Monthly administration of rituximab is useful for patients with ocular adnexal mucosa-associated lymphoid tissue lymphoma

Watchful waiting is an acceptable treatment option for asymptomatic primary ocular adnexal mucosa-associated lymphoid tissue lymphoma: A retrospective study

BACKGROUND

Primary ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma (POAML) is the most common subtype of indolent ocular adnexal lymphomas. Although radiotherapy (RT) is the standard of care for localized POAML, it can occasionally lead to permanent side effects. Other treatment strategies, such as rituximab (R) monotherapy and immunochemotherapy, have been used for POAML treatment, but their long-term benefits and relative merits remain unclear. While watchful waiting (WW) is a potential option for some indolent lymphomas, the benefits of WW for POAML patients are also unclear.

METHODS

We here retrospectively analyzed 75 patients who were diagnosed with POAML between 2008 and 2019 in the institutions of the Kyoto Clinical Hematology Study Group.

RESULTS

Commonly involved sites were conjunctiva (42.7%), orbit (36.0%), and lacrimal gland (12.0%), and most patients (92.0%) presented with Ann Arbor stage IE disease. The treatment strategy was selected at the physicians' discretion. More patients without subjective symptoms by tumor mass were subjected to WW (29 patients), while more patients with tumor-derived subjective symptoms were treated by tumor-directed therapy (24 received focal RT, and 19 received R monotherapy). Complete response rates were 79.2% and 42.1% in the RT and R groups, respectively. At 60 months of follow-up, the estimated proportions of POAML patients not requiring new treatment were 69.4%, 85.2%, and 53.8% in the WW, RT, and R groups, respectively. There were no significant differences in the time to start a new treatment between WW and RT groups (median: both not reached [NR], p = 0.187) and between WW and R groups (median: NR vs. 69.0 months, p = 0.554). No specific predictive factor for the future need of treatment was identified in the WW group.

CONCLUSION

Our results demonstrate WW may be an acceptable treatment option for POAML, especially for asymptomatic patients.

Investigation of epidemiological characteristics and development of a nomogram to predict survival in primary ocular adnexal lymphoma

BACKGROUND

Studies on the epidemiology and prognosis of primary ocular adnexal lymphoma (POAL) are scarce for its low occurrence. The goal of our research was to assess the epidemiologic characteristics, prognostic variables and survival of POAL patients.

METHODS

The Surveillance, Epidemiology and End Results (SEER) database was used to collect data on patients identified with POAL from 1975 to 2011 and the incidence rate of POAL from 1975 to 2017. To discover independent predictive markers for overall survival (OS) and disease-specific survival (DSS), multivariable Cox regression analysis was utilised. The independent prognostic factors found by multivariate Cox regression analysis were used to generate a nomogram.

RESULTS

A total of 2839 patients were diagnosed with POAL, with an average age of 64.1 years. The total incidence of POAL was 2.51/1000000 (according to the overall adjustment of the 2000 American standard) from 1975 to 2017, and the annual percentage change (APC) was 2.47 (95% confidence interval 1.64-3.32, p < 0.05), showing a sharp upward trend. After multivariate Cox regression analysis, age, gender, year of diagnosis, marital status, primary site, laterality, pathological type and treatment strategy were evaluated as independent prognostic factors of OS or DSS (p < 0.05). A nomogram was constructed to forecast the DSS of 1, 3, 5 and 10 years. The concordance index (C-index) and the calibration plots demonstrated the robustness and accuracy of the nomogram.

CONCLUSIONS

Although POAL is sporadic, the incidence has generally increased in the past 36 years. In recent years, survival rates have risen, and radiotherapy can render better OS and DSS. The nomogram specially made for POAL is robust and precise in predicting the DSS of 1, 3, 5 and 10 years.

Extranodal Marginal Zone Lymphoma: Pathogenesis, Diagnosis and Treatment

Simple Summary

Extranodal marginal zone lymphoma (EMZL) is an indolent lymphoproliferative disease morphologically composed of small heterogeneous B lymphocytes. It generally occurs with a localized stage and can arise in various organs, the most frequent being the stomach, lung, and ocular adnexa. Depending on the presentation and the possible association with infectious agents, different therapeutic approaches are to be undertaken. The purpose of this review is to describe the biology underlying this pathology, the diagnostic, and therapeutic approach.

Abstract

Extranodal Marginal Zone Lymphoma (EMZL lymphoma) is an indolent B-cell lymphoma with a median age at diagnosis of about 60 years. It accounts for 7–8% of all B-cell lymphomas. It can occur in various extranodal sites, including stomach, lung, ocular adnexa, and skin; furthermore, the disseminated disease can be found in 25–50% of cases. Several infectious agents, such as Helicobacter pylori (H. Pylori) in the case of gastric Mucosa Associated Lymphoid Tissue (MALT) Lymphoma, can drive the pathogenesis of this cancer, through the autoantigenic stimulation of T cells, but there may also be other factors participating such autoimmune diseases. Initial staging should include total body computed tomography, bone marrow aspirate, and endoscopic investigation if indicated. Fluorescence in situ hybridization (FISH), should be performed to detect the presence of specific chromosomal translocations involving the MALT1 and BCL10 genes, which leads to the activation of the NF-κB signaling pathway. Depending on the location and dissemination of the disease, different therapeutic choices may include targeted therapy against the etiopathogenetic agent, radiotherapy, immunochemotherapy, and biological drugs. The purpose of this review is to illustrate the complex biology and the diagnosis of this disease and to better define new treatment strategies.

Atypical lymphoid proliferation of the orbit

Objective: Lymphoproliferative disorders are a group of lesions characterized by abnormal proliferation of lymphocytes. In the orbit, they can occur in the ocular adnexae. These neoplasms have defined clinical and pathologic characteristics and account for more than 20% of all orbital tumors. Several types of lymphoproliferative lesions have been described in the orbit. One example is lymphoid hyperplasia, which commonly involves the lacrimal gland. A benign lesion like lymphoid hyperplasia will show a general normal archetype of the tissues-involved lacrimal gland. We expect a polyclonal group of cells with more or less normal architecture of a follicle. On the other hand, lymphoma will show less organized arrangement of cells, and we expect them to be of monoclonal lineage. Methods: This is a case report of a 55-year-old Filipino female who came in for blurring of vision of both eyes. During her assessment, there was an incidental finding of bilateral upper eyelid swelling, and a 30x15 mm palpable firm mass under the right superior orbital rim and a 30x10 mm mass under the left were noted. The right globe was displaced inferiorly, but no proptosis was seen on exophthalmometry. On plain CT scan, we noted a homogenous mass with molding or contouring around the orbital structures. On coronal view, we noted homogenous masses that mold around the globe and recti, and this also confirmed on axial cuts. A section biopsy was done via anterior orbitotomy. Results: Our patient's histopath had features of both. On scanning magnification, we noted a very cellular round cell tumor. The round cell lesion seemed to be reminiscent of a germinal center of a lymph node. Around it we noticed the glandular structures, which were expected, since this specimen was from the lacrimal gland. A closer view of the lesion on high power showed these lymphocytes within a germinal center. These are large macrophages that actively phagocytose apoptotic lymphoid cells in germinal centers. We expect to see a lot of them in benign hyperplasia, but only a few will be present in malignancies. In summary, our patient had both benign and malignant features, resulting in a histopath result of atypical lymphoid proliferation. Conclusion: Atypical lymphoid proliferation is a rare orbital tumor with benign and malignant features. There is no standard protocol for treatment, and proper multi-specialty coordination is important. External beam radiation therapy with linear accelerator (LINAC) appears to be an effective treatment, with no recurrence in our patient after 5 months.

Weekly Rituximab Followed by Monthly Rituximab Treatment for Autoimmune Disease Associated With RAS-associated Autoimmune Leukoproliferative Disease

Recently, a new disease of lymphocyte homeostasis caused by somatic mosaicism for the RAS mutation has been discovered (known as RALD, RAS-associated leukoproliferative disorder). Since few cases have been reported in literature, the prognosis and standard treatment for autoimmune diseases associated with RALD remain poorly understood. Standard rituximab therapy (375 mg/m for 4 wk) is effective in patients with autoimmune diseases, but early recurrences are common. We highlight the potential for monthly administration of rituximab in a patient with autoimmune thrombocytopenia and hemolytic anemia associated with RALD. RALD was diagnosed in an 11-year-old girl following a 9-year history of severe hepatosplenomegaly and autoimmune cytopenias. Genetic analyses confirmed somatic mosaicism for the G13C KRAS mutation without an autoimmune lymphoproliferative syndrome-related gene mutation. Rituximab therapy was used because of the refractory character of the autoimmune cytopenias which failed to respond to steroids and other immunosuppressive agents. Her treatment consisted of weekly infusions of rituximab for 4 weeks followed by monthly rituximab for 11 months. She maintained her response in hematologic parameters for 2 years after monthly rituximab was ceased and her scores representing quality of life were improved. Rituximab could improve clinical responses and quality of life of the patients with RALD.

Chemotherapy alone is an alternative treatment in treating localized primary ocular adnexal lymphomas

This study investigated the treatment efficacy and long-term adverse effects of various treatment modalities for primary ocular adnexal lymphomas (POALs). We retrospectively reviewed 107 patients who received first-line chemotherapy, radiotherapy, and other treatment modalities from 1990 to 2015. Nighty-three (87%) patients were diagnosed with mucosa-associated lymphoid tissue (MALT) lymphoma, with the orbit being the most common site (49 patients, 46%). Among 91 patients with stage I–IIE1 disease, 26 underwent chemotherapy, 34 underwent radiotherapy, and 31 received other treatment modalities. For chemotherapy, radiotherapy, and other treatment modalities, the 5-year event-free survival (EFS) rates were 90.0%, 89.7%, and 85.8% and the 5-year overall survival (OS) rates were 100%, 90.4%, and 87.5%, respectively. Moreover, among 80 patients with stage I–IIE1 MALT lymphoma, the complete remission, 5-year EFS and OS rates were not significantly different between patients receiving chemotherapy and those receiving radiotherapy. Among 16 patients with stage IIE2–IVE disease, the 5-year EFS rates for chemotherapy alone (n = 11) and combined radiotherapy and chemotherapy (n = 5) were 61.7% and 80%, respectively, whereas the 5-year OS rate for both groups was 80.0%. Neutropenia (15.2%) was the most common side effect in patients who received chemotherapy, whereas cataract (16.3%) was the most common late sequela in patients who received radiotherapy. Multivariate analysis revealed that old age (> 60 y) and an advanced stage (stage III/IV) were prognostic factors for poor OS. Our results indicate that chemotherapy yields satisfactory disease control and fewer side effects, and acts as an alternative therapy for patients with localized POALs.

Ocular adnexal marginal zone lymphoma: Clinical presentation, pathogenesis, diagnosis, prognosis, and treatment

Ocular adnexal marginal zone lymphoma (OAML) represents 1-2% of all non Hodgkin lymphomas. In the last few years many advances in understanding the pathogenesis and the molecular basis involved in its development have been done. Many potential risk factors have been proposed; a dysregulation of immune response in association with a chronic antigenic stimulation, have been hypothesized as possible pathogenic mechanism. In particular, Chlamydia psittaci infection has been related to OAML arising, and eradicating antibiotic therapy has been addressed as a safe and cost-effective approach. Management of OAML is still heterogeneous and matter of debate. There is no consensus about the best upfront treatment and therapeutic decision should take into account several patient-, lymphoma- and treatment-related factors. Novel agents and chemotherapy-free strategies are being investigated to reduce side effects and improve tumor control. This review is focused in recent knowledge improvements in this lymphoma.

Favourable response to rituximab by an ocular adnexal primary lymphoma

CASE REPORT

A 70-year-old woman who presented with an extranodal marginal zone B-cell lymphoma in lacrimal gland and conjunctiva. Initial treatment with rituximab yielded an immediate good response. Five months later she showed lymphoid proliferation in her contralateral conjunctiva. Although no additional treatment was performed, the patient has been free of systemic symptoms and recurrences.

DISCUSSION

Rituximab is a quite good therapeutic agent in low grade adnexal lymphomas.

Rituximab as Single Agent in Primary MALT Lymphoma of the Ocular Adnexa

Ocular Adnexal Lymphomas are the first cause of primary ocular malignancies, and among them the most common are MALT Ocular Adnexal Lymphomas. Recently systemic immunotherapy with anti-CD20 monoclonal antibody has been investigated as first-line treatment; however, the optimal management for MALT Ocular Adnexal Lymphomas is still unknown. The present study evaluated retrospectively the outcome of seven consecutive patients with primary MALT Ocular Adnexal Lymphomas, of whom six were treated with single agent Rituximab. All patients received 6 cycles of Rituximab 375 mg/mq every 3 weeks intravenously. The overall response rate was 100%; four patients (67%) achieved a Complete Remission, and two (33%) achieved a partial response. In four patients an additional Rituximab maintenance every 2-3 months was given for two years. After a median follow-up of 29 months (range 8-34), no recurrences were observed, without of therapy- or disease-related severe adverse events. None of the patients needed additional radiotherapy or other treatments. Rituximab as a single agent is highly effective and tolerable in first-line treatment of primary MALT Ocular adnexal Lymphomas. Furthermore, durable responses are achievable with the same-agent maintenance. Rituximab can be considered the agent of choice in the management of an indolent disease in whom the "quality of life" matter is of primary importance.