Orbital lymphomas: clinical and radiological features

A rare case of orbital mantle cell lymphoma presenting as a well-demarcated mass on magnetic resonance imaging

A 71-year-old male presented with painless and slowly progressive proptosis of the right eye. The patient had no history of cancer and was in good health. Orbital magnetic resonance imaging showed a well-demarcated, slightly lobulated intraconal orbital mass hypo-isointense on T1- weighted and isointense on T2-weighted images, demonstrating contrast enhancement in the right orbit. The lesion had a central cavitary region. An anterior orbitotomy with lower lid crease incision was performed and the lesion was excised in toto. Histopathologic examination revealed diffuse infiltration of monomorphic population of small lymphoid cells. Immunohistochemical staining demonstrated diffuse and strong positivity for CD20, CD5, and cyclin D1. Histopathological and immunohistochemical findings were consistent with mantle cell lymphoma. Positron emission tomography-computed tomography did not show systemic involvement. The patient underwent orbital external beam radiotherapy (36 Gy). There was no recurrence and/or systemic involvement at 2.5 years follow-up.

Diffuse Large B-cell Lymphoma of the Orbit With Intracranial Extension: A Rare Entity

Primary diffuse large B-cell lymphoma of the orbit is a rare diagnosis that accounts for less than 1% of all non-Hodgkin's lymphoma (NHL) cases. We present here the case of a middle-aged woman with a past medical history of intellectual delay and hypothyroidism who presented with a large diffusely infiltrating mass of the left orbit. A biopsy of the lesion during the patient's hospitalization confirmed a diagnosis of diffuse, large B-cell lymphoma. Due to extensive local invasion, she was deemed a poor surgical candidate. While inpatient, she was started on systemic chemotherapy and discharged with close follow-up planned with the oncologic and surgical teams.

Radiological analysis of orbital lymphoma histological subtypes

PURPOSE

To characterise the radiological features of orbital lymphoma subtypes.

METHODS

This was a multicentre, retrospective study to analyse radiological and clinical characteristics of orbital lymphoma by histological subtype across two sites within Australia and the United States.

RESULTS

A total of eighty-eight patients were included. The most common subtypes were extranodal marginal zone lymphoma [EMZL] (48, 54.5%), follicular lymphoma [FL] (16, 18.2%), and diffuse large B-cell lymphoma [DLBCL] (15, 17.0%). Clinically, significant associations were found between DLBCL and vision change (p < .01), pain (p < .01), extraocular movement limitation (p = .01), and optic neuropathy (p = .01). Radiologically, there was no significant difference between the individual histopathological sub-groups with respect to bone destruction (p = .30), optic nerve involvement (p = .30) and diffuse appearance (p = .84). However, if categorised as either aggressive or indolent, aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically than indolent subtypes (Odds Ratio = 5.5, 95% CI: 1.3, 23.3; p = .02).

CONCLUSIONS

DLBCL was significantly associated with vision change, pain, extraocular movement limitation and optic neuropathy clinically. Aggressive lymphoma subtypes were significantly more likely to demonstrate globe indentation radiologically. Otherwise, there were no significant differences between lymphoma subtypes and radiological findings on MRI and CT.

Evaluation of diplopia as a vital and remarkable ocular finding among cancer patients

BACKGROUND

Diplopia is an important and debilitating symptom of malignancies due to different pathogenetic mechanisms. Data is lacking in the literature because of the rarity of the diplopia in patients with cancer.

AIMS

We aimed to evaluate the etiological and clinical factors of diplopia in patients with different types of cancer.

METHODS

We retrospectively investigated 22 cancer patients with diplopia who were admitted between 2018 and 2021. The diagnosis of primary cancer, the underlying factors causing diplopia, and the life expectancy after diplopia were evaluated.

RESULTS

Among available data of 620 cancer patients applied to our ophthalmology department, 22 (3.55%) had diplopia. Paralytic strabismus was found in 19 patients and restrictive strabismus was found in 3 patients. Among the paralytic cases, 6th nerve palsy was found to be the most common with a rate of 68%. In 18 of 22 (82%) patients, the cause of diplopia was due to orbital or brain metastasis or local invasion. Two patients had diplopia secondary to radiotherapy and 2 had diplopia due to chemotherapy.

CONCLUSION

Metastasis is the most common cause of diplopia in patients with cancer and screening for metastasis is crucial as soon as diplopia begins for a better life expectancy.

Radiation Therapy Efficacy and Toxicity for Orbital and Ocular Adnexal Mucosa-Associated Lymphoid Tissue (OAMALT): A Single-Center, Retrospective Study of 32 Cases

Purpose

Lymphomas of the orbit and ocular adnexa are histologically heterogeneous and their incidence rate has been increasing lately. However, because of their rarity and diversity, few cases have been analyzed. This study evaluated patients with orbital and ocular adnexal mucosa-associated lymphoid tissue (OAMALT), who received radiotherapy, and categorized their clinical characteristics, treatment outcomes, and complications.

Patients and Methods

We collected data on clinical presentation, age, sex, imaging, tumor location, treatment methods, pathological diagnosis, cataract incidence, cataract incidence periods, overall survival (OS), and disease-free survival (DFS) from 32 patients with orbital involvement and pathologically confirmed marginal zone B-cell lymphoma of MALT who were treated between 2009 and 2018. Twenty-two patients received 20 Gy/10 Fr using intensity-modulated radiation therapy (IMRT) plus 14 Gy/7 Fr using a 6–14-MeV electron beam therapy using a lens-sparing approach. Ten patients received 32 Gy/16 Fr or 34 Gy/17 Fr using IMRT without the lens shield technique. Kaplan–Meier analysis was used to estimate DFS and OS.

Results

The median follow-up time was 83.4 ± 24.5 months. No patient had local recurrence, although three patients developed distant metastases. The 5-year and 10-year OS rates were both 100%. The 5-year and 10-year DFS rates were 96.7% and 74.2%, respectively. Overall, 11 (32.4%) of the 34 lenses developed cataracts. The estimated 5-year, 7-year, and 10-year cumulative cataract rates were 6.9%, 30.9%, and 60.8%, respectively. The median cumulative cataract incidence period was 107.0 months. Age was the only significant parameter associated with cataract formation.

Conclusion

A radiation dose of 32–34 Gy yields excellent local control, DFS, and OS for OAMALT. Some patients may have systemic relapse, and better identification of these patients is necessary. Reducing the prescription radiation dose or using better radiation techniques to spare the ipsilateral lens could reduce cataract formation.

A case report of secondary bilateral orbital lymphoma in a child

Lymphoma is one of the most common cancers of the orbital and lacrimal glands, after squamous cell carcinoma and melanoma. Based on cell origin, most lymphoma cases are classified as non-Hodgkin lymphoma. Orbital lymphoma can be either primary or secondary. The clinical manifestations of lymphoma are diverse, with the most common symptoms being bilateral or unilateral proptosis, limited eye motility, swelling, pain, changes in visual acuity, and diplopia. In this article, we describe the case of a 6-year-old male who presented with bilateral rapid orbital swelling for 10 days. This patient underwent surgical biopsy, and the final diagnosis was bilateral orbital secondary non-Hodgkin lymphoma.

To Explore MR Imaging Radiomics for the Differentiation of Orbital Lymphoma and IgG4-Related Ophthalmic Disease

Among orbital lymphoproliferative disorders, about 55% of diagnosed cancerous tumors are orbital lymphomas, and nearly 50% of benign cases are immunoglobulin G4-related ophthalmic disease (IgG4-ROD). However, due to nonspecific characteristics, the differentiation of the two diseases is challenging. In this study, conventional magnetic resonance imaging-based radiomics approaches were explored for clinical recognition of orbital lymphomas and IgG4-ROD. We investigated the value of radiomics features of axial T1- (T1WI-) and T2-weighted (T2WI), contrast-enhanced T1WI in axial (CE-T1WI) and coronal (CE-T1WI-cor) planes, and 78 patients (orbital lymphoma, 36; IgG4-ROD, 42) were retrospectively reviewed. The mass lesions were manually annotated and represented with 99 features. The performance of elastic net-based radiomics models using single or multiple modalities with or without feature selection was compared. The demographic features showed orbital lymphoma patients were significantly older than IgG4-ROD patients (p < 0.01), and most of the patients were male (72% in the orbital lymphoma group vs. 23% in the IgG4-ROD group; p = 0.03). The MR imaging findings revealed orbital lymphomas were mostly unilateral (81%, p = 0.02) and wrapped eyeballs or optic nerves frequently (78%, p = 0.02). In addition, orbital lymphomas showed isointense in T1WI (100%, p < 0.01), and IgG4-ROD was isointense (60%, p < 0.01) or hyperintense (40%, p < 0.01) in T1WI with well-defined shape (64%, p < 0.01). The experimental comparison indicated that using CE-T1WI radiomics features achieved superior results, and the features in combination with CE-T1WI-cor features and the feature preselection method could further improve the classification performance. In conclusion, this study comparatively analyzed orbital lymphoma and IgG4-ROD from demographic features, MR imaging findings, and radiomics features. It might deepen our understanding and benefit disease management.

Imaging of head and neck mucosa-associated lymphoid tissue lymphoma (MALToma)

Marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALToma) arises in extranodal sites in the head and neck. Chronic inflammatory, infectious or autoimmune conditions are implicated in its pathogenesis. Within the head and neck, MALToma is often multifocal and indolent and the imaging appearances may be mistaken for non-malignant disease in the head and neck. The aim of this article is to illustrate the varied radiological and clinical features of MALToma in the head and neck, an awareness of which is needed for timely and correct diagnosis to guide subsequent disease management.

Clinical correlation recommended: accuracy of clinician versus radiologic interpretation of the imaging of orbital lesions

Purpose: To assess the accuracy of radiographic interpretation between the clinician and radiologist when compared to histopathology of orbital lesions. Methods: A retrospective chart review of patients at the University of California Davis Eye Center who underwent orbitotomy from 1/1/2000 to 5/22/2019 was performed. Charts with a preoperative imaging report, preoperative clinical assessment including the clinician's interpretation of imaging, and histopathologic diagnosis were included. The specific diagnoses were grouped into related classes of pathology for the analysis. The clinical and radiologic assessments were compared against the final histopathologic diagnosis for concordance. A concordance analysis was performed. Results: 242 patients (mean age 49 years, 53.5% female) were reviewed. Of these records 185 documented the clinician's clinical impression, the radiology report, as well as the histopathology report. The clinician's preoperative assessment had substantial agreement [kappa = 0.72 (0.65,0.79)] with the final histopathologic result and was correct in 75.7% (140/185) of cases whereas the radiology report was correct in 52.4% (97/185) with a moderate level of agreement [kappa = 0.47 (0.39, 0.55)]. In 49.2% (91/185) of cases the final histopathology correlated with both the clinical impression and radiology report [kappa = 0.58 (0.55, 0.61)]. Conclusions: The accurate interpretation of orbital imaging is a challenge and histopathologic examination remains the gold standard for diagnosis. While orbital imaging is a valuable diagnostic tool the interpretation of these studies is most accurate when conducted in the context of the patient's medical history, clinical exam, and with the physician most familiar with various orbital lesions.

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.

Psychological profiles in patients undergoing orthognathic surgery or rhinoplasty: a preoperative and preliminary comparison

OBJECTIVE

The aim of this study was to assess, identify, and compare the personality traits and psychosocial status of two groups of patients undergoing orthognathic surgery and rhinoseptoplasty respectively.

STUDY DESIGN

This prospective study recruited patients referred for orthognathic surgery and for rhinoseptoplasty. The research protocol included the administrations of questionnaires to the patients during their last visit before surgery, including the Minnesota Multiphasic Personality Inventory (MMPI-2), the Myers-Briggs Type Indicator (MBTI), the tree drawing test (or Baum test), and the BC Scale.

RESULTS

As for MMPI-2, the highest (pathological) percentages were encountered in Hypochondriasis and Psychasthenia scales within the Orthognathic Surgery Group, whereas in the rhinoseptoplasty group, the highest scores were obtained in the Hypochondriasis, Psychasthenia, Psychopathic Deviate, and Schizophrenia scales.

CONCLUSIONS

It would be important to assess some characteristics of the patients' mental health and emotional state prior to surgery, including depression, anxiety, panic, and aggression. The overview of these factors may give an insight into the psychological and emotional capacity of the patients undergoing orthognathic and rhinoseptoplasty surgery.

Case report: an intriguing sign in a patient with an inferior rectus muscle granular cell tumor

RATIONALE

Occurrence of granulosa cell tumors (GCTs) in the eye are rare and may be diagnosed by imaging examination and immune-histochemical studies. Two common signs of a rectus muscle tumor are the proptosis of the eye ball and the complaint of bi-ocular diploma.

PATIENT CONCERNS

A 45-year-old man visited our ophthalmology department with an about a 3-year history of vertical diplopia. His visual acuity when looking forward was normal but was severely low when gazing upward.

DIAGNOSIS

Histopathological analysis demonstrated that the encapsulated tumor contained large nested or cord-like cells with small nuclei and abundant eosinophilic cytoplasmic particles. Immunohistochemistry showed that tumor cells strongly expressed CD68, S100 and vimentin, were weakly positive for Ki67, and negative for CK. The tumor was diagnosed as a GCT.

INTERVENTIONS

The tumor was surgically removed via a transconjunctival approach along inferior rectus muscle.

OUTCOMES

The severe loss of acuity when gazing upward was ameliorated after surgery, but global mobility did not improve. Long-term follow-up was still needed.

LESSONS

Ophthalmologists should be aware that when a patient's visual acuity is normal when looking forward but severely low when gazing upward, it may be a sign of a GCT of the inferior rectus muscle.

Differentiation of orbital lymphoma and idiopathic orbital inflammatory pseudotumor: combined diagnostic value of conventional MRI and histogram analysis of ADC maps

Background

The overlap of morphological feature and mean ADC value restricted clinical application of MRI in the differential diagnosis of orbital lymphoma and idiopathic orbital inflammatory pseudotumor (IOIP). In this paper, we aimed to retrospectively evaluate the combined diagnostic value of conventional magnetic resonance imaging (MRI) and whole-tumor histogram analysis of apparent diffusion coefficient (ADC) maps in the differentiation of the two lesions.

Methods

In total, 18 patients with orbital lymphoma and 22 patients with IOIP were included, who underwent both conventional MRI and diffusion weighted imaging before treatment. Conventional MRI features and histogram parameters derived from ADC maps, including mean ADC (ADC_mean), median ADC (ADC_median), skewness, kurtosis, 10th, 25th, 75th and 90th percentiles of ADC (ADC₁₀, ADC₂₅, ADC₇₅, ADC₉₀) were evaluated and compared between orbital lymphoma and IOIP. Multivariate logistic regression analysis was used to identify the most valuable variables for discriminating. Differential model was built upon the selected variables and receiver operating characteristic (ROC) analysis was also performed to determine the differential ability of the model.

Results

Multivariate logistic regression showed ADC₁₀ (P = 0.023) and involvement of orbit preseptal space (P = 0.029) were the most promising indexes in the discrimination of orbital lymphoma and IOIP. The logistic model defined by ADC₁₀ and involvement of orbit preseptal space was built, which achieved an AUC of 0.939, with sensitivity of 77.30% and specificity of 94.40%.

Conclusions

Conventional MRI feature of involvement of orbit preseptal space and ADC histogram parameter of ADC₁₀ are valuable in differential diagnosis of orbital lymphoma and IOIP.

Clinicopathologic and Magnetic Resonance Imaging Analysis of a Multifocal Orbital Lymphoid Tumor

Objective

To distinguish between a multifocal orbital lymphoid tumor and a major simulator represented by a diffuse lymphaticovenous malformation.

Methods

We performed a comparison of clinical and radiographic (magnetic resonance imaging [MRI]) findings of these two disparate entities and demonstrated how a misdiagnosis can be prevented.

Results

Orbital lymphoid tumors develop in adults at around 60 years of age, whereas extensive lymphaticovenous malformations are generally detected in the first decade. Despite these differences, this is the first description of clinical confusion between them. MRI with gadolinium injection in the current lymphoid tumor displayed a low signal on T2-weighted images, rapid and uniform enhancement, and reduced diffusion. Lymphaticovenous malformations are heterogeneous, display poor or only focal perfusion, and fail to exhibit diminished diffusion. Newer techniques such as diffusion-weighted imaging and dynamic contrast-enhanced imaging may be able to provide additional differential diagnostic information. The final pathologic diagnosis was an extranodal marginal zone lymphoma.

Conclusions

Despite the obvious distinctions between orbital lymphoid tumors and lymphaticovenous malformations, several clinical radiologic specialists misdiagnosed the present orbital lesion as a vascular lesion. A combined clinicoradiographic analysis should obviate such errors and facilitate the correct diagnosis in the future.

Multimodality Imaging Spectrum of the Extranodal Lymphomas in the Head and Neck-A Pictorial Review

Lymphoma is the second most common malignant neoplasm of the head and neck region, involving the nodal and/or extranodal sites or both in a variable fashion. Lymphoma may mimic a variety of tumors in this region depending on the subsite involved. The usual presentation of lymphomatous disease is presence of multiple enlarged, often conglomerate, lymph nodes without significant necrosis. Extranodal lymphomas demonstrate more complex radiologic features, but careful evaluation can identify distinct imaging patterns to suggest extranodal lymphomatous disease from other more common lesions. Knowledge of these imaging features can help raise suspicion for lymphoma as a differential consideration. This can be of critical importance since further work-up and management can be vastly different between lymphomatous disease and other disease entities. The authors present a pictorial review of the spectrum of imaging findings in extranodal head and neck lymphomas.

Characteristics of orbital lymphoma: a clinicopathological study of 26 cases

OBJECTIVE

Evaluation of the medical data of patients with orbital and adnexal lymphoma.

DESIGN

Cohort study of all cases diagnosed with orbital or adnexal lymphoma at Meir Medical Center between 1993 and 2007.

PARTICIPANTS

Twenty-six patients, with intraorbital or subconjunctival masses with orbital involvement, were examined and followed up between 1 and 8 years.

MATERIALS AND METHODS

Examined data included: clinical presentation, age, gender, imaging, tumor location, surgical management, and pathological diagnosis.

RESULTS

Presenting signs and symptoms included proptosis, eyelid lesions, tearing, chemosis, decreased visual acuity, ptosis, pain, squint, and optic nerve compression. In five cases, lymphoma was misdiagnosed on neuroimaging. Bone changes were seen in four patients. All cases were B cell lymphomas; with the majority (22 cases) of small B cell type; consisting of primary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue and two cases of small cell lymphoma. One small cell lymphomas was of follicular type on a background of CLL, and the other was CLL/SLL type. Fourteen cases were primary orbital disease, and 12 cases were systemic disease. Macroscopic appearance of lymphoma at open biopsy was characteristic in most cases. Flow cytometry phenotyping gave rapid reliable diagnosis of the disease.

CONCLUSIONS

Epiphora or chemosis in the presence of an orbital mass should alert the ophthalmologist to suspect lymphoma. Lymphoma may be easily misinterpreted on neuroimaging for other diseases. Bone changes seen on CT are more common than is generally perceived. Macroscopic appearance at open biopsy was characteristic.

A Rare Case of Aggressive, Huge Primary Orbital Lymphoma with Intracranial Extension and Bone Invasion

Primary orbital lymphoma is a rare entity with only 1% of extranodal lymphomas. They usually present to ophthalmologist and surgical reserved for biopsy or tissue diagnosis. We present a patient who was referred to neurosurgery for a rapid growing orbital lymphoma. It grows from a small nodule in the eyelid to a huge, aggressive, disfiguring lesion invading bone and dura with intracranial extension within 3 months. The patient was treated with total surgical excision followed by systemic chemotherapy.

The Role of Fine Needle Aspiration of Orbital Lesions: A Case Series

OBJECTIVE

This paper analyzes a series of ultrasound (US)-guided orbital fine needle aspirations (FNAs) which provide diagnostic information that cytopathologists approaching orbital lesions for the first time can find useful and underlines the importance of teamwork.

STUDY DESIGN

The investigators retrospectively obtained data from 24 consecutive orbital FNAs. For all patients, a complete clinicoradiological database was created. FNAs were performed under US guidance with 25-gauge needles and an aspiration biopsy syringe gun, and sent to the Department of Pathology for examination and data management.

RESULTS

The mean age of the patients was 54 years. Imaging studies included US, magnetic resonance imaging and computed tomography scans; 9 lesions involved the right orbit and 15 the left orbit. The mean lesion size was 23.6 ± 7.2 mm. After microscopic examination, 7 smears were labeled as 'nondiagnostic', while in 17 cases a definitive diagnosis was proposed, which always proved to be correct (70.8%, specificity = 100%).

CONCLUSIONS

The investigators believe that FNA biopsy of orbital masses is a necessary step; its weaknesses lie in the particularly delicate site of sampling and the extreme heterogeneity of lesions. Nevertheless, when orbital FNA is performed within a well-coordinated multidisciplinary team, it is a powerful tool that can be used to define the most appropriate management of these patients.

[Malignant tumours of the eye: Epidemiology, diagnostic methods and radiotherapy]

Malignant tumours of the eye are not common, barely representing 1 % of all cancers. This article aims to summarise, for each of the main eye malignant diseases, aspects of epidemiology, diagnostic methods and treatments, with a focus on radiation therapy techniques. The studied tumours are: eye metastasis, intraocular and ocular adnexal lymphomas, uveal melanomas, malignant tumours of the conjunctive, of the lids, and retinoblastomas. The last chapter outlines ocular complications of radiation therapy and their management.

Primary orbital tumors: a review of 122 cases during a 23-year period: a histo-clinical study in material from the ENT Department of the Medical University of Silesia

BACKGROUND

The aim of this study was to investigate the distribution of different types of primary orbital tumors, histopathological diagnosis, and postoperative complications.

MATERIAL AND METHODS

We analyzed 122 patients (68 women and 54 men) with orbital tumors, hospitalized in the ENT Department of the Medical University of Silesia in Katowice during 1990-2013. The patients were characterized in terms of anatomic, topographical, histopathological, and clinical parameters. The role of diagnostic imagining such as CT, NMR, and fine-needle aspiration (FNB) in preoperative diagnostics is discussed.

RESULTS

of FNB, cytological, and histopathological examination of the postoperative specimens were compared. Results There were 56 (46%) patients with malignant tumors, 42 (34%) with benign tumors, 19 (16%) with inflammatory tumors, and 5 patients (4%) had other tumors. In cases of malignant tumors, local recurrence up to 5 years was found in 36 (64.3%) cases. In the other 20 (35.7%) cases of malignant tumors, the patients remained under close follow-up in the outpatient clinic, without signs of local recurrence (follow-up 1-17 years). According to histopathological examination, malignant tumors were detected in 45.9% of patients and non-malignant tumor in 34.4% of patients. In 19.7% of patients, inflammatory and other types of tumors were diagnosed.

CONCLUSIONS

We characterized the occurrence and pathological profiles of orbital tumors. The tumor location, histopathological diagnosis, and postoperative complications give us important information for the diagnosis of tumor prior to biopsy or tumor resection and for the determination of the treatment strategy and possible complications after surgery.