Burkitt lymphoma presenting as a conjunctival mass

Orbital lymphoma

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

Burkitt's Lymphoma Presenting as Oculomotor Palsy in an HIV-Positive Patient

Purpose

To report a case of Burkitt's lymphoma (BL) in an HIV-positive patient presenting as complete third nerve palsy.

Methods

Interventional case report. A 34-year-old man presented with headache, left eye pain, diplopia, and complete ptosis of several hours’ duration. Left eye examination disclosed complete third nerve palsy with pupillary involvement. Significant hepatomegalia was noted at physical examination and computed tomography (CT) scan of the abdomen showed multiple solid lesions.

Results

Liver biopsy was consistent with Burkitt's lymphoma. Bone marrow biopsy was normal. Brain imaging was normal. Work-up also revealed positivity for human immunodeficiency virus. Chemotherapy treatment was started. Two months later, ocular motility examination was normal.

Conclusions

Although BL affects the central nervous system very rarely, BL should be considered in any immunosuppressed patient presenting with diplopia or ophthalmoparesis.

Sporadic Burkitt's lymphoma/acute B-cell leukaemia presenting with progressive proptosis and orbital mass in a child

Burkitt's lymphoma (BL) is an aggressive B-cell non-Hodgkin lymphoma that is found predominantly in children, with the highest incidence occurring in Africa. The sporadic form occurs in non-endemic areas and typically involves the ileo-caecum and the bowel, whereas orbital and paranasal sinus involvement is rare. Here, we present an unusual case of sporadic BL in a Caucasian male child with rapidly progressive painful proptosis of the right eye. Magnetic resonance imaging showed an oval-shaped, extraconal mass in the supero-lateral part of the right orbit that deformed and dislocated the eyeball antero-inferiorly. The patient underwent anterior orbitotomy, and a biopsy of the excised tissue revealed a starry-sky appearance characteristic of BL. Postoperative aggressive chemotherapy was initiated with a good response after one week.

Malignant lymphoma of the conjunctiva

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

Mantle cell lymphoma diagnosed by conjunctival salmon-pink lesion biopsy

Conjunctival lesions are rarely seen in mantle cell lymphoma. Here, we report a patient who developed bilateral conjunctival lesions in the course of chronic lymphocytic leukemia as an initial diagnosis, resulting in the final diagnosis of mantle cell lymphoma by conjunctival biopsy. A 66-year-old man developed conjunctival salmon-pink lesions on both sides in the 1.5-year course of chronic lymphocytic leukemia. He also had irregularly shaped masses with low tissue density in the orbital apex on both sides. Bilateral conjunctival biopsy showed subepithelial infiltration with lymphoid cells, positive for CD20, CD5, and cyclin D1, but negative for CD3, CD10, and CD23. Immunohistochemical restaining of the previous bone marrow biopsy specimen demonstrated lymphoid cells positive for cyclin D1, confirming the diagnosis of mantle cell lymphoma with leukemic presentation. As the case presenting stage IV lymphoma with systemic lymphadenopathy, he underwent 3 courses of combination chemotherapy with fludarabine and cyclophosphamide, and then 6 courses of bendamustine with rituximab, leading to complete remission for the following 3 years. In conclusion, mantle cell lymphoma should be included in the differential diagnosis of conjunctival salmon-pink lesions.

A reappraisal of the diagnostic and therapeutic management of uncommon histologies of primary ocular adnexal lymphoma

Lymphoma is the most common malignancy arising in the ocular adnexa, which includes conjunctiva, lachrymal gland, lachrymal sac, eyelids, orbit soft tissue, and extraocular muscles. Ocular adnexal lymphoma (OAL) accounts for 1%-2% of non-Hodgkin lymphoma and 5%-15% of extranodal lymphoma. Histology, stage, and primary localizations are the most important variables influencing the natural history and therapeutic outcome of these malignancies. Among the various lymphoma variants that could arise in the ocular adnexa, marginal zone B-cell lymphoma (OA-MZL) is the most common one. Other types of lymphoma arise much more rarely in these anatomical sites; follicular lymphoma is the second most frequent histology, followed by diffuse large B-cell lymphoma and mantle cell lymphoma. Additional lymphoma entities, like T-cell/natural killer cell lymphomas and Burkitt lymphoma, only occasionally involve orbital structures. Because they are so rare, related literature mostly consists of anecdotal cases included within series focused on OA-MZL and sporadic case reports. This bias hampers a global approach to clinical and molecular properties of these types of lymphoma, with a low level of evidence supporting therapeutic options. This review covers the prevalence, clinical presentation, behavior, and histological and molecular features of uncommon forms of primary OAL and provides practical recommendations for therapeutic management.

Extraocular muscle enlargement leading to the diagnoses of Burkitt lymphoma and acquired immune deficiency syndrome

Orbital involvement in nonendemic Burkitt lymphoma is rare. The authors report a unique case of a patient who sought treatment for extraocular muscle enlargement without a concurrent orbital mass, which subsequently led to the diagnoses of Burkitt lymphoma and acquired immune deficiency syndrome in an adult patient. The case report adhered to the principles of the Declaration of Helsinki and Health Insurance Portability and Accountability Act compliance. This single case report was institutional review board exempt, given that it does not meet the definition of human subjects' research.

Orbital involvement in nonendemic Burkitts lymphoma

Burkitt's lymphoma (BL) is a rare monoclonal proliferation of Blymphocytes and is classified as a poorly differentiated lymphocytic lymphoma. Typically, Burkitt's lymphoma involves the jaw bones, but the orbit can also be involved. Burkitt"s lymphoma is seen, sporadically in India, and 3 cases of orbital Burkitt's lymphoma were diagnosed during the past 4 years. Three cases of acute proptosis in children are presented to us. The provisional clinical diagnosis was rhabdomyosarcoma and the histopathology revealed Burkitt's lymphoma. The fast growth rate, hematologic manifestations and the urgency of diagnosis are emphasized. We present 3 cases here and review prevailing concepts about Burkitt's lymphoma.

Orbital sporadic Burkitt lymphoma in an adult diabetic African American female and a review of adult orbital cases

A case of sporadic Burkitt lymphoma (sBL) presenting with jaw and lid involvement in a diabetic adult African American female and a review of adult orbital Burkitt lymphoma cases are presented. Lid edema, visual loss, ophthalmoparesis, proptosis, and sinusitis progressed over 4 weeks despite antibiotic and steroid treatment. Upper lid biopsy histopathological evaluation and immunophenotyping revealed a homogenous mass of atypical CD10 and CD20-negative B-cells and tingible body macrophages yielding a "starry sky" appearance. Cytogenetic analysis detected a minor variant c-MYC translocation, but no Epstein-Barr virus RNA. Detection of multiple lesions prompted a diagnosis of stage IV disease that totally regressed following radiation and chemotherapy. Review results of the six adult orbital sBL cases support a poor prognosis and a heightened suspicion of variant CD10, CD20 and BCL6 positive sBL in adults presenting with jaw pain and rapidly progressive orbital symptoms, particularly in female, African American, and diabetic patients.

Orbital burkitt lymphoma in immunocompetent patients: a report of 3 cases and a review of the literature

PURPOSE

To describe a series of 3 immunocompetent patients with the sporadic form of orbital Burkitt lymphoma and review the outcomes of such patients reported in the scientific literature.

METHODS

Retrospective review of medical records and the literature. Cases of orbital Burkitt lymphoma in immunocompromised and African patients were excluded from the review. Measured parameters included gender, age, ocular signs, imaging results, the range of systemic involvement, and treatment.

RESULTS

Current cases and review of the scientific literature resulted in 16 immunocompetent patients with sporadic orbital Burkitt lymphoma. The median age at presentation was 12 years. Most common ocular signs at presentation were proptosis (13/16), external ophthalmoplegia (9/16), and eyelid edema (7/16). Optic neuropathy was noted in 5 of 16 patients. Concomitant paranasal sinus involvement was present in 8 of 16 patients. Fourteen (88%) of the patients had systemic involvement, of which the most common locations were central nervous system (6/16), lymphatics (6/16), bone marrow (6/16), and liver (4/16). Survival data were available for 13 patients. Seven patients (54%) died within 12 months of presentation.

CONCLUSIONS

Sporadic orbital Burkitt lymphoma occurs in immunocompetent individuals with a wide age range. Fifty percent presented with adjacent paranasal sinus involvement. Concurrent or eventual systemic involvement is common. The large number of patients with central nervous system involvement in our review of the literature supports the role of lumbar puncture and neuroimaging in the workup of all patients with orbital Burkitt lymphoma. Prognosis remains guarded, with significant mortality within 1 year of presentation.

Rapid onset proptosis and vision loss as the initial presentation of Burkitt lymphoma

Burkitt lymphoma is a rapidly growing, high-grade non-Hodgkin lymphoma occurring in three distinct clinical subtypes: endemic, sporadic, and human immunodeficiency associated. The sporadic subtype typically presents as an abdominal mass. Orbital involvement has rarely been reported. The authors report a case of Burkitt lymphoma presenting as rapidly progressive proptosis and loss of vision. Given the tumor's rapid growth rate, potential for vision loss, and good response to chemotherapy, clinicians should be aware of this rare presentation.

Lymphoma of the ocular adnexa: A study of 353 cases

We studied the cases of 353 patients with lymphoma involving the ocular adnexa diagnosed at the Massachusetts General Hospital between 1974 and 2005. The patients included 153 males and 200 females, aged 7 to 95 years, with a mean age of 64 years. In 277 cases, there was no known history of lymphoma. Seventy-six patients had a history of lymphoma, with the ocular adnexa being involved at relapse or with progression of the previously diagnosed lymphoma. The patients had marginal zone lymphoma (182 cases), follicular lymphoma (80 cases), mantle cell lymphoma (18 cases), small lymphocytic lymphoma/chronic lymphocytic leukemia (13 cases), lymphoplasmacytic lymphoma (4 cases), splenic marginal zone lymphoma (2 cases), low-grade B cell, not subclassified (19 cases), precursor B lymphoblastic lymphoma (3 cases), diffuse large B-cell lymphoma (26 cases), and 1 case each of high-grade B-cell lymphoma, not subclassified, peripheral T-cell lymphoma, unspecified type, extranodal NK/T-cell lymphoma, nasal type, and Hodgkin lymphoma, nodular sclerosis type. Almost all marginal zone lymphoma patients (168 of 182, 92%) had primary ocular adnexal lymphoma. Fourteen marginal zone lymphoma patients (8%) had a prior history of lymphoma, usually arising in another extranodal site. Twenty-five of 80 (31%) follicular lymphoma patients had a prior history of lymphoma, usually arising in lymph nodes. Patients with mantle cell lymphoma, chronic lymphocytic leukemia, lymphoplasmacytic lymphoma, and splenic marginal zone lymphoma almost always had a prior history of lymphoma or were known to have widespread disease at the time of diagnosis of ocular adnexal lymphoma. A subset of the diffuse large B-cell lymphomas were associated with large destructive masses involving adjacent structures such as paranasal sinuses, raising the possibility that they may have arisen from one of the adjacent structures and involved the ocular adnexa by direct extension. The relatively high proportion of low-grade lymphoma, not subclassified, highlights the difficulty that may arise in distinguishing different types of low-grade lymphoma, particularly when biopsies are small and artifactually distorted. Ocular adnexal lymphoma is primarily a disease of older adults, with a slight female preponderance. Most lymphomas are low-grade B-cell lymphomas, with marginal zone lymphoma being by far the most common type. Marginal zone lymphoma typically involves the ocular adnexa primarily, whereas other types of low-grade B-cell lymphoma often involve the ocular adnexa secondarily. High-grade B-cell lymphomas only occasionally involve the ocular adnexa, and T-cell lymphoma, NK-cell lymphoma, and Hodgkin lymphoma are only rarely encountered in this site.

Lymphomas involving the eye and the ocular adnexa

PURPOSE OF REVIEW

This review assesses the current status of the different methods used in screening for diabetic retinopathy. This update is particularly timely because the incidence of diabetes is rising rapidly and the number of patients with vision-threatening diabetic retinopathy is increasing.

RECENT FINDINGS

We evaluate the different methods used and their results in improving the delivery of eye care to patients with diabetic retinopathy. In populations with poor access to ophthalmic care, screening techniques such as the nonmydriatic camera used in offices of primary care physicians may be useful in identifying lesions of diabetic retinopathy requiring treatment. One of the limitations is the lack of dilation and cataract formation, which may result in ungradable photographs. Patients with treatable lesions as well as those with ungradable photographs should be referred for comprehensive ocular examination.

SUMMARY

Screening techniques do not replace the eye examination. Ophthalmologists can play an important role in diabetic care apart from treating eye disease. Counseling can be provided to patients regarding the importance of blood glucose and blood pressure control and may motivate patients to achieve strict glucose and blood pressure control.

Precursor B lymphoblastic lymphoma of the orbit in a child: an unusual presentation of a non-Hodgkin lymphoma

OBJECTIVE

The majority of ocular adnexal lymphomas are marginal zone lymphomas, which occur rarely in children. This case report describes a 6 years old child with a precursor B lymphoblastic lymphoma presenting in the ocular adnexa. The combination of multi-agent chemotherapy with adjuvant radiotherapy seems to be necessary in order to achieve a complete remission of this subtype of lymphoma's in ocular adnexa.

DESIGN

Retrospective case study.

METHOD

A review of the clinical, pathological, radiological findings and follow-up in a patient from the files available at our center, which were reviewed between the years 1974 and 2004.

Bilateral benign lymphoid hyperplasia of the conjunctiva in a paediatric patient

A 14-year-old boy presented with a 6-month history of bilateral slowly enlarging conjunctival lesions. There was no associated ocular or systemic symptomatology. Examination revealed bilateral salmon-coloured nodular lesions of the bulbar conjunctiva. The remainder of his ophthalmic and general examinations were normal. Extensive investigation excluded regional or systemic involvement. Excision biopsy of the lesions showed a predominantly mature B lymphocyte infiltrate with immunohistochemistry and flow cytometry consistent with reactive lymphoid hyperplasia. Polymerase chain reaction testing for Epstein-Barr virus was negative. At 2 years follow-up, the patient remained healthy and there was no evidence of recurrence. Benign lymphoid hyperplasia of the conjunctiva with bilateral involvement is extremely rare in children. Only a few case reports have been documented in the literature.

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 lymphocytic infiltrates associated with Epstein-Barr virus

PURPOSE

To describe the clinicopathologic features of two patients with Epstein-Barr virus (EBV) associated conjunctival lymphocytic infiltrates.

DESIGN

Two case reports.

METHODS

The clinical histories and pathologic findings of two patients with salmon-colored conjunctival infiltrates are described.

MAIN OUTCOME MEASUREMENTS

Clinical observation and pathologic examination of conjunctival biopsy specimens with accompanying immunohistochemical staining, flow cytometric immunophenotyping, and polymerase chain reaction analysis when appropriate.

RESULTS

One patient had ipsilateral preauricular lymphadenopathy, elevated serum EBV titers, and a unilateral reactive lymphocytic infiltrate resulting in a conjunctival mass. The other patient had bilateral conjunctival lymphocytic infiltrates causing conjunctival masses. There was an expanded clonal population of B lymphocytes in the conjunctival mass in the second patient. Both patients had EBV antigen in their conjunctival lymphocytic infiltrates.

CONCLUSIONS

Conjunctival lymphocytic lesions associated with EBV represent a spectrum of reactive infiltrates to monoclonal populations.

Lymphoma at uncommon sites

Lymphoma can often present in unusual situations. This article provides a comprehensive review of the literature in which both non-Hodgkin's lymphoma and Hodgkin's disease are discussed.

Management of paediatric lymphoma

The high cure rate obtained in most paediatric lymphomas allows an optimistic vision of future treatments, with decreased primary late effects observed in patients who have completed therapy: decreased cognitive functional impairment, reproductive dysfunction, poor social adaptation, and risk of second malignancies. The deleterious effects of radiation therapy on neurocognitive functions is now well documented (Meadows et al, 1981) but, apart from rare acute toxicities (Sasazaki et al, 1992), reports on those following high-dose methotrexate are scarce, and sometimes discordant (Jannoun and Chessels, 1987; Robertson et al, 1992). Longer follow-up evaluation is warranted before definitive conclusions concerning the relationship between computed tomography scan findings and clinical outcome can be reached. The reproductive function of males is much more severely altered than that of females (Jaffe et al, 1988). Several reports have demonstrated the major dose-dependent toxicity of alkylating agents on male fertility. Male patients receiving more than 9 g/m2 of cyclophosphamide have a particularly high risk of sterility (Aubier et al, 1989) and children with less than 4 g/m2 of cyclophosphamide, a very low risk Patte et al, 1996a). Women treated before the age of 20 who do not receive abdominal irradiation usually have normal reproductive function, although early puberty (Quigley et al, 1989) and early menopause (Byrne et al, 1992) have been documented. The risk of a second malignancy is not as great as in children with a solid tumour or Hodgkin's disease (Anderson et al, 1993). The risk is higher in patients treated with alkylating agents (Lemerle et al, 1989). With the increasing cure rate, a social problem may arise for adults who "have had cancer'. The increased awareness by politicians and health insurance companies should help to solve, at least partially, this new problem (Monaco, 1987). As cure rates increase, emerging concerns involve the familial repercussions of this heavy treatment (Lansky et al, 1978; Cairns et al, 1979). At this stage, there is no demonstrated deleterious effect from treatment for the progeny of cured children (Mulvihill et al, 1987; Stein, 1993). Cure of children with lymphoma is a reality, and one should think in terms of "complete cure' when facing a distressed child with a heavy tumour burden arriving for diagnosis (Schweisguth, 1979). Since 1980, the progress of molecular biology techniques has permitted the precise molecular characterization of gene alterations (oncogenes, immunoglobulins, and T-cell receptor genes) involved in the process of malignant transformation of normal lymphocytes (Bhatia et al, 1996; Williams et al, 1996). In parallel, treatment of malignant NHL of childhood has improved dramatically. The progress in molecular biology has not led to a modification of the clinical management of NHL of childhood which remains mainly empirical. Precise cytohistological classification of lymphomas has resulted in the characterization of low- and high-risk patients requiring distinct therapeutic approaches. The major goals of the next few years will be to increase the cure rates of those patients with CNS and bone marrow involvement at diagnosis, probably through an intensification of chemotherapy (increase in the dose or intensity of the chemotherapy); to define precisely subgroups of good-prognosis patients requiring less aggressive treatment that would decrease the risk of long-term events; and to salvage previously heavily treated patients at relapse. The precise analysis of gene alterations in lymphoma cells of a given patient may have important clinical applications in this respect (Bhatia et al, 1996).