Ocular adnexal lymphoma: validation of American Joint Committee on Cancer seventh edition staging guidelines

Assessment of prognostic factors in patients with primary ocular adnexal lymphoma when considering competing risk elements

BACKGROUND

Accurate prognostic factors for primary ocular adnexal lymphoma (POAL) are scarce. Survival models and prognostic factors derived without considering competing risk factors suffer from major statistical errors. This study aimed to accurately assess prognostic factors in POAL patients using competing risk models, and compare this to the traditional COX proportional hazards model.

METHODS

This retrospective study utilised data from the Surveillance, Epidemiology, and End Results (SEER) program 2010-2015 and included patients with B-cell POAL. The cumulative incidence function and Gray's test for cause-specific survival were calculated as univariate analysis. The competing risk models were a Fine-Gray subdistribution hazard model and a cause-specific model, and a traditional COX model was employed as a multivariate analysis.

RESULTS

This study enrolled 846 eligible patients with POAL: 60 patients (7.09%) died from POAL and 123 patients (14.54%) died from other causes. Multivariate competing risk models indicated that age, laterality, histology subtype, the 7th edition of American Joint Committee on Cancer stage T, and radiotherapy were independent predictors for cause-specific survival of patients with POAL. There was high consistency between the two competing risk models. The COX model made several misestimations on the statistical significance and hazard ratios of prognostic factors.

CONCLUSIONS

This study established competing risk models as a method to assess POAL prognostic factors, which was more accurate than traditional methods that do not consider competing risk elements.

Specific location of ocular adnexal lymphoma and mortality: an international multicentre retrospective study

AIMS

To examine whether the specific location of ocular adnexal lymphoma (OAL) and the American Joint Committee on Cancer (AJCC) TNM tumour stage are prognostic factors for mortality in the main OAL subtypes.

METHODS

Clinical and survival data were retrospectively collected from seven international eye cancer centres. All patients from 1980 to 2017 with histologically verified primary or secondary OAL were included. Cox regression was used to compare the ocular adnexal tumour locations on all-cause mortality and disease-specific mortality.

RESULTS

OAL was identified in 1168 patients. The most frequent lymphoma subtypes were extranodal marginal zone B-cell lymphoma (EMZL) (n=688, 59%); follicular lymphoma (FL) (n=150, 13%); diffuse large B-cell lymphoma (DLBCL) (n=131, 11%); and mantle cell lymphoma (MCL) (n=89, 8%). AJCC/TNM tumour-stage (T-stage) was significantly associated with disease-specific mortality in primary ocular adnexal EMZL and increased through T-categories from T1 to T3 disease. No associations between AJCC/TNM T-stage and mortality were found in primary ocular adnexal FL, DLBCL, or MCL. EMZL located in the eyelid had a significantly increased disease-specific mortality compared with orbital and conjunctival EMZL, in both primary EMZL and the full EMZL cohort. In DLBCL, eyelid location had a significantly higher disease-specific mortality compared with an orbital or lacrimal gland location.

CONCLUSION

Disease-specific mortality is associated with AJCC/TNM T-stage in primary ocular adnexal EMZL patients. Lymphoma of the eyelid has the highest disease-specific mortality in primary EMZL, and in the full cohort of EMZL and DLBCL patients.

MRI‐Based Radiomics Nomogram for Preoperative Differentiation Between Ocular Adnexal Lymphoma and Idiopathic Orbital Inflammation

BACKGROUND

Ocular adnexal lymphoma (OAL) and idiopathic orbital inflammation (IOI) are malignant and benign lesions for which radiotherapy and corticosteroids are indicated, but similar clinical manifestations make their differentiation difficult.

PURPOSE

To develop and validate an MRI-based radiomics nomogram for individual diagnosis of OAL vs. IOI.

STUDY TYPE

Retrospective.

POPULATION

A total of 103 patients (46.6% female) with mean age of 56.4 ± 16.3 years having OAL (n = 58) or IOI (n = 45) were divided into an independent training (n = 82) and a testing dataset (n = 21).

FIELD STRENGTH/SEQUENCE

A 3-T, precontrast T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and postcontrast T1WI (T1 + C).

ASSESSMENT

Radiomics features were extracted and selected from segmented tumors and peritumoral regions in MRI before-and-after filtering. These features, alone or combined with clinical characteristics, were used to construct a radiomics or joint signature to differentiate OAL from IOI, respectively. A joint nomogram was built to show the impact of the radiomics signature and clinical characteristics on individual risk of developing OAL.

STATISTICAL TESTS

Area under the curve (AUC) and accuracy (ACC) were used for performance evaluation. Mann-Whitney U and Chi-square tests were used to analyze continuous and categorical variables. Decision curve analysis, kappa statistics, DeLong and Hosmer-Lemeshow tests were also conducted. P < 0.05 was considered statistically significant.

RESULTS

The joint signature achieved an AUC of 0.833 (95% confidence interval [CI]: 0.806-0.870), slightly better than the radiomics signature with an AUC of 0.806 (95% CI: 0.767-0.838) (P = 0.778). The joint and radiomics signatures were comparable to experienced radiologists referencing to clinical characteristics (ACC = 0.810 vs. 0.796-0.806, P > 0.05) or not (AUC = 0.806 vs. 0.753-0.791, P > 0.05), respectively. The joint nomogram gained more net benefits than the radiomics nomogram, despite both showing good calibration and discriminatory efficiency (P > 0.05).

DATA CONCLUSION

The developed radiomics-based analysis might help to improve the diagnostic performance and reveal the association between radiomics features and individual risk of developing OAL.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: 3.

A deep learning model combining multimodal radiomics, clinical and imaging features for differentiating ocular adnexal lymphoma from idiopathic orbital inflammation

OBJECTIVES

To evaluate the value of deep learning (DL) combining multimodal radiomics and clinical and imaging features for differentiating ocular adnexal lymphoma (OAL) from idiopathic orbital inflammation (IOI).

METHODS

Eighty-nine patients with histopathologically confirmed OAL (n = 39) and IOI (n = 50) were divided into training and validation groups. Convolutional neural networks and multimodal fusion layers were used to extract multimodal radiomics features from the T1-weighted image (T1WI), T2-weighted image, and contrast-enhanced T1WI. These multimodal radiomics features were then combined with clinical and imaging features and used together to differentiate between OAL and IOI. The area under the curve (AUC) was used to evaluate DL models with different features under five-fold cross-validation. The Student t-test, chi-squared, or Fisher exact test was used for comparison of different groups.

RESULTS

In the validation group, the diagnostic AUC of the DL model using combined features was 0.953 (95% CI, 0.895-1.000), higher than that of the DL model using multimodal radiomics features (0.843, 95% CI, 0.786-0.898, p < 0.01) or clinical and imaging features only (0.882, 95% CI, 0.782-0.982, p = 0.13). The DL model built on multimodal radiomics features outperformed those built on most bimodalities and unimodalities (p < 0.05). In addition, the DL-based analysis with the orbital cone area (covering both the orbital mass and surrounding tissues) was superior to that with the region of interest (ROI) covering only the mass area, although the difference was not significant (p = 0.33).

CONCLUSIONS

DL-based analysis that combines multimodal radiomics features with clinical and imaging features may help to differentiate between OAL and IOI.

KEY POINTS

• It is difficult to differentiate OAL from IOI due to the overlap in clinical and imaging manifestations. • Radiomics has shown potential for noninvasive diagnosis of different orbital lymphoproliferative disorders. • DL-based analysis combining radiomics and imaging and clinical features may help the differentiation between OAL and IOI.

Ultra-low-dose radiation treatment for early-stage ocular adnexal MALT lymphoma

PURPOSE

To investigate the long-term outcomes of ultra-low-dose (4 Gy) radiation treatment (RT) in patients with early-stage ocular adnexal mucosa-associated lymphoid tissue (MALT) lymphoma.

METHODS

This retrospective case series includes eight patients with ocular adnexal MALT lymphoma who received ultra-low-dose RT at a single tertiary referral center between March 2016 and February 2018. Response to treatment and the time taken to respond were analyzed.

RESULTS

Of the eight patients (three men, five women), seven patients had conjunctival lymphoma (T1N0M0), and one patient had orbital lymphoma (T2N0M0). Six patients with T1 disease showed complete response (CR), and the median time to CR was 4.5 months (range 2-5). Partial response was achieved in the remaining two patients (one each with T1 and T2). During the median follow-up period of 44 months (range 30-54), none of the patients had a relapse or needed additional treatment. RT was well-tolerated in all patients with no ocular complications, including cataracts and dry eye.

CONCLUSION

This case series suggests that ultra-low-dose RT is effective and well-tolerated in patients with early-stage ocular adnexal MALT lymphoma. Further studies with a larger sample size and long-term follow-up are needed to evaluate the local control rate and disease-free survival precisely.

Primary disease sites and patterns of spread in cases of neurolymphomatosis in the orbit associated with lymphoma

BACKGROUND

Neurolymphomatosis involving the cranial nerves (CNs) is rare. We sought a better understanding of the primary disease sites and patterns of spread in neurolymphomatosis of the orbit and retro-orbital cranial nerves.

METHODS

Patients with lymphoma and MRI evidence of neurolymphomatosis of CN II, III, IV, V₁, or V₂ were retrospectively reviewed. Demographics and primary disease site and sites of neurolymphomatosis on MRI were recorded. Wilcoxon rank sum test was used to compare number of sites of neurolymphomatosis with lymphoma type and survival.

RESULTS

The study included 18 patients. The most frequent types of lymphoma were diffuse large B-cell (DLBCL) (n = 9) and marginal zone (n = 3). In 9 patients, lymphoma presented as a mass (n = 7) or infiltrative disease (n = 2) directly involving the orbit; in 6, a maxillofacial mass spread directly to CNs; and in 3, lymphoma at remote sites spread to orbital CNs. Overall, 81 sites of neurolymphomatosis were noted. The most common sites were the maxillary nerve (V₂) including at the infraorbital fissure or foramen rotundum (17 patients; 19 nerves), pterygopalatine fossa (16 patients; 19 nerves), and cavernous sinus (9 patients; 12 nerves). Number of sites of neurolymphomatosis was significantly lower for DLBCL than for other lymphoma types (p = 0.007). Number of sites of neurolymphomatosis did not affect survival (p = 0.26). The mean interval between the pathologic diagnosis and MRI documentation of the full extent of neurolymphomatosis was 39 days after pathologic diagnosis.

CONCLUSIONS

Based on our study results, neurolymphomatosis in the orbit appears to be frequently associated with an orbital and/or maxillofacial mass and commonly involves CN V₂, the pterygopalatine fossa, and the cavernous sinus. DLBCL may be associated with fewer sites of neurolymphomatosis than other lymphomas. In patients with lymphoma, a systematic search for neurolymphomatosis is imperative for early detection.

Morphologic Cross-Sectional Imaging Features of IgG4-Related Orbitopathy in Comparison to Ocular Adnexal Lymphoma

Aim

To detect radiological features that, in addition to clinical findings, may aid in correct differentiation between IgG4-related ophthalmic disease (IgG4-ROD) and ocular adnexal lymphoma (OAL).

Methods

In this retrospective, single-center, comparative analysis, we compared cross-sectional imaging findings of 13 consecutive patients with histologically proven IgG4-ROD and a control group of 29 consecutive OAL-patients diagnosed between 10/2014 and 09/2019. Statistical significance was accepted at a p<0.05 significance level.

Results

IgG4-ROD-patients had longer time-to-diagnosis, higher orbital recurrence rates, but smaller lesions compared to OAL-patients (p=0.002; p=0.006 and p=0.006; Mann–Whitney U-test). Frequent cross-sectional imaging findings in both IgG4-ROD-patients and OAL-patients included extraocular muscle enlargement (92% and 93%, respectively; most often in the lateral rectus muscles and the levator-complex), and lacrimal-gland enlargement (85% and 83%, respectively). Other imaging findings comprised infraorbital nerve-involvement (IgG4-ROD, 23%, OAL, 17%) and orbital fat inflammation (IgG4-ROD, 23%, OAL, 28%). Bony infiltration and remodeling, heterogenous contrast-media distribution, and infiltration of the lacrimal system were seen slightly more often in IgG4-ROD (23%, 38%, 15% and 15% versus 17%, 14%, 3% and 7%). However, cross-sectional imaging features did not differ significantly between patient subgroups. Clinical symptoms predominantly occurred unilaterally (IgG4-ROD, 9/13, 69%, OAL, 24/29, 83%), while imaging findings were most often bilateral (IgG4-ROD, 11/13, 85%, OAL, 23/29, 79%, p<0.001, McNemar test).

Conclusion

No morphological cross-sectional imaging sign could reliably distinguish between IgG4-ROD and OAL, leaving histopathology indispensable for definite diagnosis. Yet, importantly, for both IgG4-ROD and OAL, cross-sectional imaging frequently detected bilateral orbital disease when only one eye was clinically affected.

[Ocular lymphoma : Precise diagnostics and classification as key for successful personalized treatment]

BACKGROUND

Personalized medicine is nowadays the standard of care for patients with oncological diseases. A prime example is the lymphoma, which has substantial points of contact with ophthalmological care due to the intraocular and periocular involvement.

OBJECTIVE

This article provides a description of the current personalized diagnostics and treatment of ocular lymphomas.

METHODS

This article constructs a relationship between the current knowledge in the literature, guidelines and recommendations and the clinical experience with ocular lymphomas. It explains in particular the molecular and also individual personalized treatment concepts.

RESULTS

The primary suspicion of lymphatic or other ocular oncological diseases is raised by an ophthalmologist based on clinical symptoms. The exact diagnostic procedure is carried out with molecular biological techniques, such as immunohistology and polymerase chain reaction analyses. A staging of the mass is indispensable and the stage classification according to the Ann Arbor criteria for a correct assignment of the lymphoma is of clinical importance. Based on these precise diagnostics an individualized choice of treatment and subsequent personalized follow-up care are carried out. During the complete process from the diagnostic procedure to treatment and aftercare, psycho-oncological support should be offered to the patient.

CONCLUSION

Personalized medicine is already actively performed in the care of ocular lymphomas. The patient is in the forefront and plays a decisive role. By considering the special features of the tumor and patient parameters, the life expectation and relapse-free interval as well as quality of life have been improved for many types of lymphoma. It must be assumed that these advantages also apply to ophthalmology.

Prognostic factors for relapse and survival among patients with ocular adnexal lymphoma: validation of the eighth edition of the American Joint Committee on Cancer (AJCC) TNM classification

Background/Aims

To validate the prognostic performance of the American Joint Committee on Cancer (AJCC) eighth edition classification for ocular adnexal lymphoma (OAL).

Methods

We performed a retrospective review of 140 consecutive patients treated for primary OAL between March 2010 and September 2017. Associations between T/N/M categories at presentation and disease-related outcomes, including relapse, progression-free survival (PFS) and overall survival (OS) were evaluated.

Results

Seventy-nine women and 61 men (median age, 52 (range 20–84) years; median follow-up, 57 (range 7–131) months) were included. Histological subtypes included mucosa-associated lymphoid tissue lymphoma (92.1%, n=129), diffuse large B-cell lymphoma (5.0%, n=7), follicular lymphoma (1.4%, n=2) and mantle cell lymphoma (1.4%, n=2). Patients with ≥T2 disease had significantly higher risks of overall relapse (unadjusted HR)=4.32, p=0.016), decreased PFS (uHR=5.19, p=0.004) and decreased OS (uHR=9.21, p=0.047). Patients with ≥N1 disease had significantly higher risks of overall relapse (uHR=9.17, p<0.001) and decreased PFS (uHR=9.24, p<0.001). M1 disease was significantly associated with higher risks of overall relapse (uHR=3.62, p=0.036), decreased PFS (uHR=5.13, p=0.001) and decreased OS (uHR=9.24, p=0.013). On considering TNM categories as continuous data, the uHRs for per level increase in T, N and M categories were 1.77, 1.83 and 2.30 for overall relapse and 1.72, 1.87 and 2.78 for decreased PFS, respectively (p<0.05 for each comparison).

Conclusion

The T, N and M categories of the AJCC eighth edition classification have prognostic value for relapse and survival among patients with primary OAL. Particularly, nodal/metastatic involvement at presentation indicated less favourable outcome.

[Conjunctival malignancies]

Conjunctival malignancies are rare. However, some of these tumors are among the most aggressive malignancies in ophthalmology and require radical forms of therapy that may lead to blindness or loss of the ipsilateral eye and tumor-associated death. The most relevant primary conjunctival malignancies for oncologists are squamous cell carcinoma, malignant melanoma and malignant lymphoma. Surgical therapy is the primary treatment for squamous cell carcinoma and malignant melanoma. An adjuvant therapy in the form of topical chemotherapy or radiation is necessary in most cases. The isolated malignant lymphoma of the conjunctiva is biopsied excisionally if possible. However, if an incisional biopsy was unavoidable, additional irradiation should be performed; malignant lymphoma generally responds very well to relatively low irradiation doses with a good prognosis quad vitam. More aggressive forms, such as diffuse large cell B‑cell lymphoma or mantle cell lymphoma, must also be treated systemically at an early stage.

Understanding and Classification of Ocular Lymphomas

BACKGROUND

Lymphomas that involve the tissues of the ocular adnexae and the eye itself can be confusing for both the new and seasoned learner alike. In this review, I present a simple way of classifying these disorders that will help to facilitate understanding of these myriad entities.

SUMMARY

Classifications of lymphomas have changed significantly over the last 40 years, but in recent decades, the basic structure of the WHO classification has remained the same, facilitating understanding.

KEY MESSAGES

The ocular lymphomas can be divided into those that are external to the eye (ocular adnexae) and those that are internal (vitreoretinal and uveal). At each of these sites specific subtypes of lymphoma are common. Focusing on these common subtypes can aid the learner to create a scaffold that enables current understanding and upon which they can build for the future.

Two cases of primary ocular adnexal lymphomas diagnosed after pre-biopsy corticosteroid treatment using polymerase chain reaction-based gene rearrangement analysis

PURPOSE

To report the limited usefulness of polymerase chain reaction (PCR)-based immunoglobulin (Ig) and T-cell receptor (TCR) gene rearrangement analysis in diagnosing primary ocular adnexal lymphomas (OAL) treated with corticosteroids before biopsy.

OBSERVATIONS

This was a case series of two patients: a 47-year-old woman and a 43-year-old man, who both presented with impaired visual acuity and ophthalmoplegia of the involved eyes. Both patients had previously received non-diagnostic biopsy and had been subsequently treated with corticosteroids. The visual acuity and ophthalmoplegia progressively worsened after a variable duration of remission. Ocular magnetic resonance imaging revealed gadolinium-enhancing intra- and extraconal lesions. Systemic evaluations did not reveal any other lesions outside of the orbit. Differential diagnoses were lymphoproliferative disorders, including undiagnosed primary OALs, and idiopathic ocular inflammation. Both patients were exposed to repeated biopsies. The biopsied tissue demonstrated marked lymphocytolysis due to corticosteroid usage; therefore, histology and immunophenotype were non-diagnostic. EuroClonality/BIOMED-2 PCR-based gene rearrangement analyses detected genetic clonalities of Ig and TCR and suggested diagnoses of primary OALs of B-cell and T-cell origins, respectively. An OAL of B-cell origin was treated with radiotherapy; an OAL of a rare T-cell origin was treated with high-dose methotrexate-based chemotherapy and adjuvant radiotherapy. Both patients remained progression free for more than 36 months.

CONCLUSIONS AND IMPORTANCE

PCR-based gene rearrangement analysis can be of limited usefulness in suggesting a diagnosis of primary OAL in patients receiving pre-biopsy corticosteroid treatment. Identification of genetic clonality is of clinical importance to provide treatment options for undiagnosed OALs.

Clinicopathological Features of Ocular Adnexal Mantle-Cell Lymphoma in an International Multicenter Cohort

Importance

To our knowledge, the clinical features of ocular adnexal mantle-cell lymphoma (OA-MCL) have not previously been evaluated in a large multicenter cohort.

Objective

To characterize the clinical features of OA-MCL.

Design, Setting, and Participants

This retrospective multicenter study included patient data collected from January 1, 1980, through December 31, 2015, at 6 eye cancer centers in 4 countries. Medical records of 55 patients with OA-MCL were reviewed; the median length of follow-up was 33 months.

Main Outcomes and Measures

Overall survival, disease-specific survival, and progression-free survival were the primary end points.

Results

Fifty-five patients were included; ocular adnexal MCL was found to be most common in older individuals (mean age, 70 years) and men (n = 42 of 55; 76%). Patients with OA-MCL frequently presented with disseminated lymphoma (n = 34 of 55; 62%), and were likely to experience stage IVE disease (n = 35 of 55; 64%), with bilateral involvement (n = 27 of 55; 47%), tumor masses (n = 27 of 36; 75%), and involvement of the orbit (n = 32 of 55; 58%). Chemotherapy with or without external beam radiation therapy was the most frequently used treatment. Overall survival rates for the entire cohort were 65% at 3 years (95% CI, 52%-78%) and 34% at 5 years (95% CI, 21%-47%). Disease-specific survival after 5 years was 38% for the entire cohort (95% CI, 25%-51%); the disease-specific survival adjusted by eye cancer center was better in patients who had received rituximab in addition to the chemotherapy regimen (hazard ratio, 3.3; 95% CI, 1.0-14.7; P = .06). The median progression-free survival was 2.3 years (95% CI, 1.8-2.7 years) in patients who experienced recurrence after primary treatment, and 4.1 years (95% CI, 3.9-4.3 years) in patients who presented with a relapse of systemic lymphoma in the ocular adnexal region.

Conclusions and Relevance

These results suggest that the distinctive features of OA-MCL are its appearance in older male individuals, advanced stage and bilateral manifestation at the time of diagnosis, and aggressive course. The prognosis of patients with OA-MCL might be improved by addition of rituximab to chemotherapy treatment.

Case Report: Primary Conjunctival Non-Hodgkin Marginal Zone Lymphoma

SIGNIFICANCE

Ophthalmic manifestations of non-Hodgkin lymphoma are rare, and the diagnosis can be delayed because of nonspecific symptoms and a tendency to mimic the appearance of other ocular diseases. Suspicious presentations will require confirmation of the lymphoma through surgical biopsy.

PURPOSE

The purpose of this study was to present an isolated conjunctival non-Hodgkin marginal zone lymphoma without systemic involvement, which was successfully managed with external beam radiation.

CASE REPORT

A 49-year-old man reported a red, temporal bulbar conjunctival growth on the left eye for several weeks, which was initially treated as a nodular episcleritis. When the condition did not resolve, a subsequent biopsy diagnosed a low-grade non-Hodgkin marginal zone lymphoma; further testing found no systemic involvement. No intraocular involvement was noted, and B-scan ultrasound and magnetic resonance imaging did not demonstrate any uveal or orbital extension. A trial of doxycycline did not lead to regression, and the isolated lesion was observed. Because of possible slow growth, the lesion was eventually treated with external beam radiation, which resulted in significant tumor regression. Four years after the radiotherapy, the tumor has not recurred, and there has been no systemic involvement.

CONCLUSIONS

This case of a low-grade extranodal marginal zone lymphoma on the temporal conjunctiva represents a less common variation of the classic fornix-based presentation. It is not unusual for conjunctival lymphomas to masquerade as another clinical entity, sometimes making the initial diagnosis challenging. If a patient does not respond as expected to conventional therapy, a biopsy to rule out malignancy should be considered.

Combined positron emission tomography/computed tomography for diagnosis and monitoring of orbital adnexal lymphoma

PURPOSE

Combined whole-body F-18-fluoro-2-deoxyglucose positron emission tomography / computed tomography ([18F]FDG-PET/CT) gives precise information about tumour morphology and metabolism. The standardized uptake value (SUV) allows quantification of tumour metabolism. The diagnostic value of PET/CT in patients with suspected orbital adnexal lymphoma (OAL) was evaluated.

METHODS

Of 21 patients with suspected OAL who underwent combined whole-body PET/CT between 07/2002 and 11/2016, 16 were scanned before and five after orbital biopsy. Histological tumour determination was performed in all cases via biopsy. Correlation between SUV_max and therapeutic status, lymphoma stage (Ann Arbor classification) and histological grading was tested.

RESULTS

All lesions could be depicted by combined whole-body PET/CT. Histology confirmed two malignant T-cell and 18 malignant B cell non-Hodgkin lymphomas as well as one patient suffering from systemic lymphoma with chronic polypoid sinusitis. SUV_max levels of orbital findings were significantly lower after therapy (p < 0.001; Fisher's exact test). Higher stage lymphomas (Ann Arbor classification) expressed significantly higher SUV_max levels (p = 0.014; Fisher's exact test). There was no significant correlation of SUV_max values and histologic grading in this patient collective.

CONCLUSION

Positron emission tomography/computed tomography (PET/CT) depicted vital tumour metabolism of OALs accurately. In cases scanned after orbital biopsy and under systemic therapy, no elevated tumour metabolic activity was expressed. This underlines the reasonable application of PET/CT for therapy monitoring besides whole-body staging. Higher-stage OALs show higher metabolic activity. Yet, for adequate therapy initiation, histology remains indispensable.

Paranasal sinus lymphoma: Retrospective review with focus on clinical features, histopathology, prognosis, and relationship to systemic lymphoma

BACKGROUND

Paranasal sinus lymphoma is a rare clinical entity.

METHODS

We conducted a retrospective case series of 68 patients with biopsy-confirmed paranasal sinus lymphoma with attention on systemic disease association.

RESULTS

Of 63 patients with paranasal sinus lymphoma, 35 (56%) had systemic involvement. Four patient groups were identified: (1) primary paranasal sinus lymphoma (44%); (2) systemic disease occurring concurrently with paranasal sinus lymphoma (25%); (3) paranasal sinus lymphoma with relapse of preexisting systemic lymphoma (22%); and (4) progression to systemic disease after primary paranasal sinus lymphoma (8%). Most of the patients with systemic disease were diagnosed at 50 + years and had positive smoking histories. There was a trend toward disease activity in the neighboring ocular location. For patients with preexisting systemic lymphoma, the mean time to paranasal sinus lymphoma was 65 months. When systemic lymphoma developed after localized paranasal sinus lymphoma, mean time to progression was 23 months. Diffuse large B cell lymphoma was the most common paranasal sinus lymphoma.

CONCLUSION

There is a risk of systemic involvement during the disease course of paranasal sinus lymphoma. Biopsy is the preferred first management step and should precede debulking or mass resection in nonemergent cases. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1065-1070, 2017.

Conjunctival Tumors: Review of Clinical Features, Risks, Biomarkers, and Outcomes--The 2017 J. Donald M. Gass Lecture

Conjunctival tumors encompass a broad range of diagnoses. The 3 most important malignant tumors include ocular surface squamous neoplasia (OSSN) (14%), melanoma (12%), and lymphoma (7%). Conjunctival malignancies are rarely found in children. Regarding OSSN, pre-disposing conditions include chronic solar radiation, immune deficiency (HIV), organ transplant, autoimmune conditions, xeroderma pigmentosum, and chronic exposure to cigarette smoke. OSSN is managed surgically or with topical/injection immunotherapy or chemotherapy. Metastasis occurs in <1%. Regarding melanoma, predisposing conditions include primary acquired melanosis (PAM), chronic nevus, and chronic solar radiation. Treatment of PAM or nevus can prevent melanoma. Melanoma management involves surgical resection with clean margins and avoidance of direct tumor manipulation ("no touch" technique). The first surgery is most important, to minimize tumor seeding. Biomarkers including BRAF, TERT, and PTEN provide information regarding risk for metastasis and allow for targeted antibiomarker therapies. Ten-year risk for melanoma metastasis is 25%. Tumors >2 mm thickness or those located in fornix, caruncle, or orbit are at highest risk for metastasis. Regarding lymphoma, predisposing conditions include benign reactive lymphoid hyperplasia, immune deficiency (HIV), immune dysfunction, and chronic inflammation/infection (Helicobacter pylori, Chlamydia psittaci). The 4 most important subtypes include extranodal marginal zone lymphoma (ENMZL), follicular lymphoma, mantle cell lymphoma (MCL), and diffuse large B-cell lymphoma. Treatment includes surgical resection, cryotherapy, radiotherapy, systemic chemotherapy, or targeted anti-B-cell therapy (rituximab). Lymphoma-related survival (5-year) depends on subtype and ranges from 97% (ENMZL) to 9% (MCL). Recognizing conjunctival tumors and understanding predisposing factors, biomarkers, and treatment strategies are vital to patient outcomes.

Recent Advances in Orbital Tumors--A Review of Publications from 2014-2016

The aim of this review article is to provide an update of the current literature on orbital tumors. The authors conducted a PubMed literature search of English language articles published between January 2014 and December 2016 using the following search items: orbit, tumors, lacrimal gland, lymphoma, hemangioma, lymphangioma. The authors included reviews, original articles, case series, and case reports with relevant new information. There is new information about the clinical spectrum of orbital tumors, capillary hemangioma, cavernous hemangioma, lymphangioma, orbital venous malformation, lacrimal gland tumors, and orbital lymphoma. This review highlights the current understanding, practice, and guidelines in the diagnosis and management of common tumors of the orbit.

An update on ocular adnexal lymphoma

Ocular adnexal lymphoma (OAL) is a relatively common lesion in the practice of ophthalmic oncology. Although OALs are usually primary tumors, secondary involvement of the ocular adnexae by systemic lymphoma is also possible. The clinical and radiological features of OAL are non-specific. Thorough morphological evaluation, aided by immunostaining, cytogenetic studies and molecular testing, are necessary for accurate diagnosis.

[Lymphoma of the ocular adnexa]

BACKGROUND

Lymphomas of the ocular adnexa are heterogeneous and demonstrate a wide range of clinical, histological, immunohistochemical and molecular genetic characteristics.

AIM

The aim of this article is to give an overview of the interdisciplinary diagnostics and individually adapted lymphoma subtype-based therapy.

DIAGNOSTICS

Depending on the lymphoma localisation, i.e. whether in the eyelid, the conjunctiva or in the orbit, a photograph or a radiological scan is required to record the tumor extent. Visual function is more likely to be impacted when the lymphoma arises in the posterior orbit, close to the optic nerve and imaging diagnostics are therefore necessary. Histological investigations are essential for confirming the lymphoma diagnosis and give information about the particular subtype, which in turn will determine subsequent patient management, Clinical staging investigations for determining the systemic extent of the lymphoma manifestation (e.g. imaging, blood analyses as well as bone marrow biopsy) are mandatory.

THERAPY

External beam radiation, local and systemic chemotherapy or in some cases antibiotics are treatment options after surgical excision in isolated ocular adnexal lymphoma. The TNM classification of the American Joint Committee on Cancer or the Ann Arbor staging system, as well as the guidelines of the German Society of Hematology and Medical Oncology are all tools to aid the choice of the appropriate individually adapted therapy for systemic disease, which includes psycho-oncological care.

Lymphoproliferative Disease of the Orbit

Lymphoproliferative diseases of the orbit account for majority of orbital tumors. The pathologies range from reactive lymphoid hyperplasia to specific IgG4-related inflammation to malignant lymphomas. This review summarizes current concepts regarding pathology, clinical presentation, diagnosis, staging, and treatment strategies of major orbital lymphoproliferative diseases based on updated and relevant bibliography.