Orbital and ocular adnexal lymphoma: a review of epidemiology and prognostic factors in Taiwan

Characteristics of orbital lymphoproliferative disorders: a retrospective study of 84 cases

OBJECTIVE

To investigate the variations in clinical presentation, imaging characteristics, and immunohistochemical features between benign and malignant orbital lymphoproliferative disorders (OLPDs).

METHODS

At the Eye Center of the First Affiliated Hospital, Zhejiang University School of Medicine, a retrospective analysis was performed on the clinical records of all patients diagnosed with OLPDs from 2014 to 2022. This study included a comparative analysis between patients diagnosed with benign and malignant OLPDs.

RESULTS

A total of 84 patients were included in this research, with a mean age of 62.24 ± 14.52 years and male-to-female ratio of 43:41. The pathological types comprised benign orbital lymphoproliferative tumours (26/84, 31%, mean age 59.31 ± 10.4 years, male-to-female ratio of 16:10) and malignant orbital lymphomas (58/84, 69%, mean age 63.55 ± 15.93 years, male-to-female ratio of 27:31). The most common symptoms in benign and malignant OLPDs were palpable mass and eyelid swelling. Typically, malignant orbital lymphoma masses exhibited low signal intensity on T1-weighted imaging (T1WI), whereas benign lymphoproliferative tumours commonly demonstrated iso-intensity on T1WI. Notably, the expression of cluster of differentiation 3, 5, 10, 23, 43, and human immunoglobulin light chain lambda demonstrated statistically significant differences between the benign and malignant OLPD groups.

CONCLUSION

Benign and malignant OLPDs exhibit similar clinical presentations and imaging characteristics. Currently, distinguishing between benign and malignant OLPDs still requires pathological biopsy. Research on specialized imaging techniques and specific biomarkers for malignant orbital lymphomas is underway, showing potential for enhancing the accuracy of non-invasive diagnoses for benign and malignant OLPDs.

Clinical characteristics and outcomes of primary orbital lymphoma

PurposeTo describe the clinical characteristics, histopathologic subtype distribution, treatment, and outcomes of patients with primary orbital lymphoma.Major FindingsThere were 126 biopsy-confirmed cases of primary orbital lymphoma, with 81 (64.3%) female and 110 (87.3%) white. The average age at diagnosis was 62.7 ± 13.9 years. There were 26 (20.6%) cases with bilateral involvement. The most frequent lymphoma subtype was MALT lymphoma (N = 76, 60.3%), followed by diffuse large B-cell lymphoma (N = 18, 14.3%) and follicular lymphoma (N = 12, 9.5%). Prognosis was generally favorable, as local recurrence occurred in only 14 (11.1%) patients and final best corrected visual acuity (BCVA) loss of >1 line was seen in 30 (28.0%) patients. Bilateral lymphoma and advanced stage (Ann Arbor Stage III or IV) at presentation were associated with increased risk of local recurrence (p = 0.0025, p = 0.049). Improved disease-specific survival was associated with diagnosis at Stage I or II (p = 0.013), MALT subtype (p = 0.034), or lack of chemotherapy requirement as primary treatment (p = 0.0073).ConclusionsIn this single center academic cohort, MALT lymphoma subtype was most common. Overall orbital recurrence frequency was low, and bilateral lymphoma and advanced stage were associated with increased risk of local recurrence. MALT lymphoma subtype was associated with improved disease-specific survival. Long-term follow-up showed that most patients retained good visual acuity in the affected eye(s).

Isolated follicular lymphoma of the inferior oblique muscle presenting as an orbital mass

A healthy, middle-aged woman presented to the ophthalmology outpatient department with a 12-month history of a palpable, non-tender mass on her right lower eyelid. The patient reported a 3-month history of night sweats. Her medical, family and social histories were unremarkable. On examination, her visual acuity was 6/6 in both eyes. She had a mass located inferior to the medial canthus and tethered to the orbital rim. She did not have diplopia, proptosis or strabismus and her ocular examination was otherwise normal. Imaging, biopsy and immunohistochemistry testing confirmed a diagnosis of follicular lymphoma isolated to the inferior oblique muscle. Following diagnosis, she underwent systemic immunomodulatory therapy. Although rare, orbital adnexal lymphoma involving the extraocular muscles should be considered in cases of identified unilateral, painless or localised orbital masses.

Retrospective Evaluation of Clinical, Demographic, and Radiological Data of Orbital Lymphoma Patients: A Single Tertiary Center Experience

Objectives

The objective of the study was to present different clinical presentations, clinical and histopathological features, and treatment outcomes of intraorbital lymphoma.

Methods

Medical records of 18 eyes of 17 patients with histopathologically proven diagnoses of intraorbital lymphoma at Dokuz Eylül University Ophthalmology Department, between 2007 and 2022, were reviewed retrospectively. The age, gender, location, laterality, stage, type of involvement, histopathological features, systemic involvement, recurrence, time from initial symptoms to diagnosis, follow-up time, and survival times were recorded. Visual acuities at the time of diagnosis and following treatment were evaluated.

Results

The mean age of the patients was 63±19.11 (range: 15-79, median age 65). The most common presenting findings were periorbital swelling, conjunctival mass, and ptosis. Periorbital region involvement was present in 10 of 17 cases (58.8%) and conjunctival involvement was present in 7 cases (41.2%). Biopsy samples were taken from all cases. Non-Hodgkin lymphoma was the most common type of lymphoma, whereas the most common histopathological diagnoses were marginal zone lymphoma and diffuse large B-cell lymphoma. One case was diagnosed with mature T-cell lymphoma. Nine cases had bone marrow involvement. While two cases refused treatment, two cases were not treated due to age and comorbid diseases. Nine cases received chemotherapy, two cases received radiotherapy (RT), 1 case received chemotherapy and RT, and one case received antibiotherapy treatment. In one case with proptosis and exposure keratitis, lateral canthatomy, temporary tarsorrhaphy, and aggressive topical treatment resulted in complete epithelialization of the cornea.

Conclusion

Orbital lymphoma is a painless and slowly progressive clinical picture that requires high clinical suspicion because it is a common tumor of the orbit. Although clinical symptoms and findings vary according to the intraorbital location of lymphoma, patients should be examined for systemic involvement and followed up in a multidisciplinary manner.

Complete response of unilateral primary lacrimal sac diffuse large B-cell lymphoma treated without radiotherapy in an adult: A rare case report and review of the literature

Diffuse large B-cell lymphoma (DLBCL) manifests extranodally in one-third of non-Hodgkin lymphoma (NHL) cases. However, primary DLBCL of the lacrimal sac is very rare. A 54-year-old man presented with a 5-month history of right-sided epiphora. He visited three private clinics and was misdiagnosed with conjunctivitis. Later, a painless mass in the right lacrimal area prompted an MRI scan followed by a CT scan, which suggested a lacrimal sac mass. The mass was surgically excised, and histopathology and immunohistochemistry revealed DLBCL. A PET/CT scan was done instead of bone marrow biopsy, which excluded systemic lymphomatous involvement, confirming the diagnosis of primary right lacrimal sac DLBCL. The patient received six standard cycles of the R-CHOP regimen. Although no radiotherapy was used, CT findings after the completion of the 4th cycle showed a complete response (CR), which was maintained in a follow-up CT scan 2 months after chemotherapy completion. Despite the rarity of the tumor, it should be considered in the differential diagnosis of long-standing or unresponsive inflammatory conditions. Radiotherapy-free management could achieve CR in limited-stage DLBCL.

Ocular adnexal lymphoma - A single-center observational study of survival outcomes

PURPOSE

This study aims to comprehensively characterize the clinical, demographic, and histopathological features of ocular adnexal lymphoma (OAL) and assess their impact on patients' survival outcomes.

METHODS

A total of 123 patients were included in the study; of these, 93 patients were selected for survival analysis. Survival data were analyzed using the Kaplan-Meier test, and correlation was assessed through the log-rank test and Cox regression analysis.

RESULTS

The median age at presentation was 56 years. Furthermore, 98% of patients had primary OAL. The orbit was the most common site of involvement. The majority of patients were of B-cell origin (98%), and only 2% of patients had T-cell lymphoma. In addition, 83% of patients were treated with chemotherapy, and with a median follow-up of 38 months, complete remission was achieved in 48% of patients. The median progression-free survival was 26.4 months. The presence of disseminated disease was strongly linked to an unfavorable prognosis ( P < 0.001) and reduced survival ( P = 0.037).

CONCLUSION

The 5-year overall survival of the entire study cohort was 81%. The prognosis for OAL is found to be favorable, but the presence of dissemination serves as a notable predictor for poor prognosis.

The Dilemma for Early-Stage Conjunctival Mucosa-Associated Lymphoid Tissue Lymphoma: To Treat or Not to Treat?

BACKGROUND

Primary ocular adnexal mucosa-associated lymphoid tissue lymphoma (MALToma) is typically treated with radiotherapy. Some studies suggested a "wait and watch" approach due to the adverse effects of radiotherapy. However, the benefits of observation for localized conjunctival MALToma remain unclear. Therefore, we aimed to explore the clinical course of early-stage conjunctival MALToma, distinguish heterogeneity between T1 and T2 patients, and identify prognostic factors.

METHODS

This retrospective study involved patients with stage T1-T2 conjunctival MALToma and lasted >6 months. Clinical characteristics were compared between T1 and T2 subjects. Prognostic factors were examined with Cox regression.

RESULTS

The research comprised 32 subjects with early-stage conjunctival MALToma, of whom 25% underwent observation. No individuals expired regardless of choosing observation or radiotherapy. The T1 patients were younger (p = 0.002) and more inclined towards observation only (p = 0.035) than the T2 subjects. Despite more of the T1 patients undergoing watchful waiting than the T2 subjects, the T1 patients seemed to have longer systemic relapse-free survival than the T2 subjects (17 vs. 13 years, p = 0.343). CD43 may imply poor prognosis (p = 0.049).

CONCLUSIONS

Careful observation may be suggested for early-stage conjunctival MALToma. While more of the T1 individuals were younger and chose observation than the T2 patients, survival seemed longer in the T1 subjects without significance. CD43 may indicate shorter survival in early-stage cases.

Mucosa-associated lymphoid tissue lymphoma of the lacrimal gland: A case report and literature review

RATIONALE

The most common subtype of primary lymphoma of the ocular adnexa is the mucosa-associated lymphoid tissue (MALT) subtype. MALT lymphoma of the lacrimal gland is relatively rare among the lacrimal gland tumors, and the early clinical symptoms are atypical, which can easily lead to misdiagnosis and missed diagnosis. Here, we report a case of MALT lymphoma of the lacrimal gland and explore its clinical manifestations, pathological characteristics, management, and pathogenesis, with the aim of helping clinicians gain an in-depth understanding of ocular adnexal MALT lymphoma.

PATIENT CONCERNS

A 60-year-old man presented to our hospital with proptosis and diplopia. The right eye deviated and shifted toward the lower part of the nose.

DIAGNOSIS

Orbital enhanced magnetic resonance imaging suggested a mass with a maximum cross-section of 3.2 × 2.1 cm. T1 weighted image was isointense, and the enhancement was more uniform and obvious.

INTERVENTIONS

The right orbital mass was treated surgically, and the final pathology report was MALT lymphoma. After the pathological report was released, the patient was transferred to the hematology department for further diagnosis and no further treatment was given eventually.

OUTCOMES

Seven months later, the patient did not complain of discomfort. Whole-body positron emission tomography-computed tomography, superficial lymph node examination and orbital magnetic resonance imaging revealed no abnormal changes.

LESSONS

The clinical manifestations of MALT lymphoma are heterogeneous. Imaging examination is important for assessing the size of the tumor and its relationship with adjacent tissues. Postoperative pathological examination may provide further evidence for the evaluation of the patient's surgical efficacy and prognosis. Management of MALT lymphoma of the lacrimal gland requires a multidisciplinary approach involving ophthalmologists, hematologists, and radiotherapists.

Comprehensive analysis of orbital lymphoma in a Turkish cohort: clinical characteristics, histological subtypes, treatment modalities, prognostic factors, and implications for management

The study analysed the clinical characteristics, treatment approaches, and survival outcomes of 97 consecutive patients with orbital lymphoma (OL) over a 25-year period at. The median age of the patients was 57.6 years, and 59.8% (n = 58) were male. Marginal zone lymphoma constitutes the most prevalent subtype, accounting for 67% of cases, whereas other common subtypes include diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, Burkitt lymphoma, and T-cell lymphomas. Unilateral involvement was observed in the majority of cases (72.3%). Common clinical presentations included mass (30.9%), swelling (26.8%), and epiphora (11.3%). Of the patients, 7.2% received rituximab alone, 14.4% received radiotherapy alone, 48.5% received chemotherapy, 27.8% received radiotherapy plus rituximab, 22.7% received radiotherapy plus chemotherapy, and 5.2% underwent surgery as the first-line treatment. During a median follow-up of 4.3 years, 15.5% of patients experienced relapse or disease progression. The 5-year and 10-year progression-free survival rates were 84.1% and 79.1%, respectively. This study contributes to our understanding of OLs and provides a foundation for further investigations in this field. Male gender, presence of B symptoms, advanced stage, secondary orbital lymphoma, aggressive histological subtype, and elevated serum lactate dehydrogenase levels were associated with poorer (either inferior or worse) progression-free survival.

Stromal area differences with epithelial-mesenchymal transition gene changes in conjunctival and orbital mucosa-associated lymphoid tissue lymphoma

Purpose

To examine the molecular biological differences between conjunctival mucosa-associated lymphoid tissue (MALT) lymphoma and orbital MALT lymphoma in ocular adnexa lymphoma.

Methods

Observational case series. A total of 129 consecutive, randomized cases of ocular adnexa MALT lymphoma diagnosed histopathologically between 2008 and 2020.Total RNA was extracted from formalin-fixed paraffin-embedded tissue from ocular adnexa MALT lymphoma, and RNA-sequencing was performed. Orbital MALT lymphoma gene expression was compared with that of conjunctival MALT lymphoma. Gene set (GS) analysis detecting for gene set cluster was performed in RNA-sequence. Related proteins were further examined by immunohistochemical staining. In addition, artificial segmentation image used to count stromal area in HE images.

Results

GS analysis showed differences in expression in 29 GS types in primary orbital MALT lymphoma (N=5,5, FDR q-value <0.25). The GS with the greatest difference in expression was the GS of epithelial-mesenchymal transition (EMT). Based on this GS change, immunohistochemical staining was added using E-cadherin as an epithelial marker and vimentin as a mesenchymal marker for EMT. There was significant staining of vimentin in orbital lymphoma (P<0.01, N=129) and of E-cadherin in conjunctival lesions (P=0.023, N=129). Vimentin staining correlated with Ann Arbor staging (1 versus >1) independent of age and sex on multivariate analysis (P=0.004). Stroma area in tumor were significant difference(P<0.01).

Conclusion

GS changes including EMT and stromal area in tumor were used to demonstrate the molecular biological differences between conjunctival MALT lymphoma and orbital MALT lymphoma in ocular adnexa lymphomas.

Clinical characteristics and treatment outcomes of secondary ocular adnexal lymphoma

BACKGROUND

To describe the clinical characteristics and treatment outcomes of secondary ocular adnexal lymphoma (OAL), and emphasise the impact of timely biopsy and systemic evaluation on the diagnosis and treatment.

METHODS

The data of patients with secondary OAL in our hospital from January 2010 to June 2021 were retrospectively reviewed.

RESULTS

A total of 54 patients (30 men and 24 women) were included in the study. The mean age at presentation was 60 years (median 62 years; range 37-83 years). The main symptoms included ocular mass (74%), periorbital swelling (43%), and proptosis (39%). The main histopathological types were mucosa-associated lymphoid tissue lymphoma (30%), diffuse large B-cell lymphoma (28%), and natural killer/T-cell lymphoma (18%). In particular, three patients exhibited different pathological types of ocular lymphoma compared to previously diagnosed systemic lymphoma. The most common site of ocular and systemic involvement was the orbit (85%) and lymph nodes (56%), respectively, and 25 (46%) patients had occult extraocular lesions. Additionally, the 5-year overall survival rate of the entire cohort was 56%, and significant differences were observed between the three main pathological types and stages of the disease (all p < 0.001).

CONCLUSIONS

Secondary OAL is a rare disease with a poor prognosis. That the disease is associated with a more aggressive pathological type is well established, indolent lymphoma is not uncommon. Furthermore, OAL and previously diagnosed systemic lymphoma may be pathologically distinct in some patients. Therefore, we recommend a prompt excision biopsy and a thorough systemic evaluation of patients with suspected OAL.

End-to-End Deep-Learning-Based Diagnosis of Benign and Malignant Orbital Tumors on Computed Tomography Images

Determining the nature of orbital tumors is challenging for current imaging interpretation methods, which hinders timely treatment. This study aimed to propose an end-to-end deep learning system to automatically diagnose orbital tumors. A multi-center dataset of 602 non-contrast-enhanced computed tomography (CT) images were prepared. After image annotation and preprocessing, the CT images were used to train and test the deep learning (DL) model for the following two stages: orbital tumor segmentation and classification. The performance on the testing set was compared with the assessment of three ophthalmologists. For tumor segmentation, the model achieved a satisfactory performance, with an average dice similarity coefficient of 0.89. The classification model had an accuracy of 86.96%, a sensitivity of 80.00%, and a specificity of 94.12%. The area under the receiver operating characteristics curve (AUC) of the 10-fold cross-validation ranged from 0.8439 to 0.9546. There was no significant difference on diagnostic performance of the DL-based system and three ophthalmologists (p > 0.05). The proposed end-to-end deep learning system could deliver accurate segmentation and diagnosis of orbital tumors based on noninvasive CT images. Its effectiveness and independence from human interaction allow the potential for tumor screening in the orbit and other parts of the body.

[The role of miRNA in the pathogenesis of diseases associated with functional dysregulation of the lacrimal gland]

At this time, the mechanism causing lacrimal gland dysfunction is not understood completely. In diseases associated with lacrimal gland involvement (Sjogren's syndrome, sarcoidosis, IgG4-associated disease, etc.) patients have been observed to experience elevated cellular apoptosis, active production of autoantibodies to glandular tissue, increased level of pro-inflammatory cytokines, functional disruption of signaling molecules leading to changes in tear production. Difficulties in differential diagnosis of lacrimal gland dysfunction in above-listed diseases are associated, on the one hand, with similarity of the clinical picture of ophthalmological manifestations, and on the other hand - with complicated morphological interpretation of changes in the glandular tissues. In this view, miRNA is a promising diagnostic and prognostic marker that would help with differential diagnosis as well as with choosing the treatment tactics. Methods of molecular profiling and identification of "molecular phenotypes" of lacrimal gland and ocular surface damage will allow the use of miRNA as biomarkers and prognostic factors for personalized treatment.

Proteotranscriptomics of ocular adnexal B-cell lymphoma reveals an oncogenic role of alternative splicing and identifies a diagnostic marker

Background

Ocular adnexal B-cell lymphoma (OABL) is a rare subtype of non-Hodgkin lymphoma. The molecular characteristics of OABL remain poorly understood. We performed an integrated study to investigate the proteotranscriptome landscape and identify novel molecular characteristics and biomarkers of OABL.

Methods

Integrated quantitative proteome and transcriptome were performed on 40 OABL 12 idiopathic orbital inflammation, 6 reactive lymphoid hyperplasia, and 13 aesthetic orbital plastic surgery specimens. Complete clinicopathologic and prognostic data of the patients were recorded.

Results

We identified high global protein-mRNA concordance as a novel characteristic of OABL. High concordance was related to OABL recurrence. By integrated expression profile, motif enrichment and trend analysis, we found that alternative splicing is inflammation-independently dysregulated in OABL. After portraying the aberrant alternative splicing event landscape, we demonstrated the oncogenic role of ADAR, a core splicing regulator that regulates the splicing of Rho GTPase and cell cycle members. We found that ADAR regulates cell proliferation and Rho GTPase inhibitor sensitivity of lymphoma. We identified DNAJC9 as a potential biomarker for OABL in proteomic analyses. Immunohistochemistry and immunofluorescent staining showed the nuclear staining of DNAJC9 was significantly higher in extranodal marginal zone lymphomas compared with inflammation specimens.

Conclusions

These results provide an integrated gene expression profiling and demonstrate that high global protein-mRNA concordance is a prognosis-related molecular characteristic of OABL. We portray the alternative splicing events landscape of OABL, and reveal the oncogenic role of ADAR. We identified strong nuclear staining of DNAJC9 as a promising pathology diagnostic biomarker for extranodal marginal zone lymphomas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13046-022-02445-8.

A survey across orbital lymphoma in Poland: Multicenter retrospective study of polish lymphoma research group (PLRG)

OBJECTIVE

To investigate the prevalence of histopathological subtypes, the clinical stage at presentation and treatment modalities in Polish patients with orbital lymphoma (OL) and to determine prognostic outcomes.

METHODS

The retrospective study of 107 patients with OL treated in a 14-year period in Polish hematological centers. The analysis included histopathological subtype, disease clinical advancement, treatment modalities, progression-free survival (PFS), and overall survival (OS).

RESULTS

The median patient age was 60 years (range 51-71). Mucosa-associated lymphoid tissue (MALT) lymphoma accounted for slightly more than half of all cases of orbital lymphoma (51%). The second most common subtype was diffuse large B-cell lymphoma (DLBCL) (29%). Primary orbital lymphoma was diagnosed in 48% of all patients. According to the Ann Arbor, localized stage IE of orbital lymphoma was diagnosed only in 39% of all patients. Systemic involvement was observed in more than half of all patients (52%). The median follow-up period was 30 months (range 0-160 months). Patients with non-MALT lymphoma had a significantly inferior PFS compared to patients with MALT lymphoma, (p = 0.047). Patients with primary orbital lymphoma had a superior PFS compared to patients with secondary orbital lymphoma [median PFS 104.5 months vs. 33.4 months], (p = 0.069). Younger patients with MALT lymphoma were characterized by superior PFS (median PFS not reached) compared to other studied subgroups of patients (older patients with MALT lymphoma, younger and older non-MALT lymphoma patients) with a median PFS of 30.5, 32.2, 32.6 months respectively (p = 0.039). Patients treated with chemotherapy alone had inferior PFS compared to patients treated with combined therapies (p = 0.034). The median PFS across patients who received chemotherapy alone was 23.7 months, whereas across other patients was 73.9 months.

CONCLUSIONS

Secondary lymphoma accounts for more than half of the orbital lymphoma in Polish population. The advanced clinical stage of the disease (non-IE according to Ann Arbor) concerns two-thirds of the overall population of patients with orbital lymphomas and one-third of MALT lymphoma patients. The high incidence of advanced stages of orbital lymphoma may indicate the need for combined treatment. Combined orbital lymphoma treatment is associated with superior PFS compared to chemotherapy alone in overall population of patients with orbital lymphoma.

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.