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

Primary diffuse large B-cell lymphoma of the lacrimal sac with involvement of maxillary sinus: a case report and review of literature

Primary lacrimal sac lymphoma is a rare condition, often presenting with nasolacrimal duct obstruction. Herein, we present a unique case of diffuse large B-cell lymphoma (DLBCL) involving the lacrimal sac, maxillary sinus, and infraorbital nerve. Prompt diagnosis via biopsy is essential for timely treatment and the prevention of tumor progression. A 66-year-old female presented with intractable epiphora, infraorbital nerve hypesthesia, and medial canthal swelling. Imaging revealed a soft tissue mass in the right maxillary sinus extending into the right inferior orbit and nasal cavity. A biopsy confirmed DLBCL, prompting systemic chemotherapy. Residual disease prompted high-dose involved-site radiation, resulting in tumor regression. To our knowledge, this is the first case of primary DLBCL of the lacrimal sac with concurrent involvement of the maxillary sinus and infraorbital nerve. This case underscores the significance of lacrimal sac biopsy in refractory dacryocystitis or unilateral sinus disease and the effectiveness of multimodal treatment approaches in managing DLBCL.

Rare Orbital Involvement Originating from Extranodal Marginal Zone Lymphoma

Ocular adnexa region (OAR) primary lymphomas are uncommon, accounting for 1-2% of non-Hodgkin lymphomas and 8% of extranodal lymphomas. Extranodal marginal zone lymphoma (EMZL) originates from several epithelial tissues, including the stomach, salivary gland, lung, small intestine, thyroid gland, and ocular adnexa region. Here, we report a 66-year-old female patient who was diagnosed with EMZL of OAR. In consideration of the possible side effect of radiotherapy, such as conjunctivitis, visual acuity impairment, and even retinal complications, she received six cycles of triweekly targeted chemotherapy with rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP) without radiotherapy. Then, she remained in complete remission up to the present day.

Surgical resection and orbital iodine-125 brachytherapy for orbital malignancy: a novel treatment for orbital lymphoma

OBJECTIVES

Orbital lymphoma is one of the most common adult orbital malignancies, accounting for approximately 10% of all orbital tumors. This study aimed to analyze the effects of surgical resection and orbital iodine-125 brachytherapy implantation for orbital lymphoma.

PATIENTS AND METHODS

This was a retrospective study. Clinical data of 10 patients were collected from October 2016 to November 2018 and followed up to March 2022. Patients underwent the primary surgery for maximal safe removal of the tumor. After a pathologic diagnosis of a primary orbital lymphoma was established, iodine-125 seed tubes were designed based on the tumor size and invasion range, and direct vision was placed into the nasolacrimal canal or/and under the orbital periosteum around the resection cavity during the secondary surgery. Then, follow-up data, including the general situation, ocular condition, and tumor recurrence, were recorded.

RESULTS

Of the 10 patients, the pathologic diagnoses included extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (6 cases), small lymphocytic lymphoma (1 case), mantle cell lymphoma (2 cases), and diffuse large B-cell lymphoma (1 case). The number of seeds implanted ranged from 16 to 40. The follow-up period ranged between 40 and 65 months. All patients in this study were alive and well had tumors that were completely controlled. No tumor recurrences or metastases occurred. Three patients had dry eye syndrome and two patients had abnormal facial sensation. No patient had radiodermatitis involving the skin around the eye, and no patient had radiation-related ophthalmopathy.

CONCLUSIONS

Based on preliminary observations, iodine-125 brachytherapy implantation appeared to be a reasonable alternative to external irradiation for orbital lymphoma.

F-18 Fluorodeoxyglucose PET/CT as a Diagnostic Tool in Orbital Inflammatory Disorders

PURPOSE

To assess the usefulness of FDG-PET/CT as a potential diagnostic tool for detecting underlying systemic diseases (SD) in patients with orbital inflammatory disorders (OID).

METHODS

All consecutive patients managed for new-onset OID between 2011 and 2018 in a tertiary referral center, who underwent FDG-PET/CT as part of the etiological diagnostic workup were evaluated. To quantify the incremental value of FDG-PET/CT over standard diagnostic workup, the Net Reclassification Index (NRI) and Integrated Discrimination Index (IDI) were used.

RESULTS

Among the 22 patients enrolled, 11 (50%) had a positive FDG-PET/CT. After clinicobiological evaluation, FDG-PET/CT correctly reclassified 4(29%) of 14 patients with SD (p = .04) and 1(13%) of 8 with idiopathic orbital inflammation syndrome (p = .32). NRI and IDI were 0.41 ± 0.17 (p = .03) and 0.38 ± 0.08 (p < .001), respectively. FDG-PET/CT successfully detected asymptomatic lesions in all (n = 4) patients with lymphoma.

CONCLUSION

FDG-PET/CT enabled accurate reclassification of more than one-quarter of patients with SD, especially extraorbital lymphomas.

Epstein-Barr virus-associated lymphoma of the orbit: Case report and review of the literature

Purpose

Herein, the authors describe an unusual presentation of EBV-associated diffuse large B-cell lymphoma in the bilateral orbits of an immunocompetent woman.

Observations

An elderly, immunocompetent woman presented with an orbital mass which was biopsied and proven to be EBV-associated lymphoma. The authors then performed a literature search and review which suggested this presentation to be rare as it has been infrequently reported in the ophthalmic literature.

Conclusions and importance

More research is needed to fully ascertain the importance of EBV in ocular adnexal lymphoma. The authors hope this case report adds to the body of literature a different presentation of EBV-associated ocular adnexal lymphoma.

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.

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.

Lacrimal sac lymphoma: a case report

Primary lymphoma originating from the lacrimal drainage system is a rare disease. Such lymphomas are mostly B-cell in origin and present nonspecific symptoms. The treatment of malignant lymphoma of the lacrimal drainage system is slightly different. We present the case of a 71-year-old woman with a painless mass below the medial canthus. Computed tomography (CT) scan of the orbit revealed a mass invading the right lacrimal sac. An incision biopsy was obtained, and the pathologic findings suggested a diagnosis of primary diffuse large B-cell lymphoma of the lacrimal sac. The patient was treated with chemotherapy and intrathecal methotrexate. After completing eight cycles of chemotherapy, the patient was followed up by a CT scan, which revealed nearly total resolution of an ill-defined enhancing mass. At the time of this case report writing, the patient is in complete remission at six months with no other complications.

Subconjunctival Rituximab Administration for the Treatment of Scleritis

PURPOSE

Scleritis is a sight-threatening inflammation, which is commonly accompanied by severe complications. Aggressive systemic immunosuppressive treatment, which is frequently needed, can be associated with serious complications, and might therefore be (temporarily) contraindicated.

METHODS

We report on the outcomes of three patients with severe, active, non-infectious scleritis, refractory or intolerant to systemic treatment, who received subconjunctival rituximab (RTX) injections. A dose of 2.5 to 7.5 mg was administered after topical anesthesia, and follow-up varied from 8 to 10 months.

RESULTS

Subconjunctival RTX showed minimal to no effect on subjective symptoms, clinical features and/or ultrasound images. No serious adverse effects occurred.

CONCLUSION

Further studies are needed to assess the effect of local administration of RTX in scleritis, but our limited observation is not promising.

Histopathological Features and Ann Arbor Stage in Periocular Lymphoma

BACKGROUND

To evaluate biodata, symptoms/signs, lymphoma type, localization, stage level, treatment choice and outcome of ocular adnexal lymphoma (OAL).

PATIENTS AND METHODS

A single-center retrospective analysis of 56 patients with OAL was performed from 1998 to 2018.

RESULTS

OAL involved the orbit in 44.6%, the conjunctiva in 32.1%, the lacrimal apparatus in 14.3% and the eyelid in 8.93%. Extranodal marginal zone B-cell lymphoma (EMZL) was found in 60.7%, follicular lymphoma (FL) in 21.4%, diffuse large B-cell lymphoma in 7.14%, mantle cell lymphoma in 5.36% and chronic lymphatic leukaemia in 5.36% patients. No relapse was seen in 76%. EMZL and FL had a significantly better overall survival compared to other lymphoma types (p=0.002). Patients with Ann Arbor stage IE had a significantly better prognosis than those with stages higher than IE (p=0.048).

CONCLUSION

Our data suggest that clinicopathological features such as Ann Arbor stage influence survival.

Second primary malignancies after ocular adnexal lymphoma diagnosis

BACKGROUND

Although studies have investigated the risk of second primary malignancies (SPMs) associated with lymphoma of various sites, limited studies have investigated this risk in patients with lymphoma originating within the ocular adnexa. We conducted a retrospective study to assess incidence of secondary malignancies in patients with a prior diagnosis of ocular adnexal lymphoma (OAL) and to determine latency periods and age-groups at increased risk for SPM occurrence.

METHODS

Retrospective analysis was performed on data obtained from Surveillance, Epidemiology, and End Results (SEER) 9 database. Patients with an initial primary malignancy diagnosis of OAL between 1973 and 2015 were included in the study. Standardized incidence ratios (SIR) and excess absolute risks (EAR) compared to a SEER reference population with similar sex, race, age, and calendar year were computed for SPMs. Excess absolute risk is per 10,000 individuals; alpha of 0.05 was used.

RESULTS

Of 1834 patients with primary ocular adnexal lymphoma, 279 developed a secondary malignancy during average follow-up of 110.03 months (+/- 88.46), denoting higher incidence than expected (SIR 1.20; 95% CI, 1.07 to 1.35; EAR 30.56). Amongst the primary lymphoma cohort, 98.7% (1810/1834) of patients had non-Hodgkin's lymphoma and amongst those that developed secondary malignancies, 99.6% (278/279) had non-Hodgkin's lymphoma. Patients exhibited increased incidence of lymphohematopoietic and non-lymphohematopoietic second malignancies and no secondary malignancies of the eye or orbit. Patients had increased incidence of secondary malignancies in the first year (SIR 2.07; 95% CI, 1.49 to 2.79; EAR 150.37) and 1-5 years following lymphoma diagnosis (SIR 1.24; 95% CI, 1.01 to 1.51; EAR 34.89). Patients with various OAL subtypes demonstrated differing patterns of site-specific and overall SPM risk.

CONCLUSIONS

Patients with prior diagnosis of ocular adnexal lymphoma possess increased risk of hematologic and non-hematologic secondary malignancies. Risk of secondary malignancy could vary by lymphoma subtype. Patients with ocular adnexal lymphoma may benefit from regular surveillance to promote early detection of second primary malignancies.

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.

Bag-of-features-based radiomics for differentiation of ocular adnexal lymphoma and idiopathic orbital inflammation from contrast-enhanced MRI

OBJECTIVES

To evaluate the effectiveness of bag-of-features (BOF)-based radiomics for differentiating ocular adnexal lymphoma (OAL) and idiopathic orbital inflammation (IOI) from contrast-enhanced MRI (CE-MRI).

METHODS

Fifty-six patients with pathologically confirmed IOI (28 patients) and OAL (28 patients) were randomly divided into training (n = 42) and testing (n = 14) groups. One hundred sixty texture features extracted from the CE-MR image were encoded into the BOF representation with fewer features. The support vector machine (SVM) with a linear kernel was used as the classifier. Data augmented was performed by cropping orbital lesions in different directions to alleviate the over-fitting problem. Student's t test and the Holm-Bonferroni method were employed to compare the performance of different analysis methods. The chi-square test was used to compare the analysis with MRI and human radiological diagnosis.

RESULTS

In the independent testing group, the differentiation by the BOF features with augmentation achieved an area under the curve (AUC) of 0.803 (95% CI: 0.725-0.880), which was significantly higher than that of the BOF features without augmentation and that of the texture features (p < 0.05). In addition, the same radiomic analysis with pre-contrast MRI obtained an AUC of 0.618 (95% CI: 0.560-0.677), which was significantly lower than that with CE-MRI. The diagnostic performance of the analysis with CE-MRI was significantly better than the radiology resident (p < 0.05) but had no significant difference with the experienced radiologist, even though there was less consistency between the radiomic analysis and the human visual diagnosis.

CONCLUSIONS

The BOF-based radiomics may be helpful for the differentiation between OAL and IOI.

KEY POINTS

• It is challenging to differentiate OAL from IOI due to the similar clinical and image features. • Radiomics has great potential for the noninvasive diagnosis of orbital diseases. • The BOF representation from patch to image may help the differentiation of OAL and IOI.

Single-fraction low-energy electronic brachytherapy for conjunctival lymphoma

Purpose

Conjunctival lymphoma represents an uncommon tumor, accounting for 5-10% of total extranodal lymphomas. Although radiotherapy is a frequent treatment option, limited capacities and lack of specialized centers are common problems in Peru, forcing radiation oncologists to apply short courses of radiotherapy. Here, we report a case series of patients treated with a novel single-shot scheme. Additionally, we present a literature review of the current short-course irradiation strategies.

Cases presentation

Three cases of conjunctival marginal zone (B-cell) lymphoma (marginal zone lymphoma [MZL]/mucosa-associated lymphoid tissue [MALT]) of the fornix are presented. Following biopsy and sonographic assessment of the lesion thickness, we applied a focused single dose of 14 Gy kilovoltage brachytherapy (prescribed to the maximum thickness of the lesion). Follow-up was scheduled in quarterly intervals. After 28, 31, and 40 months of follow-up, none of the three patients treated exhibited acute or chronic toxicities and remained local or distant disease-free.

Conclusions

Single dose kilovoltage brachytherapy was effective and safe in this small cohort of patients. Based on the literature, there is an evidence that local treatment in short-course radiotherapy is effective and should be considered amongst therapeutic options for these patients; however, this novel approach should be evaluated prospectively in a larger cohort.

Orbital Rosai-Dorfman disease initially diagnosed as IgG4-related disease: a case report

Inflammatory orbital lesions include a broad list of diagnoses, many of them with overlapping clinical and radiographic features. They often present a diagnostic conundrum, even to the most experienced orbital specialist, thus placing considerable weight on surgical biopsy and histopathological analysis. However, histopathological diagnosis is also inherently challenging due to the rarity of these lesions and the overlaps in histologic appearance among distinct disease entities. We herein present the case of an adolescent male with a subacutely progressive orbital mass that generated a significant diagnostic dilemma. Early orbital biopsy was consistent with a benign fibro-inflammatory lesion, but corticosteroid therapy was ineffective in halting disease progression. After an initial substantial surgical debulking, histopathological analysis revealed several key features consistent with IgG4-related disease (IgG4-RD), a systemic fibro-inflammatory process typically accompanied by multifocal tumor-like lesions. Surprisingly, within months, there was clear evidence of clinical and radiographic disease progression despite second-line rituximab treatment, prompting a second surgical debulking. This final specimen displayed distinctive features of Rosai-Dorfman disease (RDD), a systemic inflammatory disease characterized by uncontrolled histiocytic proliferation. Interestingly, certain features of this re-excision specimen were still reminiscent of IgG4-RD, which not only reflects the difficulty in differentiating RDD from IgG4-RD in select cases, but also illustrates that these diagnoses may exist along a spectrum that likely reflects a common underlying pathogenetic mechanism. This case emphasizes the importance of surgical biopsy or resection and histopathological analysis in diagnosing—and, ultimately, treating—rare, systemic inflammatory diseases involving the orbit, and, furthermore, highlights the shared histopathological features between RDD and IgG4-RD.

Paediatric ocular adnexal lymphoma: a population-based analysis

Objective

To investigate the incidence, clinicopathological characteristics and survival of ocular adnexal lymphoma (OAL) in the paediatric population.

Methods and analysis

In this retrospective case series, the Surveillance, Epidemiology and End Results database was accessed to identify individuals with OAL ≤18 years of age, diagnosed between 1973 and 2015. OAL located in the eyelid, conjunctiva, lacrimal apparatus and orbit were included. Main outcome measures were the age-adjusted incidence rates (IRs) per 1 000 000 population at risk (calculated for the period 2000–2015) and descriptive statistics of demographic and clinicopathological features.

Results

The IR of paediatric OAL was 0.12 (95% CI 0.08 to 0.16) per 1 000 000. Males (0.15; 95% CI 0.10 to 0.22) and blacks (0.24; 95% CI 0.13 to 0.42) had a higher tendency for OAL development. A total of 55 tumours in 54 children were identified. The majority were localised (78.4%), conjunctival (49.1%) lymphomas. Extranodal marginal zone lymphoma (EMZL, 45.5%, n=25) was the most frequent subtype, followed by diffuse large B-cell lymphoma (DLBCL, 9.1%, n=5), B lymphoblastic lymphoma (7.3%, n=4), follicular lymphoma (5.5%, n=3), Burkitt lymphoma (5.5%, n=3), anaplastic large cell lymphoma (ALCL, 3.6%, n=2), small lymphocytic lymphoma (1.8%, n=1), diffuse large B-cell lymphoma, immunoblastic (1.8%, n=1) and panniculitis-like T-cell lymphoma (1.8%, n=1). Localised, low-grade, conjunctival lymphomas were frequently treated with complete excision with or without radiation, while high-grade and distant tumours usually received chemotherapy. Only 29.1% of paediatric OAL cases were treated with radiation. Three out of five (60%) patients with DLBCL died of lymphoma at a median follow-up of 21 (range 10–86) months, and 1 out of 2 (50%) patients with ALCL died of lymphoma at 23 months from diagnosis.

Conclusion

OAL in the paediatric population is rare. The majority of OAL are EMZL and are characterised by excellent prognosis. The histological subtype was found to be the main predictor of outcome with cancer-specific deaths observed in patients with DLBCL and ALCL.

Ocular Surface Disorders in Patients with Human Immunodeficiency Virus (HIV) Infection

Purpose: To describe ocular surface disorders associated with human immunodeficiency virus (HIV). Methods: Narrative review. Results: Ocular surface neoplastic conditions, such as Kaposi's sarcoma, conjunctival lymphoma and ocular squamous cell carcinoma along with blepharitis, dry eye disease, and vernal keratoconjunctivitis, constitute ocular surface complications in HIV-infected individuals. Conclusion: This review will provide a summary of clinical presentations and treatment options for the most common HIV-related ocular surface diseases, indicating the need for a comprehensive ocular examination including ocular surface in all HIV patients 22.

Etiologies of Proptosis: A review

Proptosis, the protrusion of the eyeball from the orbit, results from a wide variety of pathologies that can be vision- or life-threatening. Clinical history, associated physical exam findings, and imaging features are all crucial in establishing the underlying etiology. The differential diagnosis is broad, and includes infectious, inflammatory, vascular, and neoplastic entities that range from benign and indolent, to malignant and aggressive. While treatment varies significantly based on the disease process, all are aimed at preserving vision, salvaging the globe, preventing disfigurement, and reducing mortality. Both internists and general ophthalmologists should be familiar with the causes of proptosis in order to initiate the work-up for, and appropriately triage, affected patients.

Clinical features and treatment outcomes of primary ocular adnexal mucosa-associated lymphoid tissue lymphoma: a single center retrospective analysis of 64 patients in China

AIM

To investigate the clinical features, treatment and prognosis of primary ocular adnexal mucosa-associated lymphoid tissue lymphoma (POAML).

METHODS

A retrospective analysis was performed on 64 patients with POAML who were admitted to the First Affiliated Hospital of Zhengzhou University from January 2006 to December 2018.

RESULTS

With a median follow-up of 61mo (range, 2-156mo), estimated overall survival (OS) rate and progression-free survival (PFS) rate at 10y reached 94.5% and 61.5%, respectively. Median OS time and PFS time were not reached. During this period, only 3 patients died, but none of them died directly due to disease progression. One patient (1.6%) developed transformation to diffuse large B-cell lymphoma (DLBCL). Of the 56 patients achieved complete remission after first-line treatment, 5 (8.9%) developed local and/or systemic relapse eventually. Patients ≥60y had significantly shorter PFS than younger patients (P=0.01). For patients with early stages (Ann Arbor stage I and stage II), univariate analysis confirmed that radiotherapy dose lower than 32 Gy were independently associated with shorter PFS (P=0.04). Other factors including gender, bone marrow involvement, the initial location of the disease, and the laterality were not associated with PFS.

CONCLUSION

The data from our center indicate that POAML has a slow clinical progression and has an excellent clinical outcome. Patients with POAML harbor a continual risk of relaps and transformation to aggressive subtype of lymphoma.

Classification, diagnosis, and management of conjunctival lymphoma

Lymphoma is a malignant lymphoproliferative tumor that can involve the conjunctiva. Approximately 5-15% of all extranodal lymphomas are found in the ocular adnexal region, with approximately 25% of those involving the conjunctiva. Ninety-eight percent of conjunctival lymphomas arise from B-lymphocytes. The most common subtype of conjunctival lymphoma is extranodal marginal zone lymphoma (80%), followed by follicular lymphoma (8%), diffuse large B-cell lymphoma (3%) and mantle cell lymphoma (3%). Natural killer and T cells (NK/T) are rare causes of lymphoma. While most conjunctival lymphomas are localized to the ocular adnexa at the time of presentation, systemic examination and management are of key importance in the long-term care of the patient. This review outlines the classification, etiology, presentation, diagnosis, and management of conjunctival lymphoma. The novel use of high resolution optical coherence tomography, both as a diagnostic tool and as a means for ongoing evaluation during treatment, is illustrated. Treatment options discussed include external beam radiation, chemotherapy, immunotherapy, antibiotic therapy, and combination regimens. Future investigation of the etiology and pathogenesis of conjunctival lymphoma is expected to reveal opportunities for innovative and individualized therapeutic agents. Collaboration between multiple disciplines is key in the advancement of the field.

A rare case of follicular lymphoma transformed to a high-grade B-cell lymphoma in orbit

Transformation of lymphoma is an infrequent phenomenon, and involvement of the eye as such is even uncommon. Histological transformation in patients with follicular lymphoma who were previously treated with immune-chemotherapy carry a poor outcome. Here, we illustrate such a case with aggressive histological transformation from a low-grade lymphoma.

Orbital lymphoma

Orbital lymphomas constitute 50-60% of ocular adnexal lymphomas. A total of 2211 cases of orbital lymphoma with a known subtype have been reported in the last 24 years (1994-2017). The vast majority of orbital lymphomas are of B-cell origin (97%), of which extranodal marginal zone B-cell lymphoma (EMZL) (59%) is the most common subtype, followed by diffuse large B-cell lymphoma (23%), follicular lymphoma (9%), and mantle cell lymphoma (5%). Orbital lymphoma is primarily a disease of the elderly. Gender distribution varies according to lymphoma subtype. However, extranodal marginal zone B-cell lymphoma (53%) and follicular lymphoma (75%) show a female predominance, whereas diffuse large B-cell lymphoma shows an even gender distribution. Mantle cell lymphoma has a striking male predominance of 80%. The histopathological subtype and the clinical stage of the disease are the best indicators of prognosis and patient outcome. Low-grade lymphomas such as extranodal marginal zone B-cell lymphoma and FL have a good prognosis, whereas high-grade lymphomas (diffuse large B-cell lymphoma and mantle cell lymphoma) are associated with a poor prognosis. When managing solitary low-grade lymphomas, radiotherapy is the treatment of choice. Chemotherapy, with or without radiotherapy, should be chosen for disseminated and high-grade lymphomas.

Comparison of Selection and Long-term Clinical Outcomes Between Chemotherapy and Radiotherapy as Primary Therapeutic Modality for Ocular Adnexal MALT Lymphoma

BACKGROUND

The choice of a primary treatment for ocular adnexal mucosa-associated lymphoid tissue lymphoma (OAML) depends on the extent of tumor spread. However, radiotherapy is commonly used as a first-line therapy despite ophthalmic complications, because most OAMLs are in a limited stage of progression. However, the initial therapeutic modality, including chemotherapy and treatment of the advanced stage, has not been fully established for OAML. Therefore, we evaluated the optimal therapeutic options and survival outcome-related parameters for patients with primary OAML.

METHODS

We evaluated 208 consecutive patients with primary OAML who were diagnosed at the Catholic University Lymphoma Group between January 2004 and April 2015.

FINDINGS

During a median follow-up of 70.0 months (range, 3.2-182.0 months) in 208 patients with primary OAML, most patients were female and the median age was 46 years old. Overall survival (OS) and progression-free survival (PFS) at 13 years were excellent (92.7% and 69.7%, respectively). Of the 117 patients who received the first-line radiotherapy, 92% achieved complete remission (CR), usually by being treated with less than 30 Gy. Radiation-related ophthalmic complications including dry eye syndrome (59%) and cataract (22%) caused a decline in the quality of life (QoL). Chemotherapy alone was used to treat 86 OAML patients, with 84.9% achieving CR and 12.8% achieving partial remission with tolerable toxicities. There were no differences in survival outcomes between patients treated with radiotherapy versus those treated with rituximab-containing chemotherapy, although the latter group had more advanced stages of OAML (OS, p = 0.057; PFS, p = 0.075).

INTERPRETATION

OAML patients were predominantly female and relatively young, and radiotherapy as a primary therapeutic option was more likely to lead to radiation-related complications, resulting in lower QoL. On the other hand, frontline chemotherapy showed consistent therapeutic outcomes with tolerable toxicities compared to radiotherapy, and there were no long-term or delayed adverse events. Therefore, when considering therapeutic efficacy and therapy-related QoL, chemotherapy is recommended for younger patients, and radiotherapy is recommended for older and chemotherapy-ineligible patients.

FUNDING

A National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIP) (No. NRF-2016R1A2B4007282).

Usefulness of 18F-FDG PET/CT for evaluating response of ocular adnexal lymphoma to treatment

The purpose of this study was to investigate the efficacy of F-fluoro-deoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for evaluating the ocular adnexal lymphoma treatment responses.We retrospectively reviewed data for 9 histologically confirmed cases of malignant lymphoma. All patients had at least one ocular adnexal tumor site and underwent FDG PET/CT before and after treatment. Patients' histological disease subtypes included diffuse large B-cell lymphoma (n = 3), mucosa-associated lymphoid tissue lymphoma (n = 2), follicular lymphoma (n = 1), NK/T-cell lymphoma (n = 1), lymphoplasmacytic lymphoma (n = 1), and Hodgkin lymphoma (n = 1). The highest FDG uptake by the ocular adnexal lesions was calculated as the maximum standardized uptake value (SUVmax). FDG uptake at ocular adnexal sites and sites of systemic disease after treatment were also assessed using the 5-point Deauville scale.In 1 of the 9 patients, a conjunctival lesion could not be detected by either pre- or posttreatment PET/CT. For 8 of the 9 patients, the SUVmax value at the ocular adnexal site significantly decreased after treatment (7.1 ± 5.1 vs 1.6 ± 0.58; P = .0196). For 7 of the 9 patients, the first posttreatment FDG uptake at the ocular adnexal site was considered a complete metabolic response, and these patients showed an improved clinical ophthalmic presentation with no relapse at ocular adnexal sites during follow-up.FDG PET/CT is useful for evaluation of the response of ocular adnexal lymphoma to treatment, although its usefulness may depend on the histological subtype and site of the lesion.

[Management of orbital inflammation in internal medicine. Proposal for a diagnostic work-up]

Inflammatory orbitopathies relate to an inflammatory state originating within the orbit and its adnexes, except the inner ocular globe. Orbital inflammation (OI) may be either localized manifestation of a proven or like autoimmune disease, or local response from immune system against infectious, structural or tumoral antigens. We review the clinical manifestations of OI, which provide helpful clues to the diagnosis and describe the inflammatory, infectious and neoplastic conditions classically associated with OI. Autoimmune diseases are probably the most common causes of OI associated with a bilateral dacryoadenitis (e.g., sarcoidosis, granulomatosis with polyangiitis, IgG4-related disease). We focused on a major part of the IgG4-RD spectrum, the IgG4-related orbital disease which has been recently described and the idiopathic orbital inflammation syndrome that one should consider in patients 40 years of age or older with non specific inflammation OI on biopsy but without underlying local or systemic disease. An algorithm for the diagnostic approach of OI was proposed. If systemic explorations fail to diagnose an underlying disease, histopathologic control is required for distinguishing non-specific OI from other differential diagnosis, especially lymphoma. In the cases of pure myositic locations and posteriorly located tumours where biopsy could damage to the optic nerve, analysis of orbital lesions in T2W IRM sequence may be helpful to distinguish idiopathic OI (IOI) from lymphoma. When the diagnostic work-up fails, a corticosteroid trial could be used, but its beneficial effect has to be cautiously interpretated before definitively diagnosing IOI. Finally, treatments used in main infllammatory orbitopathies were also reviewed.

Cognitive biases in orbital mass lesions - Lessons learned

Purpose

A patient’s presentation and clinical diagnosis can at times be clouded by their past medical history. Clinicians’ anchoring bias towards initial information, such as a history of cancer, may lead them astray when creating a differential diagnosis for a patient who presents with new signs and symptoms of a mass lesion, assuming metastatic disease without seeking tissue confirmation.

Methods

The presentation, workup, diagnosis, and treatment of two patients who presented with orbital masses in the context of a primary prostate cancer are presented in this report.

Results

In both cases, prostate cancer metastasis to the orbit was top on the differential. Ultimately, histopathological examination of biopsies taken from the orbital masses revealed orbital lymphoma in both patients.

Conclusion

With mounting rates of patients who have survived a previous cancer, multiple primary cancers within one patient are becoming increasingly common. While prostate cancer metastasis to the orbit is a relatively rare event, orbital lymphoma is a more common diagnosis in orbital masses. Therefore, when patients present with orbital masses in the context of prostate cancer, the conclusion should not immediately be metastasis and a tissue diagnosis should be sought; especially given that the treatment of these entities is different.

A case of conjunctival MALT lymphoma: successfully treated with solely extended rituximab therapy

PURPOSE

Primary ocular adnexal lymphomas are cured by radiotherapy; however, complications are frequent and relapses may occur. In this case, we aimed to report the efficacy and safety of extended systemic rituximab (anti-CD 20 monoclonal antibody) therapy of conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma.

METHODS

In the standard regimen, rituximab is used as four consecutive weekly infusions of 375 mg/m² in patients with low-grade lymphomas. We treated a patient who had bilateral conjunctival MALT lymphoma with rituximab 375 mg/m² intravenously once weekly for 10 weeks as a first-line therapy.

RESULTS

During the examination of the sixth week, we observed partial response of the lesions in both eyes. At the end of the tenth cure, complete remission was achieved. No local or systemic adverse effect was observed. The patient has no signs of recurrence during the 22-months follow-up period.

CONCLUSION

Extended rituximab therapy may be an effective and well-tolerated first-line treatment option for bilateral conjunctival MALT lymphoma.

Association of Disease Location and Treatment With Survival in Diffuse Large B-Cell Lymphoma of the Eye and Ocular Adnexal Region

Importance

Primary diffuse large B-cell lymphoma (DLBCL) of the ocular region is rare, and the utility of surgery and radiation therapy remains unresolved.

Objective

To explore the clinical characteristics and determine factors associated with overall survival in primary vitreoretinal lymphoma (PVRL) and ocular adnexal (OA)-uveal DLBCL.

Design, Setting, and Participants

This retrospective analysis included 396 patients with ophthalmic DLBCL from January 1, 1973, through December 31, 2014, using the Surveillance, Epidemiology, and End Results database. The median follow-up was 39.0 months (interquartile range, 5.1-72.9 months). All patients diagnosed with primary DLBCL of the eye or retina (PVRL) or the eyelid, conjunctiva, choroid, ciliary body, lacrimal gland, or orbit (OA-uveal lymphoma) were included. Patients diagnosed at autopsy or with additional neoplastic disease were excluded.

Main Outcomes and Measures

Patient demographic characteristics, disease location, treatment modalities, and overall survival.

Results

Forty-seven patients with PVRL (24 women [51.1%] and 23 men [48.9%]) and 349 with OA-uveal DLBCL (192 women [55.0%] and 157 men [45.0%]) had a similar mean (SD) age at diagnosis (69.6 [12.3] vs 66.1 [17.7] years). No difference in the use of surgery or radiation therapy by location was found. For all PVRL and OA-uveal DLBCL, a Cox proportional hazards regression model affirmed that age older than 60 years was associated with increased risk for death (hazard ratio [HR], 2.7; 95% CI, 1.9-4.0; P < .001). Gross total resection was associated with a decreased risk for death (HR, 0.5; 95% CI, 0.3-0.9; P = .04), whereas radiation therapy was not. The 5-year overall survival among patients with PVRL was 41.4% (SE, 8.6%); among those with OA-uveal DLBCL, 59.1% (SE, 2.8%; Mantel-Cox test, P = .007). Median overall survival was lower in PVRL (38.0 months; 95% CI, 14.2-61.8 months) than in OA-uveal DLBCL (96.0 months; 95% CI, 67.3-124.7 months; Mantel-Cox test, P = .007). In addition, median overall survival in ophthalmic-only disease was higher (84.0 months; 95% CI, 63.2-104.8 months) than that in primary DLBCL that occurred outside the central nervous system and ophthalmic regions (46.0 months; 95% CI, 44.4-47.6 months; Mantel-Cox test, P < .001).

Conclusions and Relevance

The 5-year survival in PVRL vs OA-uveal DLBCL differed by 17.7%, and overall survival was greater in ophthalmic DLBCL than in DLBCL located outside the central nervous system and ophthalmic regions. Younger age (≤60 years) and gross total resection were associated with increased survival.

Ocular adnexal marginal zone lymphoma of mucosa-associated lymphoid tissue

Ocular adnexal lymphomas are a group of heterogeneous neoplasms representing approximately 1-2% of non-Hodgkin lymphomas and 8% of extranodal lymphomas. The incidence of primary ocular adnexal lymphoid tumors has raised over the last decades, and this could be probably attributed to the more sophisticated diagnostic techniques. Due to the wide spectrum of clinical manifestations, ocular tissue biopsy is important in order to set a precise diagnosis based on histological, immunophenotypical and, in some cases, molecular findings. The most common subtype, which may account for up to 80% of primary ocular adnexal lymphomas, is extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue. This lymphoma is usually asymptomatic in the early phase of the disease causing a delay in the final diagnosis and prompt therapy. The pathogenesis of a proportion of these tumors has been linked to chronic inflammatory stimulation from specific infectious factors (e.g., Chlamydia psittaci) or to autoimmunity. The further improvement in diagnostic methods and the further understanding of the pathogenesis of ocular adnexal EMZL may contribute to the establishment of a more successful multidisciplinary therapeutic planning.

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.

Long-term course of patients with primary ocular adnexal MALT lymphoma: a large single-institution cohort study

POAML (specifically Ann Arbor stage I disease) has an excellent clinical outcome, with only a few patients succumbing to lymphoma. POAML patients face a continuous risk of distant relapse, including in the central nervous system, and transformation to aggressive lymphoma.

Chlamydia and ocular adnexal lymphomas: An Indian experience

CHLAMYDIA AND OCULAR ADNEXAL LYMPHOMAS

AN INDIAN EXPERIENCE: Ocular adnexal lymphomas (OALs) are a heterogeneous group of malignancies, majority being extranodal mucosa-associated lymphoid tissue (MALT) type. Different geographical regions have reported association of Chlamydia with OALs (MALT type). In India, role of Chlamydia in OALs remains unexplored. The aim of this study was to detect Chlamydia and to correlate with clinicopathological features of OALs in India. The clinicopathological features of 41 OAL cases were studied prospectively. Chlamydia DNA was detected by genus specific PCR amplifying major outer membrane protein (MOMP) gene followed by DNA sequencing. Chlamydia immunoexpression was evaluated by immunofluorescence and immunohistochemistry. The results were correlated with clinicopathological features including follow-up and survival. Chlamydia genome was detected in 3/41 (7.3%) OAL cases by PCR. Direct sequencing revealed C. trachomatis in 3 positive cases. Immunofluorescence and immunohistochemistry showed Chlamydia antigen in 5/41 and 1/41 cases respectively. Immunofluorescence demonstrated higher sensitivity than immunohistochemistry. A significant association was observed between Chlamydia positivity and orbital location (P=0.05). Follow-up revealed relapse in 2 Chlamydia positive cases (P=0.056). Our results demonstrate for the first time presence of C. trachomatis genome in 7.3% OAL cases in India. As no other reports are documented, more detailed studies from different regions within India are needed to explore status of Chlamydia in OALs.

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.

Primary diffuse large B cell lymphoma of the lacrimal sac

A 47-year-old man presented with epiphora and a mass around the lacrimal sac in his left eye. Imaging studies revealed a favorable diagnosis of sinusitis-related mucocele. However, the pathological study of the excised tumor demonstrated a diffuse large B cell lymphoma. The patient was consequently referred to the oncology department for further management. Malignant lymphomas of the lacrimal sac are rare and they can mimic mucoceles. As such, they should be included in the list of differential diagnoses for lacrimal sac mass.

[Salmon-pink colored conjunctival tumor with amyloid deposits]

An 82-year-old male patient presented with a salmon-pink colored conjunctival tumor of the left eye. A circumscribed, dense and whitish portion was detected by clinical examination. The histophological and immunhistochemical examination of the biopsy tissue revealed a CD20+ marginal zone lymphoma of the conjunctiva with amyloid deposits. Extranodal marginal zone lymphoma at this site is the most common lymphoma of the ocular adnexa and accounts for 5-10% of malignant diseases. An association with amyloid production is very rare and according to the current state of knowledge has no known impact on the outcome.

Malignant lymphoma of the conjunctiva

Conjunctival lymphomas constitute 25% of all ocular adnexal lymphomas. The majority are B-cell non-Hodgkin lymphomas (NHLs) (98%), whereas conjunctival T-cell NHLs are rare (2%). The most frequent subtype of conjunctival B-cell lymphoma is extranodal marginal zone lymphoma (EMZL; 81%), followed by follicular lymphoma (8%), diffuse large B-cell lymphoma (3%), and mantle cell lymphoma (3%). Extranodal marginal zone lymphoma occurs slightly more often in women and, along with follicular lymphoma, presents late in the seventh decade of life, whereas diffuse large B-cell lymphoma and especially mantle cell lymphoma have a predilection for the male gender and typically present in the eighth decade. Extranodal marginal zone lymphoma and follicular lymphoma present most frequently in the forniceal and bulbar conjunctiva. Conjunctival diffuse large B-cell lymphoma, mantle cell lymphoma and T-cell NHLs are characterized by a short duration of symptoms before the first ophthalmologic consultation. External beam radiotherapy is the treatment of choice for extranodal marginal zone lymphoma and follicular lymphoma, whereas diffuse large B-cell lymphoma, mantle cell lymphoma, and T-cell NHLs are mainly treated with chemotherapy. Conjunctival T-cell NHLs are associated with a particularly poor prognosis, with 50% of patients having progression or recurrence during a 1-year follow-up period.