Lymphocytic tumours of indeterminate nature: a 5-year follow-up of 98 conjunctival and orbital lesions

Les lymphomes malins non hodgkiniens conjonctivo-orbitaires

INTRODUCTION

Although the number of non-Hodgkin's lymphoma (NHL) cases continues to grow throughout the world, orbital NHL is still a rare tumor that is difficult to diagnose. The objective of our study was to analyze the different orbital NHLs diagnosed in our Ophthalmology Department during the last 20 years.

MATERIAL AND METHODS

[corrected] We conducted a retrospective study of conjunctive-orbital lymphomas diagnosed in the Amiens Ophthalmology Department between 1982 and 2002. The pathological reports of 22 cases were investigated, notably the mode of onset, the clinical and radiological description, the diagnostic mode, pathological results, and the type of treatment provided for these tumors.

RESULTS

Every NHL was type B. They were for the most part low grade in terms of malignancy, isolated, primitive, orbital and inactive.

DISCUSSION

Insidious, slow-growing lesions are often found, and biopsy can be difficult. This may explain delayed diagnosis. The first differential diagnosis is inflammatory pseudotumor. Only a good biopsy can confirm the diagnosis of NHL.

CONCLUSION

New immunohistochemistry and genetic diagnostic methods make it increasingly possible to screen for NHL, even if the clinical history can be misleading. Moreover, treatments that are more and more precisely targeted to the immunohistochemical type of NHL seem to be giving very promising results. Several studies are ongoing.

T-cell and T/natural killer-cell lymphomas involving ocular and ocular adnexal tissues: a clinicopathologic, immunohistochemical, and molecular study of seven cases

OBJECTIVE

Lymphomas of the eye and its adnexa are frequently of B lineage. This study aims to characterize the clinical and histopathologic features of the rare non-B-cell non-Hodgkin lymphomas (NHL) of these locations.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Seven cases of T- and T/NK-cell lymphomas involving the ocular and ocular adnexal tissues.

METHODS

A morphologic, immunohistochemical, and molecular analysis (polymerase chain reaction) of each of the tumors was undertaken. The lesions were classified according to the Revised European-American Lymphoma (REAL) classification. The clinical and follow-up data were collected.

RESULTS

The patients included four women and three men ranging in age from 32 to 88 years (mean, 63 years). The presenting ophthalmic symptoms varied from a small nodule on the upper eyelid and conjunctival swellings to dramatic loss of vision associated with gross protrusion of the globe. Five of the cases presented were secondary manifestations of a systemic lymphoma in ocular tissues; two cases represented primary disease. Three cases were "peripheral T-cell lymphomas (PTCL), unspecified" with positivity for CD3, CD8, and betaF1 and negativity for CD56. Two cases were CD3+, CD30+, and CD56- and were classified as "anaplastic large-cell lymphomas of T-cell type" (T-ALCL). The remaining two cases showed an immunophenotype of CD3+, CD56+, and betaF1- and proved to contain Epstein-Barr virus (EBV) by in situ hybridization, consistent with "T/natural killer (NK)-cell lymphoma of nasal type." Clonal T-cell populations were shown in all three of the PTCLs by Southern blot (n = 1) and polymerase chain reaction (n = 2) for the T-cell receptor gamma and beta genes in one case of ALCL but not in the T/NK-cell lymphomas. Five patients died within 2 years; only two patients (one primary PTCL and one cutaneous T-ALCL) were disease free at 4 and 5 years' follow-up, respectively.

CONCLUSION

This study shows that a heterogeneous group of T-cell lymphomas can involve the eye and its adnexal tissue. Most T-cell neoplasms are secondary manifestations of systemic disease and carry a poor prognosis. These findings, in conjunction with published data on ocular B-NHL, also indicate that immunophenotypic differentiation between T- and B-NHL in these locations is of clinical importance.

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.

Clinical and radiological presentation of 95 orbital lymphoid tumors

BACKGROUND

Although most orbital lymphoid tumors are characterized by a slow, painless onset and a mass that molds to orbital structures, different presentations may occur. Intensity on T2-weighted MRI is a possible means for differentiating lymphoid tumors (hyperintense) from pseudotumors (hypointense). In addition, it is generally assumed that 75% of orbital lymphomas are at stage I on presentation.

METHODS

The clinical, CT, and MRI presentation of 95 primary and secondary orbital lymphoid tumors (63 non-Hodgkin lymphomas and 32 lymphoid hyperplasias) and their histological grade and staging were reviewed. Immunohistochemistry and PCR were used to determine clonality.

RESULTS

No significant differences were found between non-Hodgkin lymphomas and lymphoid hyperplasias, except for the mean age of the patients (6.3 years older in non-Hodgkin lymphomas). In both groups the most common presentation was a mass with an indolent course; visual impairment was seen in 13%, conjunctival redness in 25%, pain in 12%, and acute orbital inflammation in 15% of the patients. In most cases, the CT showed one or more lobulated or rounded masses, molding to adjacent structures, or a wedge-shaped enlargement of the lacrimal gland. Intramuscular lymphomas were rare and always associated with extramuscular masses. On T2-weighted MRI, only 35% of lymphoid tumors were hyperintense. Only 49% of lymphomas were at stage I on presentation.

CONCLUSION

An inflammatory presentation is not uncommon in orbital lymphoid tumors. Shape, molding and multiple masses can help radiological diagnosis, whereas MRI T2 intensity is unreliable. Accurate staging can disclose systemic disease in more than 50% of cases of non-Hodgkin lymphoma.

The cytological, immunocytochemical and molecular genetic analysis in diagnosis of the neoplasms of the eye, eye adnexa and orbit

The fine needle aspiration biopsy was performed in 91 patients including 57 cases of retrobulbar tumors done under CT control. All aspirates were cytologically examined. In 21 cases immunocytochemical examination was performed in order to distinguish poorly differentiated neoplasms. In 19 cases malignant lymphoma was distinguished from pseudolymphoma. Cytological diagnosis was confirmed by histopathological examination in 77 cases /84%/. One result was false positive, 3-false negative. The value of immunocytochemical methods in differential diagnosis of poorly differentiated neoplasms was stressed.

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.

Orbital lymphomas and Castleman's disease

A series of 100 consecutive orbitotomies for tumour was assessed. Lymphoid infiltrations contributed 27% and malignant non-Hodgkin lymphoma was the commonest primary malignant orbital tumour in this series. The clinical and histological features of the first histologically proven case of primary orbital Castleman's disease are reported, as are the results of a study of 27 patients with pure orbital lymphoid infiltrations. The natural history of conjunctival lymphomas differs significantly from that of pure orbital lymphomas and for this reason no conjunctival lymphomas were considered in this series (which therefore contrasts with some previous reports). Histological examination with fresh unfixed tissue available for immunohistochemical staining enhances the diagnostic accuracy of these varied underlying diseases. More than one biopsy may be required before the diagnosis is established. These are significant factors given the differing lines of management for each disorder.

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.

An overview of ocular adnexal lymphoid tumors

In comparison with our earlier colleagues quoted in the introduction, we have made substantial progress in understanding the biology of ocular adnexal lymphoid tumors. While we have refined various categories with prognostic clinical value regarding possible associated systemic disease, none is foolproof and all have varying degrees of unpredictability. Comparatively well-differentiated histologic subtypes predominate among ocular adnexal lymphoid tumors. Polyclonal lesions occur less than half as often as monoclonal B-cell lesions. Molecular genetic studies have revealed small clones of monoclonal populations among the B-cells comprising most of the immunophenotypically polyclonal lesions, but no clonal genetic rearrangements have been uncovered within the preponderant constituent T-cell populations. The overall prognosis for ocular adnexal lymphoid tumors is excellent; when lumped together, 67% are not found to be associated with systemic disease with mean follow-ups of over 4 years. This is similar to experience with extranodal and extralymphatic lesions in other sites of the body, which also frequently have a small lymphocyte composition. The incidence of nonocular disease in all categories of our studies, however, will probably increase with the acquisition of longer follow-ups. Careful histopathologic evaluation is as good as immunophenotypic analysis of these lesions in predicting clinical outcome in terms of associated nonocular disease. Polyclonal and well-differentiated B-cell monoclonal lesions displayed equivalent clinical behavior. Benign polyclonal lesions may be associated with systemic disease but in a minority of cases (27%), as has also been determined in earlier studies. Clinical staging is the single most important predictor of associated monocular disease. In this study, patients with stage I-E disease had an 87% chance of not developing any nonocular lymphomatous lesion. We believe that this figure may also somewhat decrease with the passage of time. Precise anatomic localization of the lesion within the adnexa had considerable predictive value. Lesions of the conjunctiva fared the best; those of the orbit had an intermediate prognosis; while lid lesions had the worst prognosis. The most favorable prognosis would be held by a conjunctival lymphoid lesion in stage I-E composed of small lymphocytes. The fact that there is a fairly close equivalence in outcome between polyclonal and monoclonal well-differentiated lesions indicates that these lesions are in the vast majority of cases primary hyperplasias or primary lymphomas. The discovery by genetic probes of small monoclonal populations in immunophenotypically polyclonal lesions suggests that there is an evolution that goes on in situ.(ABSTRACT TRUNCATED AT 400 WORDS)

Gadolinium enhanced magnetic resonance imaging in the diagnosis of anterior visual pathway meningiomas

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Orbital and conjunctival lymphoma treatment and prognosis

115 patients with lymphoid tumours presenting in the orbit were seen between 1970 and 1984. The histological types were high-grade malignant lymphoma--18, low-grade malignant lymphoma--43, and indeterminate lymphocytic lesions--54. Eighteen patients were found to have disseminated lymphoma at presentation. The majority of the patients received radiotherapy to the orbit; local control was achieved in all cases and the ocular morbidity from radiotherapy was low with 11 patients developing lens opacities and 5 a dry eye. Survival of patients with stage I low-grade lymphoma and indeterminate lymphocytic lesions was similar to that of a normal population of the same age distribution. The clinic features and dissemination pattern of the low-grade malignant lymphomata and the indeterminate lymphocytic lesions were identical, suggesting that most, if not all, lymphoid masses presenting in the orbit are neoplastic rather than reactive in nature.

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.

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

We investigated the clinical, morphologic, immunologic, and molecular genetic characteristics of the lymphoid tumors occurring in 17 patients with bilateral ocular adnexal lymphoid neoplasia. We found no obvious differences in the age, sex, clinical appearance, or ophthalmic findings between patients with unilateral and those with bilateral ocular adnexal lymphoid neoplasms. Five orbital and two conjunctival lymphoid neoplasms removed from five patients were polyclonal pseudolymphomas, while nine orbital, eight conjunctival, and two eyelid lymphoid neoplasms removed from 12 patients were monoclonal B cell non-Hodgkin's lymphomas. Each pair of simultaneously bilateral lesions occurring in a single individual was morphologically and immunologically identical and exhibited identical immunoglobulin gene DNA rearrangement patterns. None of the five patients with polyclonal pseudolymphomas developed nonocular non-Hodgkin's lymphoma, but one developed a contralateral conjunctival monoclonal B cell non-Hodgkin's lymphoma. Six of the 12 patients with ocular adnexal monoclonal B cell non-Hodgkin's lymphomas developed nonocular non-Hodgkin's lymphoma. The incidence of previous or subsequent systemic nonocular non-Hodgkin's lymphoma in patients with bilateral ocular adnexal lymphoid neoplasms is comparable to that of patients with unilateral disease. In both patient groups, the development of nonocular non-Hodgkin's lymphoma is most commonly associated with ocular adnexal lymphoid neoplasms displaying follicular or diffuse small cleaved cell (poorly differentiated lymphocytic) morphologic characteristics.

Ocular morbidity after radiotherapy of orbital and conjunctival lymphoma

One hundred and fifteen patients were treated for lymphoma of the conjunctiva and orbit between 1970 and 1984. One hundred and twelve patients received radiotherapy to the orbit, of whom 73 (65 per cent) had at least one year of follow-up by an ophthalmic surgeon. Patients with low-grade lymphomas (97) mostly received 30 Gy in 15 fractions to the orbit over a period of 3 weeks. Those with high-grade lymphomas (18) mostly received 40 Gy in 20 fractions over 4 weeks. Most were treated using anterior and lateral radiation fields to the orbit with shielding of the cornea and lens. This technique delivered a mean lens dose of 15 Gy. The early and late ocular and orbital morbidity in these patients was low. Eight radiation-induced cataracts developed of which only six interfered with vision. None has needed cataract surgery. No patients developed radiation retinopathy and only 5 had disorders of ocular lubrication.

Ocular adnexal monoclonal lymphoid tumors with a favorable prognosis

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

Primary orbital lymphoma-pseudotumor (pseudolymphoma): case reports and review of radiotherapy literature

Five case reports of orbital pseudotumor (pseudolymphoma) and primary orbital lymphoma are presented. A review of the literature was conducted in search of differentiating clinicopathologic features suggestive of either condition as well as part of their natural histories. Radiotherapy series reporting beneficial results are summarized.

Atypical histiocytic granuloma. Light microscopic, ultrastructural, and histochemical findings in an unusual pseudomalignant reactive lesion of the oral cavity

Four cases of an ulcero-proliferative lesion of putative histiocytic origin, arising in the oral cavity, are described. This lesion, which has not been defined previously, is easily confused histologically with a malignant process of lymphoid origin, thereby representing a pseudolymphomatous proliferation. Light microscopic, ultrastructural, and histochemical characteristics including immunoglobulin negativity, positive esterase reactivity, and positive peanut lectin binding support a histiocytic origin. These lesions are not associated with systemic disease or dissemination and heal spontaneously despite their worrisome microscopic appearance.

The use of computed tomography and ultrasonography in the evaluation of orbital masses

The combined use of computed tomography scans with multiplanar reformation and ultrasonography makes it possible to locate orbital masses with a high degree of accuracy, and sometimes even to determine their histological nature without surgical biopsy. One of the unique features of computed tomography is its ability to distinguish both normal and abnormal structures of various tissue densities; this has contributed to very low false positive and false negative rates. Ultrasonography, while of limited use in the detection of posterior orbital lesions or lesions involving the orbital bones, provides an excellent cost-effective screening test for anterior and midorbit disease. It is also useful for the detection of extraocular muscle enlargement secondary to thyroid disease. In this article, a review of the characteristics and techniques of computed tomography and ultrasonography is followed by discussion of the advantages and limitations of each modality in the evaluation of six common types of orbital tumefaction.

Extranodal small lymphocytic proliferation: a clinicopathologic and immunocytochemical study

Twelve patients who presented with extranodal small lymphocytic proliferations were studied. The patients ranged in age from 33 to 67 years; six were male and six female. Locations of the initial lesion included the conjunctiva and orbit, lung, stomach, small bowel, skin, and subcutis. The histopathologic picture in all cases was that of a dense infiltrate of small lymphocytes with rounded nuclei; there were usually admixed plasma cells and sometimes germinal centers. Immunoperoxidase staining for immunoglobulin light chains demonstrated monoclonality in four cases and polyclonality in four; results were inconclusive or blocks were unavailable in the remainder. Follow-up ranged from 53 to 216 months with a median of 92 months. In three cases, there was no recurrence or recurrence only at the site of initial involvement; in three, there was a sequential involvement of different extranodal sites without significant morbidity; and in six, there was progressive disease. One of the latter patients developed nodular sclerosing Hodgkin's disease 48 months after diagnosis of the small lymphocytic process. There was no correlation between histopathologic findings and clinical source. All of the four patients with monoclonal immunoperoxidase staining and two of those with polyclonal staining had a progressive course; in the two with polyclonal staining, monoclonality was demonstrated later. It is concluded that the behavior of extranodal small lymphocytic proliferations cannot be reliably predicted by histopathologic criteria and that immunoperoxidase findings may be helpful as an indicator of an adverse course when monoclonality is demonstrated. Additional studies concerning this latter point are desirable.

Orbital lymphoid neoplasms: a clinicopathologic study of 60 patients

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

The management of lid and conjunctival malignancies

Adnexal tumors are relatively rare in a general eye practice, and the most important component in their management is early recognition. The clear differentiation between stimulating lesions and lid or conjunctival tumors can be difficult. Any recurrent lid inflammation, chronic lid ulcer, chronic unilateral keratoconjunctivitis, or a suspicious pigmented conjunctival lesion should be biopsied. The choice of treatment in lid and conjunctival tumors is partially dependent on the available surgical expertise. Lid tumors can be treated with either surgery (using frozen section control), radiation, or cryotherapy. Conjunctival tumors should first be biopsied, then treated with surgery or radiation. Exenteration is rarely indicated in the management of conjunctival tumors. A metastatic evaluation should precede possible exenteration, especially if this procedure is planned because of a recurrent or large conjunctival melanoma.

Clinicopathologic characteristics of orbital lymphoid hyperplasia

The clinical characteristics and microscopic features of the biopsy specimens of 66 patients with orbital lymphoid tumors were analyzed with respect to clinical outcome (disease remaining localized to the orbit or developing associated extraorbital lesions). The patients' average age was 63 years, and their tumors had a marked tendency to arise in the anterosuperior orbit. No clinical or radiographic findings helped to distinguish the cases of localized disease from disseminated disease. The lesions were divided microscopically into three categories: reactive lymphoid hyperplasia (16), atypical lymphoid hyperplasia (38), and malignant lymphoma (12). Extraorbital lesions developed in 25%, 50%, and 75% of cases, respectively. The five-year mortality rates were also significantly different for each type of lesion: 6%, 19%, and 58%, respectively.