Ocular adnexal non-Hodgkin's lymphoma: a review of epidemiology and risk factors

Primary ocular adnexal mantle cell lymphoma with distant spread and involvement of the contralateral eye one year later; a case report and literature review

We herein report a middle-aged gentleman who initially presented with ocular adnexal mantle cell lymphoma (MCL) on the right eyelid. The lesion was excised and the patient was treated with radiation therapy. During the initial presentation, a PET CT was performed and did not reveal disease involvement beyond the eyelid. The patient presented 3 months later with ocular adnexal MCL of the contralateral eye. Re-evaluation using PET CT revealed a slight increase in the uptake in several lymph nodes and the spleen, which, after biopsy, confirmed systemic MCL. The patient was started on six cycles of chemotherapy. The patient also underwent autologous hematopoietic stem cell transplant. Approximately 80% of primary ocular adnexal lymphomas are B-cell in origin, with MCL being the rarest subtype constituting only 5% of B-cell ocular adnexal lymphomas. Despite its rarity, it is crucial for clinicians to detect the entity early and ensure rapid initiation of appropriate therapy.

Declining incidence and improving survival of ocular and orbital lymphomas in the US between 1995 and 2018

This epidemiological study examined ocular and orbital lymphomas in the United States from 1995 to 2018, using data from the North American Association of Central Cancer Registries database of 87,543 patients with ocular and adnexal malignancies. We identified 17,878 patients (20.4%) with ocular and orbital lymphomas, with an age-standardized incidence rate (ASIR) of 2.6 persons per million (ppm). The incidence was the highest in the orbit (ASIR = 1.24), followed by the conjunctiva (ASIR = 0.57). Non-Hodgkin B-cell lymphoma was the most prevalent subtype (85.4%), particularly marginal-zone lymphoma (45.7%). Racial disparities were noted, with Asia-Pacific Islanders showing the highest incidence (orbit, 1.3 ppm). The incidence increased significantly from 1995 to 2003 (Average Percent Change, APC = 2.1%) but declined thereafter until 2018 (APC = - 0.7%). 5-year relative survival (RS) rates varied, with the highest rate for conjunctival lymphoma (100%) and the lowest for intraocular lymphoma (70.6%). Survival rates have generally improved, with an annual increase in the 5-year RS of 0.45%. This study highlights the changing epidemiological landscape, pointing to initial increases and subsequent decreases in incidence until 2003, with survival improvements likely due to advancements in treatment. These findings underscore the need for further research to investigate the root causes of these shifts and the declining incidence of ocular lymphoma.

Impact of Therapy & Age in Choroidal Cancers: A Retrospective Cohort Analysis of 7722 Patients from a US National Database

Background

Collectively, choroidal cancers represent a vast array of histopathologically diverse constituencies with profound repercussions related to mortality and metastasis. Prognosticated factors provide utility in determining clinical management and outcome propensities. To date, measures to collectively characterize choroidal cancers as a class are not impressive. This study aims to shed light on the affiliation of age and therapeutic modalities to survival in patients diagnosed with choroidal cancers.

Methods

Cohort analysis using the Surveillance, Epidemiology, and End Results (SEER) program, a freely accessible population-based database, was executed from 1975 to 2016, a 41-year time window. Univariable and multivariable Cox regression assessed survival with age and various therapeutic modalities as primary independent variables. Adjustment for several demographical and clinical variables was performed.

Results

This cohort consisted of 7722 patients at the time of diagnosis. Multivariable Cox regression demonstrated increased cause-specific hazards of 71.8% for patients aged 75+ years (HR = 1.718, CI 1.155-2.555, p < 0.008) as compared to patients aged 0-24 years. 16.2% and 58.0% increases in cause-specific mortality were showcased in patients diagnosed with 8770/3: mixed epithelioid and spindle cell melanoma (HR = 1.16, p = 0.029) and 8771/3: epithelioid cell melanoma of the choroid (HR = 1.580, p < 0.001) compared to individuals diagnosed with 8720/3: malignant melanoma NOS of the choroid. Chemotherapy significantly influenced survival in patients with choroidal cancers compared to those who did not receive chemotherapy or had an unknown status (HR = 0.377, CI 0.292-0.486, p < 0.001).

Conclusion

Like most cancers, choroidal cancers showcase poor clinical trajectory with advanced age. Specific ICD-O-3 histological subtypes predispose to increased mortality. Therapeutic modalities such as radioactive implants and chemotherapeutic agents demonstrate decreased cause-specific mortality compared to alternative treatments. Altogether, nuanced influences of age and therapy are revealed when evaluating choroidal cancers as a class, irrespective of subtype.

Augenbefall und Systemerkrankung – periokuläre und intraokuläre Lymphome

Hintergrund

Das okuläre Lymphom wird anhand seiner anatomischen Lokalisation in die intraokulären und periokulären Lymphome eingeteilt. Intraokulär kann die Uvea mit ihren Strukturen betroffen sein oder die Retina in Verbindung mit dem Glaskörper. Die periokulären Lymphome treten in Orbita, Bindehaut, Tränenapparat oder Lid auf. Von großer Bedeutung ist die Unterscheidung zwischen primären Lymphomen der Region oder systemischem Befall. Über die letzten Jahrzehnte konnte in den westlichen Ländern eine konstant steigende Inzidenz okulärer Lymphome nachgewiesen werden.

Ziel

Dieser Beitrag soll einen Überblick über die vielfältigen Manifestationen, Diagnostik, Therapie sowie Prognose und Nachsorge geben.

Material und Methoden

Der Beitrag basiert auf einer selektiven Literaturrecherche über die MEDLINE-Datenbank zum Thema okuläre Lymphome sowie den persönlichen Erfahrungen der Autoren.

Ergebnisse

Je nach Lokalisation können die Symptome sehr unterschiedlich sein. Die Diagnose erfolgt über eine Probebiopsie und anschließende zytologische/histologische und ggf. molekularpathologische Untersuchung. Strahlentherapeutische sowie systemische Verfahren stellen die am häufigsten angewendeten Therapieverfahren dar. Die Prognose hängt sehr stark von der Lokalisation, dem Subtyp des Lymphoms sowie dem Ausmaß des Tumorbefalls ab.

Diskussion

Das okuläre Lymphom berührt in Diagnostik, Therapie und Nachsorge die Schnittstellen zwischen Ophthalmologie, (Hämato‑)Onkologie, Strahlentherapie, Neurologie, Neurochirurgie, Mund-Kiefer-Gesichts-Chirurgie, Hals-Nasen-Ohren-Heilkunde, Dermatologie, Radiologie, Pathologie und Psychoonkologie. Dabei spielt der Augenarzt als Eingangsarzt bei dieser Systemerkrankung eine wesentliche Rolle.

Disparities in Ocular and Periocular Cancer Outcomes: Assessing Survival in Patients of Hispanic Origin

A nationwide cancer database was used to perform a retrospective cohort study to compare the overall survival and cause-specific survival in patients with ocular and periocular cancer from varying Hispanic origins. A total of 19,831 cases from the Surveillance, Epidemiology, and End Results (SEER) registries between 1973 and 2015 were obtained for analysis. All-cause and cause-specific mortality risk, with adjustment for age group, sex, race, tumor site, tumor histology, grade, summary stage, laterality, surgery status, radiotherapy status, and chemotherapy status, was examined using Cox proportional hazard models. Of the patients included 19,194 patients were non-Spanish-Hispanic-Latino, and 637 patients were Spanish-Hispanic Latino. The Spanish-Hispanic-Latino population was further subdivided as 398 of Mexican origin, 44 of Puerto Rican origin, 135 of South or Central American (excluding Brazil) origin, and 60 of other Spanish/Hispanic origin (including Europe origin). The mean (+/-SD) follow-up period was 98.57 (+/-93.23) months. In adjusted Cox regression, patients of Spanish-Hispanic-Latino origin demonstrated increased all-cause (HR, 1.173; 95% CI 1.022-1.347; P = 0.023) and cancer-specific mortality (HR, 1.328; 95% CI 1.099-1.604; P = 0.003) as compared to their non-Spanish-Hispanic-Latino counterparts. Upon subclassification by Hispanic origin, patients of Mexican origin had significantly increased all-cause (HR, 1.229; 95% CI 1.032-1.464; P = 0.021) and cancer-specific mortality (HR, 1.516; 95% CI 1.204-1.909; P < .001) and patients with other Hispanic/Spanish origin, including Europe, had significantly increased all-cause (HR, 1.627; 95% CI 1.16-2.28; P =0.005), but not cancer-specific (HR, 1.243; 95% CI 0.734-2.104; P = 0.418) mortality. Patients of Puerto Rican origin and South or Central American (excluding Brazil) origin had no significant difference in all-cause or cancer-specific mortality compared to those of non-Spanish-Hispanic-Latino origin. Mortality risk from ocular and periocular cancers varies extensively by specific Hispanic origin. A greater understanding of these disparities is essential to identify vulnerable populations and provide adequate treatment to optimize long-term outcomes.

Epidemiology of ophthalmic lymphoma in Canada during 1992-2010

BACKGROUND

Ophthalmic lymphoma (OL) is the most common orbital tumour, particularly in older individuals. Little is known about the epidemiology and geographic distribution of OL in Canada. Descriptive demographic statistics are an important first step in understanding OL burden and are necessary to inform comprehensive national cancer prevention programmes.

METHODS

We determined patterns of incidence and geographical distribution of the three major subtypes of OL: extranodal marginal zone B cell lymphoma, follicular lymphoma (FL) and diffuse large B cell lymphoma. Here, we used cases that were diagnosed during 1992-2010 using two independent population-based cancer registries, the Canadian Cancer Registry and Le Registre Québécois du Cancer (LRQC).

RESULTS

The OL mean annual age-standardised incidence rate for 1992-2010 was 0.65 cases per million people per year with an average annual increase in the incidence rate of 4.5% per year. The mean age of diagnosis was 65 years. OL incidence rate was the highest in the cities located along the heavily industrialised Strait of Georgia in British Columbia.

CONCLUSIONS

Our data on patient age, sex and temporal trends showed similarities with data reported in the USA and Denmark. Additional studies are needed to determine whether the observed increase in OL incidence is genuine or spurious.

Understanding and Classification of Ocular Lymphomas

BACKGROUND

Lymphomas that involve the tissues of the ocular adnexae and the eye itself can be confusing for both the new and seasoned learner alike. In this review, I present a simple way of classifying these disorders that will help to facilitate understanding of these myriad entities.

SUMMARY

Classifications of lymphomas have changed significantly over the last 40 years, but in recent decades, the basic structure of the WHO classification has remained the same, facilitating understanding.

KEY MESSAGES

The ocular lymphomas can be divided into those that are external to the eye (ocular adnexae) and those that are internal (vitreoretinal and uveal). At each of these sites specific subtypes of lymphoma are common. Focusing on these common subtypes can aid the learner to create a scaffold that enables current understanding and upon which they can build for the future.

Unilateral conjunctival infiltration of Adult T-cell leukemia/lymphoma. Case report and literature review

Adult T-cell leukemia/lymphoma (ATLL) is a peripheral T-cell lymphoma caused by human T-cell leukemia virus type 1 infection. Although conjunctival lymphoma is commonly reported with B-cell lymphoma, it rarely occurs in cases of ATLL. A 73-year-old Japanese female patient was admitted to our institution with evidence of abnormal lymphocytes, lymphadenopathy, and lung nodular lesions. Acute type ATLL was diagnosed, and therapy following the mLSG15 protocol was initiated. At the end of the second course, new bone lesions were detected. A modified treatment regimen was scheduled, but was postponed due to the appearance of gastrointestinal symptoms. Close observation resulted in a diagnosis of cytomegalovirus enteritis. One month after the diagnosis, the patient developed pain and discomfort in her left eye, which was determined to be due to a bulbar conjunctival tumor. Pathological findings revealed conjunctival infiltration of ATLL. Mogamulizumab treatment was initiated and was successful in eradicating the conjunctival lesions after the first course. However, at the end of the third course of therapy, pancytopenia was noted. Therefore, mogamulizumab therapy was discontinued, and the patient was on follow-up observation. Although there was no relapse of the conjunctival lesions, the patient died 1 year after the initial diagnosis, following therapy resistance.

Eyelid lymphoma in a patient with a gold weight implant

CASE REPORT

A male patient with an exposure keratopathy caused by lagophthalmos. A gold weight was implanted in the right upper eyelid. Eight months later, he presented with erythema and swelling of right upper eyelid. An incisional biopsy was performed, reporting extranodal marginal zone B cell lymphoma.

DISCUSSION

when a tumour at the site of a gold weight implant is refractory to treatment, it is essential to perform an incisional biopsy to establish the histopathological diagnosis. Ocular adnexal lymphomas are relatively common. The presence of foreign material can cause chronic inflammation that could be the stimulus for the development of a lymphoproliferative disorder.

An update on ocular adnexal lymphoma

Ocular adnexal lymphoma (OAL) is a relatively common lesion in the practice of ophthalmic oncology. Although OALs are usually primary tumors, secondary involvement of the ocular adnexae by systemic lymphoma is also possible. The clinical and radiological features of OAL are non-specific. Thorough morphological evaluation, aided by immunostaining, cytogenetic studies and molecular testing, are necessary for accurate diagnosis.

Rituximab as Single Agent in Primary MALT Lymphoma of the Ocular Adnexa

Ocular Adnexal Lymphomas are the first cause of primary ocular malignancies, and among them the most common are MALT Ocular Adnexal Lymphomas. Recently systemic immunotherapy with anti-CD20 monoclonal antibody has been investigated as first-line treatment; however, the optimal management for MALT Ocular Adnexal Lymphomas is still unknown. The present study evaluated retrospectively the outcome of seven consecutive patients with primary MALT Ocular Adnexal Lymphomas, of whom six were treated with single agent Rituximab. All patients received 6 cycles of Rituximab 375 mg/mq every 3 weeks intravenously. The overall response rate was 100%; four patients (67%) achieved a Complete Remission, and two (33%) achieved a partial response. In four patients an additional Rituximab maintenance every 2-3 months was given for two years. After a median follow-up of 29 months (range 8-34), no recurrences were observed, without of therapy- or disease-related severe adverse events. None of the patients needed additional radiotherapy or other treatments. Rituximab as a single agent is highly effective and tolerable in first-line treatment of primary MALT Ocular adnexal Lymphomas. Furthermore, durable responses are achievable with the same-agent maintenance. Rituximab can be considered the agent of choice in the management of an indolent disease in whom the "quality of life" matter is of primary importance.

Descriptive epidemiology of ophthalmic and ocular adnexal non-Hodgkin's lymphoma

In this article, we provide an update on incidence rates of ophthalmic non-Hodgkin's lymphoma (NHL), in the context of other NHL, in the USA. We also provide population-based estimates of incidence and survival for ocular adnexal NHL, the most common form of ophthalmic NHL, for which descriptive patterns have not been previously reported. Ophthalmic and ocular adnexal NHL have unique incidence patterns, including equal rates among both genders, predominance among Asians/Pacific Islanders, and steady and rapid increases in the past few decades. Studies of international variations in the incidence of ocular adnexal NHL may provide clues as to the underlying mechanisms influencing its unique epidemiology.