Author reply
Authors: Andrés J.M. Ferreri, Silvia Govi, Annalisa Colucci, Giulio Modorati
Journal: Ophthalmology (2011)

We appreciate Dr. Shinder's suggestion1Shinder R. Conjunctival lymphoma.Ophthalmology. 2011; 118: 1692Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar to extend the indication of intralesional rituximab from conjunctival lymphomas2Ferreri A.J. Govi S. Colucci A. et al.Intralesional rituximab a new therapeutic approach for patients with conjunctival lymphomas.Ophthalmology. 2011; 118: 24-28Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar to a larger group of anterior orbit lymphomas. This attractive idea is an attempt to increase the proportion of suitable candidates for this approach assuming that conjunctival lesions in most instances are the anterior extent of orbital lymphomas, and that orbital lymphomas are more common than conjunctival ones. However, the suggestion deserves to be discussed with caution analyzing the incidence of the different forms of ocular adnexal lymphoma and, more importantly, if this strategy is feasible in these patients. The incidence of orbital and conjunctival lymphomas at diagnosis can be estimated from the recently completed IELSG #27 phase II trial (clinicaltrials.gov #NCT01010295), where 54 consecutive patients with newly diagnosed stage-IEA (Stage I Extranodal, without B symptoms; a single lesion was present) ocular adnexal lymphomas were registered to investigate the prevalence of infectious agents, mostly Chlamydiae,3Ferreri A.J. Guidoboni M. Ponzoni M. et al.Evidence for an association between Chlamydia psittaci and ocular adnexal lymphomas.J Natl Cancer Inst. 2004; 96: 586-594Crossref PubMed Scopus (461) Google Scholar and efficacy of bacterial eradicating doxycycline therapy.4Ferreri A.J. Ponzoni M. Guidoboni M. et al.Bacteria-eradicating therapy with doxycycline in ocular adnexal MALT lymphoma: a multicenter prospective trial.J Natl Cancer Inst. 2006; 98: 1375-1382Crossref PubMed Scopus (173) Google Scholar Forty-nine patients had an indolent B-cell lymphoma (marginal zone and follicular lymphomas); 22 (45%) patients had a conjunctival lymphoma without intraorbital extension of disease, 21 (43%) had an orbital lymphoma without conjunctival lesions, and only 6 (12%) patients had a conjunctival lesion associated with an orbital mass. Thus, orbital lymphomas with an anterior extent resulting in conjunctival lesions seem to constitute a minority of these rare malignancies at diagnosis, at least in this report. Worth mentioning, this study cannot exclude, at the moment, that a higher proportion of orbital lymphomas could have conjunctival extension at relapse or progression. Regardless of their incidence, some anterior orbital lymphomas do not seem to be suitable candidates for intralesional rituximab. Despite the use of modern neuroimaging, it is difficult to delineate the target volume in some patients at the time to perform multiple intralesional injections, in particular, deep areas of the lesions can not be easily defined with a consequent risk of under-dosage. Case no. 3 of our pilot experience1Shinder R. Conjunctival lymphoma.Ophthalmology. 2011; 118: 1692Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar is a rare exception since the entire lesion, located in the inferior quadrant of the orbit, was easily accessible at the time of treatment (Fig 1A and B, available at http://aaojournal.org). Conversely, the risk of inadequate treatment for deeper lesions seems to be higher in lymphomas located in the lateral and the superior quadrants of the orbit (Fig 1C and D, available at http://aaojournal.org). With the available experience, it is difficult to say whether intraconjunctival rituximab is appropriate to consider in all cases of anterior orbital lymphoma. Only a larger cumulative experience will allow us to identify the best candidates for this novel approach. Conjunctival and Orbital LymphomaOphthalmologyVol. 118Issue 8PreviewI read with great interest the recent interventional pilot study by Ferreri et al1 describing transconjunctival rituximab administration for patients with relapsed conjunctival lymphoma. They showed disease remission in 2 of the 3 patients studied who had recurrence following prior systemic rituximab treatment. I would like to point out to the readership that “conjunctival” lymphoproliferative lesions in most instances actually represent the anterior extent of orbital lymphomas. This can be appreciated through orbital imaging, and is evidenced in the axial magnetic resonance imaging of case 3 where a medial orbital mass is seen posterior to the septum. Full-Text PDF