Ocular adnexal lymphoid proliferations: clinical, histologic, flow cytometric, and molecular analysis of forty-three cases

Diagnostic methods for primary vitreoretinal lymphoma: A systematic review

Primary vitreoretinal lymphoma is a potentially aggressive intraocular malignancy with poor systemic prognosis and sometimes significant diagnostic delays as it may masquerade as chronic uveitis. Despite the variety of diagnostic techniques, it is unclear which modality is most accurate in the diagnosis of PVRL. A systematic literature search was conducted on Ovid MEDLINE, EMBASE and the Cochrane Controlled Register of Trials for studies published between January, 2000, and June, 2023. Randomized controlled trials (RCTs) reporting on the following diagnostic tools used to diagnose patients with PVRL were included: cytology, flow cytometry, MYD88 L265P mutation, CD79B mutation, interleukin 10/interleukin-6 (IL-10/IL-6) ratio, polymerase chain reaction (PCR) for monoclonal immunoglobulin heavy chain (IgH) and immunoglobulin kappa light chain (IgK) rearrangements, and imaging findings. The aggregated sensitivity of each diagnostic modality was reported and compared using the chi-squared (χ2) test. A total of 662 eyes from 29 retrospective studies reporting on patients diagnosed with PVRL were included. An IL-10/IL-6 ratio greater than 1 had the highest sensitivity (89.39%, n = 278/311 eyes, n = 16 studies) for PVRL, where the sensitivity was not significantly different when only vitreous samples were drawn (88.89%, n = 232/261 eyes, n = 13 studies) compared to aqueous samples (83.33%, n = 20/24, n = 2) (p = 0.42). Flow cytometry of vitreous samples gave a positive result in 66/75 eyes (88.00%, n = 6 studies) with PVRL, and monoclonal IgH rearrangements on PCR gave a positive result in 354/416 eyes (85.10%, n = 20 studies) with PVRL. MYD88 L265P and CD79B mutation analysis performed poorly, yielding a positive result in 63/90 eyes (70.00%, n = 8 studies) with PVRL, and 20/57 eyes (35.09%, n = 4 studies) with PVRL, respectively. Overall, our systematic review found that an IL-10/IL-6 ratio greater or equal to one may provide the highest sensitivity in identifying patients with PVRL. Future studies are needed to employ multiple diagnostic tools to aid in the detection of PVRL and to further establish nuanced guidelines when determining the optimal diagnostic tool to use in diverse patient populations.

The red eye

The red eye is one of the most common cause encountered in ophthalmic practice but a red eye is not always related to eye diseases, instead, it may be a clinical sign of several systemic diseases which may the alarmin signal of sight-threatening or life-threatening condition. Frequently, GPs, pediatricians, immunologists, and rheumatologists are the first landing of patients with a "red eye." This paper is addressed to non-ophthalmic specialists who may be faced with patients having a red eye. Inspection of the external eye under standard office lighting or with a bright light can be easily and accurately made by a general practitioner. Three major caveats should alert the GPs to promptly refer the patient to the ophthalmologist: the presence of pain; the loss of the natural corneal transparency and specular reflex; and any patient-described reduction of visual acuity. In most cases, a red eye is due to occasional and mild ocular surface reaction as consequence of exposure of the external eye to irritants and naturally occurring environmental agents. In these cases washing the eye with a tear lubricant may help in relief of symptoms. If this treatment fails within a few days, a consultation with an ophthalmologist is suggested. The role of the general physician is crucial in the decision making to judge the severity of the ocular condition. Managing a red eye often requires the support of other specialists. Our goal is not only to preserve vision but to globally cure the patient health.

Cytologic and Molecular Diagnostics for Vitreoretinal Lymphoma: Current Approaches and Emerging Single-Cell Analyses

Vitreoretinal lymphoma (VRL) is a rare ocular malignancy that manifests as diffuse large B-cell lymphoma. Early and accurate diagnosis is essential to prevent mistreatment and to reduce the high morbidity and mortality associated with VRL. The disease can be diagnosed using various methods, including cytology, immunohistochemistry, cytokine analysis, flow cytometry, and molecular analysis of bulk vitreous aspirates. Despite these options, VRL diagnosis remains challenging, as samples are often confounded by low cellularity, the presence of debris and non-target immunoreactive cells, and poor cytological preservation. As such, VRL diagnostic accuracy is limited by both false-positive and false-negative outcomes. Missed or inappropriate diagnosis may cause delays in treatment, which can have life-threatening consequences for patients with VRL. In this review, we summarize current knowledge and the diagnostic modalities used for VRL diagnosis. We also highlight several emerging molecular techniques, including high-resolution single cell-based analyses, which may enable more comprehensive and precise VRL diagnoses.

Orbital and Eyelid B-Cell Lymphoma: A Multicenter Retrospective Study

Simple Summary

The treatment of orbital and eyelid B-cell lymphoma remains a field of progress. The aim of our study was to analyze patients diagnosed, staged and treated for orbital and eyelid B-cell lymphoma to assess clinical characteristics, treatment outcomes and recurrence patterns. We included in this study 141 cases of orbital and eyelid B-cell lymphoma. We found five lymphoma subtypes and we confirmed that the histopathologic subtype and the type of treatment were found to be the main factors influencing treatment outcome.

Abstract

Background: The aim of this study was to analyze patients diagnosed, staged and treated for orbital and eyelid B-cell lymphoma (OEL). Methods: One hundred and forty-one cases of OEL were included in this study. Primary endpoints were to analyze the histopathologic findings, the main risk factors and the type of treatment and to correlate them with recurrence of OEL. The secondary endpoint was to determine the progression-free survival (PFS) time. Results: Extranodal marginal zone B-cell lymphoma was the most frequent subtype (66%), followed by small lymphocytic lymphoma (12.7%), diffuse large B-cell lymphoma (DLBCL) (9.2%), follicular lymphoma (6.6%), mantle cell lymphoma (4.3%) and Burkitt lymphoma (1.2%). The probability of relapse was influenced by the histopathologic subtype DLBCL (OR = 7.7, 95% CI 1.8–32.3) and treatment with chemotherapy (OR = 14.9, 95% CI 2.6–83.7). Multivariate analysis showed that the histopathologic subtype DLBCL and chemotherapy treatment retained statistical significance for a poorer PFS, with hazard ratios of 8.581 (p = 0.0112) and 9.239 (p = 0.0094), respectively. Conclusions: Five lymphoma subtypes were found in patients with OEL. The histopathologic subtype and the type of treatment were found to be the main factors influencing treatment outcome.

Bilateral benign reactive lymphoid hyperplasia of the conjunctiva: a case treated with oral doxycycline and review of the literature

Background

To report a case of bilateral benign reactive lymphoid hyperplasia (BRLH) of the conjunctiva treated with oral doxycycline and perform review of the literature evaluating the presentation, treatment and risk of transformation to lymphoma.

Case presentation

A case report is described and review of the literature from January 1975 to January 2019 was performed. A 30-year-old man presented with bilateral enlarging fleshy pink medial canthal conjunctival lesions. Incisional biopsy revealed BRLH. Oral doxycycline was initiated (100 mg two times a day) for a total of 2 months. Both lesions decreased in size significantly at the patient’s two-month follow up visit. The residual lesion in the right eye was excised along with an adjacent pterygium and the patient has been free of recurrence for the past 1.5 years. The lesion in the left eye has remained stable in size after cessation of the oral doxycycline. A total of 235 cases of conjunctival BRLH were identified in our literature search. The mean age at diagnosis was 35.2 years (range, 5 to 91 years). BRLH lesions were unilateral in 75% of patients and bilateral in 25% of them. Seven patients (2.9%) had a concurrent Epstein-Barr virus (EBV) infection at the time of lesion appearance. The most common treatments were surgical excision (155/235 or 65.9%) and corticosteroids (30/235 or 12.7%), while 14% (33/235) of the patients were observed and 4.6% (11/235) received external beam radiotherapy alone. Recurrence occurred in ten patients (10/235 or 4.2%), of whom five had undergone surgical excision alone, two excision followed by external beam radiotherapy, one excision and oral corticosteroids, one radiotherapy alone and one had been treated with topical corticosteroids. Overall, only 2 of the 235 reported cases (0.8%) developed malignancy, one localized to the conjunctiva and one systemic.

Conclusions

Benign reactive lymphoid hyperplasia is one of the lymphoproliferative disorders of the conjunctiva and ocular adnexa. Extensive literature review shows that most cases are treated with surgery, steroids or observation. Oral doxycycline may be considered an alternative non-invasive treatment of BRLH conjunctival lesions. BRLH lesions warrant careful follow up as they can rarely transform into conjunctival or systemic lymphoma.

[Primary uveal lymphoma effectively treated with radiotherapy: a case report and literature review]

Primary uveal lymphoma is a type of intra-ocular lymphoma. Unlike the intra-ocular lymphomas involving the retina and vitreous, primary uveal lymphoma generally has a low-grade nature and an indolent clinical course. It is a relatively rare condition, and the diagnosis can be challenging. We present a rare case of primary uveal lymphoma involving the choroid, ciliary body, iris and conjunctiva that was successfully treated with radiotherapy and achieved full remission.

Eyelid Localization in Mantle Cell Lymphoma: Long-Lasting Complete Remission after Surface Brachytherapy

Ocular adnexal lymphoma is the most frequent malignancy occurring in the eye region. With regard to the histology of these lesions, 2% to 7% of non-Hodgkin's lymphomas located in the periocular region are mantle cell lymphomas. A few cases of mantle cell lymphoma characterized by a fairly indolent course and prolonged survival have been described in the medical literature. We here report on a patient with indolent mantle cell lymphoma presenting at relapse with an isolated eyelid mass that was treated with lens-sparing surface brachytherapy resulting in durable locoregional complete remission.

Benign Reactive Lymphoid Hyperplasia of the Conjunctiva Treated With Cyclosporine

PURPOSE

To describe a case of reactive lymphoid hyperplasia (RLH) of the conjunctiva responding to cyclosporine immunosuppressant monotherapy.

METHODS

A 66-year-old man with a 2-year history of biopsy-proven bilateral RLH presented for dry eye evaluation with chief complaints of burning, stinging, and irritation in both eyes. After slit-lamp examination and positive findings of matrix metalloproteinase 9 in the patient's tear film, he was diagnosed with meibomian gland dysfunction and tear-insufficiency dry eye disease. The patient was subsequently treated with topical cyclosporine (ophthalmic emulsion 0.5 mg/mL two times per day) in both eyes.

RESULTS

Examination at the 3-month follow-up visit revealed significant reduction of the RLH lesions bilaterally.

CONCLUSIONS

This report represents the first case of benign ocular RLH responsive to topical cyclosporine therapy. We believe that cyclosporine could play a role in treating patients with benign ocular RLH and warrants further investigation to evaluate its full efficacy.

Case 01-2017 - Primary vitreoretinal lymphoma (PVRL): report of a case and update of literature from 1942 to 2016

Primary vitreoretinal lymphoma (PVRL), as a subset of primary central nervous system lymphoma (PCNSL), is a rare and fatal ocular malignancy. Most PVRL masquerades as chronic posterior uveitis, which makes the clinical diagnosis challenging. Vitreous cells, subretinal lesions and imaging techniques are essential for clinical diagnosis. Importantly, cytopathology/histopathology identification of malignant cells is the gold standard for the diagnosis of PVRL. In addition, molecular detection of immunoglobulin heavy chain (IgH) or T cell receptor (TCR) gene rearrangements, immunophenotyping for cell markers, and cytokine analysis of interleukine-10 elevation are often used as adjunct procedures. Current management of PVRL involves local radiation, intravitreal chemotherapy (methotrexate and rituximab), with or without systemic chemotherapy depending on the involvement of non-ocular tissues. In cases with concomitant PCNSL, systemic high-dose methotrexate/rituximab based therapy in conjunction with local therapy, whole brain radiotherapy and/or autologous stem cell transplantation is considered. Although PVRL normally responds well to initial treatment, high rates of relapse and CNS involvement usually lead to poor prognosis and limited survival. A professional team of medical experts in ophthalmologists, ocular pathologists, neuro-oncologists and hemato-oncologists is essential for optimizing patient management.

Characteristics of orbital lymphoma: a clinicopathological study of 26 cases

OBJECTIVE

Evaluation of the medical data of patients with orbital and adnexal lymphoma.

DESIGN

Cohort study of all cases diagnosed with orbital or adnexal lymphoma at Meir Medical Center between 1993 and 2007.

PARTICIPANTS

Twenty-six patients, with intraorbital or subconjunctival masses with orbital involvement, were examined and followed up between 1 and 8 years.

MATERIALS AND METHODS

Examined data included: clinical presentation, age, gender, imaging, tumor location, surgical management, and pathological diagnosis.

RESULTS

Presenting signs and symptoms included proptosis, eyelid lesions, tearing, chemosis, decreased visual acuity, ptosis, pain, squint, and optic nerve compression. In five cases, lymphoma was misdiagnosed on neuroimaging. Bone changes were seen in four patients. All cases were B cell lymphomas; with the majority (22 cases) of small B cell type; consisting of primary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue and two cases of small cell lymphoma. One small cell lymphomas was of follicular type on a background of CLL, and the other was CLL/SLL type. Fourteen cases were primary orbital disease, and 12 cases were systemic disease. Macroscopic appearance of lymphoma at open biopsy was characteristic in most cases. Flow cytometry phenotyping gave rapid reliable diagnosis of the disease.

CONCLUSIONS

Epiphora or chemosis in the presence of an orbital mass should alert the ophthalmologist to suspect lymphoma. Lymphoma may be easily misinterpreted on neuroimaging for other diseases. Bone changes seen on CT are more common than is generally perceived. Macroscopic appearance at open biopsy was characteristic.

Extranodal Marginal Zone B-cell Lymphoma of the Ocular Adnexa

BACKGROUND

Low-grade B-cell lymphomas located around the eye present unique challenges in diagnosis and treatment. Extranodal marginal zone B-cell lymphoma is the most common lymphoma of the ocular adnexa (conjunctiva, orbit, lacrimal gland, and eyelid).

METHODS

A systematic search of the relevant literature was performed. Material pertinent to the diagnosis, prognosis, pathogenesis, and treatment of extranodal marginal zone B-cell lymphoma of the ocular adnexa was identified, reviewed, and analyzed, focusing on management strategies for primary localized disease.

RESULTS

The primary cause of extranodal marginal zone B-cell lymphoma of the ocular adnexa remains elusive, although an infectious agent is suspected. Radiotherapy is the most common initial treatment for localized disease. Initial treatment with chemotherapy, immunotherapy, and antibiotics has shown promising results, but the number of series is limited and controlled trials do not exist.

CONCLUSIONS

Although the long-term outcome of localized extranodal marginal zone B-cell lymphoma of the ocular adnexa is good, optimal treatment remains a goal. The variation in rates of local and systemic relapse among treated stage 1E tumors suggests that critical factors affecting outcomes are not fully understood. Radiotherapy is the standard of care; at this time, the evidence is insufficient to recommend chemotherapy, immunotherapy, or antibiotics for initial treatment of extranodal marginal zone B-cell lymphoma localized to the ocular adnexa. Well-controlled comparative studies are needed.

Benign reactive lymphoid hyperplasia of the conjunctiva in childhood

BACKGROUND/AIM

Our aim is to the report the clinical and histopathological features of benign reactive lymphoid hyperplasia (BRLH) of the conjunctiva in children and the outcomes of treatment.

METHODS

A retrospective chart review was performed for children aged 0-18 years, diagnosed with conjunctival BRLH from January 2000 to December 2013 at two large ophthalmology hospitals in the Middle East. Data were collected on patient demographics, features of the lesions, the site of the lesion, location, adnexal involvement, lymph nodes involvement, local spread, histopathology and molecular genetic studies of the cases (if available), outcomes of treatment and recurrence.

RESULTS

There were 24 patients with lymphoid lesions classified as conjunctival BRLH during the 12-year period evaluated in this study. The mean age at diagnosis was 11.6 years. Twenty-three patients were males (96%). Systemic medical history included three patients with bronchial asthma, one patient with Down's syndrome, one patient with generalised skeletal malformation and one patient with gastritis. The initial uncorrected visual acuity was 20/30 or better in 93.5% of the eyes. At presentation, the tumour was unilateral in 12 cases (50%). The conjunctival mass was located on the bulbar conjunctiva in all cases. The mass was present nasally in 96% of lesions. No cases (that were tested) had an infectious aetiology. PCR demonstrated monoclonality suggestive of lymphoma in two cases; however, this did not alter the final diagnosis as BRLH per histopathological criteria and clinical course, CONCLUSIONS: All investigated cases of paediatric conjunctival BRLH had a benign clinical course with no local or systemic dissemination and a male predominance. Recurrence was rare, and in our cohort, it was not associated with malignant transformation.

Bilateral ocular panadnexal mass as initial presentation of systemic blastoid variant of mantle-cell lymphoma

A 66-year-old man developed a slowly enlarging, bilateral, painless, periorbital, and orbital swelling with ptosis, nonaxial proptosis, chemosis, exposure keratopathy, and decreased vision in both eyes. He had fever, night sweats, and weight loss (B-symptoms), along with lymphadenopathy and elevated serum lactate dehydrogenase, with no prior history of lymphoma. A transpalpebral incisional biopsy revealed a rare case of mantle-cell lymphoma of blastoid variant, stage IVB. The main immunophenotype characteristics were cyclin D1+, CD5+, CD10-, CD23-, Bcl-6-/+, and a high (up to 80%) Ki-67 proliferation index. Following an excellent response to the immune-chemotherapy treatment plan, all ocular adnexal lymphoma manifestations disappeared completely; however, 13 months after the initial presentation, there was a recurrence of the disease with rapid worsening and death. The blastoid variant of mantle cell lymphoma, a rare subtype of mantle-cell lymphoma, is a highly aggressive neoplasm, ultimately having a fatal outcome. As the initial manifestation of the disease, ocular adnexal region blastoid variant of mantle-cell lymphoma is an exceptional event, with only one previous case reported.

Clonal analysis of bilateral, recurrent, or systemically multifocal ocular adnexal lymphoma

The purpose of this study is to determine the same or different clonality between bilateral or recurrent lesions, or between or among ocular adnexal lesions and systemically multifocal lesions in 10 consecutive patients with ocular adnexal lymphoma : 8 had extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT lymphoma) and 2 had mantle cell lymphoma, observed from 1995 to 2008 at Okayama University Hospital. A discrete DNA fragment was generated by polymerase chain reaction amplification of the immunoglobulin heavy chain gene from all samples except for two samples of bilateral orbital mantle cell lymphoma lesions and one sample of the scalp skin MALT lymphoma lesion. The size of DNA fragments were the same between bilateral orbital or conjunctival lesions of 5 patients, between original and recurrent conjunctival lesions of one patient, between the orbital lesion and the oral cavity lesion in one patient, and among bilateral orbital lesions, buccal, rectum, and stomach lesions of one patient. Sequencing of the DNA fragments showed the same sequence between bilateral or recurrent or multifocal lesions in 8 patients except for one : the bilateral orbital lesions, rectum, and stomach lesions shared the same sequence while the buccal lesion had one nucleotide difference compared to the sequence shared by the other 4 lesions. In conclusion, bilateral, recurrent, or systemically multifocal lesions of ocular adnexal lymphoma shared the clonality between or among the lesions.

Ocular adnexal lymphomas: report of 2 cases of mantle cell lymphomas and short review of literature

Mantle cell lymphoma in ocular region is a rare phenomenon which can be either primary or secondary. Most of these cases are usually diagnosed after excisional biopsy of the involved area with first visit being in the Ophthalmology OPD. We share our experience of two such cases being referred from Ophthalmology OPD. 1st case is about a 52-year-old man who came for complaints of redness of left eye with excessive lacrimation. Examination revealed congestion of left temporal bulbar conjunctiva and a small pinkish outgrowth 2 × 2 cm adherent to temporal bulbar conjunctiva. 2nd case is a 55-year-old gentlemen who presented with complaints for 8 months duration of swelling left eyelid. Excisional biopsy and histopathological examination in both the cases were done to confirm the diagnosis. CECT head and neck were done at baseline and during follow up. These cases are being presented due to the rarity and dramatic response to chemotherapy.

Descriptive epidemiology of ophthalmic and ocular adnexal non-Hodgkin's lymphoma

In this article, we provide an update on incidence rates of ophthalmic non-Hodgkin's lymphoma (NHL), in the context of other NHL, in the USA. We also provide population-based estimates of incidence and survival for ocular adnexal NHL, the most common form of ophthalmic NHL, for which descriptive patterns have not been previously reported. Ophthalmic and ocular adnexal NHL have unique incidence patterns, including equal rates among both genders, predominance among Asians/Pacific Islanders, and steady and rapid increases in the past few decades. Studies of international variations in the incidence of ocular adnexal NHL may provide clues as to the underlying mechanisms influencing its unique epidemiology.

Ocular adnexal non-Hodgkin's lymphoma: a review of epidemiology and risk factors

Ocular adnexal non-Hodgkin's lymphoma (NHL), the most common form of ophthalmic NHL, has a unique incidence pattern showing a steady and rapid increase in the past few decades, nearly equal rates among both genders, and predominance among Asians/Pacific Islanders. No major cause for ocular adnexal NHL has been identified, although infectious agents, immune disorders and genetic/epigenetic factors have all been implicated in its etiology. Identifying putative risk factors and biologic mechanisms leading to carcinogenesis in ocular adnexal NHL may enable implementation of effective preventive and/or therapeutic approaches for this malignancy. This article summarizes current knowledge on epidemiology of ocular adnexal NHL and the role of various potential risk factors in its etiology.

Asynchronous presentation of follicle center lymphoma and reactive lymphoid hyperplasia of the ocular adnexa

Although ocular lymphoproliferative diseases may be rarely encountered by dermatopathologists, the frequency may increase particularly as more and more subspecialties rely on dermatopathology services. Emerging data suggest that there are some similarities between ocular and cutaneous lymphoproliferative diseases with respect to their clinical behavior, prognosis, and cytogenetics. In this case report, a patient with ocular follicle center lymphoma who subsequently developed ocular reactive lymphoid hyperplasia is presented with an accompanying review of the literature on the subjects. The encounter of both follicular center lymphoma and reactive lymphoid hyperplasia in the same patient provides a rare opportunity to compare and contrast the clinical, histological, and immunohistochemical findings of the respective lymphoproliferative diseases situated at opposite ends of the spectrum.

Immunoglobulin heavy chain gene rearrangement in oral B cell lymphomas

OBJECTIVE

Oral non-Hodgkin lymphomas (NHLs) are an extensive group of malignant lymphoid cell neoplasms that are the second most common group of oral cancers. Subtyping NHL is important to plan for appropriate treatment, and the analysis of clonality is in many instances used for helping in the diagnosis of NHL. Thus, the aim of this study was to analyze immunoglobulin heavy chain (IgH) gene rearrangement in a series of oral B cell lymphomas to investigate the sensitivity of seminested polymerase chain reaction (snPCR).

STUDY DESIGN

Paraffin embedded tissue samples from 16 cases of oral B cell lymphomas were retrieved and subjected to snPCR to investigate the IgH gene rearrangement.

RESULTS

The results showed monoclonal IgH rearrangement in 85.7% of the cases studied, as represented by finding one band within the expected range of amplification.

CONCLUSIONS

This study found that snPCR is a consistent method for the detection of gene rearrangement in paraffin-embedded tissue.

A reappraisal of the diagnostic and therapeutic management of uncommon histologies of primary ocular adnexal lymphoma

Lymphoma is the most common malignancy arising in the ocular adnexa, which includes conjunctiva, lachrymal gland, lachrymal sac, eyelids, orbit soft tissue, and extraocular muscles. Ocular adnexal lymphoma (OAL) accounts for 1%-2% of non-Hodgkin lymphoma and 5%-15% of extranodal lymphoma. Histology, stage, and primary localizations are the most important variables influencing the natural history and therapeutic outcome of these malignancies. Among the various lymphoma variants that could arise in the ocular adnexa, marginal zone B-cell lymphoma (OA-MZL) is the most common one. Other types of lymphoma arise much more rarely in these anatomical sites; follicular lymphoma is the second most frequent histology, followed by diffuse large B-cell lymphoma and mantle cell lymphoma. Additional lymphoma entities, like T-cell/natural killer cell lymphomas and Burkitt lymphoma, only occasionally involve orbital structures. Because they are so rare, related literature mostly consists of anecdotal cases included within series focused on OA-MZL and sporadic case reports. This bias hampers a global approach to clinical and molecular properties of these types of lymphoma, with a low level of evidence supporting therapeutic options. This review covers the prevalence, clinical presentation, behavior, and histological and molecular features of uncommon forms of primary OAL and provides practical recommendations for therapeutic management.

Ocular adnexal reactive lymphoid hyperplasia in children

Aim:

To describe the clinical and histopathological features of ocular reactive lymphoid hyperplasia in children, and review the literature regarding this entity.

Materials and Methods:

In this retrospective, interventional case series, a chart review was performed of three patients diagnosed with reactive lymphoid hyperplasia. Details of clinical presentation, ocular and systemic examination findings, management and subsequent course were noted.

Results:

Three children, aged 9–14 years presented with ocular adnexal masses (two unilateral and one bilateral) with 7–12 months duration. Ocular examination revealed discrete nasal conjunctival masses in two patients, and bilateral eyelid fullness and conjunctival chemosis in the third patient. Systemic evaluation and laboratory tests were normal in all patients. Orbital imaging showed lacrimal gland enlargement in one patient. Histopathological evaluation with immunohistochemical markers established the diagnosis of reactive lymphoid hyperplasia. Two patients underwent surgical excision with complete resolution. All patients have remained stable and at their last follow-up have showed no evidence of recurrence, transformation, or systemic involvement.

Conclusion:

Reactive lymphoid hyperplasia, though uncommon in children, can have a favorable outcome with timely intervention

Molecular biomarkers for the diagnosis of primary vitreoretinal lymphoma

Primary vitreoretinal lymphoma (PVRL) or primary intraocular lymphoma, a subtype of primary central nervous system lymphoma, often masquerades as uveitis. The diagnosis of PVRL requires identification of lymphoma cells inside the eye, which is often challenging due to the frequent necrosis and admixing of PVRL cells with reactive lymphocytes. Therefore, detection of immunoglobulin heavy chain (IgH) and T-cell receptor (TCR) gene rearrangements provide molecular diagnosis of B- and T-cell lymphoma, respectively. We retrospectively evaluated 208 cases with a clinical diagnosis of masquerade syndrome from 1998 to 2010. In 200 cases with molecular analyses using microdissection and polymerase chain reaction, we found that 110 cases had IgH gene rearrangement, 5 cases had TCR gene rearrangement, and 85 cases were negative for these two gene arrangements. The molecular data corroborated the cytopathological diagnoses of PVRL and uveitis in the majority of cases. Cytokine above the detected levels in the specimens were also measured in 80 of the 208 cases. A ratio of vitreous IL-10 to IL-6 greater than 1, suggesting PVRL, was found in 56/80 cases; 53/56 had the correct diagnosis. A ratio less than 1, suggesting uveitis, was found in 24/80 cases; 17/24 correctly confirmed the diagnosis. Moreover, the molecular data corresponded well with the clinical course of the diseases. The sensitivity and specificity of these molecular biomarkers for the diagnosis of PVRL are higher than 95%.

Novel therapeutic option for orbital atypical lymphoid hyperplasia

Ocular lymphoid tumours represent a spectrum of lymphoproliferative disease and can be subdivided into benign or reactive lymphoid hyperplasia, indeterminate or atypical lymphoid proliferations and malignant lymphoma. Treatment options include a wait and watch approach, systemic steroids, local radiotherapy or systemic chemotherapy. We describe a case of bilateral atypical lymphoid hyperplasia treated successfully with combination immunotherapy and radiotherapy. A 60-year-old lady presented with proptosis and left supra-orbital mass and was diagnosed to have bilateral atypical lymphoid hyperplasia. She had extensive extraocular facial infiltrates but no other sites of involvement on staging investigations. She was treated with eight doses of rituximab 375 mg/m² at weekly intervals with a good partial response, followed by consolidative radiotherapy. Rituximab may be an effective treatment adjunct/alternative for patients with atypical lymphoid hyperplasia of the orbit, particularly where widespread lesions preclude the use of initial radiotherapy.

Recurrent subconjunctival hemorrhages leading to the discovery of ocular adnexal lymphoma

BACKGROUND

Subconjunctival hemorrhages commonly occur idiopathically or from causes including ocular surgery, trauma, anticoagulation medications, or a Valsalva maneuver. When a hemorrhage persists or recurs, a more extensive list of differential diagnoses must be considered. This report details a case in which persistent subconjunctival hemorrhages led to the discovery of ocular adnexal lymphoma.

CASE REPORT

A 68-year-old white man presented with a 7- to 8-month history of a recurrent red left eye. There was no associated pain, discharge, or change in vision over that time. The right eye was never involved. An ocular examination of the left eye found a mild nasal subconjunctival hemorrhage and a salmon-pink-colored lesion involving the superior conjunctiva. Clinical findings, photos, magnetic resonance images, and histopathology results are presented and reviewed. The signs, symptoms, incidence, pathophysiology, treatment, and prognosis of ocular adnexal lymphoma are also discussed.

CONCLUSION

Lymphomas can occur in a variety of sites in the body. It is well documented that primary tumors can originate in the ocular adnexa. Although not typical, the first sign in this case was a recurrent subconjunctival hemorrhage. The importance of a thorough ocular examination is paramount for a patient's ocular health and possibly the patient's life.

Ocular adnexal lymphomas: a review

Ocular adnexal lymphomas comprise 1% to 2% of all non-Hodgkin lymphomas and about 8% of extranodal lymphomas. They are a heterogeneous group of malignancies, the majority of which are primary extranodal lymphoma with most (up to 80%) of the marginal zone of mucosa associated lymphoid tissue type (MALT lymphoma). This review will encompass the incidence, histology, immunophenotyping, recent advances in molecular and cytogenetics, clinical features including outcome, and prognostic factors. The association with Chlamydia psittaci and the very recently recognized occurrence in the context of IgG4-related sclerosing disease will be discussed. Finally, traditional (surgery, radiotherapy, chemotherapy) and newer forms of therapy (immunotherapy and radioimmunotherapy) will be reviewed.

Intraocular lymphoma: diagnostic approach and immunophenotypic findings in vitrectomy specimens

CONTEXT

Diagnosis and classification of primary intraocular lymphoma can be challenging because of the sparse cellularity of the vitreous specimens.

OBJECTIVE

To classify and clinically correlate intraocular lymphoma according to the World Health Organization (WHO) classification by using vitrectomy specimens.

DESIGN

Clinical history, cytologic preparations, flow cytometry reports, and outcome of 16 patients diagnosed with intraocular lymphoma were reviewed.

RESULTS

The study group included 10 women and 6 men. The mean age of the patients was 63 years (range, 19-79 years). Eleven patients had central nervous system involvement and 6 patients had systemic involvement. All cases were adequately diagnosed and classified according to the WHO classification by using combination of cytologic preparations and 4-color flow cytometry with a limited panel of antibodies to CD19, CD20, CD5, CD10, and kappa and lambda light chains. The cases included 9 primary diffuse large B-cell lymphomas of the CNS type; 2 diffuse large B-cell lymphomas, not otherwise specified; 1 extranodal, low-grade, marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT); 1 precursor B-lymphoblastic lymphoma; and 3 peripheral T-cell lymphomas, not otherwise specified. Of note, all 11 cases of diffuse large B-cell lymphoma were CD10-. All the patients received systemic chemotherapy and radiation therapy. Only 4 patients were free of disease at last follow-up (range, 18 months to 8 years), with severe visual loss.

CONCLUSIONS

Intraocular lymphoma cases can be adequately classified according to the WHO classification. Diffuse large B-cell lymphoma, CD10- and most likely of non-germinal center B-cell-like subgroup, is the most common subtype of non-Hodgkin lymphoma in this site, in contrast to ocular adnexal lymphoma for which MALT lymphoma is the most common subtype.

A TNM-Based Clinical Staging System of Ocular Adnexal Lymphomas

Context.—The ocular adnexal lymphomas (OAL) arise in the conjunctiva, orbit, lacrimal gland, and eyelids. To date, they have been clinically staged using the Ann Arbor staging system, first designed for Hodgkin and later for nodal, non–Hodgkin lymphoma. The Ann Arbor system has several shortcomings, particularly when staging extranodal non– Hodgkin lymphomas, such as OAL, which show different dissemination patterns from nodal lymphomas.

Objective.—To describe the first TNM-based clinical staging system for OAL.

Design.—Retrospective literature review.

Results.—We have developed, to our knowledge, the first American Joint Committee on Cancer–International Union Against Cancer TNM-based staging system for OAL to overcome the limitations of the Ann Arbor system. Our staging system defines disease extent more precisely within the various anatomic compartments of the ocular adnexa and allows for analysis of site-specific factors not addressed previously. It aims to facilitate future studies by identifying clinical and histomorphologic features of prognostic significance. This system is for primary OAL only and is not intended for intraocular lymphomas.

Conclusions.—Our TNM-based staging system for OAL is a user-friendly, anatomic documentation of disease extent, which creates a common language for multicenter and international collaboration. Data points will be collected with the aim of identifying biomarkers to be incorporated into the staging system.

Lymphomatous proptosis as a novel feature of mantle cell lymphoma

We describe eight cases of acute proptosis due to mantle cell lymphoma (MCL), among 26 consecutive MCL cases. The median time of onset was 29 months (range 0-102) from diagnosis. Two cases presented initially with orbital masses while five as sudden disease progression after multiple courses of chemotherapy. In each case, there was dramatic loss of vision and severe proptosis, which uniformly responded to radiotherapy and/or further chemotherapy. Unilateral blindness only occurred in two cases, with recurrent orbital relapse and repeated retinal irradiation and retro-orbital optic nerve involvement, respectively. The high incidence, as well as bilateral and recurrent nature, of orbital involvement suggested a homing mechanism of MCL to this site. Despite the absence of central nervous system involvement, most cases died of refractory disease. Apart from lymphomatous polyposis of the gut, MCL cells also show predilection to ocular presentation, and must be considered as a differential diagnosis to maltoma in the two anatomical sites.

Morphologic Features of 115 Lymphomas of the Orbit and Ocular Adnexa Categorized According to the World Health Organization Classification: Are Marginal Zone Lymphomas in the Orbit Mucosa-Associated Lymphoid Tissue–Type Lymphomas?

Context.—Marginal zone lymphomas (MZLs) are the most common lymphomas encountered in the orbit and ocular adnexa. The accurate categorization of these lymphomas is critical to avoid undertreatment or overtreatment.

Objective.—To identify features of orbital MZLs that distinguish them from other lymphomas and reactive lymphoid infiltrates and support the categorization of orbital MZL as mucosa-associated lymphoid tissue (MALT)–type MZLs.

Design.—Biopsies from 149 patients with lymphoid lesions of ocular adnexa were examined. Additional immunohistochemical stains and fluorescence in situ hybridization study for the MALT1 locus were performed in selected cases, and patient charts were reviewed.

Results.—A total of 115 lymphomas and 34 reactive infiltrates were identified, of which B-cell lymphomas constituted 92% and MZLs constituted 54% of all lymphomas. Certain clinical features (young age, race, bilaterality) favored a reactive infiltrate, but none were diagnostic. Histologic features, such as infiltrative lesions, reactive B-cell follicles, and lymphoepithelial lesions, overlapped between reactive infiltrates and conjunctival MZL. In contrast to conjuctival MZL, orbital MZL infrequently showed reactive follicles, rarely showed epithelial tissue, and did not show lymphoepithelial lesions. Cytogenetic abnormality involving the MALT1 locus was demonstrated in only 15% of ocular adnexal MZLs.

Conclusion.—Many MZLs of orbital soft tissue lack key features associated with MALT-type MZL, and the designation MALT lymphoma should be avoided in their diagnosis.

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.

Asymptomatic conjunctival mucosa-associated lymphoid tissue-type lymphoma with presumed intraocular involvement

PURPOSE

To report a case of conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma with presumed intraocular involvement.

METHODS

Observational case report.

RESULTS

A 73-year-old white man presented for a routine eye examination and was found to have a salmon-colored bulbar conjunctival mass of the left eye. Ultrasound showed a low-reflective mass with diffuse thickening of the ciliary body and choroid. Immunohistochemistry and flow cytometry of an incisional biopsy specimen suggested a polyclonal lesion. Treatment with topical steroids yielded no clinical improvement, and excisional biopsy was performed. A diagnosis of MALT lymphoma was made after polymerase chain reaction (PCR) analysis of the immunoglobulin heavy chain (IgH) locus revealed a clonal B-cell population.

CONCLUSIONS

Conjunctival MALT lymphoma can present without symptoms and can extend intraocularly. PCR analysis of the IgH locus can identify lesion clonality when immunohistochemistry and flow cytometry fail to do so.

Extranodal Marginal Zone B-cell Lymphomas of the Ocular Adnexa

Extranodal marginal zone B-cell lymphomas of MALT type (MALT lymphomas) show site-dependent variations in their morphologic, phenotypic, and/or cytogenetic findings. This report describes a comprehensive analysis of 34 ocular adnexa MALT lymphomas, including interphase fluorescence in situ hybridization for MALT lymphoma-associated cytogenetic abnormalities and polymerase chain reaction for Chlamydia psittaci, which has recently been suggested to be associated with ocular adnexa lymphomas. A typical morphologic pattern was identified in 79% of cases, while overtly monocytoid cytology (12%), predominantly plasmacytic features (9%), and lymphoepithelial lesions (3%) were uncommon. Aberrant CD43 or CD5 expression was also uncommon (12% and 3%, respectively). Plasmacytic differentiation (41%) was associated with stage IV disease (P=0.036) and gains of chromosomes 3 and/or 18q (P=0.021) (79%). +3 was more frequent in the orbit than in lacrimal gland or conjunctiva (P=0.005). Each of 31 cases was negative for MALT1 translocations. IGH translocations were identified in 3 cases (10%), although the translocation partner gene could not be identified. Polymerase chain reaction assays targeting species-specific regions within the C. psittaci omp1 and omp2 genes were negative in each of 30 cases. This study identifies the characteristic morphologic, phenotypic, and cytogenetic findings in ocular adnexa MALT lymphoma, including a subset differing from those arising at other anatomic sites. The frequent presence of +3 and/or +18q suggests that these abnormalities may contribute to lymphomagenesis. The lack of C. psittaci in this series, in contrast to some prior reports, indicates that there may also be geographic heterogeneity in the pathogenesis of ocular adnexa MALT lymphoma.

Orbital marginal zone lymphomas: an immunohistochemical, polymerase chain reaction, and fluorescence in situ hybridization study

Many studies have been performed on chromosomal aberrations of extranodal marginal zone lymphomas. However, only a few have been published so far on ocular adnexal marginal zone lymphomas. We studied 18 cases of orbital lymphoid cell infiltrates. Using fluorescence in situ hybridization (FISH), we studied some of the most common chromosomal aberrations found in extranodal marginal zone lymphomas as: trisomies 3, and rearrangements of the 18q21 MALTI gene to detect the translocations t(11;18)(q21;q21) and t(14;18)(q32;q21)MALT1. Our goals were as follows: (1) study those aberrations in our material and compare them with the literature, (2) check their prognostic significance, and (3) check whether studying those aberrations with FISH can be used as a diagnostic tool to differentiate reactive from neoplastic infiltrates, in addition to immunohistochemistry and polymerase chain reaction. We found a high frequency of trisomies 3 (68%) and 18 (56.6%), the highest published so far in orbital lymphomas. On the other hand, no rearrangement was seen in any of our cases. The histologic picture and the clinical course were the same when there was one or more aberrations. As for the diagnostic significance, the presence of a prior, concurrent, or subsequent lymphoma in almost all the positive for aberrations cases suggests that either the orbital infiltrates in these cases are lymphomas, or they have, at least, a malignant potential or a genetic instability. Therefore, the demonstration of these numerical aberrations by FISH may be an additional sensitive, reliable, and relatively simple tool to differentiate reactive from neoplastic orbital lymphoid cell infiltrates when the immunohistochemistry and polymerase chain reaction, performed in a busy and routine-based histopathology laboratory, are unsatisfactory.

Diagnostic difficulties and treatment of non-Hodgkin lymphoma of the orbit

BACKGROUND

There are problems connected with the diagnosis of non-Hodgkin lymphomas of the orbit, before deciding on the correct treatment.

MATERIAL AND METHODS

Six out of 22 patients with a tumour of the orbit were treated between 1995 and 2004 for orbital non-Hodgkin lymphomas (NHL). Morphological-functional and aesthetic complications regarding the eyes, the delay between onset and diagnosing the disease and concomitant conditions were evaluated. Management was always tailored individually for each patient, depending on tumour location in the orbit. Surgical procedures comprised total or subtotal removal of the tumour via a semi-coronal access and lateral orbitotomy. Histological diagnosis of the tumours was made from the surgical specimens.

RESULTS

According to the REAL classification, 3 patients had a B-cell lymphoma from the MALT system with low malignancy, 2 other patients a diffuse B cell NHL and 1 patient a lymphoma from the germinal centre with intermediate malignancy. All patients had received chemotherapy. A 9-year remission was achieved in one, an 8-year in another and a 7-year remission in two more out of the total of 6 patients; one is living without relapse for 6 years. The last patient, in whom the lymphoma was diagnosed at the age of 70 years, died 4 years after the procedure without relapse due to cardiovascular and respiratory insufficiency.

CONCLUSIONS

Although the treatment of choice of NHL is chemotherapy, it is felt necessary to remove the whole or possibly the major part of the tumour in case of retrobulbar location when the histological subtype is unknown prior to surgery. However, the optic nerve should always been left intact, even when such tumour encircles this cranial nerve. Only sufficient biopsy material allows determination of the lymphoma subtype and selection of appropriate chemotherapy.

Characterization of lymphoproliferative lesions of the conjunctiva: immunohistochemical and molecular genetic studies

BACKGROUND

Conjunctival lymphoproliferative lesions have not been selected for independent analysis with newer immunohistochemical and molecular genetic techniques to highlight their unique profile.

METHODS

Retrospective case series examined biopsies from 16 consecutive patients with conjunctival lymphoproliferative lesions. The histopathologic, immunohistochemical, and molecular genetic features were characterized, as well as the frequency of tumour type, prognostic implications, clinical features, and treatments offered.

RESULTS

The diagnosis was lymphoma in 12 cases, atypical lymphoid hyperplasia (ALH) in 1 case, and reactive lymphoid hyperplasia (RLH) in 3 cases. The primary lymphomas consisted of 4 mucosa-associated lymphoid tissue lymphomas (MALTL), 1 follicular lymphoma (FL), 2 diffuse large B-cell lymphomas (DLBCLs), 1 lymphoplasmacytic lymphoma, and 1 T-cell lymphoma. Primary lymphomas were treated with radiation (n = 7), surgery (n = 1), and topical chemotherapy (n = 1). Complete remission was achieved in 8 of 9 primary lymphomas. Two cases of recurrence to the other conjunctiva were treated with radiation and both remained disease free. Secondary lymphomas included 2 DLBCL and 1 MALTL. Complete remission was seen in 2 patients after radiation plus chemotherapy, while the patient treated with chemotherapy alone was lost to follow-up. The 1 case of ALH presented bilaterally and achieved complete remission after topical chemotherapy treatments. The 3 RLH cases were surgically managed and 2 of the 3 recurred and were subsequently excised. Eleven lymphomas were of B-cell lineage by immunophenotyping. Molecular genetic studies of immunoglobulin heavy chain (IgH) gene rearrangement by polymerase chain reaction (PCR) showed clonal bands in 6 of 12 lymphomas, 1 of 3 RLH (polyclonal by immunophenotyping) and 1 ALH. BCL2-IgH [t(14;18)] rearrangement was seen in 8 of 12 cases (1 FL, 3 DLBCLs, 4 MALTLs) by real-time quantitative PCR.

INTERPRETATION

Conjunctival lymphomas are predominantly B-cell type with a high prevalence of MALTL. An unexpected finding was the BCL2-IgH rearrangement seen in 4 of 5 MALTL cases in our series. The significance of this remains unclear.

Primary mantle cell lymphoma of the conjunctiva: a case report

Primary non-Hodgkin's lymphomas of the conjunctiva are uncommon. They are almost exclusively extranodal marginal zone B-cell lymphomas/mucosa-associated lymphoid tissue lymphomas. In this study, we report an extremely rare case of conjunctival mantle cell lymphoma in a 78-year-old man, presenting as a unilateral epibulbar mass.

Ocular adnexal lymphoma: a review of clinicopathologic features and treatment options

The recent literature shows that interest in ocular adnexal lymphomas and their biologic and clinical characteristics—along with their possible association with Chlamydia psittaci infection and therapeutic management with rituximab or anti-Chlamydia psittaci antibiotic therapy—is considerable. These new data have modified the previously reported features of this disease and have made an updated review of the literature necessary. The aims of this review are to present the current knowledge on the biology of these lymphomas, their clinical features and prognostic factors, and the panel of all available treatment options.

Detection of Chlamydia pneumoniae in a bilateral orbital mucosa-associated lymphoid tissue lymphoma

PURPOSE

To detect Chlamydia pneumoniae (C. pneumoniae) gene in a patient with bilateral orbital musoca-associated lymphoid tissue (MALT) lymphoma.

DESIGN

Interventional case report.

METHODS

A 47-year-old Chinese man with recurrent bilateral orbital masses underwent surgical biopsy. Ophthalmologic and radiographic examinations, routine histology, immunohistochemistry, and molecular analysis for immunoglobulin heavy chain (IgH), bcl-2/IgH gene translocation, and Chlamydia genes were performed.

RESULTS

Pathology revealed orbital MALT lymphoma with B-cell monoclonality. In addition to IgH gene rearrangement, C. pneumoniae DNA was detected in the lymphoma.

CONCLUSIONS

The finding of C. pneumoniae molecular signatures in this case suggests a possible association of Chlamydia and orbital MALT lymphoma. The infection may contribute to the development of the lymphoma.

Reactive lymphoid hyperplasia one month after LASIK surgery

BACKGROUND

To describe a case of reactive lymphoid hyperplasia following laser assisted in situ keratomileusis (LASIK).

METHODS

This observational case report describes a 31-year-old man who underwent LASIK and presented 1 month later with a fleshy, conjunctival (plical) tumour in the left eye. An excisional biopsy of the tumour was performed.

RESULTS

Histopathology of the excised tumour revealed reactive lymphoid hyperplasia involving the left conjunctiva.

DISCUSSION

Conjunctival lymphomas can masquerade as chronic conjunctivitis and can be preceded by reactive lymphoid hyperplasia. It is important to identify and differentiate these tumours. This report describes the unusual occurrence of a lymphoid conjunctival tumour after LASIK eye surgery.

Ocular adnexal lymphoma: a clinicopathologic study of a large cohort of patients with no evidence for an association with Chlamydia psittaci

Non-Hodgkin lymphomas are among the most common primary tumors occurring in the ocular adnexa. Herein, we present a 14-year single-institution experience in 62 patients with primary ocular adnexal lymphomas (OALs). Association with Chlamydia psittaci infection is examined in 57 tumor specimens. Extranodal marginal zone lymphoma (EMZL) was the most frequent histologic subtype (89%). The majority of patients with EMZL (84%) presented with stage E-extranodal (IE), however only 16% had an advanced stage. All stage IE patients were treated with local radiotherapy, whereas patients with disseminated disease received systemic therapy with or without local irradiation. All but 1 patient with EMZL achieved complete remission (CR). During a median follow-up of 52 months (range, 3-153 months), the estimated 5-year overall survival (OS) and freedom from progression (FFP) were 96% and 79%, respectively. During the follow-up, 22% of patients relapsed, mainly in extranodal sites, and 4% transformed to diffuse large B-cell lymphoma. None of the patients exhibited local orbital failure in the radiation field. None of the OAL specimens harbored C psittaci DNA. Our study demonstrates that EMZLs, accounting for the majority of primary OALs, are characterized by an indolent natural history with frequent, continuous extranodal relapses. In South Florida, OALs are not associated with C psittaci infections.

Primary lymphoma of nasolacrimal drainage system: a case report and literature review

Primary lymphoma of the lacrimal drainage system (LDS) is an extremely rare condition. All of those previously reported have been of B-cell origin, with the exception of 1 case report of a natural killer/T-cell lymphoma in a Japanese woman. We report a 41-year-old Chinese woman who had a primary diffuse large B-cell non-Hodgkin lymphoma of left LDS. After 8 cycles of CHOP (cyclophosphamide [Cytoxan], doxorubicin hydrochloride [Adriamycin], vincristine, and prednisone) therapy and further 14 months' follow-up, the patient's conditions were stable without evidence of recurrence. After reviewing associated articles, an interesting finding which, to the best of our knowledge, has never been described before is that all the expired or recurrent cases of primary lymphoma of lacrimal drainage system are of women, including the only 1 case of natural killer/T-cell lymphoma. In our opinion, sex should be considered 1 of the prognostic factors in primary lymphoma of LDS. The relationship between this tumor and hormone response is to be determined.