Clinical, morphologic, immunophenotypic, and molecular genetic analysis of bilateral ocular adnexal lymphoid neoplasms in 17 patients

Eyelid edema as a first sign of lymphoma

Chronic eyelid edema may be a symptom of different disease. The most common are autoimmune diseases such as orbital pseudotumor, vasculitis, sarcoidosis, or impaired vascular or lymphatic drainage. Rarely has it been reported as the sole manifestation of the lymphoma. Eyelid lymphoma is a special clinical entity in the spectrum of hematological malignancies. Here we present our clinical experience with eyelids lymphomas. First case is a 76-year-old female patient with bilateral edema of upper eyelid non-responding to anti-inflammatory therapy. Histological examination diagnosed mantle cells lymphoma. In the second case, 58-year-old patient was diagnosed with solitary unilateral tumor of the lower eyelid, where primary biopsy was ordered and diagnosis of MALT lymphoma was established after histological examination. In both cases, it was not solitary eyelid tumor, but systemic disease with multiple lymphadenopathy and bone marrow infiltration were found in follow-up examinations. Subsequently, patients care was given to the hemato-oncologist.

Progression of Cutaneous B-Cell Pseudolymphoma to Cutaneous B-Cell Lymphoma

Background:

Debates regarding nosology and clonality surround the entity known as cutaneous pseudolymphoma and its questionable transformation to frank cutaneous lymphoma. The relevance of these arguments is important, not only from a diagnostic standpoint, but also for making inferences based upon behavior, prognosis, and treatment.

Objective:

Our goal was to demonstrate further evidence of progression from cutaneous pseudolymphoma to malignant lymphoma while at the same time advocating a comprehensive plan for evaluation, treatment, and followup of these patients.

Methods:

A retrospective review was conducted of four patients initially considered to have cutaneous B-cell pseudolymphoma (CBPL) and who were later treated for primary cutaneous B-cell lymphoma (CBCL). A review of the literature of cases suggesting progression to malignant lymphoma from precursor lesions was also performed.

Results:

Four patients initially diagnosed with CBPL by a combination of histologic, immunophenotypic, and gene rearrangement criteria had a progressive clinical course that, over a range of 17–51 months, evolved into CBCL. All patients had a comprehensive systemic workup to rule out the possibility of extracutaneous disease and were treated with local radiation therapy and close followup. There has been no evidence of extracutaneous disease with an average followup of 14 months.

Conclusion:

The potential for certain cutaneous pseudolymphomas to progress to CBCL is real. The combination of histologic and immunophenotypic criteria, along with the clinical picture, remains the best way to judge the aggressiveness of the lesion. Gene rearrangement studies, whether performed by Southern blot or polymerase chain reaction (PCR), are of limited value and should be used to support the overall clinicopathologic picture. Radiation therapy of these patients should be thought of early in the management plan and is a very successful form of treatment when combined with close followup.

Lymphoproliferative Disease of the Orbit

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

Comparison of American Joint Committee on Cancer TNM-based staging system (7th edition) and Ann Arbor classification for predicting outcome in ocular adnexal lymphoma

OBJECTIVE

To compare the TNM and Ann Arbor staging systems in predicting outcome in ocular adnexal lymphoma (OAL).

METHODS

Retrospective review of the clinical, imaging and histopathologic records of OALs between 1986 and 2009. Outcome measures included local recurrence and progression.

RESULTS

One hundred and sixty patients of OAL were included. Mean age was 65 ± 15 years (range 20-97) and 68 (43%) were male. The median follow-up of all OAL patients was 65 months (range 2.5-238). Histopathology identified low-grade, indolent B-cell lymphomas in 140 patients (87.5%) and rest had aggressive grades. Of 134 indolent OAL patients, those with unilateral disease had a 10-year progression free survival of 72% versus 48% in their bilateral counterparts (p = 0.001). Amongst unilateral OAL patients staged within the T1-2 group, a significantly better outcome was noted for patients without nodal or metastatic involvement compared to those with such involvement (p = 0.0001). The above observations helped to formulate a simple scoring system to prognosticate OALs based on their laterality and node/metastatic status. Amongst the 3 groups identified, group 1 with a score of 0 (unilateral OALs with no nodes or metastasis) had a 10-year progression free survival of 75%; group 2 with score 1 (either bilateral or positive nodes/metastasis) 50% and group 3 with score 2 (both bilateral OAL with positive nodes/metastasis) zero at 10 years (p < 0.00001).

CONCLUSIONS

The TNM-based staging system better predicts outcome in OAL than the Ann Arbor system primarily by delineation of bilateral disease and nodal/metastatic involvement at presentation.

Unusual orbital lymphoma undetectable by magnetic resonance imaging: a case report

Introduction

We report the case of a patient with orbital malignant lymphoma that was not detected by imaging studies when she presented with impaired vision, which lead to her eventual loss of sight.

Case presentation

A 71-year-old Japanese woman complained of deteriorating vision in her left eye. On examination, papilledema was detected, but magnetic resonance imaging only showed slight thickening and enhancement of the left optic nerve. A diagnosis of idiopathic optic neuritis was made and corticosteroid pulse therapy was administered. During the next four months, the patient received a total of four courses of corticosteroid pulse therapy, but she still suffered from bilateral loss of vision. A second magnetic resonance imaging procedure revealed tumors in both orbits and a biopsy showed diffuse large B-cell malignant lymphoma.

Conclusion

The possibility of malignant lymphoma should be considered in patients with recurrent optic neuropathy despite administration of corticosteroid pulse therapy, even when there are no abnormalities on cerebrospinal fluid examination or magnetic resonance imaging.

Ocular adnexal lymphoma in the Northeast Indian population

We present the clinical profile of biopsy and immunohistochemistry-proven ocular adnexal lymphomas in the Northeast Indian population. Nineteen patients between October 2004 and June 2006 with ocular adnexal lymphoma were analyzed retrospectively. Histopathological classification was done according to international working formulation. Twelve patients were male and seven were female. All were diagnosed as non-Hodgkin's lymphoma and the majority were B cell type (89%). Most of the cases (42%)were treated with radiotherapy followed by chemotherapy.

Morphologic Features of 115 Lymphomas of the Orbit and Ocular Adnexa Categorized According to the World Health Organization Classification: Are Marginal Zone Lymphomas in the Orbit Mucosa-Associated Lymphoid Tissue–Type Lymphomas?

Context.—Marginal zone lymphomas (MZLs) are the most common lymphomas encountered in the orbit and ocular adnexa. The accurate categorization of these lymphomas is critical to avoid undertreatment or overtreatment.

Objective.—To identify features of orbital MZLs that distinguish them from other lymphomas and reactive lymphoid infiltrates and support the categorization of orbital MZL as mucosa-associated lymphoid tissue (MALT)–type MZLs.

Design.—Biopsies from 149 patients with lymphoid lesions of ocular adnexa were examined. Additional immunohistochemical stains and fluorescence in situ hybridization study for the MALT1 locus were performed in selected cases, and patient charts were reviewed.

Results.—A total of 115 lymphomas and 34 reactive infiltrates were identified, of which B-cell lymphomas constituted 92% and MZLs constituted 54% of all lymphomas. Certain clinical features (young age, race, bilaterality) favored a reactive infiltrate, but none were diagnostic. Histologic features, such as infiltrative lesions, reactive B-cell follicles, and lymphoepithelial lesions, overlapped between reactive infiltrates and conjunctival MZL. In contrast to conjuctival MZL, orbital MZL infrequently showed reactive follicles, rarely showed epithelial tissue, and did not show lymphoepithelial lesions. Cytogenetic abnormality involving the MALT1 locus was demonstrated in only 15% of ocular adnexal MZLs.

Conclusion.—Many MZLs of orbital soft tissue lack key features associated with MALT-type MZL, and the designation MALT lymphoma should be avoided in their diagnosis.

Lacrimal gland extranodal marginal zone B-cell lymphoma of MALT-type

PURPOSE

To evaluate the clinical features and outcome of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT lymphoma) in the lacrimal gland.

DESIGN

Retrospective, noncomparative, observational case series in an academic referral setting.

METHODS

A consecutive series of 13 histologically verified MALT lymphoma in the lacrimal gland at presentation was studied. Clinical characteristics, treatment, and prognosis were analyzed.

RESULTS

Eight males and five females with a median age of 64 years and a median follow-up time of 48 months were included. All patients had no prior lymphoma and initially presented as MALT lymphoma in the lacrimal gland. Extraorbital involvement at diagnosis was noted in six patients (46.2%). Two patients had autoimmune disease, and both had Stage IV disease at presentation. Treatment consisted of surgical resection in one patient, radiotherapy in four, chemotherapy in four, and combined radiotherapy and chemotherapy in four. Complete remissions were obtained in eight patients (61.5%). Patients with bilateral disease (61.5%) had a higher rate of advanced-stage disease and a poor outcome. Recurrence was noted in two patients. At the last follow-up, eight patients were free of disease, three were alive with disease, one died of sepsis as a complication of chemotherapy, and one died of lymphoma.

CONCLUSIONS

MALT lymphoma in the lacrimal gland has a high rate of extraorbital involvement and synchronous bilateral lacrimal gland involvement at presentation. The prognosis is relatively poor, especially in patients with advanced disease and bilateral involvement. Extensive staging and long-term follow-up are warranted for these patients.

Imaging of the Lacrimal Gland

The lacrimal gland is situated superolateral to the eye and produces tears that moisten, lubricate, and protect the delicate corneal and conjunctival epithelium. Anatomically related to the orbit but embryologically and functionally more closely related to the salivary glands, radiological imaging has proven invaluable in delineation and differentiation of the unique range of pathological processes affecting the lacrimal gland. This article details traditional and new imaging techniques used in investigating such pathology and discusses the imaging findings and patterns of spread characteristic of various neoplastic, inflammatory, and structural processes ranging from benign adenomas, adenocarcinomas, and lymphomas to sarcoidosis, Mickulicz's syndrome, histiocytosis, and benign dacrocysts.

Bilateral synchronous primary orbital lymphoma

Extranodal marginal zone B-cell non-Hodgkin's lymphoma affecting bilateral orbital regions was diagnosed in an 80-year-old man. He was given chemotherapy and external beam irradiation therapy. Two months after treatment, repeat orbital magnetic resonance imaging showed dramatically improved lesions. In this case report, orbital non-Hodgkin's lymphoma and treatment options are discussed.

Oral chlorambucil for extranodal, marginal zone, B-cell lymphoma of mucosa-associated lymphoid tissue of the orbit

PURPOSE

To report the outcome of oral chlorambucil as a single treatment in patients with orbital mucosa-associated lymphoid tissue (MALT) lymphoma.

DESIGN

Retrospective nonrandomized clinical study.

PARTICIPANTS

Thirty-three patients with isolated orbital MALT lymphoma.

METHODS

Medical records of all patients with histology-verified orbital MALT lymphoma treated with oral chlorambucil at the Royal Melbourne Hospital were reviewed.

MAIN OUTCOME MEASURES

Complete clinical response, partial response, local relapse, systemic extension (distant relapse), and survival.

RESULTS

Thirty-three patients (19 female; mean age, 69 years) participated in the study. Patients received an average of 4 courses of oral chlorambucil with a mean total dose of 600 mg. The lacrimal gland was the most frequent site of occurrence (24%), followed by the conjunctiva, eyelid, and superior orbit. Orbital mass, swelling, and diplopia were common presenting signs. Complete response was noted in 26 patients (79%). In 2 of the patients with complete clinical response, mild residual thickening was noted on follow-up orbital imaging studies. Four patients (12%) showed disease recurrence or relapse. Mean follow-up time was 32 (+/-20) months (range, 8 months-6 years; median, 26 months). None of the patients developed granulocytopenia secondary to chemotherapy, and none suffered significant nausea or vomiting. One patient with malignant transformation died 12 months after diagnosis and initial treatment.

CONCLUSIONS

Systemic chemotherapy with chlorambucil is a reasonable option in patients with orbital MALT lymphoma. It is associated with minimal to no side effects. Additionally, it may be well tolerated by elderly patients and also may treat subclinical disease elsewhere.

The eye in malignant disease

The eye and its adnexae (the extraocular muscles, orbit, orbital walls and eyelids) can be involved in malignant disease, either as the primary source of the tumour or as a site of secondary metastatic involvement. Indeed, there is a wide variety of different tumours which are known to affect the eye, this diversity being a consequence of the richness of the ocular tissues present. In addition, disorders of vision or eye movements may be the presenting signs and symptoms of intracranial malignancy.

Ocular adnexal lymphomas: five case presentations and a review of the literature

The ocular adnexal lymphomas represent the malignant end of the spectrum of lymphoproliferative lesions that occur in these locations. The Revised European and American Lymphoma (REAL) Classification and the new World Health Organization Classification of Tumors of Hemopoietic and Lymphoid Tissues are the most suitable for subdividing the ocular adnexal lymphomas, whereby the extranodal marginal zone B-cell lymphoma represents the most common lymphoma subtype. This review is based on five cases subtyped according to the above classifications-three "typical" lymphomas (an extranodal marginal zone B-cell lymphoma, a diffuse large cell B-cell lymphoma arising from an extranodal marginal zone B-cell lymphoma, and a follicular lymphoma) and two "atypical" lymphomas (a non-endemic Burkitt lymphoma in an immune competent elderly patient, and a primary Hodgkin lymphoma of the eyelid) of the ocular adnexa. Management of patients with ocular adnexal lymphomas includes a thorough systemic medical examination to establish the clinical stage of the disease. The majority of patients with ocular adnexal lymphoma have stage IE disease. Current recommended therapy in stage IE tumors is radiotherapy, while disseminated disease is treated with chemotherapy. Despite usually demonstrating an indolent course, extranodal marginal zone B-cell lymphomas are renowned for recurrence in extranodal sites, including other ocular adnexal sites. Long-term follow-up with 6-month examinations are therefore recommended. Major prognostic criteria for the ocular adnexal lymphomas include anatomic location of the tumor; stage of disease at first presentation; lymphoma subtype as determined using the REAL classification; immunohistochemical markers determining factors such as tumor growth rate; and the serum lactate dehydrogenase level.

Conjunctival AL amyloidosis associated with a low-grade B-cell lymphoma

A rare case of localized amyloidosis associated with a low-grade B-cell lymphoma involving the conjunctiva is described. Although infiltrating small lymphocytes and plasma cells showed little cytological atypia, molecular genetic examination revealed a prominent B-cell clonal immunoglobulin heavy chain (IgH) gene rearrangement in the tumor tissue. Immunoelectronmicroscopic examination showed immunoglobulin lambda light chain specificity in the amyloid deposit and Russell bodies in the surrounding plasma cells. We concluded that the immunoglobulin lambda light chain, produced by the tumor's differentiated plasma cells, is the precursor protein of the localized amyloidosis found in this case.

Ocular adnexal lymphoma-comparison of MALT lymphoma with other histological types

AIMS

To correlate histological features of ocular adnexal lymphoma using the revised European American lymphoma classification (REAL), with stage of disease at presentation, treatment modalities, and patient outcome. MALT lymphoma defines an extranodal marginal zone B cell lymphoma as outlined in the REAL classification. Comparison groups of patients included those with primary ocular adnexal MALT lymphoma versus primary ocular adnexal lymphomas of other types, MALT lymphoma versus non-MALT lymphomas (primary and secondary), and primary ocular adnexal lymphoma (MALT lymphomas and other types) versus secondary ocular adnexal lymphomas.

METHODS

A retrospective review of the National Ophthalmic Pathology Laboratory records identified 20 cases of ocular adnexal lymphoma over a 10 year period which were reclassified using appropriate immunohistochemical stains. Patients' medical records were examined for data including stage of the disease at presentation, mode of treatment, and patient outcome.

RESULTS

Among the 20 cases identified 14 had primary ocular adnexal lymphomas. 10 of the primary lymphomas had histological features of MALT lymphoma. One case was a primary ocular adnexal T cell lymphoma, one a follicular centre, follicular B cell lymphoma, and two were large cell B cell lymphomas. Six cases had systemic disease, four large B cell, one follicular centre, follicular B cell, and one mantle cell. A significantly higher proportion of patients with MALT lymphomas had early disease (p = 0.005), initially required local treatment (p = 0.005) and were alive at last follow up (p = 0.001) than those without. Two patients with MALT lymphoma had recurrence of lymphoma which responded to further treatment.

CONCLUSIONS

Patients with primary ocular adnexal MALT lymphomas present with localised disease requiring local treatment and have a better outcome compared with patients with other types. As a small percentage of these tumours recur, patients should be followed up indefinitely.

Lymphoproliferative lesions of the ocular adnexa. Analysis of 112 cases

OBJECTIVE

Lymphoproliferative lesions of the ocular adnexa were analyzed to examine (1) the suitability of the Revised European-American Lymphoma (REAL) classification for the subtyping of the lymphomas in these sites; (2) the predictive value of the REAL classification for the evolution of these tumors; and (3) the frequency and prognostic impact of tumor type, location, proliferation rate (Ki-67 index), p53, CD5 positivity and the presence of monoclonality within these tumors.

DESIGN

Retrospective review.

METHODS

The clinical, histomorphologic, immunohistochemical, and molecular biologic (polymerase chain reaction [PCR]) features of lymphoid proliferations of the ocular adnexa were studied. STUDY MATERIALS: The ocular adnexal lymphoproliferative lesions were located as follows: orbit in 52 patients (46%), conjunctiva in 32 patients (29%), eyelid in 23 patients (21%), and caruncle in 5 patients (4%).

RESULTS

Reactive lymphoid hyperplasia was diagnosed in 12 cases and lymphoma in 99 cases; 1 case remained indeterminate. The five main subtypes of lymphoma according to the REAL classification were extranodal marginal-zone B-cell lymphoma (64%), follicle center lymphoma (10%), diffuse large cell B-cell lymphoma (9%), plasmacytoma (6%), and lymphoplasmocytic lymphoma (5%). Age, gender, and anatomic localization of the lymphomas did not have prognostic significance during a follow-up period of 6 months to 16.5 years (mean, 3.3 years). Extent of disease at time of presentation was the most important clinical prognostic factor: advanced disease correlated with increased risk ratios of having persistent disease at the final follow-up and with lymphoma-related death (P < 0.001). Histomorphologic features and immunohistochemical markers positively correlating with disseminated disease at presentation, stage at final follow-up, and occurrence of lymphoma-related death included cytologic atypia (P < 0.001), MIB-1 proliferation rate (P < 0.001), and tumor cell p53 positivity (P < 0.001). The MIB-1 proliferation rates greater than 20% in extranodal marginal-zone B-cell lymphoma corresponded to at least stage II lymphoma (P < 0.05).

CONCLUSION

The REAL classification is suitable for the subdivision of the ocular adnexal lymphomas. The MIB-1 proliferation rate and p53 positivity may aid the prediction of disease stage and disease progression, whereas PCR can support the diagnosis and reduce the number of histologically indeterminate lesions.

Orbital masses

The "space approach" will be introduced as a means of analyzing orbital masses on imaging studies. Determination in which space an orbital mass resides, the character of its margin, the presence or absence of bony changes, and evidence of extension of the mass beyond the orbit often allows the radiologist to narrow the differential diagnosis and provides essential information to the ophthalmologist for definitive diagnosis and treatment planning.

Bilateral eyelid localisation of a lymphoplasmacytoid lymphoma

Eyelid localisation of non-Hodgkin's lymphoma is rare, and even more so when it is bilateral. We report a 58 year-old man who presented with an eyelid localisation of lymphoplasmacytoid lymphoma. The initial treatment was chemotherapy with good improvement but the relapse lead us to give radiotherapy with no further relapse 20 months later. Radiotherapy is the current treatment of localised eyelid lymphomas with excellent results. The prognosis is related to the initial staging and the 10-year survival rate is close to 80%.

Cytologic evaluation of lymphoproliferative lesions of the orbit/ocular adnexa: an analysis of 46 cases

The cytologic features of 46 lymphoproliferative ophthalmic lesions were evaluated using the "squash" technique and/or touch imprints at the time of frozen section. Of the 46 lesions, 33 were located in the orbit, 12 in the conjunctiva, and one in the eyelid. Fifteen cases were benign (reactive) hyperplasias, and 31 were diagnosed as malignant lymphoproliferative tumors. The cytologic features of the reactive group included a polymorphic lymphoid population intermixed with scattered tingible body macrophages. Within the malignant category, there were 28 malignant lymphomas. All 28 cases were diagnosed as non-Hodgkin's lymphomas. Cytologically, the malignant group consisted of a monomorphic population of atypical lymphoid cells. Of the 31 malignant lymphoid lesions, 58% (18 tumors) were small lymphocytic proliferations. The remaining 13 tumors were classified as follows: mixes small/large cell or pure large cell lymphomas (nine), plasmacytoma (three), and Burkitt's lymphoma (one). Final classification using the Working Formulation was made after evaluating the cytologic preparations and surgical material. In selected cases, the monoclonal nature of the malignant lymphoproliferative lesions was confirmed by flow cytometry and/or immunocytochemistry. Cytologic preparations of the fresh specimens preserve the morphologic details of the tumor cells, which is especially important when evaluating lymphoid lesions. Additionally, multiple smears can be prepared simultaneously for ancillary studies such as immunocytochemistry. Of our 46 lymphoproliferative lesions, two-thirds were diagnosed as malignant lymphomas. Based on the morphologic and immunophenotypic findings, all the malignant lymphomas were B-cell tumors, 50% of which were low grade using the Working Formulation.

Ocular adnexal lymphoma. A clinicopathologic study with identification of lymphomas of mucosa-associated lymphoid tissue type

PURPOSE

Extranodal marginal zone B-cell lymphoma (low-grade B-cell lymphoma of mucosa-associated lymphoid tissue [MALT] type) is a distinctive type of lymphoma that usually arises in association with mucosa or other epithelial structures and has an indolent clinical course. The frequency and clinical features of MALT lymphomas in the ocular adnexa have not been well studied.

METHODS

The authors examined the clinicopathologic features of ocular adnexal lymphoma, identified a subset of cases with MALT characteristics, and determined patient outcome.

RESULTS

The 42 patients, 16 men and 26 women age 35-89 years (mean, 64) were followed an average of 4.8 years. Thirty-two patients had ocular adnexal involvement at presentation (primary ocular adnexal lymphoma) and 10 had a history of lymphoma that relapsed in the orbit (secondary ocular adnexal lymphoma). In the primary group, 23 patients had lymphoma confined to the ocular adnexa, 3 had a single lesion that invaded adjacent structures, and 6 had distant spread at the time of presentation. Twenty-five patients achieved a complete remission. Nine patients, including 6 patients whose disease was localized initially, had progression or relapse of disease in distant sites. At last follow-up, 21 patients were free of disease, 9 were alive with disease and 2 had died of lymphoma. In the secondary group, at last follow-up, 1 patient had died of other causes, free of lymphoma, 3 patients were alive with disease and 5 had died of lymphoma (outcome not known in 1 case). Using the recently described revised European-American lymphoma classification, we found 16 MALT lymphomas, 8 diffuse large B cell, 12 follicular center, 3 mantle cell, 1 B-small lymphocytic lymphoma, and 2 unclassifiable low-grade lymphomas. The most common type of primary lymphoma was MALT type (15 of 30 classifiable cases), and the most common secondary lymphoma was follicular center (6 of 10). No increased frequency of conjunctival or lacrimal gland involvement by MALT lymphomas was found. All 33 lymphomas with immunophenotyping were of B lineage.

CONCLUSIONS

Ocular adnexal lymphomas are B-cell tumors that develop in older adults, predominantly among women. Primary orbital lymphomas have a favorable prognosis; a high proportion of them have MALT characteristics.

Molecular genetic analysis demonstrates that multiple posttransplantation lymphoproliferative disorders occurring in one anatomic site in a single patient represent distinct primary lymphoid neoplasms

BACKGROUND

Posttransplantation lymphoproliferative disorders (PT-LPDs) are a clinicopathologically heterogeneous group of lymphoid proliferations of varied clonal composition, the majority of which are associated with Epstein-Barr virus (EBV) infection. The clonal content and clonal relatedness of 24 separate PT-LPD lesions occurring synchronously in one organ in a single patient were investigated.

METHODS

Twenty-four separate PT-LPD lesions from the colon and mesentery of a 15-year-old male, developing 4 months after cardiac transplantation, were studied for clonality based on immunoglobulin heavy chain (IgH) gene rearrangements for the presence, clonality, and type of EBV infection and for the presence of c-myc, ras, and p53 gene alterations. Southern blot hybridization, polymerase chain reaction, and single strand conformation polymorphism assays were employed.

RESULTS

All 24 lesions were histologically similar (polymorphic B-cell lymphomas) but exhibited varied clonality and were clonally distinct with respect to both IgH gene rearrangements and EBV infection. All lesions were infected with EBV type A. Structural alterations of oncogenes or tumor suppressor genes were not identified.

CONCLUSIONS

Separate PT-LPD lesions occurring synchronously in a single organ or patient may be clonally distinct, suggesting that they represent multiple distinct primary lymphoid proliferations rather than metastatic disease as in conventional malignant lymphomas. This may explain partially the rapid development in some patients of a large PT-LPD tumor burden that may regress rapidly after reduction of immunosuppression.

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.

Primary T-cell immunoblastic lymphoma of the orbit in a pediatric patient

BACKGROUND

The authors report a case of an 8-year-old pediatric patient with a 2-week history of painless periorbital swelling unresponsive to antibiotic treatment.

METHODS

Computed tomography (CT) showed a large, lateral, anterior left orbital soft tissue mass with bony erosion into the anterior cranial fossa through the roof of the orbit laterally. Surgical exploration showed a hard white mass that had eroded through the roof of the left orbit and into the anterior cranial fossa, with herniation of the brain and associated dura through the defect. Results of a complete evaluation of the child for systemic lymphoma, including a lumbar puncture, chest x-ray, bone scan, bone marrow aspirate, and chest/abdomen CT, were negative.

RESULTS

Results of histopathologic and immuno-histochemical evaluation showed a primary orbital T-cell immunoblastic lymphoma. The patient was treated with intrathecal ara-C (Cytosar-U) and methotrexate, 16.2 Gy of whole brain irradiation, and a chemotherapeutic protocol consisting of cyclophosphamide (Cytoxin), vincristine (Oncovin), methotrexate, daunomycin, and prednisone. The patient remains free of lymphoma 33 months after diagnosis, with 20/20 visual acuity in both eyes.

CONCLUSION

The authors believe that this is the youngest documented case of a primary T-cell immunoblastic lymphoma of the orbit.

Immunoblastic B-cell malignant lymphoma involving the orbit and maxillary sinus in a patient with acquired immune deficiency syndrome

BACKGROUND

A 44-year-old man was diagnosed with acquired immune deficiency syndrome (AIDS)-related complex in 1986. Four years later, erythema and swelling of the right lower eyelid and face and a palpable mass along the right inferior orbital rim developed. Computed tomographic scans of the orbits disclosed a mass involving the right superior antrum and inferior orbit. Histopathologic examination and immunohistochemical studies of the tumor were performed.

METHODS

Immunohistochemical studies were performed on paraffin sections of the neoplasm. Markers used included leukocyte-common antigen and L26 (pan B-cell marker), and MT1, Leu22, polyclonal CD3, UCHL-1, and OPD4 (pan T-cell markers). Additional markers included cytokeratin, HMB-45, lysozyme, S-100 protein, kappa, and lambda.

FINDINGS

The neoplastic cells were strongly to moderately positive with LCA, L26, MT1, and Leu22. Negative staining was observed with the remaining nine antibodies.

CONCLUSION

Orbital lymphomas in patients with AIDS have been rarely documented; those few reported cases showed a B-cell phenotype. The authors report an immunoblastic B cell with immunophenotypic coexpression of T-cell markers.

Molecular-genetic analysis of ocular adnexal benign lymphoid hyperplasias by a two-step polymerase-chain-reaction

Twelve biopsied ocular adnexal benign lymphoid hyperplasias (OABLH) satisfying benign histological criteria were investigated for clonal immunoglobulin (Ig) heavy-chain gene rearrangement by means of a two-step polymerase chain reaction (PCR) method using formalin-fixed and paraffin-embedded tissue. Of the 12, 4 (33%) demonstrated clear single bands of the rearranged gene for the Ig heavy-chain, of between 100 and 150 base pairs. The selected cases were all free of malignant lymphoma and all of the lesions were small (2 x 2-22 x 6 mm; median 4.5 x 3 mm). Histopathological and cytological features were not essentially different between monoclonal and non-monoclonal examples. Immunohistochemistry was of little benefit in separating the two. It is concluded that OABLH demonstrating a benign clinical course frequently contain monoclonal B cell populations suggesting a continuous progressive spectrum of lesions in B cell neoplasia. In addition, the significance of molecular-genetic analysis for OABLH and the utility of the two-step PCR method should be emphasized.

Orbital lymphoma versus reactive lymphoid hyperplasia: an analysis of the use of computed tomography in differential diagnosis

Computed x ray tomography (CT) studies of 40 patients with proptosis or periorbital swelling, in whom biopsy showed lymphoma in 23 and reactive lymphoid hyperplasia in 17, were analysed in an attempt to identify radiological differences between the two conditions. The results indicate that homogeneity of an orbital mass is a sensitive but non-specific indication of lymphoma, 75% of lymphomatous masses and only 23% of reactive lesions being homogeneous. Bone destruction was seen only in cases of lymphoma, but was rare. Other radiological features of the mass or the affected orbital structures did not allow discrimination of tumour from a reactive lesion.

Gastric "pseudolymphoma" with restricted light chain expression in a patient with obscure gastrointestinal blood loss

We present a case report of a gastric "pseudolymphoma" (GL) that exhibits restricted light chain expression and, therefore, illustrates the dilemma encountered when histologically benign lesions have phenotypic abnormalities suggesting malignancy. For many years this lesion has been considered usually benign; however, recent reports such as this one demonstrate immunologic signs of monoclonality in an otherwise histologically benign lesion. This finding challenges our assumptions as to the nature of this lesion and our definition of cancer. The lesion also displays "Castleman-like" features (angiofollicular hyperplasia) as well as "common inflammatory" germinal centers. In addition we briefly review the literature.

Rearrangements of immunoglobulin gene and oncogenes in ocular adnexal pseudolymphoma

The organization of immunoglobulin heavy chain (IgH), light chain (kappa and lambda) and T cell receptor (TCR) beta chain gene loci in 10 patients with ocular adnexal pseudolymphoma was investigated. Eight of them showed IgH gene rearrangement in at least one of the 3 restriction enzymes-digested DNAs extracted from ocular adnexal neoplasms. In contrast, none of them exhibited clonal TCR beta chain gene rearrangement. The configuration of bcl-1, bcl-2 and c-myc oncogenes was also studied by Southern blot technique. Two patients had a rearranged joining region, IgH-containing fragment that comigrated with the rearranged bcl-1 fragment. C-myc gene rearrangement was found in only one patient who also had bcl-1 gene rearrangement. In ocular adnexal pseudolymphoma, none demonstrated bcl-2 gene rearrangement; however, in bone marrow cells, one patient with systemic lymphadenopathy exhibited both IgH and bcl-2 gene rearrangements. Three genotypic subsets of these ocular adnexal pseudolymphoma can be identified by the configuration of IgH gene and related oncogenes: with germline configuration of IgH gene and bcl-1, bcl-2 and c-myc oncogenes; with rearrangement of IgH gene but germline configuration of these oncogenes; and with recombination between rearranged IgH and bcl-1 genes. These results suggest in ocular adnexal pseudolymphoma a spectrum of clonal change evolving from polyclonal to monoclonal B-population, and further to monoclonal B-population with rearranged bcl-1, c-myc and/or bcl-2 oncogenes.

Primary orbital malignant lymphoma: a clinicopathology study of 17 cases

We investigated the clinicopathologic characteristics of 17 patients (13 men and 4 women) with primary orbital malignant lymphoma using the Working Formulation. Most of the cases belonged to the low-grade malignancy group, and more women than men were in the histologically high-grade malignancy group. The phenotype of the tumor cells was investigated immunohistochemically. All cases showed the monoclonal feature of a B-cell lineage. All patients received chemotherapy with or without radiotherapy. Of 16 subjects, 15 achieved a complete remission; none of these patients has had a recurrence since the completion of the initial therapy (range of follow-up from 16 months to 10 years). One patient died.

Lymphoid hyperplasia and malignant lymphoma occurring in the ocular adnexa (orbit, conjunctiva, and eyelids): a prospective multiparametric analysis of 108 cases during 1977 to 1987

We performed a prospective multiparametric correlative clinical, histopathologic, and immunologic analysis of 117 ocular adnexal lymphoid proliferations developing in 108 patients between October 1977 and July 1987. The ocular adnexal lymphoid proliferations were distributed among the 108 patients as follows: orbit 69 (64%), conjunctiva 30 (28%), and eyelids nine (8%). The 117 ocular adnexal lymphoid proliferations were classified as follows: polyclonal lymphoid hyperplasia, 32 (22 orbit, nine conjunctiva, one eyelid) (27%); monoclonal B cell lymphoma, 81 (48 orbit, 25 conjunctiva, eight eyelid) (69%); null cell lymphoma, one (orbit) (1%); and histologically indeterminate, three (one each: orbit, conjunctiva, eyelid) (3%). Patients presenting with ocular adnexal polyclonal lymphoid hyperplasia and monoclonal B cell lymphoma, and patients developing unilateral and bilateral ocular adnexal lymphoid proliferations did not differ significantly with respect to age, sex, presenting complaints, duration of symptoms, or ophthalmic findings. Classifying ocular adnexal lymphoid proliferations into benign and malignant categories by histopathologic criteria and into polyclonal and monoclonal B cell categories by immunophenotypic criteria was not useful in predicting eventual outcome, including the occurrence of extraocular lymphoma. However, the clinicopathologic characteristics did differ according to the anatomic site of involvement and histopathology of the ocular adnexal lymphoid proliferations. Lymphoid infiltrates of the conjunctiva were associated with a lower incidence of extra-ocular lymphoma (20%) than were those of the orbit and eyelid, 35% and 67%, respectively (statistically significant, P less than .03). Ocular adnexal small lymphocytic and intermediate lymphocytic lymphomas were less often associated with extra-ocular lymphoma than were ocular adnexal lymphomas of all other histologic types, 27% and 46%, respectively (P less than .09). However, the single most important and statistically significant prognostic factor in these patients was the extent of disease at the time of presentation with an ocular adnexal lymphoid proliferation (P less than .001). Eighty-six percent of patients presenting with a unilateral or bilateral clinical stage lE ocular adnexal lymphoid proliferation, regardless of the histopathology or the immunophenotype, had a benign indolent clinical course and failed to develop ocular or extra-ocular lymphoma during a median follow-up period of 51 months. The results of this study substantially improve our understanding of extranodal small lymphocytic proliferations in general, and those of the ocular adnexa in particular.

T-cell lymphoma of the orbit

In a 52-year-old man with drooping of the right upper eyelid and a palpable mass in the superior temporal quadrant of the right orbit, a biopsy specimen revealed diffuse mixed-type lymphoma with immunostaining evidence of a helper T-cell phenotype. No other foci of lymphoma were found. The orbital lesion was treated with irradiation (total dose, 4,200 cGy administered in 20 treatments). At 4 1/2 years after treatment, the patient had had no recurrence.

Gastric small lymphocytic proliferation with immunoglobulin gene rearrangement in pseudolymphoma versus lymphoma

The nature of gastric infiltrates consisting primarily of benign-appearing small lymphocytes is at present a controversial issue. Earlier reports of gastric lymphoma developing in gastric pseudolymphoma and more recent immunohistochemical studies demonstrating monoclonal B-cell populations in pseudolymphoma suggest that at least some cases represent low-grade lymphomas or clonal precursor lesions that may develop into lymphoma. Observations of a small lymphocytic infiltrate arising in the region of a gastric ulcer that lacked definitive morphologic evidence of malignancy (lymphoma) but was clearly a monoclonal B-cell proliferation by immunohistochemical and gene rearrangement studies support the notion that some gastric lymphoproliferative lesions that histologically have been called pseudolymphomas may include one or more clonal lymphoid expansions. A histopathologic/molecular model suggesting a potential pathway for the development of morphologically recognizable lymphoma from benign-appearing small lymphocytic infiltrates is presented, and the concept that for a variety of lymphoid proliferations clonality and malignancy may not be synonymous is discussed.

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.