Lymphoid proliferations in the orbit: malignant or benign?

Establishment of a combination scoring method for diagnosis of ocular adnexal lymphoproliferative disease

Lymphoproliferative diseases (LPDs) of the ocular adnexa encompass the majority of orbital diseases and include reactive follicular hyperplasia (RFH), atypical lymphoid hyperplasia (ALH), and mucosa-associated lymphoid tissue lymphoma (MALToma). Lymphoid follicles (LFs) are usually observed during the histological examination of LPDs. Currently, because there is a lack of specific clinical signs and diagnostic immunohistochemical biomarkers, it is difficult for pathologists to distinguish MALToma from ocular RFH and ALH, which makes the clinical management of these conditions difficult. Here, we analyzed the clinical features of patients with ocular adnexal LPDs (n = 125) and investigated the structure of LFs in paraffin-embedded tissue samples using anti-CD23 and anti-IgD immunochemistry. We found that some clinical features including age, sex, and laterality were different among RFH, LFH, and MALToma. Additionally, immunohistochemistry revealed that the expression of IgD and CD23 was higher in RFH patients and decreased in patients with ALH and MALToma. Moreover, LFs in RFH were intact, whereas the structures of most LFs were disrupted in ALH. In MALToma specimens, few intact LFs were observed. In a further investigation, we combined the results for CD23/IgD immunohistochemistry and the structure of LFs to establish a scoring method for the differential diagnosis of LPDs. According to the BIOMED-2 protocol, we further detected IgH gene monoclonal rearrangement in 73 cases (35 RFH, 17 ALH, and 21 MALToma cases). The sensitivity of our scoring method, based on a comparison with the results of IgH gene monoclonal rearrangement detection, was 85.7% (18/21) for MALToma and 35.3% (6/17) for ALH. Our study provides a method that may be useful for the differential diagnosis of RFH, ALH, and MALToma.

Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions

OBJECTIVE

To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions.

METHODS

Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination.

RESULTS

The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %.

CONCLUSION

CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management.

KEY POINTS

• CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

Ptosis as an initial manifestation of orbital lymphoma: a case report

Ptosis on its own is an infrequent initial manifestation of orbital lymphoma. Orbital lymphoma usually presents as a palpable mass with proptosis, diplopia, and conjunctival ("salmon-pink") swelling. We report here a 62-year-old female patient who presented with right eye ptosis. The initial imaging study showed an indistinct enlargement of the superior rectus-levator muscle complex. After 3-4 months, ptosis and upward gazing movement were further restricted. The imaging study revealed a definite soft-tissue mass in the superior orbit surrounding the superior rectus-levator muscle complex. A tumor biopsy through anterior orbitotomy revealed a large diffuse B-cell lymphoma. With the experience of this case, we suggest that orbital lymphoma should be included in the differential diagnosis of ptosis accompanied by impairment of levator muscle function.

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.

Bilateral reactive lymphoid hyperplasia of the orbit in a child with Russell-Silver syndrome

Russell-Silver syndrome (RSS) primarily includes intrauterine growth retardation, postnatal growth failure, body asymmetry, and craniofacial disproportion. Four types of malignancies have been reported in patients with RSS: craniopharyngioma, testicular seminoma, hepatocellular carcinoma, and Wilms tumor.

Precursor B-cell lymphoblastic lymphoma presenting as an orbital mass

A previously healthy 12-year-old boy presented with acute onset of proptosis of his left eye. CT scan demonstrated a mass involving the left orbit, left maxillary sinus, and left ethmoid sinus with extension through the cribriform plate into the anterior cranial fossa. Incisional biopsy of the mass revealed a precursor B-cell lymphoblastic lymphoma. Precursor B-cell lymphoblastic lymphoma is a rare type of non-Hodgkin's lymphoma seen exclusively in children and young adults. This is the first reported case of precursor B-cell lymphoblastic lymphoma presenting in the orbit. Treatment is primarily by systemic chemotherapy and is potentially curative. The principal role of the ophthalmologist is in diagnosis and monitoring of such patients. The clinical features and multidisciplinary diagnosis and management of childhood non-Hodgkin's lymphomas are reviewed.

The surgical management of lacrimal gland pseudotumors

PURPOSE

Lacrimal gland pseudotumors belong to the group of orbital pseudotumor. Systemic corticosteroids are advocated as the primary treatment of choice in orbital pseudotumor, but recurrent and refractory cases are commonly described. In this retrospective study, the authors evaluate alteerative treatment options such as surgical excision or debulking of lacrimal gland pseudotumors.

METHODS

The records of 26 patients referred to the Orbital Center of Amsterdam between 1976 and 1994 with a diagnosis of lacrimal gland pseudotumor were reviewed with special reference to computed tomography scans, histopathologic specimens (in 23 patients), treatment regimens, and final clinical outcome.

RESULTS

Histopathologic review showed 15 nonsclerosing (classic) and 8 sclerosing lacrimal gland pseudotumors. Initial treatment consisted of corticosteroids alone (9/26), surgery alone (7/26), a combination of surgery and irradiation (5/26), a combination of surgery and corticosteroids (4/26), or indomethacin alone (1/26). Surgery comprised tumor excision or tumor debulking. Of the patients treated with corticosteroids alone, 55% (5/9) responded initially but only 22% (2/9) obtained a cure. However, all patients treated with surgery combined with corticosteroids/irradiation (9/9), with surgery alone (7/7), or with indomethacin alone (1/1) responded well without recurrences. The main complication of therapy was dry eye syndrome, the incidence being highest in patients who received surgery of the palpebral lobe or irradiation. The mean follow-up was 4.9 years.

CONCLUSION

Surgical excision or debulking is a safe and effective treatment option in lacrimal gland pseudotumors, even in the histopathologic sclerosing variant.

What is orbital pseudotumor?

We have reviewed the literature in order to delineate the clinicopathologic definition of orbital pseudotumor, also called idiopathic nonspecific orbital inflammation. The clinical picture of orbital pseudotumor varies widely, with signs of mass effect, inflammation and/or infiltration. On computed tomography, orbital pseudotumor presents as a unilateral focal or diffuse mass. The histopathologic hallmark of orbital pseudotumor is a mixed inflammatory infiltrate with fibrosis of varying degree. Contrary to an old belief, orbital pseudotumor is not related to orbital reactive lymphoid hyperplasia (pseudolymphoma) and is not a lymphoid tumor. Atypical histopathologic findings of orbital pseudotumor include dominant sclerosis, granulomatous inflammation, vasculitis, and tissue eosinophilia. In the absence of systemic fibroinflammatory, granulomatous, and vasculitic disease, these atypical histopathologic patterns can be considered to represent subclasses of orbital pseudotumors rather then distinct entities. Clinical and prognostic characteristics of both histopathologically classical and atypical orbital pseudotumors appear to be heterogeneous. The etiology of orbital pseudotumor is unknown, but infection, autoimmune disorder, and aberrant wound healing have all been put forward as possibilities. In conclusion, orbital pseudotumor is one distinct disease albeit with many clinical and histopathologic guises.

Are systemic corticosteroids useful in the management of orbital pseudotumors?

PURPOSE

Systemic corticosteroids are the established primary treatment for orbital pseudotumors, but patients with recurrent and refractory pseudotumors commonly are observed. In this retrospective study, the authors aimed to assess the value of corticosteroids in the management of orbital pseudotumor.

METHODS

The clinical notes, computed tomography scans, and histologic specimens of patients with orbital pseudotumor seen at the Orbital Center, Amsterdam, between 1976 and 1994 were analyzed with particular regard to the clinical and visual outcome. The patients were categorized according to the anatomic location of the pseudotumor within the orbit. Patients with pseudotumors restricted to the lacrimal gland or an extraocular muscle were excluded.

RESULTS

The authors studied 32 patients with orbital pseudotumor, 20 of whom had histopathologic confirmation. Twenty-seven of these 32 patients received systemic corticosteroids as an initial treatment. Of these 27 patients, 21 (78%) showed an initial response and 10 (37%) obtained a cure. After the initial response, 11 (52%) of the 21 patients recurred. Optic nerve involvement was present in 13 (41%) of the 32 patients, and all except 1 patient recovered with corticotherapy. The mean follow-up of therapy was 4.3 years (range, 5.3 months-21.5 years).

CONCLUSION

The authors found a moderate response, a high recurrence, and a low cure rate in patients treated with corticosteroids for orbital pseudotumor, and they therefore challenge the value of corticosteroids in both diagnosing and treating this condition. However, in patients with pseudotumor-induced optic neuropathy, corticosteroids remain of value.

Results of radiotherapy in patients with stage I orbital non-Hodgkin's lymphoma

This paper describes the results of radiotherapy in early stage orbital non-Hodgkin's lymphoma. From 1970 to 1985, 33 orbital localizations in 30 patients were treated. The total dose applied ranged from 21 to 57 Gy (2 Gy per fraction), two-thirds of all patients received a dose of 40 Gy. The complete-response rate was 94% and the 10 years actuarial survival was 90%; no significant difference in survival was observed between patients with low grade or intermediate grade lymphoma. No local recurrence was detected during follow up and 20% of the patients developed generalized disease. Two optic nerve neuropathies and three retinopathies were observed in five patients, four of these occurred at a dose level of less than 43 Gy. Keratitis occurred in 58% of the patients treated, a sicca syndrome in 30% and cataract of different grades in 58% of the patients treated. Although local control was excellent, severe complications were observed in 13% of the patients who received a dose of less than 43 Gy.

Potential antigen-presenting cells in normal extraocular muscles demonstrated with double immunoenzyme staining

Antigen-presenting cells are of crucial importance for the initiation and regulation of regional immune responses. In a previous study, indirect morphological evidence that morphologically normal human orbital tissues contain HLA-DR-positive macrophages, which may represent antigen-presenting cells, has ben obtained. In the present study, these cells were characterized in detail using double immunoenzyme staining techniques with monoclonal antibodies directed against several well-characterized monocyte/macrophage markers and against HLA-DR gene products. The orbital muscular tissues appear to contain numerous HLA-DR, monocyte/macrophage marker double-stained cells, which are considered to be potential antigen-presenting cells. The cells are widely distributed in the connective tissue of all the orbital muscular tissues studied and consist of several subsets with different phenotypes. Furthermore, site-specific differences were shown between recti muscles and the levator/Müller's muscles with respect to the distribution of HLA-DR and one monocyte/macrophage marker (OKM5). Many of the orbital antigen-presenting cells appear to be of the dendritic type and are considered to be of major importance in regulating local orbital immunity.

Immunological responses in the eyelid and orbit

Immunological responses in the eyelid and the orbit are reviewed: (1) A local immune response is dependent on the presence of lymphoid tissue in an organ. Lymphoid tissue is found in the conjunctival fornices and in the lacrimal gland but not in the orbit. The eyelids also have lymphatic drainage into the local lymph nodes. A local immune response is found in the palpebral conjunctiva and in the lacrimal gland, measureable both as immunoglobulin or specific antibody levels in tears or as immunoglobulin producing cells within the tissue. No local immunity has been demonstrated in the orbit. (2) The other type of immune response found in the eyelids, the lacrimal gland and the orbit is the involvement of these tissues in systemic diseases. Systemic diseases with an immunological basis, which affect the above mentioned tissues are: atopic diseases of the skin, autoimmune diseases, immunodeficiency diseases and lymphoproliferative diseases. (3) Finally, it is possible that the extraocular muscles and the lacrimal gland have tissue specific antigens and therefore may be target tissues for organ specific autoimmune processes.

A primary extranodal lymphoma associated with IgM-kappa paraproteinaemia: different secretory capacities of cutaneous and circulating lymphoma cells

We report a patient with non-Hodgkin's lymphoma of small lymphocytic type with IgM-kappa monoclonal gammopathy who developed extranodal involvement with orbital and nasal manifestations, followed by generalized subcutaneous nodules. Immunological study disclosed that the peripheral blood and the subcutaneous nodule were both involved in a common monoclonal proliferation of B cells at various stages of differentiation, including secretory cells which accounted for the serum paraprotein. The secretory capacity was far greater in the peripheral blood than in the subcutaneous tissue. These clinical and immunological manifestations might reflect the physiological behaviour of a particular B cell subset which shows a preference for mucocutaneous sites to secrete IgM in the peripheral blood.