Adnexal Marginal Zone B-cell Lymphoma Research Articles

The Biology of Ocular Adnexal Marginal Zone Lymphomas.

Simple SummaryOcular adnexal marginal zone lymphoma (OAMZL) is a distinct type of lymphoma that presents in tissues around the eyeball. The lymphoma develops from mature B lymphocytes that have been triggered by antigens for prolonged times. It seems that the B cells often recognize autoantigens. The lymphoma cells often carry specific chromosomal gains and, in some cases, chromosomal translocations. A main factor in the development of this lymphoma is the constitutive activation of the NF-κB pathway, which occurs through various types of genetic alterations. Further key pathogenetic mechanisms involve epigenetic changes, indicated by recurrent mutations in epigenetic regulators.This review focuses on the biology of ocular adnexal marginal zone B-cell lymphomas of the mucosa-associated lymphatic tissue (MALT) (OAMZL) subtype. The ocular adnexa includes all structures and tissues within the orbit except for the eye bulb. In the region of the ocular adnexa, MALT lymphomas represent the most common subtype of lymphoma, accounting for around 8% of all non-Hodgkin lymphomas. These lymphomas are often preceded by inflammatory precursor lesions. Either autoantigens or infectious antigens may lead to disease development by functioning as continuous antigenic triggers. This triggering leads to a constitutive activation of the NF-κB signaling pathway. The role of antigenic stimulation in the pathogenesis of OAMZL is supported by the detection of somatic mutations (partially with further intraclonal diversity) in their rearranged immunoglobulin V genes; hence, their derivation from germinal-center-experienced B cells, by a restricted IGHV gene usage, and the validation of autoreactivity of the antibodies in selected cases. In the established lymphomas, NF-κB activity is further enforced by mutations in various genes regulating NF-κB activity (e.g., TNFAIP3, MYD88), as well as recurrent chromosomal translocations affecting NF-κB pathway components in a subset of cases. Further pathogenetic mechanisms include mutations in genes of the NOTCH pathway, and of epigenetic regulators. While gene expression and sequencing studies are available, the role of differential methylation of lymphoma cells, the role of micro-RNAs, and the contribution of the microenvironment remain largely unexplored.

Abstract 1293: Ocular adnexal lymphomas and chlamydia association: an Indian scenario

Abstract Purpose: Ocular adnexal lymphomas (OALs) are rare, distinct subgroup of lymphomas constituting about 1-2% of all non-Hodgkins lymphomas (NHL) and approximately 8-20% of extranodal lymphomas. Most commonly it affects the lacrimal gland, lids, orbit and conjunctiva. It is reported that OALs may be an antigen driven disorder, however, the source of antigen(s) is not understood. Varying reports from different countries are available which suggests the role of Chlamydophila psittaci (Cp) in development and maintenance of ocular adnexal marginal zone B-cell lymphoma (OAMZL). The present study was undertaken to detect the presence of Chlamydia infection in patients with ocular adnexal lymphomas in Indian scenario. Materials and Methods: Prospective analysis of 41 OAL cases and 21 controls was performed. Diagnosis of Non-Hodgkin's lymphoma was confirmed by clinicopathological features and Hematoxylin & Eosin stained sections of FFPE tumors. WHO formulation of NHL (2001) was used for histopathological classification. Immunohistochemistry (IHC) was done on FFPE tumors using CD20, CD3, CD5, CD10, Cyclin-D1 and anti Chlamydia antibodies. Chlamydia antigen detection was performed on 27/41 OAL cases by indirect immunofluorescence (IFS), using monoclonal anti Chlamydia antibody. Nested PCR (n-PCR) was used to detect Chlamydia gene expression using genus specific primers and the products were sequenced & analyzed using NCBI Blast Software. Patients were followed up for 7-45 months (Mean follow up 26.6 months ± 12.1). Results: Of the forty one cases, thirty two cases (78%) were diagnosed as MALT lymphomas, six (15%) were diffuse large B-cell lymphomas (DLBCL) and three (7%) were mantle cell type lymphomas. The mean age of patients was 54.6 ±14.9 years with male preponderance. Chlamydia gene was detected by nested PCR in 3/41 (7%) cases, out of which, two were MALT lymphomas & one was mantle cell lymphoma. Sequencing showed all the three cases were positive for Chlamydia trachomatis. All the 3 PCR positive cases were also positive for IFS and only one case was positive by IHC for Chlamydia. The tumor was located in the orbit in two cases and eyelid in one case. Follow-up data revealed, systemic spread in two cases with bone marrow involvement (Stage T3N3M1b). All the 3 cases were subjected to 4-6 cycles of chemotherapy along with involved field radiotherapy and relapse occurred in 2 cases. Conclusion: Our study has shown association of C.trachomatis in 7% (3/41) OAL cases instead of C.psittaci infection, as reported in different geographic regions. However, this study has opened a new vista for further research on Chlamydia infection in OAL in this region (India) also. Note: This abstract was not presented at the meeting. Citation Format: Mansi Bhardwaj, Anjana Sharma, Seema Sen, Gita Satpathy, Neelam Pushker, Seema Kashyap, Lalit Kumar. Ocular adnexal lymphomas and chlamydia association: an Indian scenario. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1293. doi:10.1158/1538-7445.AM2015-1293

Orbital IgG4-Related Disease: Clinical Features and Diagnosis

Orbital IgG4-related disease, which can occur in adults of any age, is characterized by IgG4-positive lymphoplasmacytic infiltrations in ocular adnexal tissues. The signs and symptoms include chronic noninflammatory lid swelling and proptosis. Patients often have a history of allergic disease and elevated serum levels of IgG4 and IgE as well as hypergammaglobulinemia. Orbital IgG4-related disease must be differentiated from idiopathic orbital inflammation and ocular adnexal marginal zone B-cell lymphoma to ensure appropriate and effective treatment. Systemic steroid therapy decreases the size of the lesions, but relapse often occurs when systemic steroid therapy is discontinued.

Possible role of chlamydiae in ocular adnexal lymphoma

Background: Ocular adnexal lymphomas (OAL) represent malignant lymphoid neoplasms which develop as primary or secondary tumor manifestations in the orbit, conjunctiva, lacrimal gland and eye lid. Some reports suggest that OALs may be an antigen driven disorder, but the source of antigen(s) is not understood. Chlamydia psittaci (Cp) has been linked to the development and maintenance of ocular adnexal marginal zone B-cell lymphoma (OAMZL) in some countries with varying reports but no study was done in Indian population. The present study was designed to detect chlamydial antigen in ocular adnexal lymphomas in Indian patients. Methods: Prospective analysis (2010-2011) of 18 cases of ocular adnexal non-Hodgkin's lymphomas was undertaken. Clinicopathological features were reviewed to confirm the diagnosis of non-Hodgkin's lymphoma. Classification of all the eighteen cases was done according to WHO classification (2001). Immunohistochemical characterization of was performed using commercial monoclonal antibodies CD20, clone L26; CD3, clone LN10; CD5 clone 4C7; CD10, clone 56C6 and mAb Cyclin-D1 antibodies. Immunohistochemical localization of C.trachomatis and C.psittaci antigens was also performed on all the cases using mAb Novus biological, A21.65. Follow up details of 5/18 (28%) patients was available. Results: Of the 18 cases of ocular adnexal non-Hodgkin's lymphomas, 16 cases (89%) were diagnosed as MALT lymphomas and 2 cases were diffuse large B-cell lymphomas (DLBCL). All 16 cases of MALT lymphomas were B-cell type (CD20 positive), while they were negative for CD3, CD5, CD10 and Cyclin-D1. Chlamydial antigen expression for C.trachomatis and C.psittaci was detected in a single case of MALT lymphoma. The tumor was located in the left orbit. No systemic spread was present at the time of diagnosis. Follow-up study did not reveal recurrence at 6 months. Conclusion: MALT lymphomas have been linked with Cp infection in different geographical regions. Bacterial clearance with antibiotic therapy is often followed by lymphoma regression. The association of C.psittaci with MALT lymphoma may necessitate new treatment modalities against MALT lymphomas.

Chlamydia psittaci-negative ocular adnexal marginal zone B-cell lymphomas have biased VH4-34 immunoglobulin gene expression and proliferate in a distinct inflammatory environment

Ocular adnexal marginal zone B-cell lymphomas (OAMZLs) arise in the connective tissues of the orbit or in the mucosa-associated lymphoid tissue of the conjunctiva. Here, we present the immunological and genetic analyses of 20 primary Chlamydia psittaci (Cp)-negative OAMZLs. Analysis of the immunoglobulin variable heavy chain (IgV(H)) gene usage demonstrated a significant preference for V(H)4-34. A combined analysis across all previously published OAMZLs confirmed that this is a general feature of OAMZL, in particular of the Cp-negative group. Our series of OAMZLs did not express the characteristic rheumatoid factor V(H)DJ(H) rearrangements that were previously found in salivary gland- and gastric-marginal zone B-cell lymphomas (MZBCLs). We did not detect the MZBCL-specific chromosomal translocations, t(11;18) API2-MALT1 (mucosa-associated lymphoid tissue1) and t(14;18) IgH/MALT1. Two cases contained a premature stop codon in the A20 gene (TNFAIP3) and one case harbored the activating MYD88 hotspot mutation L265P. Variable nuclear expression of BCL10, NFκB1 (p50) and NFκB2 (p52) suggests that other additional genetic abnormalities affecting the NFκB pathway exist within this group of lymphomas. OAMZL showed variable expression of the chemokine receptor CXCR3 and integrin α4β7 by the tumor B cells, and low interferon-γ and interlukin-4 mRNA levels in the tissue, indicative of an inflammatory environment with features in between those previously found in cutaneous and other extranodal MZBCL. The strongly biased usage of V(H)4-34 in Cp-negative OAMZLs suggests involvement of a particular stimulatory (auto-) antigen in their development.

Exposure to animals and increased risk of marginal zone B-cell lymphomas of the ocular adnexae.

Background:Ocular adnexal marginal zone B-cell lymphoma (OAMZL) has been associated with Chlamydophila psittaci, an infection that may be transmitted by carrier animals. However, it is still unclear whether exposure to animals affects the risk of OAMZL in comparison with other lymphoma histotypes. We therefore investigated the role of professional and/or domestic exposures to animals in the occurrence of OAMZL, as compared with other types of lymphoma.Methods:A hospital-based case–control study was carried out on 43 consecutive OAMZL patients (cases) and 87 consecutive patients with nodal non-Hodgkin's lymphomas (NHLs; controls). Multiple logistic regression (MLR) odds ratios (ORs), and 95% confidence intervals (CIs) were used to estimate the association between exposures to animals and OAMZL risk.Results:A higher proportion of cases reported a lifetime exposure to household animals (79.1% vs 64.4% among controls), with a non-statistical significant MLR-OR of 2.18 (95% CI: 0.85–5.62). The OAMZL cases more frequently reported a history of occupation in breeding and/or slaughtering than controls (34.9% vs 6.9%), with an overall increased risk of 7.69 (95%CI: 2.65–22.34).Conclusion:These results indicate that, compared with nodal NHLs, the risk of OAMZL is markedly increased by contact with animals, particularly by occupational exposures.

Final Results of a Multicenter Phase II Trial with Translational Elements to Investigate the Possible Infective Causes of Ocular Adnexal Marginal Zone B-Cell Lymphoma (OAMZL) with Particular Reference to Chlamydia Species and the Efficacy of Doxycycline As First-Line Lymphoma Treatment (the IELSG#27 TRIAL)

Abstract▪267▪This icon denotes a clinically relevant abstract BACKGROUND:Chlamydophila psittaci (Cp) infection carries a potential pathogenic role in OAMZL and has been detected in tumor tissue of a high proportion of patients (pts), with geographic differences in its prevalence rates. The use of immunohistochemistry, immunofluorescence and electronic microscopy techniques has identified monocyte/macrophage as carriers of Cp in OAMZL, and bacteria eradication with doxycycline (DOXY) has been associated with lymphoma regression in half of pts. Notwithstanding these achievements, clinical and therapeutic knowledge on this association mainly result from retrospective studies or trials including also patients with relapsed disease after wide-ranging follow-up. Prospective studies focusing exclusively on pts with newly diagnosed OAMZL do not exist. Herein, we report the final results of the first international prospective phase II trial aimed to investigate Cp prevalence and DOXY efficacy as first-line therapy in pts with newly diagnosed OAMZL (ClinicalTrial.gov NCT01010295). AIMS:To elucidate prevalence of Chlamydiae infections, and to evaluate the efficacy of DOXY both in terms of bacterial eradication and as upfront anti-lymphoma therapy in pts with newly diagnosed OAMZL. METHODS:This trial included two different parts, named A and B. The part A included pts with newly diagnosed stage-IEA OAMZL and measurable/parametrable disease; these pts were assessed for chlamydial infection and were treated with DOXY 100 mg orally twice daily for 21 days. The part B included pts with lymphoma categories other than MZL, non neoplastic lesions of the ocular adnexae or OAMZL not eligible for part A; these pts were treated following local guidelines.Chlamydial infections were assessed on diagnostic tumor samples, conjunctival swabs and peripheral blood mononuclear cells (PBMC) from A and B pts by three different PCR protocols targeting 16rRNS and intergenic spacer 16S–23S, ompA and hsp60, respectively. Bacterial eradication was tested on conjunctival swabs and PBMC collected at basal time, at 3 and 12 months after DOXY (only part A pts). Clinical and ophthalmologic examination and MRI imaging were performed at the same timepoints, and every six months during follow-up. RESULTS:From August 2006 to November 2010, 54 pts from 6 centers were enrolled; 34 pts with OAMZL entered the part A, while 13 pts with non-parametrable OAMZL and 7 pts with other lymphoproliferative disorders entered the part B. Diagnostic material was available for molecular analysis in 44 cases; Cp was detected in biopsies of 32/37 OAMZL (86%) and in 4/7 non-MZL. All cases were negative for C. pneumoniae and C. trachomatis. Among 36 Cp+ pts, infection was detected in 100% of swabs and in 75% of PBMC; swabs or PBMCs from pts with Cp-negative OAMZL were invariably negative.All pts completed the planned DOXY treatment; no relevant toxicity was reported. Among 34 pts entering the part A, 28 were evaluable for bacteria eradication (Cp detected in swabs in 8 pts, in PBMC in one, in both samples in 19). At 3 months from DOXY, Cp was not detected in swabs and PBMC of 14 evaluable pts, with an eradication rate of 50%; at one year of follow-up, Cp was still detected in three of these apparently eradicated pts.Lymphoma regression after DOXY treatment (part A) was complete in six pts (18%; 95%CI: 5–31%), and partial in 16 (ORR= 65%, 95%CI: 49–81%); 11 had SD and one PD. At a median follow-up of 27 months (range 3–51), 13 pts experienced relapse, with a 2-year PFS of 55±9%. A trend to a higher response rate (82% vs. 53%; p=0.12) and 3-yr PFS (72% vs. 52%; p=0.14) was observed in eradicated pts. No significant association between site of presentation (conjunctiva vs. orbit) and clinical outcome was detected. There was no association between animal exposure and bacteria eradication or lymphoma response. All patients but two (stroke and myocardial infarction) are alive, with a 3-yr OS of 92%. CONCLUSIONS:Cp infection is frequent in newly diagnosed OAMZL, and could be also present in other lymphoproliferative disorders of the ocular adnexae. First-line DOXY is an active, safe and rational strategy in pts with limited-stage OAMZL, with lymphoma regression in 65% of cases. However, DOXY failed to eradicate Cp infection in half of pts, with a negative impact on outcome. Further investigations aimed to identify additional potential infective agents associated with OAMZL and more active antibiotic regimens are warranted. Disclosures:Montalban:Red Temática de Investigación Cooperativa en Cancer (RETICC): Research Funding; Asociación Española contra el Cancer: Research Funding.

Recurrent Extranodal Marginal Zone B-Cell Lymphoma Presenting as a Huge Cheek Mass after Radiotherapy on Ocular Adnexal Lymphoma

Extranodal marginal zone B-cell lymphoma of mucosa associated lymphoid tissue (MALT), also known as MALT lymphoma, is a distinctive group of B-cell lymphomas specified in the World Health Organization classification. The most common anatomic site of origin of MALT lymphoma is the stomach. Other common sites include the skin, salivary glands, ocular adnexa, intestines, and lung. However, it is known that virtually any extranodal anatomic site in the body can be involved by MALT lymphoma. Because patient with MALT lymphoma exhibits an indolent natural history and a favorable prognosis, treatments like excision or radiotherapy or antibiotics should be chosen carefully. Results from radiotheraphy series have demonstrated relatively good local controls with a prolonged clinical course in patients with ocular adnexal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (ocular MALT lymphoma). We report a case of recurrent extranodal marginal zone Bcell lymphoma that presented in the unusual location of the cheek after initial treatment with radiotherapy in ocular MALT lymphoma. To our knowledge, this presentation has not previously been reported in the literature.

Chlamydial infection: the link with ocular adnexal lymphomas

Chlamydiae are obligate intracellular bacteria that grow in eukaryotic cells and cause a wide spectrum of diseases. They can establish persistent infections, are mitogenic in vitro, promote polyclonal cell proliferation in vivo and induce resistance to apoptosis in infected cells-properties that might contribute to tumorigenesis. In fact, Chlamydophila psittaci (Cp) has been linked to the development and maintenance of ocular adnexal marginal zone B-cell lymphoma (OAMZL). In this indolent malignancy, Cp is transported by monocytes and macrophages and causes both local and systemic infection. Cp elementary bodies are viable and infectious in the conjunctiva and peripheral blood of patients with OAMZL. Bacterial eradication with antibiotic therapy is often followed by lymphoma regression. Despite recent advances in the understanding of this bacterium-lymphoma association, several questions remain unanswered. For instance, prevalence variations among different geographical areas and related diagnostic and therapeutic implications remain a major investigational issue. We will focus on clinical and therapeutic implications of chlamydial infections in patients with lymphomas and summarize the current knowledge on the association between Cp infection and OAMZL. Available data on the epidemiology, biology and pathogenesis of this association are analyzed and new investigative and clinical approaches are discussed.

IgG4-producing marginal zone B-cell lymphoma

IgG4-related disease is a recently proposed clinical entity with several unique clinicopathological features. A chronic inflammatory state with marked fibrosis, which can often be mistaken for malignancy, especially by clinical imaging analyses, unifies these features. Little is known about lymphomagenesis in the context of IgG4-related disease, we recently first reported the ocular adnexal marginal zone B-cell lymphomas arising from IgG4-related disease. To the best of our knowledge, no existing study has ever established the neoplastic potential of IgG4-producing cells. In the present report, we describe the first IgG4-producing lymphoma. The patient was a 72-year-old male who was being followed for an asbestos-related pleural plaque. During follow-up, computed tomography revealed bilateral renal masses and multiple swollen retroperitoneal lymph nodes. A retroperitoneal lymph node biopsy was performed. Histologically, the interfollicular areas were expanded by medium to large plasmacytoid cells. These plasmacytoid cells showed nuclear pleomorphism and had prominent Russell bodies. Immunohistochemistry and double immunofluorescence staining of these cells revealed IgG4 positivity and monotypic lambda-light chain predominance. A portion of these cells were partially positive for CD20, negative for CD3, and somewhat faintly positive for CD138. In addition, serum IgG4 was elevated. Southern blot analysis of the lymph node specimen detected immunoglobulin heavy chain gene rearrangement. The present study indicates that, not only can malignant lymphomas occur in the setting of IgG4-related disease, but IgG4-producing cells can also be neoplastic.

Extraocular Muscle Involvement in Marginal Zone B-Cell Lymphomas of the Orbit

Introduction: Marginal zone B-cell lymphoma is the most frequent ocular adnexal lymphoma. It may involve the conjunctiva, lacrimal gland, eyelid, extraocular muscle, and orbital connective tissue. Extraocular muscle infiltration is rare. Methods: We report here a series of 5 patients presenting with extraocular muscle infiltration due to marginal zone B-cell lymphoma, extracted from a retrospective study of 39 patients with primitive ocular adnexal marginal zone B-cell lymphoma presenting within a 15-year period, from 1993 to 2007, at two university hospitals. Results: Out of 39 patients, two females and three males presented with extraocular muscle involvement (one levator muscle, one medial rectus muscle, one lateral rectus muscle, one inferior rectus muscle, and one inferior oblique muscle). In 4 cases, the right eye was involved. The median age of presentation was 60 years. Proptosis and diplopia were the main clinical signs. A mean duration of symptoms was 12 months before diagnosis was given. Three patients were stage IE at the diagnosis, according to Ann Arbor classification, and one was at stage IV. Three patients received radiotherapy and two received chemotherapy. Three patients underwent local relapses at a median time of 40 months. The patients with relapses were treated with chemotherapy alone in one case, radiotherapy alone in one case, and immunotherapy and chemotherapy in one case. The mean follow-up period was 54 months. Discussion: When compared to other locations of marginal zone B-cell lymphomas of the orbit, extraocular involvement occurred in younger patients and had similar prognosis. Conclusion: Extraocular muscle involvement is a rare location of marginal zone B-cell lymphoma that had to be known and can simulate thyroid orbitopathy.