Primary orbital lymphoma: a radiotherapeutic experience

Evolution of Care of Orbital Tumors with Radiation Therapy

Orbital tumors are rare lesions comprising 0.1% of all tumors and less than 20% of all ocular diseases. These lesions in children and adults differ significantly in their incidence, tumor type, and treatment management. Although surgery and systemic therapies are commonly used in the management of these diseases, radiation therapy has become a widely used treatment for both benign and malignant tumors of the orbit. Radiotherapy is used as a definitive treatment to provide local control while avoiding morbidity associated with surgery for some tumors while it is used as an adjuvant treatment following surgical resection for others. For many tumors, radiation provides excellent tumor control with preservation of visual function. This article is dedicated for presenting the most common applications of orbital radiotherapy. A brief overview of the commonly available radiation therapy modalities is given. Dose constraint goals are reviewed and acute and long-term side effects are discussed. Orbital tumors covered in this article include optic glioma, ocular melanoma, retinoblastoma, orbital rhabdomyosarcoma, orbital lymphoma, and lacrimal gland tumors. Background information, indications for radiotherapy, and goals of treatment for each case example are described.

Primary Non-Hodgkin's Lymphoma of the Orbit

Between 1954 and 1980, 9 patients with non-Hodgkin's lymphoma of the orbit were treated at the Regional Radiotherapy Centre, Mount Vernon Hospital. Following radiotherapy complete local regression of the tumour was seen in every case. Three patients subsequently developed recurrent disease which proved fatal in two cases. The overall 5 year survival was 89%.

Radiotherapy in the Management of Orbital Lymphoma: A Single Institution's Experience Over 4 Decades

PURPOSE

To report our institution's treatment techniques, disease outcomes, and complication rates after radiotherapy for the management of lymphoma involving the orbits.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 44 patients curatively treated with radiotherapy for stage IAE (75%) or stage IIAE (25%) orbital lymphoma between 1969 and 2013. Median follow-up was 4.9 years. Thirty-eight patients (86%) had low-grade lymphoma and 6 (14%) had high-grade lymphoma. Radiation was delivered with either a wedge-pair (61%), single-anterior (34%), or anterior with bilateral wedges (5%) technique. The median radiation dose was 25.5 Gy (range, 15 to 47.5 Gy). Lens shielding was performed when possible. Cause-specific survival and freedom from distant relapse were calculated using the Kaplan-Meier method.

RESULTS

The 5-year local control rate was 98%. Control of disease in the orbit was achieved in all but 1 patient who developed an out-of-field recurrence after irradiation of a lacrimal tumor. The 5-year regional control rate was 91% (3 patients failed in the contralateral orbit and 1 patient failed in the ipsilateral parotid). Freedom from disease, cause-specific survival, and overall survival rates at 5 and 10 years were 70% and 55%, 89% and 89%, and 76% and 61%, respectively. Acute toxicity was minimal. Ten patients (23%) reported worsened vision following radiotherapy, and cataracts developed in 17 patients. Cataracts developed in 13 of 28 patients treated without lens shielding (46%) and 4 of 16 patients (25%) treated with lens shielding.

CONCLUSION

Radiotherapy is a safe and effective local treatment in the management of orbital lymphoma.

Outcome of primary orbital lymphoma treated with induction chemotherapy followed by conformal radiotherapy

PURPOSE

To analyze the clinical outcome of primary orbital lymphoma (POL) patients treated with a combined modality approach with local radiotherapy after induction chemotherapy.

METHODOLOGY

We retrospectively retrieved demographic, treatment and outcome data of patients treated for POL from 2000 to 2010. The charts were reviewed and the data were tabulated in a predesigned pro-forma.

RESULTS

23 patients of POL were found evaluable. Median age was 55 years (range 24-70 years). Of 23 patients, 15 were male and 8 female, making the male:female ratio approximately 1.9:1. Patients were thoroughly evaluated and staged. All but one patient received multi agent chemotherapy. Radiotherapy was delivered for all cases. Radiation was delivered by 3DCRT technique. Median dose of radiation was 45Gy (range 20-45Gy). Median follow up was 26.8 months. None of the patients had any evidence of local failure or systemic progression.

CONCLUSION

A combined modality therapy with a combination of CHOP/COP based chemotherapy and moderate dose of radiotherapy imparts excellent long term local and systemic disease control.

Orbital lymphoma: role of radiation

The purpose of this article is to review the literature for clinical presentation, treatment, outcome and complications of using radiotherapy for the treatment of orbital lymphoma. For this, MEDLINE, EMBASE, and the Cochrane Library were searched through January 2007 for published data on primary non-Hodgkin's lymphoma (NHL) of the orbit. The search was conducted in all document types, using the following terms "Non-Hodgkin's lymphoma, MALT (mucosa associated lymphoid tissue) and orbit". Data extracted were based on age, sex, therapeutic methods and outcome of treatment. When full articles were not available, abstracts were used as a source of information. Only those articles whose abstracts or full text were available in English were included in table. The review of reports of NHL of the orbit, in general, served as a source of information about its clinical behavior, treatment and overall prognosis. Fifty-six publications were identified, including six in languages other than English. There was no randomized trial. All the studies were retrospective. The studies were heterogeneous in patient number (3 to 112), histology, disease stage (IE to IV), radiotherapy doses used (4 to 53.8Gy), local control rates (65 to 100%), distant relapse rates (0 to 67%, from low grade to high grade) and five-year survival rates (33 to 100%). Three of the studies with a good number of patients also demonstrated clinical benefit with radiotherapy in terms of superior efficacy or less toxicity. Available data support the acceptance of radiotherapy as a standard therapeutic option in patients with low to intermediate grade orbital lymphoma. Toxicity of radiotherapy is mild if delivered precisely.

Primary non Hodgkin's lymphoma of the lacrimal sac

BACKGROUND

Primary Non Hodgkin's Lymphoma (NHL) of the lacrimal sac is rare.

METHODS

The clinical features of a 78 year old female who presented with epiphora and swelling of the left lacrimal sac are described.

RESULTS

Computerised tomography showed a mass involving the left lacrimal sac. Histopathological examination revealed a diffuse large B cell NHL. Immunohistological examination demonstrated B cell origin. Chemotherapy could not be administered due to co morbid conditions. The patient was treated with radiotherapy to a dose of 45 Gy in 25 fractions. Patient is disease free and on follow up after 36 months.

CONCLUSION

Primary radiotherapy is a treatment option with curative potential for localized NHL of the lacrimal sac and may be considered in patients who cannot tolerate appropriate chemotherapy.

The clinical characteristics and treatment results of ocular adnexal lymphoma

PURPOSE

To assess the clinical pattern, the histopathological findings, the response to treatments, the recurrence pattern and the prognosis of malignant lymphoma in the ocular adnexa.

METHODS

This study was performed on 22 total eyes from 17 patients who were diagnosed with ocular adnexal malignant lymphoma. We retrospectively analyzed the medical records for patient information including the histological classification based on age, the gender of each patient, the symptoms and signs at the initial diagnosis, the presence of binocular invasion, the findings of the surgical biopsy, the clinical stage of each patient's tumor, and the treatment methods used and their effectiveness. The mean follow-up period was 24.8 months.

RESULTS

The mean age of patients studied was 46.8 years old. Six females and 11 males were included in the study. Fifteen cases consisting of 20 total eyes represented extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT). Five of seven patients (71.4%) whose lymphoma occurred within the conjunctiva relapsed after irradiation or chemotherapy, and four of the relapsed patients were salvaged with further therapy.

CONCLUSIONS

Extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) constituted 88.2% of all lymphomas involving the ocular adnexa. Lymphoma in the ocular adnexa responded well to conventional treatment, but the recurrence rate of lymphoma in the conjunctiva was significantly high.

Outcome and prognostic factors in orbital lymphoma: a Rare Cancer Network study on 90 consecutive patients treated with radiotherapy

PURPOSE

To assess the outcome and prognostic factors in patients with orbital lymphoma treated by radiotherapy (RT).

METHODS AND MATERIALS

Between 1980 and 1999, 90 consecutive patients with primary orbital lymphoma were treated in 13 member institutions of the Rare Cancer Network. A full staging workup was completed in 56 patients. Seventy-eight patients had low-, 6 intermediate-, and 6 high-grade lymphoma, and 75 had a single orbital localization. All patients underwent RT with a median dose of 34.2 Gy (range 4.0-50.4). Eleven patients received chemotherapy in addition to RT.

RESULTS

After RT, local control was achieved in 97% of the patients. Local progression occurred in 2% and local relapse 1%. The rate of systemic relapse was 20%, and 9% of the patients developed metachronous contralateral eye involvement. The 5-year disease-free survival, overall survival, and cause-specific survival rate was 65%, 78%, and 87%, respectively. In univariate analyses, the statistically significant favorable prognostic factors were younger age, low grade, normal erythrocyte sedimentation rate, absence of muscular infiltration, complete response to treatment, conjunctival localization, and normal lactate dehydrogenase value for overall survival, disease-free survival, and freedom from treatment failure. In multivariate analysis, the favorable factors were younger age and low grade for overall and disease-free survival; a favorable response, conjunctival localization, and complete staging were highly significant for disease-free survival and freedom from treatment failure. Neither the RT technique nor the total dose influenced the outcome. Cataract and xerophthalmia were the most prominent late toxicities.

CONCLUSION

Moderate- to low-dose RT alone is able to control primary orbital lymphoma with low morbidity. A full staging workup is warranted in these patients. Prognostic factors were identified that could be useful in the overall management of this uncommon site of primary lymphoma.

Role of radiotherapy for primary orbital lymphoma

To define the role of radiation therapy of primary orbital lymphoma, a retrospective analysis was undertaken for 18 patients with primary orbital lymphoma who were treated with curative radiotherapy between 1984 and 1995. The histology was found to be low grade lymphoma in 11 patients, intermediate grade in 7. All patients were of Ann Arbor stage IE, but bilateral involvement of the orbit was observed in 3 patients (16.6%). Anatomical subsites involved were the retrobulbar, eyelid, and conjunctiva in eight, five, and four patients, respectively. The median radiation dose was 30 Gy ranging from 20 Gy to 50 Gy. Twelve of 18 patients received a radiation dose of 30 Gy or less. To properly protect the lens during irradiation, the contact lens blocks were used for nine patients with conjunctival and eyelid tumor or the hanging eye bar blocks were applied for eight patients with retrobulbar tumor. Chemotherapy was given for seven patients with intermediate-grade malignant lymphoma. Two patients had been treated by surgery before referral.

Primary orbital lymphoma

BACKGROUND/AIMS. Localized orbital non-Hodgkin's lymphoma is a rare form of extranodal lymphoma. The aim of this study was to evaluate the outcome of 48 patients presenting with stage I-E non-Hodgkin's lymphoma (NHL). METHODS. Out of 118 charts of patients with lymphoproliferative lesions, those of 48 patients with stage I-E orbital lymphoma seen over a 22-year period from 1977 through 1999 were reviewed. RESULTS. Twenty-five patients were male and 23 were female. Their mean age was 58.7 (12-85) years. The mass was localized inside the orbit in 37 cases and in the lacrimal gland region in 11 cases; bilateral involvement was observed in two cases. The duration of the symptoms at the time of presentation ranged from 10 days to 10 years with a mean duration of 18 months. The 24 cases with low-grade lymphoma are all alive without disease, whatever therapeutic approach was performed (biopsy, radiotherapy, chemotherapy). In intermediate and high-grade NHL the rate of recurrence after chemotherapy has been 50% and 33%, respectively, compared to 75% and 50% after biopsy alone and 75% after radiotherapy (not administered in high-grade forms). CONCLUSION. The therapeutic approach to localized orbital non-Hodgkin's lymphoma must take the histologic grading into consideration. The 24 cases with low-grade lymphoma had a good prognosis. The 17 cases with the intermediate-grade form and the 7 cases with the high-grade form had a better prognosis when treated with chemotherapy.

Clinical stage IEA-IIEA orbital lymphomas: outcomes in the era of modern staging and treatment

BACKGROUND AND PURPOSE

The present study examines outcomes in patients with primary orbital lymphomas who underwent complete staging.

MATERIALS AND METHODS

From 1978 to 1997, 21 adult patients at the M.D. Anderson Cancer Center had stage IEA-IIEA orbital non-Hodgkin's lymphomas based on staging that included computed tomography scans. Sixteen (76%) patients had working formulation low-grade lymphomas, and five (24%) had aggressive lymphomas. Fourteen of 16 (88%) patients with low-grade lymphomas were treated with radiotherapy alone, and four of five (80%) patients with aggressive lymphomas were treated using combination chemotherapy with or without radiotherapy. Total radiotherapy doses ranged from 30.0 to 40.0 Gy using daily 1.5-2.0 Gy fractions.

RESULTS

The median follow-up was 84 months. For the low-grade lymphomas, the 5-year local control, progression-free survival, and overall survival rates were 100, 100, and 92%, respectively. For the seven low-grade lymphomas treated with radiotherapy alone to 30.0 Gy in 20 fractions, the 5-year local control, progression-free, and overall survival rates were 100, 100, and 75%, respectively. The 5-year incidence of complications, which were typically mild, in eyes irradiated to 30 Gy in 20 fractions versus higher biologically effective doses were 25 and 38%, respectively (P = 0.62). Of the five patients with aggressive lymphomas, none of the four who underwent chemotherapy with or without radiotherapy relapsed (all four remain alive), whereas the one treated with radiotherapy alone for stage IEA disease experienced a distant relapse.

CONCLUSIONS

In patients with low-grade lymphomas, a good therapeutic ratio was obtained with low-dose radiotherapy alone. In patients with aggressive lymphomas, chemotherapy with or without radiotherapy resulted in excellent local control, progression-free survival, and overall survival; however, the statistical power was limited.

Orbital lymphoma: radiotherapy outcome and complications

BACKGROUND AND PURPOSE

Orbital non-Hodgkin's lymphomas (NHL) have traditionally been treated with radiation. Forty-eight patients presenting with orbital NHL were treated with radiation and were evaluated for local control, overall survival, cause-specific survival, and complications.

MATERIALS AND METHODS

Forty-five patients had low-grade and 3 patients had intermediate-grade histologic findings. Orbit-only disease occurred in 22 patients, the conjunctiva in 16, both in five, and lacrimal gland only in five. Patient age ranged from 35 to 94 years (median, 68). Ann Arbor stages were cIEA (34), cIIEA (six), cIIIEA (two), and cIVEA (six). Radiation doses ranged between 15 and 53.8 Gy (median, 27.5 Gy).

RESULTS

Follow-up ranged from 0.14 to 18.23 years (median, 5.35). Median overall survival and cause-specific survival were 6.5 and 15.5 years, respectively. Patients with clinical stage I or II disease had significantly better overall and cause-specific survival than patients with stage III or IV disease. Ten-year relapse-free survival in 41 patients with stage I or II disease was 66%. However, there was continued downward pressure on relapse-free survival out to 18 years. One local failure occurred. Twenty-five patients sustained acute complications. There were 17 minor and four major late complications. All major late complications occurred with doses more than 35 Gy.

CONCLUSIONS

Excellent local control with radiation doses ranging from 15 to 30 Gy is achieved. Patients with stage I or II disease have better overall and cause-specific survival than patients with stage III or IV disease. Late relapse occurs in sites other than the treated orbit, even in patients with early-stage disease. Doses 35 Gy or higher result in significant late complications and are therefore not indicated for patients with low-grade tumors.

Primary non-Hodgkin's lymphoma of the lacrimal sac: a case report and a review of the literature

BACKGROUND

Primary non-Hodgkin's lymphoma of the lacrimal sac is extremely rare, with most reported cases representing secondary involvement of a systemic malignancy.

METHODS

The clinical record of a 70-year-old female who presented with epiphora and swelling of the lacrimal sac area is described. A review of the literature of patients with primary lacrimal sac lymphoma also is presented.

RESULTS

Computed tomography demonstrated a lacrimal sac mass involving the nasolacrimal canal. Histopathologic examination of a biopsy specimen revealed a diffuse large cell lymphoma. Using immunohistologic staining, the tumor was a B-cell type, similar to those described in the literature. The patient was treated with 50 gray of irradiation and chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone. The patient remained free of lymphoma 26 months after initial treatment. An ocular examination was unremarkable except for epiphora.

CONCLUSIONS

Radiotherapy and/or chemotherapy can treat localized lymphoma of the lacrimal sac successfully.

A retrospective analysis of different modalities for treatment of primary orbital non-Hodgkin's lymphomas

We have reviewed 37 patients with primary orbital lymphoma, using the Ann Arbor criteria and the Working Formulation and its modification. Thirty-one patients had stage I disease, four stage II, one stage III and one stage IV. The male to female ratio was 2.7:1. There were 34 low-grade tumours (including 24 mantle zone) and three intermediate-grade. Patients were divided into three groups according to their primary treatment. Group 1: radiotherapy (17 cases); Group 2: surgery alone (13 cases); Group 3: chemotherapy (seven cases). Patients were followed up from 5 months to 24.3 years, with a mean and median of 7.6 and 6.2 years, respectively. The BMDP software package was used for survival estimation (Kaplan-Meier) and determination of prognostic variable (univariate Cox regression). Local relapse-free survival at 10 years was 100% in Group 1, 0% in Group 2 and 42% in Group 3 with a statistically significant difference (p < 0.01) in favour of radiotherapy. Statistically significant good prognostic features were: complete remission (CR) in response to initial treatment, primary radiotherapy and older age. For stage I cases, there was no difference in distant relapse-free survival in the three groups. The overall cause-specific survival for stage I patients at 10 years was 100% for each group and at 20 years was 100, 67 and 0% for Groups 1, 2 and 3. The difference between the primary radiotherapy and chemotherapy-treated groups was significant at the p = 0.08 level. Statistically significant prognostic factors were early stage, low-grade histology and primary radiotherapy. In one patient, ptosis and diplopia appeared after surgery. One case of glaucoma required enucleation, one patient suffered severe dry eye syndrome. All patients (11/11) in whom the lens received direct radiation developed cataracts of different degrees if follow-up was long enough. Cataract formation was prevented by adequate lens shielding. One patient in CR from a stage I low-grade tumour died from chemotherapy-induced marrow aplasia. Primary orbital lymphoma is an indolent, usually stage I disease, showing low to intermediate-grade histology. After biopsy the best treatment is 30 (low-grade) to 40 Gy (intermediate-grade) carefully planned, lens-sparing megavoltage radiation without adjuvant chemotherapy.

Non-autoimmune hyperthyroidism associated with isolated bilateral ocular lymphoma mimicking Graves' disease with ophthalmopathy: a cause of misdiagnosis

A very rare association of non-autoimmune hyperthyroidism due to nodular goiter with isolated bilateral non-Hodgkin's ocular lymphoma is described. A 66-year-old woman presented with bilateral proptosis, marked periocular swelling, conjunctival hyperemia and chemosis, severe extraocular muscle impairment with diplopia. Thyroid function tests showed normal free thyroid hormone concentrations with undetectable serum thyrotropin levels. Patient was placed on antithyroid drug treatment, ocular conditions deteriorated. More than two years later, when first seen in our institution, orbital CT scan showed the presence of a retro-ocular mass that, at biopsy, proved to be B-cell non-Hodgkin's lymphoma, apparently with no localization in other sites. Thyroid evaluation revealed subclinical hyperthyroidism due to an autonomous thyroid nodule in the left lobe of the gland. Radiotherapy of the orbit was followed by a dramatic regression of lymphoma, but further staging some months later showed involvement of several abdominal lymph node structures. This case underscores the need of a thorough diagnostic work-up of ocular disease resembling Graves' ophthalmopathy, even when it is bilateral and associated with overt or subclinical hyperthyroidism.

Radiation therapy for primary orbital lymphoma

PURPOSE

The influence of tumor size, grade, thoroughness of staging workup, and radiation dose on disease control, radiation-related complications, and incidence of systemic progression of primary orbital lymphoma is analyzed.

METHODS AND MATERIALS

Twenty patients with Stage I primary orbital lymphoma were treated from August 1976 through August 1991 at Mallinckrodt Institute of Radiology. Staging workups included physical examination, chest x-ray, complete blood count (CBC), liver function test, and computerized tomography (CT) scan of the orbit, abdomen, and pelvis. Nineteen patients had bone marrow biopsy. The histological types based on the National Cancer Institute working formulation were 9 low-grade and 11 intermediate-grade, including five lymphocytic lymphomas of intermediate differentiation. The extension of disease and the volume of tumor were evaluated by CT scan of the orbit. The most commonly used radiation therapy technique was single anterior direct field with 4 MV or 6 MV photons. Lens was shielded or not treated in eight patients. Dose ranged from 20 to 43.2 Gy. Thirteen of 20 patients received 30 Gy. Minimum follow-up was 24 months (median, 4 years).

RESULTS

Local control was achieved in all 20 patients. One patient with lymphocytic lymphoma with intermediate differentiation developed disseminated disease. Actuarial disease-free survival (DFS) was 100% and 90% at 2 and 5 years, respectively. No retinopathy was observed. Cataracts were noted in seven patients at 1 to 10 years following irradiation (median, 2 years). Three patients developed lacrimal function disorder; however, no corneal ulceration occurred.

CONCLUSIONS

Thirty Gy in 15 fractions appears to be a sufficient dose for local control with acceptable morbidity, especially for low-grade, as well as certain types of intermediate-grade lymphomas, such as diffuse small cleaved cell and lymphocytic lymphoma of intermediate differentiation. Systemic dissemination is minimal, provided local control is achieved and initial staging workups are adequate.

Lacrimal collecting system lymphomas: integration of magnetic resonance imaging and therapeutic irradiation

Lymphomas arising within the lacrimal collecting system are rare tumours and unusual causes of lacrimal obstructive symptoms. The presentation, diagnosis, and treatment of this disease in five patients are described, as well as a review of the existing literature. Emphasized in this series is the efficacy of magnetic resonance imaging of these presentations and the importance of irradiation in their treatment.

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.

Radiotherapy is successful treatment for orbital lymphoma

PURPOSE

To describe the clinical presentation, treatment technique, outcome and complications in a large single institutional experience using radiotherapy for treatment of orbital lymphoma.

METHODS AND MATERIALS

Twenty-five patients with lymphoma of the orbit or ocular adnexa were treated with radiotherapy at Stanford University Medical Center during the fourteen year period, 1977-1991. Patients were staged using the Ann Arbor criteria with chest x-ray, computerized tomography of abdomen and orbits, lymphangiogram, and bone marrow biopsy. Patients with disease localized to the orbits as well as those with disseminated disease and symptomatic orbital lesions were treated. Thirty-one involved eyes were treated. Mean radiotherapy dose was 35.3 Gy, with a range of 28 Gy to 40.2 Gy. Lens protection was used in all cases. Two patients with diffuse large cell lymphoma also received chemotherapy as part of their initial treatment. Follow-up ranged from 10 months to 13 years, with a mean follow-up time of 4 years.

RESULTS

Twenty patients had disease confined to one or both orbits (Stage I). One patient had a monoclonal atypical infiltrate, while the remainder had a histologic diagnosis of malignant lymphoma: diffuse small lymphocytic, 13; follicular mixed, 3; diffuse small cleaved, 3; diffuse large cell, 2; follicular small cleaved, 1; follicular and diffuse small cleaved, 1; undifferentiated, 1. Two local relapses occurred; the actuarial 5-year freedom from local relapse is 89%. Actuarial 5-year freedom from distant relapse, freedom from any relapse and overall survival are 77%, 70%, and 93%, respectively. Acute complications of treatment were mild. Late complications included transient cystoid macular edema (one patient), asymptomatic subcapsular and medial sector cataract formation (two patients), retinopathy (two patients), mild eyelid retraction (one patient), and dry eye with secondary conjunctivitis (one patient).

CONCLUSION

Carefully planned radiotherapy with lens shielding is an effective and safe treatment in the management of orbital lymphoma. We recommend megavoltage radiation doses of 30-35 Gy in 180-200 cGy fractions for low grade lesions, and 36-40 Gy for intermediate and high grade lesions.

Application of magnetic resonance imaging and three-dimensional treatment planning in the treatment of orbital lymphoma

Radiotherapy for lymphoma of the orbit must be individualized for each patient and clinical setting. Most techniques focus on optimizing the dose to the tumor while sparing the lens. This study describes a technique utilizing magnetic resonance imaging (MRI) and three dimensional (3D) planning in the treatment of orbital lymphoma. A patient presented with an intermediate grade lymphoma of the right orbit. The prescribed tumor dose was 4050 cGy in 18 fractions. Three D planning was carried out and tumor volumes, retina, and lens were subsequently outlined. Dose calculations including dose volume histograms of the target, retina, and lens were then performed. Part of the retina was outside of the treatment volume while 50% of the retina received 90% or more of the prescribed dose. The patient was clinically NED when last seen 2 years following therapy with no treatment-related morbidity. Patients with lymphomas of the orbit can be optimally treated using MRI based 3D treatment planning.

Results of radiotherapy in patients with stage I orbital non-Hodgkin's lymphoma

This paper describes the results of radiotherapy in early stage orbital non-Hodgkin's lymphoma. From 1970 to 1985, 33 orbital localizations in 30 patients were treated. The total dose applied ranged from 21 to 57 Gy (2 Gy per fraction), two-thirds of all patients received a dose of 40 Gy. The complete-response rate was 94% and the 10 years actuarial survival was 90%; no significant difference in survival was observed between patients with low grade or intermediate grade lymphoma. No local recurrence was detected during follow up and 20% of the patients developed generalized disease. Two optic nerve neuropathies and three retinopathies were observed in five patients, four of these occurred at a dose level of less than 43 Gy. Keratitis occurred in 58% of the patients treated, a sicca syndrome in 30% and cataract of different grades in 58% of the patients treated. Although local control was excellent, severe complications were observed in 13% of the patients who received a dose of less than 43 Gy.

Local control and complications after radiation therapy for primary orbital lymphoma: a case for low-dose treatment

Orbital involvement at the time of initial presentation is unusual in non-Hodgkin's lymphoma. In an effort to identify potential ways of improving the radiotherapeutic management of this disease, the records of 22 patients were reviewed retrospectively. All had biopsy-proven orbital non-Hodgkin's lymphoma, and the minimal, median, and maximal durations of follow-up in surviving patients were 4.8 years, 7.0 years, and 17.4 years, respectively. Permanent local control was achieved in 21 of the 22 patients (96%). Complications were scored according to a grading scheme in which grade 1 was the least significant complication and grade 4 was blindness as a result of radiation therapy. Of the 12 patients who received a radiation dose less than 35 Gy, 6 developed a grade 1 or grade 2 complication. Of the 10 patients treated with greater than or equal to 35 Gy, 6 experienced a complication, 1 of whom had a grade 4 complication resulting in blindness and another who developed a severe keratitis, which was scored as a grade 3 complication resulting in decreased visual acuity. At last follow-up, 10 patients were alive at 4.8 to 17.4 years after completion of radiation therapy, 4 had died of intercurrent disease at 3 months to 10.6 years, and 8 had died of disease at 3 months to 15.8 years. Actuarial survival for the entire group was 75% at 5 years and 48% at 10 years. Survival in patients with Stage I AE disease (lymphoma confined to orbit) at presentation was 87% at 5 years and 50% at 10 years, and survival in patients with Stage II A through Stage IV disease was 36% at 5 years and at 10 years. Primary orbital lymphoma is an indolent disease characterized by prolonged survival after radiation therapy. Excellent local control can be achieved with radiation doses of 20 Gy to 35 Gy. Higher doses may result in an increased risk of complications.

Conjunctival lymphoma: results and treatment with a single anterior electron field. A lens sparing approach

Lymphoma of the conjunctiva is rare. It presents in older patients as a mass lesion and usually remains localized. Surgery is limited to biopsy, and radiation therapy is the definitive treatment of choice. The entire conjunctiva is treated. Relatively high doses (approximately 30 Gy) are required for local control, which may lead to cataract formation. Twelve patients with conjunctival lymphoma were treated at the Massachusetts General Hospital between 1979 and 1988. Ten of 12 patients presented with a unilateral lesion; 2 of 12 with bilateral lesions. Two of 12 patients were found to have systemic disease at the time of presentation. One patient developed conjunctival lymphoma 5 years after the diagnosis of generalized disease. Using electron beam, all patients were treated with a single anterior circular field to total doses ranging from 24 Gy to 30 Gy delivered in 8 to 16 fractions over 9 to 20 days. In all cases, the lens was shielded by a specially designed plastic contact lens bearing a 12 mm diameter lead shield. The lens dose was determined at varying depths beneath the shield for 6 MeV and 9 MeV electron beams and ranged from a minimum of 5% to an absolute maximum of 18% of the total dose delivered to the tumor. Local control was maintained in all patients with follow-up to 9 1/2 years. One patient relapsed distantly 3 years after treatment. One of 12 patients died of systemic disease 4 years after treatment of the ocular lesion. Two patients developed cataracts 4 and 5 years after treatment; one had bilateral cataract, although only one eye had been treated. Both patients were over 75 years old. In both cases, the cataracts were felt to be senile cataracts which are ophthalmologically and radiographically distinguishable from radiation induced lesions.

Orbital and conjunctival lymphoma treatment and prognosis

115 patients with lymphoid tumours presenting in the orbit were seen between 1970 and 1984. The histological types were high-grade malignant lymphoma--18, low-grade malignant lymphoma--43, and indeterminate lymphocytic lesions--54. Eighteen patients were found to have disseminated lymphoma at presentation. The majority of the patients received radiotherapy to the orbit; local control was achieved in all cases and the ocular morbidity from radiotherapy was low with 11 patients developing lens opacities and 5 a dry eye. Survival of patients with stage I low-grade lymphoma and indeterminate lymphocytic lesions was similar to that of a normal population of the same age distribution. The clinic features and dissemination pattern of the low-grade malignant lymphomata and the indeterminate lymphocytic lesions were identical, suggesting that most, if not all, lymphoid masses presenting in the orbit are neoplastic rather than reactive in nature.

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.

Irradiation of bilateral orbital lymphoma: a non-coplanar technique with case reports

Bilateral synchronous involvement of the orbits by lymphoma is an uncommon event. Therefore, the irradiation techniques for this disease are not well refined. Depending on the technique used, one has to decide between underdosing the anterior segment of the orbit and the frequently involved lacrimal glands or to tolerate shield related in homogeneities in the range of 40 to 50% as well as higher doses to the midline structures, e.g. the optic chiasma. To avoid the above shortcomings we developed a technique by which half the prescribed dose is delivered by pairs of beams angulated in the transverse plane and the other half by pairs of beams angulated in the sagittal plane. Film dosimetry in a phantom confirms that the entire orbit, including its anterior portion, is well covered, the lens is protected, and the dose to the mid-sagittal structures is not increased. The dose inhomogeneity is in the range of 20% which represents a substantial improvement over alternative methods. Two irradiated patients with bilateral orbital lymphoma are presented with local control and no ophthalmic or other side effects as of last follow-up.

Primary orbital lymphoma-pseudotumor (pseudolymphoma): case reports and review of radiotherapy literature

Five case reports of orbital pseudotumor (pseudolymphoma) and primary orbital lymphoma are presented. A review of the literature was conducted in search of differentiating clinicopathologic features suggestive of either condition as well as part of their natural histories. Radiotherapy series reporting beneficial results are summarized.

Radiotherapy of lymphoid diseases of the orbit

Thirty-two patients with orbital pseudotumor (18), reactive lymphoid hyperplasia (2), atypical lymphoid infiltrate (4) or malignant lymphoma (8) were treated in the Division of Radiation Therapy at Stanford University between January 1973 and May 1983. Of the 20 patients with pseudotumor or reactive lymphoid hyperplasia, 10 had unilateral lesions and 10 had bilateral lesions. Biopsy samples were obtained in 15 patients; in five patients with bilateral disease the diagnosis was made on the basis of computed tomography (CT) and clinical findings. The majority of patients were referred because of disease refractory to treatment with corticosteroids. The patients were given a mean dose of 2360 rad using complex, individualized megavoltage techniques including lens shielding. Radiotherapy was well tolerated with no significant acute or late complications. Fifteen patients had complete resolution of symptoms after treatment; five had continued symptoms. Of the 12 patients with malignant lymphoma or atypical lymphoid infiltrate, four had systemic lymphoma with orbital involvement and eight had orbital involvement only. The diagnosis was made by biopsy in all patients and immunophenotyping was done in six cases, of which 5 were monoclonal. Patients were evaluated with a chest radiograph, lymphogram or abdominal CT, bone marrow biopsy and orbital CT. A mean dose of 3625 rad was delivered to the orbit only. Most of the patients received complex megavoltage treatment using bolus. All patients in this group had a complete response and local control. There were no relapses in those with localized disease. Two patients developed cataracts. Carefully planned orbital radiotherapy provides local control without symptomatic sequelae for orbital masses ranging from pseudotumor to malignant lymphoma.

Radiation therapy of conjunctival and orbital lymphoid tumors

Lymphoid tumors of the conjunctiva and orbit are rare and remain localized in the majority of cases. Sometimes it is not possible either clinically or histologically to differentiate between a non-Hodgkin's lymphoma (NHL) and benign lymphoid hyperplasia. A series of 24 patients is reported. Nineteen were classified as having malignant NHL and 5 benign hyperplasia; 1 of these 5 later developed metastases, however. All patients had systemic work-up: 18 had Stage I, 1 had Stage II, and 5 had Stage IV disease. All patients received local radiation therapy with doses of 2400 to 2750 rad in 2-3 weeks for lesions of the eyelid and conjunctiva, and between 3000 and 3750 rad in 3-4 weeks for retrobulbar lesions. The lens was shielded in all patients except in 2 who had NHL of the vitreous body. A method of shielding the lens with a lead block mounted on a "low vac lens" is described, and the dose distribution within the eye and orbit is presented. The dose to the ocular lens is reduced to about 10% of the tumor dose with this technique. Patients who were treated with doses higher than 3000 rad experienced conjunctivitis and skin erythema that resolved completely. No other effects of radiation on normal structures of the ocular adnexa were observed in the 20 patients who are alive and without signs of tumor 10-46 months with a median follow-up time of 22 months.

Lymphoreticular tumors of the orbit

Lymphoreticular tumors in the orbit are uncommon. Only 42 patients were identified from over 2000 patients with tumors of lymphoid tissue seen between 1958 and 1979. The patients were divided into 3 groups: primary malignant, secondary malignant, and benign lymphoma. In the primary malignant lymphoma groups, there were 24 patients with a median age of 64 (40 to 87) years and a 2.4:1 female to male ratio: 2 cases were bilateral. In 19 (79%) patients with the lymphoma limited to one orbit the tumor was controlled in every case with doses from 25 to 45 Gy. There were no serious complications. Subsequently lymphoma developed at other sites in 7 (37%) patients. The 5 and 10 year cause specific actuarial survival rates were 70 and 62%. In the 8 patients with secondary malignant lymphoma, the orbital disease was controlled by irradiation, although all patients required further treatment and died of their disease. Radiotherapy controlled all 7 patients with benign lymphoma without any complications.

Radiation therapy treatment of stage I and II extranodal non-Hodgkin's lymphoma of the head and neck

We have reviewed the records of 76 patients with Stage I or II extranodal non-Hodgkin's lymphoma who were referred to the Division of Radiation Oncology, Mallinckrodt Institute of Radiology, during the years 1964 through 1974. The histologic slides were reviewed in the 67 cases in which they were available. Forty-three percent of Ann Arbor Stage I and II patients relapsed after primary radiation treatment.Seventy-three percent of these failed in sites distant from the irradiated volume. Failures in the treated volume were infrequent (7%) except in those patients presenting with primary lesions of the brain (4/5). Those patients presenting with lesions of Waldeyer's ring experienced a decrease in survival with increasing tumor size. Because of the high rate of failure in distant sites with tumors in the lingual and palatine tonsils, we are recommending the study of adjuvant chemotherapy in these cases, after primary radiation treatment.