Reticulum cell sarcoma (histiocytic lymphoma) of the orbit

Ocular adnexal lymphoproliferative lesions

Ocular adnexal lymphoproliferative lesions consist of a spectrum of disease entities, including reactive lymphoid hyperplasia, atypical lymphoid hyperplasia, and lymphoma. No clinical or radiologic criteria facilitate a distinction among these lymphoproliferative lesions. The two hyperplastic processes may evolve to localized or systemic lymphoma. A similar pattern is evident in other mucosa-associated lymphoid tumors elsewhere in the body. Most ocular adnexal lymphomas are small lymphocytic non-Hodgkin's tumors with an indolent course; frequently, they remain localized to the ocular adnexa. In comparison, intermediate- and high-grade lymphomas are less common in the ocular adnexa but more aggressive. An approach to the diagnosis and treatment of these complex entities is suggested. Despite new pathologic classification schemes, immunophenotypic labeling, and molecular genetic analysis, the prognosis for patients with small-cell lymphoma in the ocular adnexa is difficult to predict.

Visual involvement in primary non-Hodgkin's lymphomas

This paper reviews the modalities of involvement of the visual function in patients with primary non-Hodgkin's lymphomas. They include the lymphomatous uveitis, the invasion of the orbital cavities and cavernous sinuses, and the involvement of the optic nerves, chiasm and optic tracts by lymphomatous lesions. Two cases of primary non-Hodgkin's lymphomas with visual disturbances are reported and the different mechanisms of visual pathway damage and clinical troubles are discussed from a large review of the pertinent literature.

Intraocular non-Hodgkin's lymphoma treated with systemic and intrathecal chemotherapy and radiotherapy. A case report and review of the literature

A case of therapy-resistant bilateral intermediate uveitis is presented. Vitreous biopsy and lumbar puncture resulted in the diagnosis of high-grade malignant non-Hodgkin's lymphoma (NHL). Because chemotherapy and radiotherapy continue to yield better results in the treatment of NHL and a cure can be reached in a large group of patients with high-grade malignant NHL, early diagnosis is very important. We therefore recommend early vitreous biopsy in persistent, bilateral, granulomatous intermediate uveitis, especially in older patients. Our patient achieved a complete remission (follow-up period at the time of writing, 18 months after the beginning of polychemotherapy and radiotherapy). The chemotherapy modalities are briefly discussed.

Primary central nervous system lymphoma

Primary lymphoma of the central nervous system (CNS), including reticulum cell sarcoma, microglioma, and histiocytic lymphoma, represents less than 1% of all primary brain tumors. In the last 10 years, this tumor has tripled in frequency in the nonimmunosuppressed population. By 1991, the tumor will be the most common neurological neoplasm by virtue of the increase in sporadic occurrence and in the acquired immunodeficiency syndrome (AIDS) population. Three percent of AIDS patients will develop this tumor either prior to AIDS diagnosis or during their subsequent course. In addition to acquired immunosuppression, patients with inherited disorders (such as Wiskott-Aldrich syndrome, severe combined immunodeficiency, and X-linked immunodeficiency) and other acquired disorders of the immune system are predisposed to the development of CNS lymphoma. Immunological studies have suggested a role for Epstein-Barr virus in the production of this tumor. Although subtypes exist, non-Hodgkin's lymphoma of the CNS most commonly consists of histiocytic cells or large immunoblastic cells bearing B cell surface markers in close proximity to the lateral and third ventricles. Sixty percent of these deposits are multiple, and subarachnoid invasion is seen in one-quarter of patients. Vitreous involvement of the eye occurring prior to and during the course of CNS lymphoma has been noted in up to 25% of patients. The involvement of multiple areas of the neuraxis, the eye, and multiple intracranial sites often occurs in the absence of obvious systemic lymphoma. Therapeutic trials of brain radiation therapy are associated with median survivals of less than 1 year. Uniform complete responses of intracranial deposits are recorded following chemotherapy with high-dose intravenous methotrexate, CHOP (cyclophosphamide, hydroxydaunomycin/doxorubicin, Oncovin (vincristine), and prednisone), high-dose cytosine arabinoside, and intra-arterial methotrexate with barrier modification.

Intraocular reticulum cell sarcoma: diagnosis by choroidal biopsy

A patient with uveitis and retinal pigment epithelial detachments underwent an extensive medical examination and pars plana vitrectomy in an attempt to confirm the clinical diagnosis of reticulum cell sarcoma. None of these examinations revealed the presence of malignancy. Transscleral biopsy of subretinal lesions confirmed the histopathological diagnosis of reticulum cell sarcoma. The patient was begun on systemic chemotherapy and external beam radiation to the eye and orbit, with resultant preservation of the eye, vision, and probable extension of life because of early detection of reticulum cell sarcoma by choroidal biopsy. This technique may be advantageous in the diagnosis cases of eyes with clinical evidence of reticulum cell sarcoma, no systemic signs of malignancy, and negative vitreous biopsies.

Genotypic monoclonality in immunophenotypically polyclonal orbital lymphoid tumors. A model of tumor progression in the lymphoid system. The 1986 Wendell Hughes lecture

Molecular genetic (genotypic) analysis elucidates gene rearrangements within lymphocytes that are responsible for either immunoglobulin production in B-lymphocytes or the expression of cell-surface antigen recognition receptors in T-lymphocytes. Molecular genetic analysis is far more sensitive than immunophenotypic methods for the detection of small clones of lymphocytes because as few as 2 to 5% of cells in an infiltrate can be discovered to possess the same rearranged DNA sequences with genetic probes. In truly polyclonal proliferations, each lymphocyte reorganizes its immunoglobulin or T-antigen receptor genes in a unique manner, resulting in an almost infinite number of combinations of genetic rearrangement and the absence of any new hybridizing bands upon Southern blotting. In monoclonal proliferations, a new, homogeneous, nongermline band is identified on Southern blotting because a sufficiently large number of lymphocytes exhibit an identical genetic rearrangement. In a group of five orbital lymphoid tumors that appeared to be benign reactive hyperplasias by light microscopy and that were polyclonal by immunophenotypic methods, three were found by molecular genetic analysis to harbor small clones of B-lymphocytes with new rearrangement bands on Southern blotting. No clonal abnormalities of T-lymphocytes were found in these five lesions, despite the fact that they were the preponderant cells in the tumors. These observations suggest that "reactive lymphoid hyperplasia" of the orbit may be an unstable lesion, owing to a T-cell immunoregulatory imbalance, with the potential for developing clonal expansions of B-lymphocytes that nonetheless usually remain localized to the orbit.

Primary cerebral lymphoma presenting as steroid-responsive chiasmal syndrome

A case of multiple primary cerebral lymphoma presenting with bitemporal hemianopsia due to a large suprasellar lesion is described; the visual symptoms improved after corticosteroid treatment. Involvement of the optic pathways is very unusual in primary central nervous system lymphomas; the visual symptoms can be due to lymphomatous uveitis or to infiltration of the optic nerves by leptomeningeal lymphoma, whereas bitemporal hemianopsia due to chiasmal compression has not been reported as first symptom of a cerebral lymphoma. The CT finding of multiple hyperdense well-enhanced lesions and their symmetrical distribution in the basal ganglia and frontal horns suggest the diagnosis of lymphoma. Improvement of neurological deficits during corticosteroid treatment is another feature typical of cerebral lymphomas.

Ocular adnexal monoclonal lymphoid tumors with a favorable prognosis

Fourteen patients with well- or intermediately differentiated monoclonal B-lymphocytic tumors of the conjunctiva or orbit had a favorable prognosis with follow-ups of 4 to 9 years (mean and median, 7.5 years). The lesions were, for the most part, diffuse proliferations of small lymphocytes, either with round or minimally indented nuclear outlines. Mitotic activity was sparse to nonexistent; occasionally there were scattered small abortive or residual germinal centers, and some lesions exhibited lymphoplasmacytoid features and dispersed multinucleated giant cells (polykaryocytes). None of the six patients with conjunctival lesions had extraocular manifestations. An identical tumor of the submandibular gland developed in one of eight patients with orbital lesions and another patient had multiple extranodal involvements of the oropharynx, liver, and both kidneys, but after chemotherapy the patient has survived for 8 years from orbital presentation and is currently in remission. The authors believe that these low-grade tumors share many biologic resemblances to extranodal lymphoepithelial tumors of other organs (lung, gut, parotid, thyroid), which as a group have been aggregated together as mucosa-associated lymphoid tumors (MALT) and which can often remain localized to their sites of origin.

Unilateral eyelid, conjunctival, and choroidal tumours as initial presentation of diffuse large-cell lymphoma

Simultaneous ipsilateral eyelid, conjunctival, and choroidal tumours developed in an otherwise healthy man. Biopsy of the eyelid mass led to the diagnosis of large-cell lymphoma. Further examination revealed systemic lymphoma. Although the ocular and adnexal lesions responded to systemic chemotherapy, additional skin tumours later developed. Large-cell lymphoma (also called reticulum cell sarcoma and histiocytic lymphoma) is becoming increasingly recognised for its ophthalmic manifestations. The clinical signs, diagnostic investigations, and treatment of this disease are discussed.

B- and T-lymphocytes in ocular disease

Ocular inflammatory diseases and ocular adnexal lymphoid tumors have become less obscure and intimidating by virtue of our ability to study the infiltrates in these various diseases for their B-lymphocyte and T-lymphocyte composition. Comparisons are also possible between lymphocytic profiles in the peripheral blood and the precise composition of the in situ infiltrates within the ocular tissue themselves. The availability of monoclonal antibodies, which can determine T-lymphocytic subsets such as T-helper cells and T-suppressor/cytotoxic cells, natural killer cells, and monocytes-histiocytes, has provided a powerful technology for the delineation of the distinctive immune composition of the inflammatory infiltrates, as well as any possible disturbances in T-cell immunoregulation. B-lymphocytes produce immunoglobulins, which may be misdirected as autoantibodies in local or systemic autoimmune diseases. Immunoglobulin-mediated and therefore B-cell derived conditions include vasculitis, progressive cicatricial ocular pemphigoid, Mooren's corneal ulcer, scleritis, and hay fever and vernal conjunctivitis. Other diseases in which B-lymphocytes, their immunoglobulin products or immune complexes formed with presently unknown antigens are potentially at fault are chronic non-specific uveitis; iridocyclitis in Behcet's syndrome; Fuch's heterochromic syndrome, ankylosing spondylitis, and Reiter's syndrome; Graves' disease; and idiopathic inflammatory orbital pseudotumor and myositis. T-cells do not produce immunoglobins, but rather secrete lymphokines or interact directly with receptors or determinants on viruses or target tissues (eg. immunosurveillance against neoplasia); it is possible that some autoimmune diseases are the result of neo-antigens on the surfaces of host tissues that have been coded for by a cryptic inciting virus. T-cell diseases include phlyctenulosis graft rejections, graft versus host disease, and possibly sympathetic ophthalmia and temporal arteritis. Natural killer cells are involved in many of the same diseases as cytotoxic T-cells, except that the former require no period of sensitization (natural immunity), whereas cytotoxic T-cells must undergo an antigen-specific blast transformation (acquired immunity of the delayed hypersensitivity type). In many diseases in which B-cell derived auto-antibodies are at fault, there may be local tissue or systemic T-cell imbalances, with a reduction in T-suppressor cells and a relative augmentation in T-helper cells, thereby facilitating production of misdirected auto-antibodies.(ABSTRACT TRUNCATED AT 400 WORDS)

Intraocular lymphomas. Natural history based on a clinicopathologic study of eight cases and review of the literature

Eight patients with intraocular lymphoma were studied; all were middle-aged or elderly, usually presenting with a unilateral visual deficit. All patients also had an extraocular lymphoma with either systemic (2) or isolated central nervous system (CNS) involvement (6). When ocular symptoms preceded CNS symptoms, they presented from 11 months to 10 years earlier. Intraocular lymphoma tended to affect the eye ipsilateral to the CNS tumor either exclusively or initially, and to the greatest degree histologically. Histologic examination of intervening optic pathways revealed extension of intraocular tumor across the optic nerve into orbital leptomeninges in 3 cases. Corresponding CNS tumors showed prominent leptomeningeal involvement. All intraocular and extraocular tumors showed diffuse growth patterns with histiocytic (large cell), poorly differentiated lymphocytic or mixed lymphocytic-histiocytic subtypes. CNS tumors were detected only after onset of neurologic symptoms, and were almost always fatal, although CNS irradiation prolonged survival for years in some cases. Our data suggest that the peculiar link between intraocular and CNS lymphomas may reflect both multicentric and metastatic disease processes. The prompt recognition of intraocular lymphomas as a harbinger of extraocular tumor may prove valuable in earlier recognition and treatment of the disease.

Ocular adnexal lymphoid neoplasms: clinical, histopathologic, electron microscopic, and immunologic characteristics

Clinicopathologic analysis of 400 ocular adnexal lymphoid neoplasms has demonstrated that the orbital lymphoid neoplasms occur primarily in the sixth and seventh decades of life; that their benignancy or malignancy is generally indistinguishable clinically; that the orbital malignant lymphomas are most commonly small cell lymphomas; that the orbital "histiocytic" lymphomas almost always represent an anomalous deposit of disseminated lymphoma; and that the percentage of patients with orbital lymphoma who develop systemic disease varies with the histopathology: two thirds of cases of poorly differentiated lymphocytic lymphomas, as defined cytomorphologically, have associated systemic disease. Prospective correlative clinicopathologic and immunologic analysis of 25 cases has shown that cell marker analysis divides the ocular adnexal lymphoid infiltrates into immunologically polyclonal proliferations, which show diverse but benign histopathologic features, and immunologically monoclonal B cell proliferations, which have the histologic features of malignant lymphomas. The benign, polyclonal ocular pseudolymphomas recapitulate the cell marker profile of a benign reactive lymph node with similar variations in the T cell:B cell ratio. The ocular adnexal and nodal B cell lymphomas are analogous in that they most commonly express surface IgM heavy chains and kappa light chains, express Ia antigens in parallel with SIg, and occasionally contain neoplastic B cells at various developmental stages--i.e., Ia+SIg+ and Ia+SIg-. Correlative immunologic and ultrastructural studies have demonstrated that electron microscopy is a reliable and reproducible technique for indirectly assessing the mono- or polyclonality of an ocular adnexal lymphoid neoplasm. This study is focused on the use of hybridoma-derived monoclonal antibodies, which are capable of detecting maturational stages of B and T cell differentiation and functionally distinct T cell subsets, in order to investigate the interactional and immunoregulatory defects that participate in the generation of the ocular adnexal lymphoid proliferations.

Malignant lymphoma presenting in the orbit: a clinicopathologic study of a rare immunoglobulin-producing variant

Malignant lymphoma with orbital presentation and associated serum paraproteinemia has seldom been reported in the literature. We report two such cases of lymphoplasmacytic type, one of which was also associated with amyloidosis. Both cases were studied with immunohistologic and one with electron microscopic techniques with results that confirmed that the neoplastic cells were producing the abnormal serum immunoglobulin.

Orbital lymphoid neoplasms: a clinicopathologic study of 60 patients

Sixty cases of orbital lymphoid neoplasms originally accessioned as malignant lymphomas were analyzed histopathologically and the follow-up data evaluated separately for each category as follows: inflammatory pseudo-tumor, 5; reactive lymphoid hyperplasia, 8; atypical lymphoid hyperplasia, 7; and malignant lymphocytic lymphoma (classified according to Rappaport), 40. Significant clinical differences were not observed among these patients, suggesting that the lesions must be distinguished by histologic rather than clinical criteria. Systematic application of the histologic criteria discussed here improved diagnostic accuracy and our ability to predict clinical outcome as substantiated by follow-up data. Two of 13 patients (15%) with benign pseudo-lymphomas, 2 of 7 patients (29%) with atypical lymphoid hyperplasia, 2 of 8 patients (25%) with well differentiated lymphocytic lymphomas, and 22 of 32 patients (68%) with less differentiated lymphocytic lymphomas either had or later developed systemic lymphomas. Thus, the degree of cytologic differentiation appears to be the single most important factor for determining the prognosis of patients with orbital lymphoid neoplasms.

Immunologic characterization of ocular adnexal lymphoid neoplasms

We correlated the light microscopic features of ten ocular adnexal lymphoid neoplasms with the results of selected immunologic and histochemical lymphocyte marker studies. The lesions were divided into three histomorphologic patterns: inflammatory pseudotumor, reactive follicular hyperplasia, and malignant lymphoma. The six inflammatory pseudotumors, and reactive follicular hyperplasia, despite diverse histomorphology, were immunologically polyclonal and consisted of from 45 to 73% T cells and 27 to 60% B cells, the B cells being polyclonal with respect to light chain determinants. The four malignant lymphomas were immunologically monoclonal. Each consisted of a predominant B-cell proliferation, greater than 50% of the cells, which were monoclonal with respect to surface light chain determinants. No T-cell proliferations were observed. Our preliminary data indicate that, as in systemic lymphoid neoplasms, benign reactive lymphoid hyperplasias are immunologically polyclonal whereas malignant lymphomas are immunologically monoclonal. The systematic application of immunologic and histochemical techniques to the study of ocular adnexal lymphoid neoplasms may elucidate the natural history of these lesions.