T-cell malignant lymphoma with conjunctival involvement

Anaplastic Large-Cell Lymphoma With Vitreous Humor Involvement

Purpose: To describe a case of T-cell lymphoma with bilateral vitreous involvement. Methods: A case report was reviewed, and a literature review, including search terms such as "anaplastic large-cell lymphoma (ALCL)" and "T-cell lymphoma with ocular involvement", was performed. Results: A 56-year-old man presented with slurred speech, left-sided weakness, and floaters in his right eye. He was found to have an enhancing right frontal lobe mass with biopsy positive for ALCL. The right eye demonstrated 2+ vitreous cell, with a vitreous biopsy consistent with ALCL. His floaters resolved, and the patient was asymptomatic until he developed floaters in his left eye 1½ years later. A subsequent vitreous biopsy revealed recurrence of ALCL in the fellow eye. Conclusions: ALCL is a rare T-cell lymphoma uncommonly reported as having vitreous infiltration.

Malignant lymphoma of the conjunctiva

Conjunctival lymphomas constitute 25% of all ocular adnexal lymphomas. The majority are B-cell non-Hodgkin lymphomas (NHLs) (98%), whereas conjunctival T-cell NHLs are rare (2%). The most frequent subtype of conjunctival B-cell lymphoma is extranodal marginal zone lymphoma (EMZL; 81%), followed by follicular lymphoma (8%), diffuse large B-cell lymphoma (3%), and mantle cell lymphoma (3%). Extranodal marginal zone lymphoma occurs slightly more often in women and, along with follicular lymphoma, presents late in the seventh decade of life, whereas diffuse large B-cell lymphoma and especially mantle cell lymphoma have a predilection for the male gender and typically present in the eighth decade. Extranodal marginal zone lymphoma and follicular lymphoma present most frequently in the forniceal and bulbar conjunctiva. Conjunctival diffuse large B-cell lymphoma, mantle cell lymphoma and T-cell NHLs are characterized by a short duration of symptoms before the first ophthalmologic consultation. External beam radiotherapy is the treatment of choice for extranodal marginal zone lymphoma and follicular lymphoma, whereas diffuse large B-cell lymphoma, mantle cell lymphoma, and T-cell NHLs are mainly treated with chemotherapy. Conjunctival T-cell NHLs are associated with a particularly poor prognosis, with 50% of patients having progression or recurrence during a 1-year follow-up period.

Conjunctival Angioimmunoblastic T-Cell Lymphoma

Angioimmunoblastic T-cell lymphoma (AITL) represents an uncommon variant of T-cell lymphomas and most often presents insidiously with systemic symptoms. This report constitutes the first documented case of conjunctival AITL, masquerading as nodular episcleritis, and describes both the clinical and pathological findings. Furthermore, conjunctival T-cell lymphoma in general remains a rare occurrence, and a survey of previously reported cases reveals a wide variation in clinical presentation. A high index of suspicion, thorough examination and conjunctival biopsy are essential to reaching the diagnosis of conjunctival lymphoma.

Malignant conjunctival T cell lymphoma diagnosed by punch biopsy as a primary manifestation of systemic cancer

This report documents a case of T cell lymphoma manifesting only with a conjunctival mass. A 67-year-old man underwent a diagnostic punch biopsy, histopathological examination, and immunohistochemical study for a pink-yellow colored mass infiltrating the bulbar conjunctiva in the lower fornix of the eyelid. A biopsy specimen of the conjunctival mass was found histopathologically to be a malignant T cell lymphoma. Systemic involvement was diagnosed within four weeks after the initial diagnosis by computed tomography, showing evidence of extension at the level of the ethmoidal cells, optic nerve, periorbital tissue, and pancreas. T cell lymphoma of the conjunctiva as a primary manifestation of systemic cancer is an uncommon entity. Punch biopsy may be the first diagnostic pathway useful to initiate a search for systemic involvement of a malignant lymphoid tumor of T cell lineage.

Spectrum of CD30+ lymphoid proliferations in the eyelid lymphomatoid papulosis, cutaneous anaplastic large cell lymphoma, and anaplastic large cell lymphoma

PURPOSE

To report the clinicopathologic features of 3 patients with CD30(+) lymphoid proliferations of the eyelid.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients with cutaneous CD30(+) lymphoproliferative lesions of the eyelid.

METHODS

Three patients with CD30(+) non-mycosis fungoides T-cell lymphoid infiltrates of the eyelid were identified. The histories, clinical findings, pathologic features including immunohistochemical staining, treatments, and outcomes were reviewed and compared.

MAIN OUTCOME MEASURES

Pathologic findings including immunohistochemical analysis.

RESULTS

The patients included an 81-year-old man, an 18-year-old man, and a 42-year-old woman with CD30(+) lymphoid proliferations of the eyelid and adjacent soft tissue. The first patient had an isolated crateriform eyelid lesion that was classified as lymphomatoid papulosis (LyP). The second patient had an isolated multinodular lesion of the eyelid that was classified as cutaneous anaplastic large cell lymphoma (cALCL). The third patient presented with eyelid edema with an underlying mass and was found to have widely disseminated anaplastic large cell lymphoma (ALCL). Diagnoses were dependent on clinical findings.

CONCLUSIONS

The CD30(+) lymphoid proliferations represent a spectrum of conditions ranging from indolent LyP, to moderately aggressive cALCL, to highly aggressive ALCL. Interpretation of the pathologic findings in CD30(+) lymphoid proliferations is based in part on clinical findings.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any material discussed in this article.

Optic neuropathy due to anaplastic large cell lymphoma

PURPOSE

To report a case of anaplastic large cell lymphoma (ALCL) of the central nervous system (CNS) producing an optic neuropathy.

METHODS

Observational case report.

RESULTS

A 29-year-old male presented with new onset headaches. Magnetic resonance imaging (MRI) of the brain revealed a large enhancing parietal lobe mass. Ocular exam at that time was normal. Initial diagnoses included possible bacterial cerebritis and fungal abscess. Serial lumbar punctures showed increased white blood cells but cytology was negative. A brain biopsy was non-diagnostic. The patient then presented with a left optic neuropathy. Repeat MRI of the brain and orbits revealed infiltration of the clivus and left orbital apex including the optic nerve. The patient had elevated liver function studies and an abdominal ultrasound disclosed two hypoechoic lesions. Liver biopsy confirmed the diagnosis of ALK-1 positive ALCL. The patient was treated with chemotherapy but expired seven months after the initial presentation.

CONCLUSION

ALCL should be considered to be a very rare but potential cause of optic neuropathy. To our knowledge, this is the first reported case of ALCL causing an optic neuropathy.

Peripheral T-cell lymphoma presenting as sclerouveitis

PURPOSE

To report an unusual case of ocular peripheral T-cell lymphoma presenting as sclerouveitis.

METHODS

A 53-year-old woman presented with painful, unilateral sclerouveitis and was initially treated with antivirals and corticosteroids for what was presumed to be isolated ocular HSV infection with vasculitis. When she failed to improve the conjunctiva was biopsied and characterized by immunohistochemical and molecular methods. The literature regarding conjunctival T-cell lymphomas as well as lymphomas mimicking scleritis is reviewed.

RESULTS

Biopsies of a scleral/conjunctival nodule from the right eye were obtained on 2 occasions, the second of which revealed the presence of intermediate to large size lymphocytes that were CD3, T-cell intracellular antigen 1 and Granzyme B positive but CD56 and Epstein Barr virus negative. Polymerase chain reaction showed clonal T-cell receptor gamma rearrangements in DNA samples isolated from biopsy tissue. Another biopsy was obtained from a mucosal lesion in the oropharynx, which was shown to contain an identical T-cell receptor gamma rearrangement. These results led to the diagnosis of peripheral T-cell lymphoma. Conjunctival T-cell lymphomas have been reported in two other patients both of which also had involvement of upper airway structures. Five other reports of lymphoma mimicking scleritis are discussed.

CONCLUSIONS

Peripheral T-cell lymphoma should be considered in the differential diagnosis of patients who present with sclerouveitis of unknown etiology unresponsive to conventional therapy. If a conjunctival T-cell lymphoma is identified a systemic evaluation for lymphoma with particular attention to the upper airway is justified.

Cutaneous presentation on the eyelid of primary, systemic, CD30+, anaplastic lymphoma kinase (ALK)-negative, anaplastic large-cell lymphoma (ALCL)

AIM

To report an unusual case of cutaneous presentation on the eyelid of systemic (or nodal), CD30+, anaplastic large-cell lymphoma (ALCL).

METHODS

A 39-year-old man presented with a rapidly growing exophytic mass on the left upper eyelid, with a protuberant, ulcerated aspect and with discharge. The patient showed lymph node involvement 3 months after the appearance of the lesion on the eyelid (the lesion itself appeared 1 week before examination).

RESULTS

The histopathologic and immunohistochemical diagnosis was ALCL, T-cell phenotype, strongly positive for CD43 and CD30, and negative for CD3, anaplastic lymphoma kinase (ALK), and B-cell antigens. Treatment was by radiotherapy and, later, chemotherapy (cyclophosphamide, adriamycin, vincristine, and prednisolone, CHOP) for skin recurrences and lymphadenopathies over 5 years. There has been no recurrence for more than 6 years.

CONCLUSIONS

Primary, systemic, CD30+, ALK-negative, ALCL presentations generally have a poor prognosis and tend to occur in older individuals, although the clinical outcome is highly variable and difficult to predict in individual cases. Only three cases of ALCL have been described in the ocular adnexae and none was ALK-negative.

Conjunctival T-cell Lymphoma

OBJECTIVE

To report a patient with conjunctival T-cell lymphoma, an extremely rare entity.

DESIGN

Single case report.

METHODS

Based on clinical examination, an excisional biopsy and immunostaining were performed on the conjunctival lesion. For management, we excised and performed triple freeze-thaw cryotherapy to the involved area, and we consulted the oncology service.

MAIN OUTCOME MEASURES

T-cell and B-cell markers, and clinical examination of the lesion.

RESULTS

Both examination and laboratory assessment revealed no evidence of systemic involvement. Conjunctival biopsy showed expansion of the substantia propria with an infiltrate of chronic inflammatory cells (including lymphocytes, plasma cells, and eosinophils), and prominent lymphocyte exocytosis with reactive epithelial changes. The CD-45 RO (T-cell marker) was strongly positive, whereas the CD-20 (B-cell marker) was negative. The T-cell receptor gene rearrangement was positive with beta clonality, confirming the diagnosis of T-cell lymphoma.

CONCLUSIONS

T-cell lymphoma is a rare but possible diagnosis of gelatinous conjunctival lesions. The oncology consultants were reluctant to treat the patient with systemic chemotherapy or radiation because extraconjunctival extension could never be documented. The answer to the question of what is the most appropriate treatment for conjunctival T-cell lymphoma remains unknown.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.