Benign lymphoepithelial lesion with large cysts: case report

Lacrimal gland orbital lobe cysts associated with MALT lymphoma and primary Sjögren's syndrome

PURPOSE

To describe, for the first time, the occurrence of a large cyst in the orbital lobe of the lacrimal gland in association with marginal zone B-cell MALT lymphoma in three female patients, two of whom also had primary Sjögren's syndrome.

METHODS

Retrospective case note review.

RESULTS

Three female patients, aged 35, 41 and 47 years, presented with progressive proptosis caused by an enlarging cyst within the orbital lobe of the lacrimal gland. Two of the patients had primary Sjögren's syndrome. Excision of the cyst and part of the lacrimal gland revealed marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type within the gland or wall of the cyst in all cases. The cysts were partially lined by ductular epithelium. One patient had systemic lymphoma, was treated with chemotherapy and remains in remission one year later; the other two had disease apparently confined to the lacrimal gland and are disease-free at 9 months and at three years after local irradiation, respectively.

CONCLUSION

To our knowledge, these are the first reported cases of cysts affecting the orbital lobe of the lacrimal gland in patients with B-cell MALT lymphoma of the gland. Although cystic changes have been described in other exocrine glands, lung and thymus in patients with Sjögren's syndrome, this association has also not been described in the lacrimal gland before.

Bilateral and multicystic major salivary gland disease: a rare presentation of primary Sjögren's syndrome

We present a case of a 15-year-old girl with bilateral parotid and sub-mandibular salivary gland enlargement as the sole presentation of primary Sjögren's syndrome. The clinical, radiological, immunological and pathological features have been discussed. The relevant literature has been reviewed. To our knowledge this is the only reported case of Sjögren's syndrome presenting as multicystic disease with bilateral major salivary gland involvement.

Lymphoepithelial cysts of salivary glands: an immunohistochemical study of HIV-related and HIV-unrelated lesions

An indolent lesion of the salivary glands that mimics Sjøgren syndrome has been repeatedly reported in HIV-infected (HIV+) patients. It is characterized by the occurrence, usually in the parotid gland, of variably sized lymphoepithelial cysts (LECs), whose origin is still unclear. We have compared the morphological and immunohistochemical features of six cases of LEC in HIV+ patients with those of five cases of LEC in HIV-negative (HIV-) patients. The results of the study show that LECs have similar histological and immunohistochemical features in both HIV+ and HIV- patients, and that they may simultaneously affect the salivary gland parenchyma and the intrasalivary lymph nodes. Furthermore, a diffuse lymphoid infiltrate is invariably observed in the glandular tissue around LECs and it is consistently associated with ectatic changes of the striated ducts. These data and the finding of an equivalent proliferation fraction of the epithelial compartment in both LEC and salivary retention cysts, used as controls for this study, are consistent with the hypothesis that cyst formation is secondary to the obstruction of salivary ducts by exuberant lymphoid infiltration.

B- and T-Lymphocyte distribution in benign and malignant lymphoepithelial lesions of the parotid gland: Correlation with Epstein-Barr virus expression and a proposed mechanism of malignant transformation

Epstein-Barr virus expression in malignant lymphoepithelial lesions (LEL) of the parotid gland has been well established. The virus is occasionally expressed in benign LEL, especially in immunocompromised hosts. The pathogenesis of the disease as it relates to virus expression and lymphocyte subsets has not been clearly defined. In this study, we attempted to identify B- and T-lymphocyte distribution in the lesions as it relates to EBV expression in LELs of the parotid gland. Formalin-fixed paraffin-embedded sections of 18 cases of LEL of the parotid gland were immunohistochemically tested for the distribution of B- and T-lymphocytes in the lesions, using the antibodies L-26 (CD 20) for B-lymphocytes and UCHL-1 (CD-45RO) for T-lymphocytes. The sections were also tested by in situ hybridization for EBV mRNA expression, using the EBER-1 probe specific for EBV-1 gene. The 18 lesions included seven malignant LEL, seven benign LEL and four benign lymphoepithelial cysts. All malignant LELs showed a high and diffuse level of epithelial expression of EBV mRNA. Of the 11 benign lesions, only one case showed focal epithelial expression of EBV mRNA. This was a case of benign LEL in an HIV-positive male. All the benign lesions, except that expressing EBV mRNA, showed a T-/B-lymphocyte ratio averaging 2:1. All cases expressing EBV mRNA, including the case of benign LEL in the HIV-positive patient, showed a T-/B-lymphocyte ratio averaging 1:3. Our findings suggest that a T-lymphocyte-mediated immune response may play an essential role in suppressing proliferation of EBV in benign LEL of the parotid gland. This immune mechanism may be significantly disturbed in the malignant lesions, leading to uncontrolled viral replication and carcinogenesis.

Observations on two cases of apparent submandibular gland cysts in HIV positive patients: MR and CT findings

OBJECTIVE

To present two cases of probable lymphoepithelial cysts of the submandibular glands in patients who were human immunodeficiency virus (HIV) positive and who also had lymphoepithelial cysts of the parotid glands.

MATERIALS AND METHODS

Computed tomography and MRI of two HIV positive patients with lymphoepithelial cysts of the parotid glands and cysts in the submandibular glands were correlated with the histories and the possible presence of other known causes of submandibular gland multiple cysts.

RESULTS

Because of the present treatment philosophy regarding HIV positive patients with major salivary gland cysts, surgical resection of these glands was not performed. All other known causes of multiple submandibular gland cysts were excluded by either history or laboratory data.

CONCLUSION

Computed tomography and MRI on two patients with known HIV infection and bilateral parotid lymphoepithelial cysts are presented. Both patients also had bilateral multiple submandibular gland cysts and no evidence of obstructive glandular disease, autoimmune disease, or other organ system cysts. These cases of presumed submandibular gland lymphoepithelial cysts are rare in the literature. They are presented in the hope that other radiologists will be stimulated to document the occurrence of this entity.

Nodal inclusion cysts of the parotid gland and parapharyngeal space: a discussion of lymphoepithelial, AIDS-related parotid, and branchial cysts, cystic Warthin's tumors, and cysts in Sjögren's syndrome

The purpose of this report is to examine the computed tomography scans, magnetic resonance images, and pathologic findings in 44 patients, 42 of whom had inclusion-type cysts of the parotid and parapharyngeal space of varying etiologies. Two additional cases of cystic changes in the benign lymphoepithelial lesion (BLEL) of Sjögren's syndrome are highlighted here, since they had unusually large cystic components mimicking acquired immunodeficiency syndrome-related parotid cysts (ARPCs). A retrospective examination identified 18 ARPCs, 3 lymphoepithelial cysts (LECs), 13 cystic Warthin's tumors, 8 branchial cysts, and 2 cases of cysts in patients with Sjögren's syndrome (BLEL), all of whom had imaging studies and pathologic confirmation. There were 30 men and 14 women with an age range of 25 to 72 years (median, 46.82 years). Any similarities in the imaging appearances were noted, as were any differences in pathologic detail. On imaging, only the cystic Warthin's tumors had any focal wall nodularity; the other cysts had smooth walls. When multiple parotid cysts were present, the distinguishing feature between ARPCs and cysts in BLEL (and some cystic Warthin's tumors) was the presence of diffuse cervical adenopathy in patients with ARPCs. Imaging usually could not differentiate between a solitary parotid LEC, a branchial cyst, and some cystic Warthin's tumors. Extraparotid lesions were either branchial cysts or cystic Warthin's tumors. Physicians should be aware of the variety of different inclusion-type cysts that may occur in the parotid gland and parapharyngeal space, all of which may have similar imaging appearances. Although imaging clearly identifies these cysts and may suggest a specific diagnosis, it must always be remembered that the precise diagnosis remains in the province of the pathologist.