|Year : 1984 | Volume
| Issue : 2 | Page : 101-104
Management of eyelid lymphoma
JK Singh, KK Singh
Radium Institute, patna Medical College Hospital Patna, India
K K Singh
New Bahadurpur area, South East of Rajender Nagar,Patna-800 016
|How to cite this article:|
Singh J K, Singh K K. Management of eyelid lymphoma. Indian J Ophthalmol 1984;32:101-4
In spite of maximum care to arrive at a definite diagnosis by whatever method of investigations, the treatment aspect of such primary lymphoma of eye lid is still under maximum disputes,. In this regard interesting facts emerge whether such malignant tumors should be locally treated by conservative method of surgery and radiotherapy or they should be treated on the prescribed line of treatment recommended for lymphoma at any other sits. Whether to give benefits of doubt to the histopathological and clinical confusions and disputes or the treatment aspect should be such, as to cover the involved part with wide over margin. In this context the authors' view is that, benefit of doubt should be granted to the patients rather than the clinico-pathological controversy.
| Materials and method|| |
Case No. 1
A 14 years old female child with two distinct small separate swellings in the upper eyelid, each one measuring nearly 1.25 to 1.98 cm in diameter. They appeared as two tiny nodules which increased to attain bigger size within a variable period of seven months. They were non-tender, firm and fixing. There was partial distortion of the upper eyelid. There was no other swelling anywhere anywhere in the body Both eye balls were completely normal including conjunctiva and cornea. On ophthalmoscopic examination. Liver or spleen was not palpable. There was no relevant family or personal history. The patient was throughout afebrile. WR & VDRL were found negative. The haematological, WR & LVDRL; urine & radiological. The repeated surgical attempts to remove the swelling resulted in rapid recurrence. Histopathologic examination revealed the presence of reticulum type of cell s with many mitotic divisions and hyperchromatic nuclei surrounded by lymphocytic cells, specially around the blood vessels.
Case No. 2
A 43 years old labourer in a Jute factory complained of difficulty in closing the left eyelid for the last eight months. Inspite of household and general medicinal treatment the swelling in the eyelid did not subside. Instead it had become a multinodular firm swelling with thickening and oedema of the overlying skin situated at the lateral half of the left upper eyelid. It was nontender and produced proptosis. Ophthalmoscopic examination of both the eye revealed normal fundus. The vision was alright. Routine haematological, radiological and other related investigations were not found significant Histopathological examination reported mature lymphocytic infiltration and other cells showing nuclei of different shape, size and staining property with frequent mitotic divisions.
Case No. 3
A 53 years old farmer presented with disturb ing itching over and around the left lower eyelid which he had for the last 18 months Usual medicinal treatment could not help. He was operated upon About 9 months ago. The patient remained satisfied for nearly 3 months until he started the same trouble again. He was operated again by different Surgeon and tissue was sent for histopathological report. Ii revealed nodular and differentiated lymph. ocytic type of malignant lymphoma. Family and personal history was not remarkable neither routine investigations reveled anything meaningful.
| Principle and technique of treatment|| |
The principle of treatment evolved was not only to cover the affected eyelid but to give proper radiation to all the nodes upto supraclavicular level by anterior and posterior fields of radiation. The anterior field included the area from one cm. above the supraorbital arch down below upto clavicle. Medically the field area covered 1 cm. across the midline. Laterally the radiation area covered the lateral end of the supraorbital arch. The posterior field did not level of infraorbital margin down to the level of clavicle posteriorly. The reason of not including the upper eyelid form the posterior field was to avoid unnecessary radiation to the base of the skull and posterior part of the orbital content. The possibility of radiation cataract could not be avoided since, the doses received at 4 cm. behind the eyelid was nearly above 3000 rads in 4 weeks time and in this range of dose formation of cataract in follow up period could not be ruled out. The treatment was done by Thyratron 60 Telecobalt unit with short SSD of 40 cm. The portion of trachea and spinal cord was shielded after having delivered 3000 rads by lead sheets of 10 cm. thickness which was supposed to reduce the radiation by nearly 1/10th of the doses delivered. At all the level the treated area was made to receive doses of radiation between 3500 to 4000 rads in overall 4 weeks period (except trachea and spinal cord were radiation dose was restricted at nearly 3000 rads).
| Observation|| |
All the three patients were observed strictly in the follow up clinic for 3,21/2 and 2 year s respectively. In the beginning they showed marked conjunctivitis, and oral dryness. Mucositis of mild to moderate degrees occurred in the radiated area. Conjunctivitis was managed by daily irrigation of the conjunctiva by sterile normal saline followed by 3-4 times daily application of Efcorlin-N eye drop. Wherever indication of intercurrent infection was suspected, suitable broad range antibiotics were given. Mucositis pain was amicably relieved by the use of soluble Disprin and Benzocaine lozengages. A judicious general management was done with oral and systemic haematinics, vitamins and proteinous bland diet and supplements. In case No. 3 the patient became suddenly very anaemic with loss of appetite, requiring repeated blood transfusions in the last week of treatment. Post radiotherapeutic management was done on the same line as described above and patients were kept under continuous care and supervision effects of radiation. At occasions 40 units of ACTH was given by intramuscular injection to reduce the inflammatory interstitial oedema.
No permanent and irrecoverable damage to any anatomical structure or functional capacity was caused by the applied mode of radiation dosimetry.
| Discussion|| |
It is evidently true that, lymphoid tumours of the orbit present considerable diagnostic difficulty for the pathologist. Considerable lack of agreement among skilled observers concerning terminology and cell type persisted,. The basic histologic pictures found in Foster et a1 series were lymphocytic and reticulum cell type of malignant lymphoma. They reported that lymphomas might occur unilorally or bilaterally in the lids, conjunctiva, lacrimal gland, or posterior orbit and noted that the prognosis did not seem to vary on the location of the disease.
In several studies the incidence of patients with primary eye lesion developing generalised disease was not stated. However, such an occurrence was reported in 7 to 9 patients by Ahlstrom et a1 at 1-10 years interval after treatment of the primary lesion. Irradiation has generally been considered the treatment of choice and many authors,, believed that surgical intervention should usually be indicated only to establish the diagnosis and if surgical excision of the mass was already done, post-operative radical radiotherapy should follow. Foster et a1 also reported that 6 of their 9 patients developed generalised disease within one year after treatment.
In the present series all the patients had swelling and proptosis of the eyelid and in 2 out of the 3 cases the involved site was painful, looked inflammed and was tender to some extent but in none of them orbital bones were found involved neither there was any evidence towards generalisation of the disease during follow up period. Only one patient was very young in age and at this age group eye-lid lymphoma has not been found a common site in the available literature.
Wide field irradiation included the primary site of the lesion and radiation field was extended to cover the ipsilateral nodes upto supraclavicular level. This was done with the view that such radiosensitive tumours also have been well documented for frequency with which wide extension of the disease occur in the future and so, a conservative localised radiation to only the local lesion may lead to recurrence around the treated site or extension of the disease in the form of nodal involvement in the surrounding area. The radiation doses given were also in tune of recommended doses for the treatment of malignant lymphoma at other sites. Mild to moderate radiation reaction was tolerably recoverable by frequent and meticulous checkup and management of the patients on just conservative lines.
None of the cases showed any distortion of the eyelid or any permanent damaging sequela of the treatment etc. Patients recovered from the radiation side effects within 6 weeks after completion of treatment. Very slow cataract formation changes were seen in one of the patients. In face of danger to life with recurrence at low dose radiotherapy for protecting lens, possibility of cataract formation was happily accepted in our view. This is why we have included ipsilateral node upto supraclavicular level in our radiation field. It is a trial on small number of available cases and without long enough follow up period to conclude about the above recommendation, we earnestly feel that this modality and principle of treatment need further evaluation on larger number of patients and with longer duration of follow up period.
| Summary|| |
3 patients with malignant lymphoma of lids treated with radiation are described.
| References|| |
|1.||Turner. L.. and Howell, D., 1956, South. M.F. 59:1036. |
|2.||Zimmerman, L.E. 1964, Lymphoid Tumors in Ocular and Adnexal Tumors. Edited by M. Boniuk. Chapter 17. C.V., Mosby Company, St. Louis, 1964. |
|3.||Foster, S.C., Wilson, C.S. and Trefter, P.K., 1971, Am. J. Roentgenol. Radium Ther. Nucl. Med. 111:343. |
|4.||Ahlstrom, S., Lindgren M and Olivercrona, H., 1965, Radiologic treatment of Orbital lymphoma. Acta radiol. (Therapy), 3:441. |
|5.||McGvic, J.S. 1955. A.M.A. Arch. Ophthalmol. 53:236. |
[Figure - 1], [Figure - 2], [Figure - 3]