraocular muscles and the lacrimal gland have tissue specific antigens and therefore may be target tissues for organ specific autoimmune processes.

Genotypic monoclonality in immunophenotypically polyclonal orbital lymphoid tumors. A model of tumor progression in the lymphoid system. The 1986 Wendell Hughes lecture

Molecular genetic (genotypic) analysis elucidates gene rearrangements within lymphocytes that are responsible for either immunoglobulin production in B-lymphocytes or the expression of cell-surface antigen recognition receptors in T-lymphocytes. Molecular genetic analysis is far more sensitive than immunophenotypic methods for the detection of small clones of lymphocytes because as few as 2 to 5% of cells in an infiltrate can be discovered to possess the same rearranged DNA sequences with genetic probes. In truly polyclonal proliferations, each lymphocyte reorganizes its immunoglobulin or T-antigen receptor genes in a unique manner, resulting in an almost infinite number of combinations of genetic rearrangement and the absence of any new hybridizing bands upon Southern blotting. In monoclonal proliferations, a new, homogeneous, nongermline band is identified on Southern blotting because a sufficiently large number of lymphocytes exhibit an identical genetic rearrangement. In a group of five orbital lymphoid tumors that appeared to be benign reactive hyperplasias by light microscopy and that were polyclonal by immunophenotypic methods, three were found by molecular genetic analysis to harbor small clones of B-lymphocytes with new rearrangement bands on Southern blotting. No clonal abnormalities of T-lymphocytes were found in these five lesions, despite the fact that they were the preponderant cells in the tumors. These observations suggest that "reactive lymphoid hyperplasia" of the orbit may be an unstable lesion, owing to a T-cell immunoregulatory imbalance, with the potential for developing clonal expansions of B-lymphocytes that nonetheless usually remain localized to the orbit.

Orbital lymphoid tumors located predominantly within extraocular muscles

Lymphoid masses can be centered predominantly within an extraocular muscle (EOM), as exemplified by computed tomography (CT) scanning and biopsy confirmation in the seven cases reported in this study. In these patients, an insidious and painless onset of exophthalmos was overshadowed by ptosis or a motility disturbance (particularly limited upgaze) in the absence of chemosis and lid erythema. The lesions were located in the superior rectus-levator complex (6 cases) and in the medial rectus muscle (1 case). One patient, with an exclusive infiltration of the levator, had a complete ptosis, whereas four others had a partial ptosis. Important clinical clues included palpable masses (4 cases) and preserved downward gaze (all cases), the latter suggesting the absence of fibrotic restriction, as is often seen in Graves' myopathy and the idiopathic myositis of pseudotumor. The biopsy specimens showed spill-over of the hypercellular and stroma-free lymphoid tissue into the orbital fat (all cases) and into the lacrimal gland (3 cases). Full extraocular motility on upgaze was restored after local orbital radiotherapy, although a residual ptosis persisted in five cases. Five patients had well-differentiated lesions and nonocular disease did not develop, whereas a widespread disease developed in one of two patients with a cytologically malignant lymphoma; the patient eventually died.

Clinical, morphologic, immunophenotypic, and molecular genetic analysis of bilateral ocular adnexal lymphoid neoplasms in 17 patients

We investigated the clinical, morphologic, immunologic, and molecular genetic characteristics of the lymphoid tumors occurring in 17 patients with bilateral ocular adnexal lymphoid neoplasia. We found no obvious differences in the age, sex, clinical appearance, or ophthalmic findings between patients with unilateral and those with bilateral ocular adnexal lymphoid neoplasms. Five orbital and two conjunctival lymphoid neoplasms removed from five patients were polyclonal pseudolymphomas, while nine orbital, eight conjunctival, and two eyelid lymphoid neoplasms removed from 12 patients were monoclonal B cell non-Hodgkin's lymphomas. Each pair of simultaneously bilateral lesions occurring in a single individual was morphologically and immunologically identical and exhibited identical immunoglobulin gene DNA rearrangement patterns. None of the five patients with polyclonal pseudolymphomas developed nonocular non-Hodgkin's lymphoma, but one developed a contralateral conjunctival monoclonal B cell non-Hodgkin's lymphoma. Six of the 12 patients with ocular adnexal monoclonal B cell non-Hodgkin's lymphomas developed nonocular non-Hodgkin's lymphoma. The incidence of previous or subsequent systemic nonocular non-Hodgkin's lymphoma in patients with bilateral ocular adnexal lymphoid neoplasms is comparable to that of patients with unilateral disease. In both patient groups, the development of nonocular non-Hodgkin's lymphoma is most commonly associated with ocular adnexal lymphoid neoplasms displaying follicular or diffuse small cleaved cell (poorly differentiated lymphocytic) morphologic characteristics.

Ocular adnexal monoclonal lymphoid tumors with a favorable prognosis

Fourteen patients with well- or intermediately differentiated monoclonal B-lymphocytic tumors of the conjunctiva or orbit had a favorable prognosis with follow-ups of 4 to 9 years (mean and median, 7.5 years). The lesions were, for the most part, diffuse proliferations of small lymphocytes, either with round or minimally indented nuclear outlines. Mitotic activity was sparse to nonexistent; occasionally there were scattered small abortive or residual germinal centers, and some lesions exhibited lymphoplasmacytoid features and dispersed multinucleated giant cells (polykaryocytes). None of the six patients with conjunctival lesions had extraocular manifestations. An identical tumor of the submandibular gland developed in one of eight patients with orbital lesions and another patient had multiple extranodal involvements of the oropharynx, liver, and both kidneys, but after chemotherapy the patient has survived for 8 years from orbital presentation and is currently in remission. The authors believe that these low-grade tumors share many biologic resemblances to extranodal lymphoepithelial tumors of other organs (lung, gut, parotid, thyroid), which as a group have been aggregated together as mucosa-associated lymphoid tumors (MALT) and which can often remain localized to their sites of origin.

T-cell receptor beta chain gene rearrangements: genetic markers of T-cell lineage and clonality

We have performed a series of investigations involving T-cell receptor beta chain (T beta) gene rearrangements in benign and malignant nonhematopoietic, B-cell, and T-cell proliferations. These studies provide the conceptual basis and the operational approach for the use of T beta gene rearrangements as markers of T-cell lineage, clonality, and differentiation, analogous to immunoglobulin gene rearrangements in B cells. Southern blot hybridization analysis for T beta gene rearrangements can now be utilized to identify and distinguish between non-T cells, polyclonal T cells, and monoclonal T cells. Determination of T beta gene rearrangements will play an important role in the further investigation and classification of T-cell neoplasia. However, the identification of a genetic marker of clonality for T cells has significant diagnostic and prognostic value as well. For example, determination of the T beta gene rearrangement unique to a particular malignant T-cell clone provides a specific genetic marker for that clonal T-cell proliferation. This genetic marker of the T-cell clone may provide a useful tool for monitoring the patient's therapeutic response and clinical course for early signs of relapse. Nonetheless, our studies demonstrate that the lineage specificity of immunoglobulin and T beta gene rearrangements is not absolute. It appears that only a multiparametric approach combining extensive monoclonal antibody immunophenotypic analysis, in vitro testing for functional help and suppression, and Southern blot hybridization analysis for immunoglobulin and T beta gene rearrangements allows the conclusive and unequivocal demonstration of the B- or T-cell derivation of all lymphoid neoplasms. Lymphoid malignancies that cannot be assigned to the B- or T-cell lineage following this extensive multiparametric analysis are exceedingly uncommon.

Immunohistochemical and ultrastructural study of unusual IgM lambda lymphoplasmacytic tumor of the lacrimal gland

A 72-year-old man developed a slowly enlarging mass involving the left lacrimal gland. Excisional biopsy disclosed a lymphoplasmacytoid tumor which was found by immunohistochemistry techniques to be a monoclonal proliferation, expressing cytoplasmic IgM lambda. However, serum protein immunoelectrophoresis disclosed a monoclonal spike in the gamma-globulin region with IgG lambda. The patient was still systemically well with no evidence of lymphoma almost ten years after the initial recognition of the lacrimal gland mass. This unusual case demonstrated the difficulty of classifying orbital lymphoid tumors and the problems of accurately predicting the clinical course and prognosis in affected patients.

Staging and therapy of orbital lymphomas

Ten patients with non-Hodgkin's lymphoma primarily affecting the orbital region were evaluated at Michael Reese Hospital and Medical Center, Chicago, between 1976 and 1983. Diagnoses were based on the histopathologic classification systems of the Working Formulation of the Non-Hodgkin's Lymphomas and Rappoport. Sequential staging procedures performed at the time of diagnosis included liver-spleen scans, Technecium-99 bone scans, gallium 67 scans, computerized axial tomograms of the orbit and abdomen, bone marrow examination and cerebral spinal fluid analyses. Adverse prognostic factors included the following: orbital bone erosions, Stage IV disease, and large cell or mixed cell, diffuse histologic features. The type of histopathologic findings combined with the results of sequential staging procedures is useful in identifying those patients who would benefit most from systemic chemotherapy.

Acute orbital myositis: a case report

A case of acute orbital myositis is presented in this report. CT scanning provided an immediate diagnosis and hence institution of treatment. There was a typically rapid response to steroids. A previous presentation, prior to the advent of CT, had been misdiagnosed as Tolosa-Hunt syndrome. Orbital pseudotumour can be acute or chronic, and acute orbital myositis is now regarded as one of five subtypes of the former.

Clinicopathologic and immunologic characteristics of non-Hodgkin's lymphomas presenting in the orbit. A report of eight cases

Of 325 consecutive cases of non-Hodgkin's malignant lymphomas, 8 patients (2.4%) showed orbital presentation. The clinicopathologic and immunologic analysis of the eight patients revealed characteristic biologic features. Despite the apparently isolated orbital presentation, all cases had subclinical systemic disease. Seven of the eight cases exhibited lymphoplasmacytic/cytoid features, with concurrent type II cryoglobulinemia in five of them. In addition, during their clinical course, five patients showed single or multiple subcutaneous nodules with the same histologic and immunologic pattern as the orbital tumor. This study demonstrates that most orbital lymphomas share particular clinicopathologic and immunologic features, suggesting an origin from a B-cell subset with preferential homing to orbital tissues and subcutis.

Lymphoid proliferations in the orbit: malignant or benign?

Clinical, pathological, and immunological analysis of 20 patients with ocular adnexal lymphoid disease has demonstrated several parameters which are useful for distinguishing malignant from benign lesions. Patients in the fourth or fifth decade of life presenting with an acute history of pain, oedema, epiphora, double vision, and ptosis, with a mass localised in the lacrimal gland area, are more likely to have a pseudolymphoma or a chronic inflammatory lesion than a true non-Hodgkin lymphoma (NHL). It is not possible to obtain a definite diagnosis without surgical intervention, because only three out of nine patients with orbital NHL had evidence of a monoclonal B cell population in peripheral blood on admission to the Orbital Centre. Furthermore it was confirmed that the identification of the various orbital lymphoid infiltrates becomes more distinct when immunological techniques are added to the clinical and histopathological methods of investigation. Multidisciplinary cooperation leads to further improvement of diagnosis and treatment of ocular adnexal lymphoproliferative disease.

The nonspecific orbital inflammatory syndromes

The nonspecific orbital inflammatory syndromes are a peculiar group of inflammations that may occur in acute or subacute forms and can become chronic. They may be diffuse or primarily localized to a specific tissue of the orbit. The nonspecific inflammations that are targeted toward specific tissues are myositis, dacryoadenitis, perineuritis, and periscleritis. Each of these syndromes has definite signs, symptoms, ultrasonic and radiologic findings. Therefore, this group of nonspecific inflammations should be more clearly classified for purposes of better understanding and better management. All of these inflammatory syndromes in the acute form respond well to high doses of oral corticosteroids tapered gradually over a period of months, but may be reoccurrent or become chronic. The subacute form responds less well. Occasionally, patients require radiation to stop the inflammation in the subacute or chronic state, but these patients are often left with a functional deficit. The cause, although presumed to be an immune disorder involving the orbital tissues, remains unknown.

B- and T-lymphocytes in ocular disease

Ocular inflammatory diseases and ocular adnexal lymphoid tumors have become less obscure and intimidating by virtue of our ability to study the infiltrates in these various diseases for their B-lymphocyte and T-lymphocyte composition. Comparisons are also possible between lymphocytic profiles in the peripheral blood and the precise composition of the in situ infiltrates within the ocular tissue themselves. The availability of monoclonal antibodies, which can determine T-lymphocytic subsets such as T-helper cells and T-suppressor/cytotoxic cells, natural killer cells, and monocytes-histiocytes, has provided a powerful technology for the delineation of the distinctive immune composition of the inflammatory infiltrates, as well as any possible disturbances in T-cell immunoregulation. B-lymphocytes produce immunoglobulins, which may be misdirected as autoantibodies in local or systemic autoimmune diseases. Immunoglobulin-mediated and therefore B-cell derived conditions include vasculitis, progressive cicatricial ocular pemphigoid, Mooren's corneal ulcer, scleritis, and hay fever and vernal conjunctivitis. Other diseases in which B-lymphocytes, their immunoglobulin products or immune complexes formed with presently unknown antigens are potentially at fault are chronic non-specific uveitis; iridocyclitis in Behcet's syndrome; Fuch's heterochromic syndrome, ankylosing spondylitis, and Reiter's syndrome; Graves' disease; and idiopathic inflammatory orbital pseudotumor and myositis. T-cells do not produce immunoglobins, but rather secrete lymphokines or interact directly with receptors or determinants on viruses or target tissues (eg. immunosurveillance against neoplasia); it is possible that some autoimmune diseases are the result of neo-antigens on the surfaces of host tissues that have been coded for by a cryptic inciting virus. T-cell diseases include phlyctenulosis graft rejections, graft versus host disease, and possibly sympathetic ophthalmia and temporal arteritis. Natural killer cells are involved in many of the same diseases as cytotoxic T-cells, except that the former require no period of sensitization (natural immunity), whereas cytotoxic T-cells must undergo an antigen-specific blast transformation (acquired immunity of the delayed hypersensitivity type). In many diseases in which B-cell derived auto-antibodies are at fault, there may be local tissue or systemic T-cell imbalances, with a reduction in T-suppressor cells and a relative augmentation in T-helper cells, thereby facilitating production of misdirected auto-antibodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Lymphoproliferative disorders of the orbit: an immunological approach to diagnosis and pathogenesis

A prospective immunological study of patients with proptosis due to intraorbital lesions composed largely or exclusively of lymphoid tissue indicates that the use of antisera to specific heavy and light chain antibody components can be helpful in distinguishing between polyclonal and truly neoplastic monoclonal disorders. On the basis of combined histological and immunological information it is possible to delineate 4 categories of patient: those with unequivocal chronic inflammation, those with a virtually pure lymphoproliferative lesion and a polyclonal profile, and those with a monoclonal lymphomatous disorder which may be histologically comparable to the previous category or, in a fourth group, be unmistakably malignant on cytological grounds. The first of these groups will normally respond to corticosteroid treatment, but the others, including the polyclonal lymphoproliferative masses, need radiotherapy. The finding of reduced numbers of circulating T cells in the presence of low plasma levels of IgA, and of autoantibodies in the serum of a third of the patients, could mean that individuals developing lymphoproliferative lesions in the orbit, whether hyperplastic or neoplastic, are partially immunodeficient.

Acute and subacute orbital myositis

Of 12 consecutive patients (nine women and three men ranging in age from 18 to 70 years) with orbital myositis, four had histories of ocular or systemic autoimmune disease. Five patients treated within two weeks of developing acute orbital pain and extraocular muscle dysfunction were classified as having acute myositis. They responded to corticosteroids within 72 hours although three had single recurrences during six- to 16-month follow-up periods. No patients were heterotropic or proptotic at the final examination. Seven patients with less severe or atypical symptoms who had delays of two or more months between onset and treatment were classified as having subacute myositis. All had recurrences with five having two or more. Three required supplemental radiation therapy during seven- to 20-month follow-up periods. At the final examinations, six patients had motility defects and one had proptosis, indicating that delays in treatment may lead to recurrences, extraocular muscle dysfunction, and proptosis.

Identification of T lymphocytes in ocular adnexal neoplasms by hybridoma monoclonal antibodies

We performed indirect immunofluorescence with the OKT series of hybridoma monoclonal antibodies in order to determine the total number of T cells and their subset distribution, that is, the percentages of helper (OKT3+T4+T8-) and suppressor/cytotoxic (OKT3+T4-T8+) T cells, in 28 ocular adnexal lymphoid neoplasms. OKT3+T4+ (helper) T cells vastly predominated in each of ten benign, polyclonal ocular lymphoid proliferations. The helper-suppressor T-cell ratio (T4-8) ranged from 2.5 to 8.2 (mean, 5.4) in these ten cases. In comparison, the mean T4-T8 ratio in 24 benign reactive lymph nodes was 3.4. These findings strongly suggested that the polyclonal ocular lymphoid proliferations represent a T-cell antigen-dependent response characterized by a proliferation of helper T cells, which in turn drive B cells to proliferate and to differentiate, eventually resulting in the formation of a clinically detectable tumor. The mean T4-T8 ratio was 2.3 in 18 ocular and in 16 nodal monoclonal B-cell proliferations, suggesting that the benign T cells in these proliferations represent a residual cell population rather than a distinctive subset originating in response to the B-cell neoplasm.

An immunological study of germinal centres in four ophthalmic immunocytomas

Four ophthalmic lymphoplasmacytic/lymphoplasmacytoid (LP) immunocytomas with germinal centres were reviewed histologically and studied immunologically by means of the peroxidase-antiperoxidase (PAP) method. In two cases a histological diagnosis of LP immunocytoma was made, while in the other two cases a non-Hodgkin's lymphoma could not be histologically differentiated with certainty from a pseudolymphoma or reactive process. Immunological analysis confirmed the diagnosis in the former two cases and led in one of the latter also to a diagnosis of LP immunocytoma. In the fourth case the development of LP immunocytoma out of a pseudolymphoma could be demonstrated. In the four LP immunocytomas the germinal centres showed a monoclonal pattern of immunoglobulin in one case, a polyclonal pattern in one case and a negative reaction in two cases. The role of germinal centres in relation to the development of LP immunocytoma is discussed.

Apparent monoclonal origin of lymphocytes and plasma cells infiltrating ocular adnexal amyloid deposits: report of 2 cases

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Combined clinical and computed tomographic diagnosis of orbital lymphoid tumors

Computed tomography has made it possible to make a strongly presumptive preoperative diagnosis of orbital lymphoid tumors, particularly when the radiographic findings are analyzed in conjunction with the clinical features. Twenty-six patients (with 27 orbital lymphoid tumors) had an average age of 57 years and had painless swelling or low-grade proptosis averaging 7.5 months in duration. The computed tomographic findings were highly characteristic. Almost all of the tumors had a retrobulbar or superior orbital component. In both the coronal and axial planes, distinctive growth patterns and contourings were discovered. The lesions molded themselves to preexisting orbital structures without eroding bone or enlarging the orbit. Against the bone, globe, and muscle edges, the lesions featured smooth, sharply demarcated contours with abruptly acute or perpendicular angulations, whereas a streaky profile became apparent as they irregularly infiltrated the retrobulbar fat, reflecting involvement of microfascial structural elements. No distinguishing differences were discovered in the growth patterns of the benign and the malignant tumors.

The expression of surface antigen Leu 1 by ocular adnexal lymphoid neoplasms

Leu 1 is a surface membrane antigen expressed by benign systemic T cells, most cases of B-cell-derived chronic lymphocytic leukemia, and approximately one half of the systemic B-cell lymphomas. Benign systemic B cells are Leu 1-. Our studies showed that the percentage of Leu 1+ cells was essentially the same as the percentage of OKT3+E+ (T) cells in six ocular adnexal pseudolymphomas, strongly suggesting that the benign B cells in these lesions were similarly Leu 1-. These studies also showed that malignant B cells in six of 15 (40%) ocular B-cell lymphomas were Leu 1+. Thus, the expression of Leu 1 by some malignant ocular adnexal B cells but not by benign ocular adnexal B cells appears to be analogous to the situation for lymph nodal and other systemic B cells. Although the explanation for the existence of this shared determinant is unknown, Leu 1 expression may possess clinical and diagnostic significance as a marker of neoplastic B cells.

The use of computed tomography and ultrasonography in the evaluation of orbital masses

The combined use of computed tomography scans with multiplanar reformation and ultrasonography makes it possible to locate orbital masses with a high degree of accuracy, and sometimes even to determine their histological nature without surgical biopsy. One of the unique features of computed tomography is its ability to distinguish both normal and abnormal structures of various tissue densities; this has contributed to very low false positive and false negative rates. Ultrasonography, while of limited use in the detection of posterior orbital lesions or lesions involving the orbital bones, provides an excellent cost-effective screening test for anterior and midorbit disease. It is also useful for the detection of extraocular muscle enlargement secondary to thyroid disease. In this article, a review of the characteristics and techniques of computed tomography and ultrasonography is followed by discussion of the advantages and limitations of each modality in the evaluation of six common types of orbital tumefaction.

The immunologic characterization of 40 extranodal lymphoid infiltrates: usefulness in distinguishing between benign pseudolymphoma and malignant lymphoma

In the studies described here, 40 extranodal lymphoid tumors obtained from 38 patients were evaluated by cell-marker analysis and the results correlated with the light microscopic features. These infiltrates were investigated for the present composition of cells expressing Ia antigens, surface immunoglobulin (SIg), including kappa and lambda light chains, sheep erythrocyte (E) rosette formation, and acid a-naphthyl acetate esterase (ANAE) activity. Fifteen biopsy specimens consisted of variable proportions of benign T and polyclonal B cells; these 15 lesions had the histopathologic features of benign pseudolymphomas. The remaining biopsy specimens consisted almost entirely of B cells bearing monoclonal SIg (18 cases) or a great preponderance of T cells (five cases) or non-B, non-T (null) cells (two cases); these 25 lesions were classified histopathologically as malignant lymphomas. Thus, the extranodal lymphoid infiltrates were divisible, according to their cell-marker characteristics, into two categories: lesions that are immunologically polyclonal and lesions that are immunologically monoclonal B-cell proliferations or consist of a great preponderance of T or null cells. In each case, polyclonality correlated with benign cytomorphologic features and monoclonality correlated with malignant histopathology. Cell-marker analysis appears to represent an important adjunct to light microscopy in distinguishing histologically problematic benign pseudolymphomas from malignant lymphomas that arise in the extranodal tissues. Cell marker analysis will undoubtedly provide insights into the histogenesis, natural history, and biologic behavior of the extranodal lymphoid neoplasms not attainable using light microscopy alone.

Ocular adnexal lymphoid neoplasms: clinical, histopathologic, electron microscopic, and immunologic characteristics

Clinicopathologic analysis of 400 ocular adnexal lymphoid neoplasms has demonstrated that the orbital lymphoid neoplasms occur primarily in the sixth and seventh decades of life; that their benignancy or malignancy is generally indistinguishable clinically; that the orbital malignant lymphomas are most commonly small cell lymphomas; that the orbital "histiocytic" lymphomas almost always represent an anomalous deposit of disseminated lymphoma; and that the percentage of patients with orbital lymphoma who develop systemic disease varies with the histopathology: two thirds of cases of poorly differentiated lymphocytic lymphomas, as defined cytomorphologically, have associated systemic disease. Prospective correlative clinicopathologic and immunologic analysis of 25 cases has shown that cell marker analysis divides the ocular adnexal lymphoid infiltrates into immunologically polyclonal proliferations, which show diverse but benign histopathologic features, and immunologically monoclonal B cell proliferations, which have the histologic features of malignant lymphomas. The benign, polyclonal ocular pseudolymphomas recapitulate the cell marker profile of a benign reactive lymph node with similar variations in the T cell:B cell ratio. The ocular adnexal and nodal B cell lymphomas are analogous in that they most commonly express surface IgM heavy chains and kappa light chains, express Ia antigens in parallel with SIg, and occasionally contain neoplastic B cells at various developmental stages--i.e., Ia+SIg+ and Ia+SIg-. Correlative immunologic and ultrastructural studies have demonstrated that electron microscopy is a reliable and reproducible technique for indirectly assessing the mono- or polyclonality of an ocular adnexal lymphoid neoplasm. This study is focused on the use of hybridoma-derived monoclonal antibodies, which are capable of detecting maturational stages of B and T cell differentiation and functionally distinct T cell subsets, in order to investigate the interactional and immunoregulatory defects that participate in the generation of the ocular adnexal lymphoid proliferations.

Correlation of CT scanning and pathologic features of ophthalmic Graves' disease

Correlating the CT scan features of patients with orbital Graves' disease with histopathologic observations allows one to focus more specifically on the distinguishing features of this disease with future research implications. Both CT scanning and pathologic studies have shown clearly that the extraocular muscles are the primary focus of the disease. Swelling of the extraocular muscles generally occurs within their bellys with sparing of the tendons. This contrast with idiopathic inflammation of the muscles or myositis, which tends to involve the tendon as well. All of the associated findings in orbital Graves' disease probably flow from the enlarged volume of the extraocular muscles: proptosis, bowing of the medial lamina papyracea to accommodate the swollen belly of the medial rectus muscle, venous engorgement from stasis induced by direct compression of the orbital venous drainage, conjunctival and lid swelling, and lacrimal gland enlargement. Both radiographic and pathologic changes in the orbital fat are secondary and comparatively insignificant. While there appears to be no selective inflammation of the optic nerve meninges or the perineural connective tissues, enlargement of the extraocular muscle bellys where they converge at the crowded orbital apex brings about compression of the optic nerve, impairs its function, and causes visual decrease. Lymphocytic and plasmacytic infiltration along with edema within the endomysium of the extraocular muscles leads to the activation of fibroblasts with the production of acid mucopolysaccharides and progressive fibrosis. It is not known what attracts the lymphocytes to the extraocular muscles, why certain extraocular muscles are affected preferentially, why the disease may be asymmetrically unilateral, and whether a defect in T cell or B cell functions (or both) is immunologically at fault.

Malignant lymphoma presenting in the orbit: a clinicopathologic study of a rare immunoglobulin-producing variant

Malignant lymphoma with orbital presentation and associated serum paraproteinemia has seldom been reported in the literature. We report two such cases of lymphoplasmacytic type, one of which was also associated with amyloidosis. Both cases were studied with immunohistologic and one with electron microscopic techniques with results that confirmed that the neoplastic cells were producing the abnormal serum immunoglobulin.

Ocular pathology for clinicians. 6. Lymphoid tumor of the lid

A 56-year-old white man presented with bilateral inferior lid tumors with a rubbery consistency suggesting lymphoid lesions. An excisional biopsy specimen of the larger lesion in the left lower lid led to routine pathologic, immunologic, histochemical, and electron microscopic investigations. The tumor displayed a diffuse pattern microscopically and was composed of atypical lymphocytes with intermediate differentiation. The immunologic and histochemical marker studies revealed that 90% of the constituent lymphocytes were B-lymphocytes bearing IgM-IgD immunoglobulins on their surface membranes; the remaining 10% of the cells being reactive T-lymphocytes. A diagnosis of a monoclonal proliferation was established and a systemic workup revealed disseminated lymphoma. The use of immunoglobulin and histochemical analyses of ocular adnexal lymphoid tumors is outlined.

Orbital lymphoid neoplasms: a clinicopathologic study of 60 patients

Sixty cases of orbital lymphoid neoplasms originally accessioned as malignant lymphomas were analyzed histopathologically and the follow-up data evaluated separately for each category as follows: inflammatory pseudo-tumor, 5; reactive lymphoid hyperplasia, 8; atypical lymphoid hyperplasia, 7; and malignant lymphocytic lymphoma (classified according to Rappaport), 40. Significant clinical differences were not observed among these patients, suggesting that the lesions must be distinguished by histologic rather than clinical criteria. Systematic application of the histologic criteria discussed here improved diagnostic accuracy and our ability to predict clinical outcome as substantiated by follow-up data. Two of 13 patients (15%) with benign pseudo-lymphomas, 2 of 7 patients (29%) with atypical lymphoid hyperplasia, 2 of 8 patients (25%) with well differentiated lymphocytic lymphomas, and 22 of 32 patients (68%) with less differentiated lymphocytic lymphomas either had or later developed systemic lymphomas. Thus, the degree of cytologic differentiation appears to be the single most important factor for determining the prognosis of patients with orbital lymphoid neoplasms.

Submillimeter resolution CT scanning of orbital diseases

continuous improvement in image quality produced by CT scanning has occurred since 1972 when the resolution element of the new EMI scanner was 3.0 X 3.0 X 12 mm. We are now working with a fourth generation machine with a resolution element of 0.75 X 0.75 X 2.0 mm. This hundred fold improvement in spatial resolution has had important clinical impact in analyzing diseases of the orbit.