Journal of Clinical Oncology, Vol 19, Issue 5
(March), 2001: 1572-1573
© 2001 American Society for Clinical Oncology
Unusual Sites of Malignancy
Case 2. Orbital Lymphoma
Anthony Abner,
Roger Lange,
Gregory Gauvin
Mount Auburn Hospital, Cambridge, MACopyright © 2001 American Society of Clinical Oncology
A 60-year-old man presented with a sensation of a foreign body in his right eye. On physical examination, he was noted to have significant proptosis with conjunctival reaction ( Fig 1). A computed tomography scan showed a large orbital mass ( Fig 2). A biopsy was positive for a low-grade B-cell lymphoma composed mainly of small cells. A gallium scan showed increased uptake limited to the orbit ( Fig 3). Radiation therapy was administered using computed tomography planning with computerized isodose contours ( Fig 4) There was an obvious mass in the lateral orbit extending beyond the lateral canthus with proptosis. In order to treat the entire volume of disease and minimize dose to the normal brain, an anterior beam was paired with a right lateral beam. The red isodose line shows that the entire tumor volume received 100% of the administered dose, while the optic chiasm received less than 50%. It was not possible to find a beam arrangement that spared the lens; thus, there is a very high probability of cataract formation. After 20 Gy was delivered using this field arrangement, the patient was resimulated with reduced fields ( Fig 5) to account for the change in contour. Note the substantial regression in the mass and the extent of proptosis. Follow-up six weeks after completion of treatment showed no clinical evidence of proptosis. Three years after treatment, the patient remains without evidence of either recurrent disease in the orbit or progression elsewhere. His vision is normal, although he initially complained of tearing of the eye, presumably due to blockage of the nasolacrimal duct, and subsequently of a dry eye.
Orbital lymphomas are predominately low-grade, small, B-cell types and are associated with systemic disease occurring either sequentially or concurrently in about one third of cases; this risk seems to increase with bilateral orbital involvement.1 Jenkins et al2 have reviewed 180 cases and reclassified these according to the Revised European American Lymphoma system. The risk of distant relapse was greatest in those patients with diffuse large-cell lymphoma and for those patients with marginal zone lymphoma. The use of intensity-modulated radiation therapy with both photons and protons has recently been reviewed.3 The majority of patients will have normal vision, and damage to the optic nerve is rare, although cataract formation will occur in a large fraction of patients who are treated without lens blocks.4-6
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