Non-Hodgkin's orbital lymphoma

Cystic mucosa-associated lymphoid tissue lymphoma of lacrimal gland associated with vision loss: A case report

Purpose

To report an atypical case of cystic extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of lacrimal gland associated with vision loss.

Observations

An 89-year-old woman was presented with a rapidly progressing proptosis, lagophthalmos, and vision loss. Endophthalmitis was also present. Computed tomography scan images showed a hyperdense mass with hypodense cystic areas occupying the superolateral orbit, which displaced the globe antero-inferiorly with optic nerve compression and stretching. An erosion to the adjacent superior and lateral orbital walls was also demonstrated. Complete tumor excision was performed via upper transconjunctival orbitotomy concurrently with enucleation. The immunohistopathological diagnosis was MALT lymphoma.

Conclusions and importance

This case emphasizes the importance of considering lymphoma in the differential diagnosis of a cystic superolateral orbital mass.

The management of an orbital diffuse large B-cell lymphoma

BACKGROUND

The orbit represents a rare site of presentation of non-Hodgkin lymphoma. The diagnosis and management of orbital lymphomas may be challenging because these neoplasms present few specific features.

METHODS

A 69-year-old woman presented with painless swelling of the left lower eyelid of 5 years' duration. Magnetic resonance imaging and incisional biopsy were necessary to establish a diagnosis of orbital diffuse large B-cell lymphoma. Staging was completed, thanks to a computed tomographic study of the chest and abdomen.

RESULTS

The patient underwent systemic chemotherapy with 1 regimen (doxorubicin, vincristine, prednisone, 6-mercaptopurine, and methotrexate), followed by 1 R-COMP-14 regimen (rituximab, cyclophosphamide, nonpegylated liposome-encapsulated doxorubicin, vincristine, and prednisone). Complete resolution of the disease was obtained.

CONCLUSIONS

Although not typically performed by the head and neck surgeon, an understanding of the staging process is crucial for multidisciplinary management of orbital lymphomas.

Orbital lymphomas: clinical and radiological features

The purpose of this prospective study was to evaluate the clinical and radiological features of a consecutive series of orbital lymphomas in two Institutions in the North West of Italy. A prospective study was performed of all cases of diagnosed orbital lymphomas. Data on patient demographics, symptoms and clinical findings, histological type of lymphoma, site of lesion, imaging, and systemic involvement were recorded in each case. The mean age of the enrolled 20 patients was 63.65 years. Most orbital lymphomas were located in the superior-lateral quadrant. Superior rectus muscle was the most frequently involved orbital structure. Most patients were affected by extranodal marginal-zone lymphomas. The diagnosis of orbital lymphomas may be challenging, because these neoplasms present few specific features. Although not typically performed by the maxillofacial surgeon, an understanding of the staging process is crucial for multidisciplinary management of orbital lymphomas.

Orbital metastases

BACKGROUND

Orbital metastasis, although uncommon, is a condition optometrists should consider in a patient presenting with proptosis, ptosis, diplopia, or a lid mass with a history of cancer. However, in as many as 19% of cases, patients have no prior or concurrent history of systemic cancer when presenting with ophthalmic symptoms. If suspecting an orbital metastasis, neuroimaging is important, as well as a referral to the patient's primary care provider, oncologist, and ophthalmologist.

CASE REPORTS

Three patients with orbital metastasis are discussed. The first was a 55-year-old white man who initially presented with a left ptosis of unclear etiology. Magnetic resonance imaging of his orbits and an orbital biopsy found metastatic esophageal adenocarcinoma. Radiotherapy and chemotherapy were initiated, but the patient died shortly afterward. The second patient was a 49-year-old black man who also presented with a ptosis of the right upper eyelid. An area of the retina appeared elevated; ophthalmic B-scan and computed tomography of the orbits confirmed the presence of a mass, determined to be metastatic lung carcinoma to the right orbit. A course of radiotherapy was initiated, but the patient died 3 days after completing therapy. The last case was a 77-year-old white man with a history of metastasis to the left orbit from non-Hodgkin's lymphoma. On examination, he had proptosis of the left eye, initially thought to be caused by a recurrence of the metastasis. However, a computed tomography scan showed a new meningioma in the same orbit, and treatment was started. The proptosis improved, and the patient continues to be followed up regularly.

CONCLUSIONS

Any patient with proptosis and/or ptosis with a history of cancer should be evaluated for orbital metastasis. Optometrists should keep in mind that an orbital metastasis may represent the initial manifestation of undiagnosed systemic cancer. Prognosis can be poor, and thus treatment is sometimes palliative in nature, intending to slow the progression of the disease instead of providing a cure.

Intraocular pressure change in orbital disease

Intraocular pressure change has been found concurrent with many orbital pathologies, particularly those involving proptosis. The objective of this review is to offer an inclusive classification of orbital disease-related intraocular pressure change, not only for oculoplastics and glaucoma specialists, but also for general ophthalmologists. Various orbital conditions associated with increased intraocular pressure and glaucoma are comprehensively summarized, and pathophysiology, clinical manifestations, and treatment options of these diseases are discussed. Graves disease, arterio-venous shunts, trauma, and orbital neoplasia, and other common conditions are discussed in detail; less frequent syndromes such as orbitocraniofacial deformities, phakomatoses, and mucopolysaccharidoses are included for the sake of comprehensiveness, but discussed less extensively.

Treatment of primary orbital lymphomas

We present an overview of the treatment and clinical outcome of 15 orbital lymphomas, carried out in our center from 1993 to 2002. The surgical approach was determined by the location, and type of the lesion. Lateral orbitotomy was performed in five laterally located lesions, a transconjunctival approach in five medial, basal, extra-, intraconal lesions. Pterional intradural and extradural and intradural approaches (three) were used in case of intracranial involvement or location in the apex and optic canal. Two lesions of the lid or extraconal space were operated via eyebrow incision. Ten patients were diagnosed as extranodal marginal zone lymphoma. Diffuse large B-cell lymphoma (DLCL) was encountered in two patients, follicular lymphoma (FCL) in two patients, and diffuse lymphoplasmacytic/lymphoplasmacytoid lymphoma in one patient. All patients except one failed to reveal systemic disease and had a localized orbital lymphoma. Twelve of the patients responded to radiation therapy with usually 40 Gy. Cyclophosphamide, doxorubicin, vincristine, prednisone chemotherapy was applied in two patients, once in combination with radiotherapy. Local recurrence was seen in one patient with FCL. Systemic manifestation occurred in one patient with DLCL, undergoing ifosfamide, carboplatin, etoposide chemotherapy with complete remission. The course of orbital non-Hodgkin's lymphoma is variable and requires a multidisciplinary treatment. Therapeutic options include surgical biopsy, radiation therapy, and chemotherapy.