Report of a Primary Lymphoma of the Conjunctiva

Path. Res. Pract. 187, 78-84 (1991)

Report of a Primary Lymphoma of the

Conjunctiva:~

A Lymphoma of MALT Origin? 1. Petrella, A. Bran, A. Foulet, L. Arnould, L. Chirpaz and R. Michiels Laboratoire d'Anatomie Pathologique, Faculte de Medecine, Dijon, France

SUMMARY A case of primary conjunctival lymphoma is reported herein. A 47-year-old woman presented with an indolent salmon-coloured tumour of the lower epibulbar conjunctiva. Histologically, we found a lymphoid infiltrate in the epithelium and subepithelium consisting oftwo components. One component was characterized by centrocytic-like cells and the other by lymphocytic, plasmacytoid and plasma cells. An immunohistological study demonstrated a light chain restricted immunoglobulin expression ofthe tumour cells as well as some residual polytypic follicles exhibiting reticular dendritic cells. Tumour cell proliferation was associated with a T cell reactive population. A comprehensive investigation (in particular an orbital scan) did not demonstrate any other localization of this lymphoma. Such a lesion raised the question of a possible MALT origin, by analog with MALT-lymphomas of the gastrointestinal tract described by Isaacson and colleagues.

Introduction Ocular lymphoid infiltrates can be found in the orbit, conjunctiva, eye lids and lacrimal glands. Most previous studies have not distinguished between lymphoid infiltrates of the conjunctiva, which normally contains lymphoid tissue and the orbit, lids and lacrimal glands which do not l4 . This is primarily because most lymphoid infiltrates occur in the orbit and cases in others sites are too infrequent to be examinated separately. An additional reason that most studies do not distinguish between the locations of lymphoid infiltrates is because some of them are multifocaP, 24. The nature of ocular lymphoid infiltrates is difficult to determine. Knowles and Jacobiec proposed in 1980 a classification based on morphology and clinical outcome. This classification identified 4 groups: 1) inflammatory pseudo-tumour, 2) reactive lymphoid hyperplasia, 3)

* Supported by a grant from the "Ligue Bourguignonne de Lutte contre Ie Cancer". 0344-0338/91/0187-0078$3.50/0

atypical lymphoid hyperplasia and 4) malignant lymphoma 13 • Presently, immunohistochemical studies allow a more precise determination of the benign or malignant nature of ocular lymphoid infiltrates3, 6,16,25. Nevertheless, the conjunctiva deserves particular attention because it is a mucosa unlike the orbital tissue and it is the only ocular adnexa which prossesses its own lymphoid tissue 14 • This conjunctival associated lymphoid tissue (CALT) protects the eye against foreign antigens. Histiocytic Langerhans-type cells, T lymphocytes, B lymphocytes and IgA plasma cells are components of CALTt, 2. In physiological conditions, most of the epithelial and subepitheliallymphocytes are T cells (predominantly T 8). B lymphocytes, found only in the subepithelium, are rare and may be either scattered or grouped in follicles. IgA plasma cells are also rare and only found in association with Krause glands 22 . Such a mucosal lymphoid system has also been described in other mucosa and in particular in the gastro-intestinal tract 20 . Several cases of extranodal malignant lymphomas arising from the gastro-intestinal associated lymphoid tissue (GALT) have been recently reported 7- 1O,18. © 1991 by Gustav Fischet Vetlag, Stuttgart

Conjunctival Primary Lymphoma . 79

In this paper we report a case of primary malignant lymphoma of the conjunctiva with an immunohistological study and propose that this lymphoma arose from CALT. Case Report

Clinical data A 47-year-old woman was referred to the Department of Ophthalmology, Dijon General Hospital, with a four month history of right eye discomfort. An ophthalmological examination revealed a salmon-coloured tumour of two millimeters thickness by three millimeters in width involving the entire lower epibulbar conjunctiva between the two canthi (Fig. 1). Pain and epiphora were absent. A physical examination was noncontributory. A conjunctival tumour biopsy and subsequent excision was performed under local anesthesia. Part of the specimen was fixed in Bouin's solution and embedded in paraffin and plastic (Durcupan) with the remainder snap-frozened for immunohistological studies. Protein immunoelectrophoresis, chest X-ray, orbital and total body CT scans, abdominal sonogram, gastroscopy, colonoscopy and bone marrow biopsy were unremarkable. The patient did not receive any treatment other than the local excision of the tumour. After one year of follow-up no relapse has occurred.

Fig. 2. Lymphoid infiltrate of the conjunctiva resembling a thin band (Paraffin-embedded section, HES, x 40).

Histological findings We observed an epithelial and superficial subepithelial lymphoid infiltrate forming a thin band without involvement of the deep mucosa (Fig. 2). This infiltrate had an obvious biphasic appearance. One component consisted of areas of small centrocytic-like (CCl) cells with clumped

Fig. 3. Centrocytic-like cellular component with epithelial infiltration (Paraffin-embedded section, HES, x 320).

Fig. 1. Salmon-coloured lesion of the epibulbar conjunctiva.

chromatin, slightly irregular nuclear contours and relatively pale or clear enlarged cytoplasms (Fig. 3). The second and moderately predominant component (approximate ratio 1.5 :1) consisted of areas of lymphocytes, plasma cells and plasmacytoid cells (Fig. 4). In some areas there were roughly nodular foci exhibiting centroblastic cells and tingible body macrophages and resembling residual germinal centers (Fig. 5). The epithelium was infiltrated by the CCL cells in some areas (Fig. 2) and completely eroded in others. We also noted numerous blood vessels, numerous hemosiderin deposits, rare polykaryocytes 12 and numerous mast cells.

80 . T. Petrella et al. Table 1. Results of immunohistochemistry on paraffin sections Antibodies

al

yl

1-1 1

AI )(.1

LN 12 LN 22 MB 2 2 UCHL

Comments Rare scattered positive plasma cells Negative Numerous positive plasma cells especially under the epithelium Rare scattered positive plasma cells Numerous positive plasma cells especially under the epithelium Some positive cells, scattered or in roughly nodular foci Most of the cells are positive Most of the cells are positive 13 Some positive cells in roughly nodular patterns

Miles (Miles-France, 13 rueJ Jaures, 93807 Puteaux, France).Biotest (Biotest, LandsteinerstralSe 5, D-60n Dreieich, FRG).Dako (Dako Corporation, 22 North Milpas Street, Santa Barbara, California, USA). I

2 3

Fig. 4. Lymphoplasmocytoid cellular component with the presence of polykaryocytes (Paraffin-embedded section, Giemsa, x 400).

MB 2 antibodies, which showed their B lymphocyte lineage. The staining with LN 1 antibody showed some positive cells in nodular foci. UCHL 1 antibody stained T cells which were most often grouped in roughly nodular patterns. A study with light and heavy chains on paraffinembedded sections demonstrated monoclonality of the tumour cells. Cytoplasms of most of the plasma cells were stained by anti-mu and anti-kappa antibodies, whereas the plasma cells stained by anti-gamma, anti-alpha and antilambda antibodies were rare and scattered. Some plasmycytoid cells were also stained by anti-mu and anti-kappa, showing a thin perinuclear staining. Interestingly, most of the monoclonal plasma cells (IgM kappa) were found in bands under the conjunctival epithelium (Fig. 6). Some

Fig. 5. Residual germinal center exhibiting centroblasts with one tingible body macrophage and one mitosis (Plastic-embedded section, HES, x 400).

Some PAS-positive intranuclear inclusions were noted in plasma cells and plasmacytoid cells (Dutcher bodies). Peds's staining confirmed numerous hemosiderin deposits.

Immunohistological findings We used a three-step immunoperoxidase technique. The antibodies used and the results of immunohistochemistry on paraffin-embedded sections are summarized in Table 1. The tumour cells were stained by LN 2 and

Fig. 6. Cluster of plasma cells underlying the epithelium stained for kappa chain (Paraffin-embedded section, X 300).

Conjunctival Primary Lymphoma· 81 Table 2. Results of immunohistochemistry on frozen sections Antibodies

CD

Comments

al

xl

NA NA NA NA NA NA

Rare positive scattered plasma cells Very rare positive cells in nodular foci Negative Most of the cells are positive Some positive cells, scattered or in roughly nodular foci Most of the cells are positive

L 26 2 Dako-CD 19 2 Dako-CD 22 2 B 63 lOB 3 1 2E 11 OKT 104 anti-ORO

NA CD 19 CD 22 CD 23 CD 24 CDw32 CD 38 NA

Most of the cells are positive Most of the cells are positive Most of the cells are positive Some of the cells in roughly nodular foci Most of the cells are positive Some positive cells in roughly nodular foci Positive for plasma cells and plasmacytoid cells Some positive cells in roughly nodular foci

lOT 6 1 lOT 11 1 IOT3 1 IOT4 1 T 12 T 22 lOT 8 1

CD 1 CD 2 CD3 CD4 CDS CD7 CD 8

Negative Some positive Some positive Some positive Some positive Negative Some positive

LeuM 35

CD 14

Very rare positive cells

01

yl

[.II

A'

cells cells cells cells

in in in in

nodular nodular nodular nodular

foci foci foci foci

and and and and

rare rare rare rare

scattered scattered scattered scattered

cells cells cells cells

cells in nodular foci and numerous scattered cells

NA: Not applicable. - I Immunotech (Luminy, 13288 Marseille, France); 2 Dako (Dako Corporation, 22 North Milpas Street, Santa Barbara, California, USA); 3 Coulter Clone (Coulter Corporation, Hialeah, Floride, USA); 4 Ortho (Ortho Diagnostic System, Raritan, New jersey, USA); 5 Becton-Dickinson (Becton-Dickinson, Moutain View, California, USA).

Fig. 7. Lymphoid infiltrate stained for kappa chain (Frozen section, x 400).

Fig. 8. Some lymphoid cells in a nodular focus stained for lambda chain (Frozen section, x 320).

intranuclear monotype stainings were also noted in scattered plasma cells and plasmacytoid cells. The antibodies and results of immunohistochemistry on frozen sections are summarized in Table 2. Cell membrane positivity for L 26, CD 19, CD 22 and lOB 3 (CD 24) antibodies confirmed the B lymphocyte lineage of the tumour cells. Furthermore, these cells exhibited mu chain

and restricted kappa chain (Fig. 7) on their membrane, which confirmed the monoclonality found on paraffinembedded sections. Some lambda chain positive cells were scattered or grouped in roughly nodular foci (Fig. 8 and lOb). Some CD 23 and CDw 32 positive cells were identified and were only located in roughly nodular foci. The anti-DRC antibody allowed the detection of some

82 . T. Petrella et al.

Fig. 9. Small residual follicle exhibiting reticular dendritic cells with anti-CRD antibody (Frozen section, x 320).

reticular dendritic cells also grouped in nodular foci of various sizes and sometimes voluminous (Fig. 9 and lOa). Comparison of the serial frozen sections revealed the nodular foci of lambda chain positive cells, CD 23 positive cells, CDw 32 positive cells and reticular dendritic cells to be concordant. OKT 10 (CD 38) antibody stained clearly some plasma cells and plasmacytoid cells, whereas all the other cells were negative. Reactive T cells represented 5 to 10% of the cells. They were scattered or grouped in nodular foci and expressed all the T antigens except CD 1 and CD 7. Among the T cells scattered in the areas of tumour cells, T 8 lymphocytes were predominant. Furthermore, CD 5 was negative on tumour cells. Discussion Primary and secondary ocular malignant lymphomas are well known and represent 4.5% of extra-nodal Non Hodgkin's malignant Lymphomas (NHL) according to Freeman 4 . The orbit is the most frequent location of ocular lymphomas 16 ,24. Isolated conjunctival involvement is rare; less than 1.5% of all conjunctival tumours s . Conjunctival lymphomas are almost always of B lymphocyte lineageS, 16. To the best of our knowledge, only one case of conjunctival involvement by a T cell lymphoma, a mycosis fungoides, has been reported 19 . By conventional histology alone it is difficult to determine the benign or malignant nature of conjunctival lymphoid infiltrates. In a retrospective study Morgan reports a misdiagnosis rate of greater than 20% 17. The differential diagnosis of conjunctival lymphoid infiltrates includes reactive lymphoid hyperplasia (RLH), atypical lymphoid hyperplasia (ALH) and conjunctival lymphomas as described by Knowles and Jacobiec 13 ,14. RLH can exist in two different patterns. It can be either a

Fig. 10. a) Voluminous residual follicle exhibiting reticular dendritic cells with anti-CRD antibody; b) The same residual follicle on a serial section exhibiting lymphoid cells stained with antilambda antibody (Frozen sections, x 320).

diffuse monomorphous infiltrate of small mature lymphocytes or a juxtaposition of numerous follicles with large activated germinal centers. In the latter pattern, germinal centers show benign signs such as numerous mitoses, tingible body macrophages and polymorphous lymphoid cells. The histogenesis of RLH is not well understood and is most likely the physiologic consequence of an endogenous or exogenous stimulus. For Knowles and Jacobiec those lesions are always polyclona[1s. These authors have also described an atypical lymphoid hyperplasia (ALH), whose benign or malignant nature was impossible to determine histologically but whose outcome was similar to RLH and generally favourable. ALH consists of a nodular or diffuse infiltrate containing, in addition to mature lymphocytes

Conjunctival Primary Lymphoma . 83 and plasma cells, some atypical lymphoid cells "of-questionable type" with more voluminous and hyperchromatic nuclei scattered in the infiltrate 13 • Work done by Medeiros et a1. on 60 conjunctival and orbital lesions showed that most of the histologically undeterminated infiltrates expressed a monoclonality and thus must be considered malignant l6 . For Medeiros et a1. the only histological criteria of malignancy was the presence of Dutcher bodies. In addition hemosiderin deposits are seen more frequently in malignant lesions16,23. CCL cells, although found in lymphomas, are also observed in benign polytypic lesions l6 . Sigelman and Jacobiec have reported that benign lesions never erode the conjunctival epithelium 23 but Medeiros et a1. did not study this parameter. Histologically, our case does not resemble the benign lesions described by Knowles and Jacobiec. At the very most it could be classified as an ALH if the CCL cells were considered as atypical lymphoid cells. Furthermore, Lennert's classification of NHL does not adequately describe our case since it contains both Iymphoplasmocytic and centrocytic-like elements. Histologic characteristics of the present case are summarized as follows: a monotype infiltrate (IgM kappa) made of a mixture of mature lymphocyte areas, plasma cell and plasmacytoid cell areas and CCL cell areas; an infiltration and erosion of the conjunctival epithelium by CCL cells; some residual polytypic follicles confirmed by immunohistological studies; monotypic plasma cells underlying the epithelium; the presence of Dutcher bodies, polykaryocytes, mast cells and hemosiderin deposits; the presence of aT-lymphocyte reactive population and a clear demarcation of the lower and lateral borders. Isaacson et a1. have described malignant NHL in the gastro-intestinal tract, arising from the GALT and called MALT-Iymphoma7-lo, 18. For Isaacson the three main components which contribute to the histology of gastric lymphoma are CCL cells, plasma cells and follicles 7. An important and distinctive feature of CCL cells is their tendency to invade mucosal epithelium and form characteristic Iymphoepithelial lesions. Those CCL cells are LN 1-, CD 23-, CD 5-, CD 22+ and CDw 32+ 7. The plasma cells are characteristically subepithelial and monoclonal but not invasive. Follicles are a prominent feature of most primary gastric lymphomas. These are usually clearly reactive and can be numerous or virtually absent 7. It is clear that most of Issacson's criteria of gastric MALT-lymphomas are similar to characteristics of the present case of primary conjunctival lymphoma. We found important histologic and immunologic similarities with the exception of the CDw 32 antigen which is usually positive in MALT-lymphomas but was negative in our case. Most of the criteria taken individually are nonspecific for a MALT-lymphoma. In particular CD 23 seems most often negative in Blymphomas 21 and CD 5 can be either positive or negative for lymphocytic lymphoma and lymphoma of follicular origin 21 . Thus CD 5 negativity cannot be a provisional criteria for MALT-lymphoma. Conjunctival RLH is most likely an abnormal reaction of the CALT-system and the presence of invaded polyptypic

folliclessugge,sts the possibility that our case developed from a pre-existing RLH and consequently from CALT. Apart from the gastro-intestinallocalizations, Isaacson et a1. report MALT-lymphomas arising from the salivary glands, lung and thyroid gland 7. Although the salivary and the thyroid glands may not possess their own lymphoid system it is possible that a MALT-lymphoma could arise from an accumulation of lymphoid cells from a preexisting disease such as myoepithelial sialadenitis or Hashimoto's disease 7. In light of the arguments discussed about the present case, we propose that the conjunctiva should be added to this list of tissue. Acknowledgements We are indebted to Professor J. Audouin (Hotel-Dieu, Paris) for reviewing the case. We also thank Mrs A. Pelletier and Mr S. Regnier for their technical assistance, Mr G. Delorme who prepared microphotographs, Professor PM Carli for providing the following monoclonal antibodies: MB 2, B 6, lOB 3, 2 E 1, OKT 10 and Dr Andrew Bourne for assistance in translation. References I Chandler ]W (1983) Immunologic defense mechanisms of the occular surface. Ophthalmology 90: 585-591 2 Chandler ]W, Axelrod A] (1980) Conjunctiva-associated lymphoid tissue: a probable component of the mucosa-associated lymphoid tissue. In: Masson (Ed). Immunologic Diseases of the Mucous Membranes; Pathology Diagnosis and Treatment. New York 3 Ellis ]H, Banks PM, Campbell R] (1985) Lymphoid tumors of the ocular adnexa. Ophthalmology 92: 1311-1324 4 Freeman C, Berg ]W, Cutler S] (1972) Occurence and prognosis of extranodallymphomas. Cancer 29: 252-260 5 Grossniklaus HE, Green WR (1987) Conjunctival lesions in adults: a clinical and histopathologic review. Cornea 6:

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mucosa-associated lymphoid tissue. A distinctive type B-cell lymphoma. Cancer 52: 1410-1416 10 Isaacson PG, Wright DH (1984) Extranodal malignant lymphoma arising from mucosa-associated lymphoid tissue. Cancer 53: 2515-2524 II ]akobiec FA, Me Lean], Font RL (1979) Clinicopathologic characteristics of orbital lymphoid hyperplasia. Ophthalmology 86:948-966

12 Kjeldsberg CR, Kim H (1981) Polycaryocytes resembling Warthin-Finkeldey giant cells in lymphoid disorders. Hum Pathol

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13 Knowles OM, ]acobiec FA (1980) Orbital lymphoid neoplasms. A clinicopathologic study of 60 patients. Cancer 46:

576-589

84 . T. Petrella et al. 14 Knowles DM,Jacobiec FA (1982) Ocular adnexal lymphoid neoplasms: Clinical, histopathologic, electron microscopic, and immunologic characteristics. Hum Pathol13: 148-162 15 Knowles DM, Jacobiec FA, Halper JP (1979) Immunologic characterization of occular adnexal lymphoid neoplasms. Am J Ophthalmol 87: 603-619 16 Medeiros LJ, Harris NL (1989) Lymphoid infiltrates of the orbit and conjunctiva. A morphologic and immunophenotypic study of 99 cases. Am J Surg Pathol13: 459-471 17 Morgan G (1971) Lymphocytics tumors of the conjunctiva. J Clin Pathol 24: 585-595 18 Myhre MJ, Isaacson PG (1987) Primary B-cell gastric lymphoma - A reassessment of its histogenesis. J Pathol 152: 1-11 19 O'Day J, Rotstein H, Wiener JM (1985) Conjunctival involvement with mycosis fungoides in a patient receiving PUVA-therapy. Ophthalmology 92: 109-113

20 Parrott DMV (1976) The gut as a lymphoid organ. Clin Gastroenterol 5: 211-218 21 Picker LJ, Weiss LM, Medeiros LJ, Wood GS, Warnke RA (1987) Immunophenotypic criteria for the diagnosis of nonHodgkin's lymphoma. Am J Pathol128: 181-201 22 Sacks EH, Wieczorek R (1986) Lymphocytic subpopulations in the normal human conjunctiva: a monoclonal antibody study. Ophthalmology 93: 1276-1283 23 Sigelman J, Jakobiec FA (1978) Lymphoid lesions of the conjunctiva, relation of histopathology to clinical outcome. Ophthalmology 85: 818-843 24 Tewfik HH, Platz CE, Corder MP, Panther SK, Blodi FC (1979) A clinicopathologic study of orbital and adnexal nonHodgkin's lymphoma. Cancer 44: 1022-1028 25 Turner RR, Egbert P, Warnke RA (1984) Lymphocytic infiltrates of the conjunctiva and orbit: immunohistochemical staining of 16 cases. Am J Clin Pathol 81: 447-452

Received December 20, 1989 . Accepted March 21, 1990

Key words: Conjunctiva - Lymphoma - MALT - Ocular tumor - CALT Dr. Tony Petrella, Laboratoire d'Anatomie Pathologique, Faculte de Medecine, 7 Boulevard Jeanne d'Arc, 21000 Dijon, France