CLINICAL HISTORY
A 51-year-old white female presented with a swelling of the right upper eyelid, which she had watched closely for 4 months. She was then evaluated with X-rays and treated with antibiotics for sinusitis. There was no improvement after one month. An MRI at the referring hospital revealed a homogeneous intensity in the area of the lacrimal gland. The muscle and nerves were normal. She was subsequently referred to Loyola. She denied any changes in visual acuity, diplopia, discharge, or dry eyes. Physical exam revealed fullness of the right upper eyelid with inferior displacement of the globe. A CT scan was performed. The patient underwent an excisional biopsy of the lesion.
LABORATORY DATA
Noncontributory
ANCILLARY STUDIES
A CT Scan (Figure 1) confirmed the presence of an ill-defined soft tissue mass in the superior-lateral aspect of the right orbit in the region of the lacrimal gland. No calcifications were present in the mass. There was no involvement of the bone.
GROSS PATHOLOGY
The mass measured 3.3 x 1.6 x 1.2 cm. On cut section, the parenchyma was tan-red and homogeneous.
MICROSCOPIC PATHOLOGY
The lacrimal gland contained a dense lymphoid infiltrate which showed a vaguely nodular pattern of growth. (Figure 2) Some areas had residual lacrimal gland structures. (Figure 3) The nodules were composed of numerous small lymphocytes and a variable number of large atypical cells. Occasional mitotic figures were seen. (Figure 4) At higher magnification some of the large cells demonstrated nuclei with irregular nuclear membrane contours and prominent nucleoli.
MICROSCOPIC FEATURES
Immunohistochemistry
The PAN T demonstrated a population of T cells in and around the nodular areas. It did not stain the large cells. (Figure 5).
The PAN B showed that the nodules contained predominantly B cells. (Figure 6).
The large cells also stained with PAN B. (Figure 7)
No lymphoepithelial lesions were seen. (Figure 8)
Ki-67, a proliferation marker, was positive in the large cells. (Figure 9)
Flow Cytometry
When flow analysis was performed looking at all the cells. No monoclonality for kappa or lambda was seen. There were no CD 10-positive B cells. A possible small population of CD 5-positive B cells was identified. (Figure 10)
The analysis on only the large cells clearly demonstrated an excess of lambda-positive B cells. (Figure 11)
MOLECULAR PATHOLOGY
Gene rearrangement analysis showed a clonal rearrangement in 2 separate digests. The studies were performed on B cells isolated using CD 19-coated beads because of the presence of a large polyclonal population. (Figure 12)
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