Lymphoproliferative L�sionen der okul�ren Adnexe

Primary extranodal lymphoma of the glands. Literature review and options for best practice in 2019

Primary extranodal non-Hodgkin's lymphomas (EN-NHL) are a heterogeneous group of malignancies that involve numerous entities with significant difference in terms of tumor site locations, prognostic factors, biology expression, and therapeutic options. In the literature, many EN-NHL types were reported from limited series which only allowed narrow views for elucidating prognostic factors and defining the role of loco-regional therapies in the era of new systemic and biologically targeted therapies. The Rare Cancer Network (RCN), an international multidisciplinary consortium, has published a number of reports on several EN-NHL sites which included many gland locations. In this review, we will focus on the recent literature for a selected number of EN-NHL types in both exocrine and endocrine gland locations. We aim to provide renewed and clear messages for the best practice in 2019 for diagnosis, histopathology, treatments, and also their prognostic implications. We believe that better understanding of molecular and genetic characteristics of these particular diseases is crucial for an appropriate management in the era of personalized treatment developments.

Benign Lymphoid Hyperplasia Presenting as Bilateral Scleral Nodules

Purpose. To report a case of transient lymphoid hyperplasia presenting as bilateral nodular scleral mass in a young male patient. Design. Observational case report. Methods. Chart review. Causes of scleritis were considered and excluded based on detailed history, physical examination, and laboratory investigations. Results. Excisional biopsy of scleral lesions indicated lymphoid tissue. Immunohistochemical studies revealed a polyclonal population of T and B cells consistent with a benign reactive process. Conclusions. Chronic exposure of the ocular adnexa to many allergens and irritants may lead to activation of the inflammatory cascade. In severely allergic patients activation may be exponential and elicit an immune-mediated response resulting in a transient lymphoid reactive process.

[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.

[Persisting lesion of the conjunctiva. A masquerade syndrome?]

A 26-year-old female patient was referred because of a persisting swelling and redness of the conjunctiva for 4 months accompanied by pruritus. An ultrasound biomicroscopy showed hypoechogenic structures separated by multiple hyperechogenic septa. A biopsy was performed which revealed a marginal B-cell lymphoma of the mucosa-associated lymphoid tissue (MALT) type. A generalized lymphatic disease could be excluded by positron emission tomography-computed tomography (PET-CT). In agreement with the patient an extensive excision was performed followed by a wait and see strategy including close monitoring by ophthalmological and general internist control examinations.

[Therapy of tumors of the anterior orbit]

Tumors of the orbit are diagnosed on clinical and neuroradiological criteria. A biopsy may histologically confirm uncertain mass lesions. The patients' age and medical history predispose for certain tumor entities among the rather heterogenous spectrum of possible diagnoses. The therapy depends on the degree of malignancy and its location within the orbit. Among the different options, surgical excision is the most common followed by radiation therapy either in combination with surgery or alone. Chemotherapy plays a subsidiary role in certain lymphomas or metastases. This review covers the surgical techniques and treatment principles for tumors of the anterior orbit, explains radiotherapy techniques and briefly covers chemotherapy. Pediatric tumors of the orbit are covered separately.

Diagnostic difficulties and treatment of non-Hodgkin lymphoma of the orbit

BACKGROUND

There are problems connected with the diagnosis of non-Hodgkin lymphomas of the orbit, before deciding on the correct treatment.

MATERIAL AND METHODS

Six out of 22 patients with a tumour of the orbit were treated between 1995 and 2004 for orbital non-Hodgkin lymphomas (NHL). Morphological-functional and aesthetic complications regarding the eyes, the delay between onset and diagnosing the disease and concomitant conditions were evaluated. Management was always tailored individually for each patient, depending on tumour location in the orbit. Surgical procedures comprised total or subtotal removal of the tumour via a semi-coronal access and lateral orbitotomy. Histological diagnosis of the tumours was made from the surgical specimens.

RESULTS

According to the REAL classification, 3 patients had a B-cell lymphoma from the MALT system with low malignancy, 2 other patients a diffuse B cell NHL and 1 patient a lymphoma from the germinal centre with intermediate malignancy. All patients had received chemotherapy. A 9-year remission was achieved in one, an 8-year in another and a 7-year remission in two more out of the total of 6 patients; one is living without relapse for 6 years. The last patient, in whom the lymphoma was diagnosed at the age of 70 years, died 4 years after the procedure without relapse due to cardiovascular and respiratory insufficiency.

CONCLUSIONS

Although the treatment of choice of NHL is chemotherapy, it is felt necessary to remove the whole or possibly the major part of the tumour in case of retrobulbar location when the histological subtype is unknown prior to surgery. However, the optic nerve should always been left intact, even when such tumour encircles this cranial nerve. Only sufficient biopsy material allows determination of the lymphoma subtype and selection of appropriate chemotherapy.

Klassifikation biomedizinischer Forschungsberichte als Grundlage evidenzbasierter Medizin in der Augenheilkunde

BACKGROUND

Evidence-based medicine requires careful appraisal of published data derived from experimental and clinical studies. Based on classification of biomedical research reports, evidence levels can be determined and recommendations for therapeutic decisions can be made.

METHODS

A classification system for clinical studies was developed. It was evaluated in classifying the reports published in Der Ophthalmologe during 2003-2004 (study design: descriptive cross-sectional study, case series).

RESULTS

In the 2-year interval, 70 longitudinal and 95 cross-sectional studies were published. The vast majority of the longitudinal studies were interventional cohort studies. Not considering case reports, 73% of the original articles were longitudinal prospective studies, 1% were retrospective (case-control) studies, and 26% were cross-sectional studies.

CONCLUSIONS

The study design of all published articles could be classified using the classification system. This classification system proves to be applicable in the context of clinical studies in ophthalmology and may be helpful in the process of critical appraisal of the literature and synthesis of clinical evidence and an evidence-based recommendation.

[Diseases of the lacrimal gland]

Experience with the differential diagnosis of lacrimal gland illnesses is limited in daily practice due to their rarity. It is therefore of particular importance to have guidelines for the practitioner by which he can decide on the application of conservative or surgical therapy, and whether it is necessary to take a biopsy to clarify the diagnosis. There is a wide spectrum of possible illnesses which include systemic diseases, inflammatory disorders, neoplastic, benign and malignant tumors. When a pleomorphic adenoma cannot be excluded, biopsy is contraindicated and complete tumor excision with its capsule is necessary to prevent the possibility of malignant transformation and a negative effect on long-term prognosis. In this overview, special interest is placed on the typical clinical aspects and imaging features of lesions of the lacrimal gland fossa, their differential diagnosis and management.