Conjunctival MALT Lymphoma Case 10

A: MALT lymphoma - Note the pink mucosal thickening of the bulbar and palpebral conjunctiva.

Original Message

Dear ECN Colleagues

B: MALT lymphoma - Note the pink mucosal thickening of the bulbar and palpebral conjunctiva.

Does anyone have experience using topical Interferon Alfa for patients with conjunctival MALT lymphomas? Previous reports of this technique describe subconjunctival injections (inside the lesions of 1,000,000 or 1,500,000 IU) IFN 3 times a week for four weeks. I wonder if anyone has tried to give interferon just topical as drops, for example 4 times a day?

Eva Dafgård Kopp MD PhD
St Eriks Eye Hospital, oncology service

Comments of ECN Members:

From: Maria Saornil MD 

I only have the experience of one present case (Figures above). I have finished the 1 month subconjunctival injections and I wonder if there is any previous experience with topical drops because I would like to try with this patient since the regression has been not total.

From: Kenneth Hu MD -
New York City
Can you give me the reference for the use of any IFN with injections or drops for MALT.

And Our Results from a PubMed Search:

1: Blasi MA, Gherlinzoni F, Calvisi G, Sasso P, Tani M, Cellini M, Balestrazzi E.
Local chemotherapy with interferon-alpha for conjunctival
mucosa-associated lymphoid tissue lymphoma: a preliminary report. Ophthalmology. 2001 Mar;108(3):559-62.

2: Lachapelle KR, Rathee R, Kratky V, Dexter DF.
Treatment of conjunctival mucosa-associated lymphoid tissue lymphoma with intralesional injection of interferon alfa-2b.
Arch Ophthalmol. 2000 Feb;118(2):284-5.

3: Cellini M, Possati GL, Puddu P, Caramazza R.
Interferon alpha in the therapy of conjunctival lymphoma in an HIV+ patient.
Eur J Ophthalmol. 1996 Oct-Dec;6(4):475-7.

Pompano Beach, Florida
From: Barry Schechter, MD 

I have used Interferon Alfa subconjunctivally for 2 cases of MALT lymphoma. In another case, I did try topical, but the lesion was relatively large, and the patient was developing a follicular allergic response after 5 weeks. Had to convert to injections.

From: Paul T. Finger, MD, FACS 
Date: Wed Dec 18, 2002
Subject: Treatment of MALT Lymphomas

Our online discussion of interferon therapy for MALT lymphomas spilled into the local Tumor Board at The New York Eye and Ear Infirmary. A spirited discussion of observation, radiation, drug therapies occurred. Several of the attending physicians mentioned that they have been observing certain patients with small to moderately sized, biopsy proven conjunctival MALT lymphomas without treatment. My question is, how many ECN list members have "treated" a biopsy proven conjunctival MALT patients with observation alone?

Warm regards,

From: "Bertil.Damato
Date: Wed Dec 18, 2002 4:29:32 PM US/Eastern
Subject: RE: Interferon for MALT Lymphomas

We recently treated a patient with subconjunctival injections of interferon and she complained of flu-like symptoms, but her cervical nodes regressed. This would suggest that topical interferon therapy is a useful form of palliative treatment, when standard systemic treatment is inappropriate.

Kind regards,
Bertil Damato

From: "Bita Esmaeli"
Date Wed Dec 18, 2002
Subject: Interferon for MALT Lymphomas

While I appreciate the interesting concept of using topical drops for MALT, I have a difficult time justifying the use of a topical non-specific immune modulator for a disease that has a definite potential for systemic involvement. Given the various forms of standard successful therapy for lymphomas (chemotherapy, radiotherapy and recently Monoclonal antibody therapy), topical interferon therapy or multiple injections may be difficult to justify.

We have treated aggressive forms of MALT with involvement of the sinuses, eyelid, conjunctiva,etc. As with all forms of lymphoma, the management should be dictated by the histologic grade and stage of lymphoma.

Best wishes,
Bita Esmaeli, MD, FACS
M. D. Anderson Cancer Center
Houston, Texas
Tel: (713) 794-1247

From: Ian McLean, MD 
Date: Thu Dec 19, 2002 12:18:16 PM US/Eastern
Subject: RE: ECN International Tumor Board

Dear ECN List Members:
I think the diagnosis of a MALT lymphoma or Extranodal Marginal Zone Lymphoma (ENMZL) is fraught with hazards. Just recently we had a case that didn't have light chain restriction but the lymph node pathologists at the AFIP were willing to call it an ENMZL. I had heavy chain gene rearrangement studies performed and there was no monoclonal band. Without either light chain restriction or heavy chain rearrangement, I do not think you should call this tumor a MALT lymphoma. My point is that this case would have been a "biopsy proven" MALT lymphoma, if I had accepted the diagnosis of the lymph node pathologists.

Best wishes for a productive new year,
Ian W. McLean
Ophthalmic Pathology, AFIP

From: "Keizer, R.J.W. de (OOG)"
Date: Sat Dec 21, 2002 9:59:12 AM US/Eastern
Subject: RE: ECN International Tumor Board

Dear ECN List Members
I have seen several of these patients. Two of them were treated several times with cryo surgery and several months of "observation." These tumors regressed and stayed very small for months. After approximately two years radiotherapy was performed.

Prof RJW de Keizer

From: Paul T. Finger MD
Date: Sat Dec 21, 2002 10:21:33 AM US/Eastern
Subject: Re: ECN International Tumor Board

Dear Prof. de Keizer:
Thank you for this response. I have several patients who did not want treatment. One was eventually treated with systemic chemotherapy due to extraocular disease. Another just wants to wait and see if the tumor's grow. He is wary of radiation therapy. The third had a "total" resection and want to wait and see if there is a recurrence (now 2 years tumor free). It is obvious that there is significant controversy and little direction concerning the management of these cases. This is an ideal situation for a multicenter collaborative study.

Happy holidays,
Paul T Finger, MD

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