A 35-year-old woman had suffered from minor irritation in both eyes, oculus uterque (OU), and was treated with topical eye drops based on a diagnosis of allergic conjunctivitis at an initial clinic. Since her conjunctival lesions did not improve, she was referred to our hospital on 17 December 2010. Her visual acuity was 20/20 OU with a normal intraocular pressure. Slit-lamp examination demonstrated fleshy salmon-pink tumors in the upper and lower conjunctival fornix that extended into the inferior palpebral conjunctiva (Figure
A,B ). The fundus was normal. Laboratory data and complete blood counts were within normal limits. No systemic abnormality was detected except for the conjunctivas. Biopsy of the inferior conjunctival tumors was performed OU.
Figure 1 Slit-lamp (A, B) and histological (C, D) examinations at the initial presentation. Slit-lamp examination reveals a conjunctival tumor with a salmon-pink appearance (A, B). Histological examination demonstrates a collection of small lymphoid cells in the (more ...)
Formalin-fixed, paraffin-embedded serial tissue sections were cut at a 4 μm thickness, and dewaxed paraffin sections were stained with H & E staining. The sections were also submitted for immunohistochemistry. After preparation of dewaxed paraffin sections, endogenous peroxidase activity was inhibited by immersing the slides in 3% hydrogen peroxide in methanol for 10 minutes. Then, non-specific binding of the primary antibody was blocked by incubating the slides in blocking bovine serum for 30 minutes. The slides were incubated with primary antibodies, consisting of anti-CD20, CD3, immunoglobulin G (IgG) kappa and IgG lambda antibodies (Dako, Carpinteria, CA, USA), at room temperature for two hours. Positive signals were visualized using diaminobendizine as a substrate.
Histological examination demonstrated a collection of small lymphoid cells in the stroma (Figure
C) OD. Immunohistochemically, Ig light chain restriction was not detected. In contrast, diffuse atypical lymphoid cell infiltration was noted together with lymphoepithelial lesions OS (Figure
D). Immunohistochemically, atypical lymphoid cells were positive for CD20, a marker for B cells. The tumors were histologically diagnosed as RLH OD, and EMZL OS. After the extraction of DNA from the fleshy unfixed conjunctival tumor tissues, PCR analysis detected Ig heavy chain (IgH) gene rearrangement in VH(FR1)/JH region OD and VH(FR2)/JH region OS. Radiotherapy with a total dosage of 30 Gy was administered OS. Slit-lamp examination demonstrated a less marked change of the conjunctival tumor OD (Figure
A), whereas the tumor volume marginally regressed OS after radiation (Figure
B). Biopsy of the inferior conjunctival tumors was performed again on 27 October 2011. A histological examination showed diffuse atypical lymphoid cell infiltration, admixed with plasma cells OD (Figure
C). Immunohistochemically, the atypical lymphoid cells were positive for CD20 with deviation to kappa chains of Ig in the infiltrating lymphoid cells. Isolated DNA from the second biopsy tissue revealed IgH gene rearrangement in VH(FR1)/JH and VH(FR2)/JH regions OD. Therefore, a diagnosis of EMZL was made, arising from RLH OD. In contrast, small lymphoid cells infiltrated the stroma OS (Figure
D), where IgH gene rearrangement was not detected.
Figure 2 Slit-lamp (A, B) and histological (C, D) examinations 11 months after the initial presentation. The salmon-pink conjunctival tumor remains unchanged OD (A). The conjunctival tumor shows marginal regression after radiotherapy OS (B). Histologically, diffuse (more ...)