Orbital Apex Malignant Lymphoma Diagnosed Using Whole-Body Computed Tomography

Abstract

This article aims to report a case of orbital apex malignant lymphoma diagnosed using whole-body CT, emphasizing the challenges in diagnosis and the importance of timely investigation and treatment. A 69-year-old female with a history of rheumatoid arthritis and hypertension presented with a one-week history of headache and newly developed left eye ptosis. Initial examination revealed 20/20 visual acuity, left eye ptosis, and impaired upward eye movement. A subsequent orbital MRI, performed one week later, identified a mass extending from the left superior rectus muscle to the orbital apex. Elevated soluble IL-2 receptor levels were noted, and whole-body CT revealed multiple liver and pancreatic masses, as well as cardiac lesions. Biopsies from these sites led to a diagnosis of diffuse large B-cell lymphoma. Despite prompt initiation of chemotherapy, the optic nerve damage persisted, resulting in significant visual impairment. Whole-body CT imaging plays a crucial role in diagnosing challenging cases of orbital apex lesions by identifying primary or metastatic sites suitable for biopsy. This case emphasizes the necessity of prompt and comprehensive diagnostic evaluations and timely treatment initiation in suspected malignant lymphoma to prevent irreversible complications such as optic nerve damage.

Keywords: diffuse large b-cell lymphoma (dlbcl); mri; neuro-ophthalmology; orbital apex lymphoma; whole-body ct.

Figure 1. Ophthalmic examination findings and CT scanning images at initial visit

(A) Photograph of the eyes and (B) eye movement assessment at the initial evaluation. The patient exhibited left eye ptosis and restricted upward movement of the left eye. (C) CT scan images showing no aneurysm in the internal carotid artery-posterior communicating artery region. (D) Fundoscopic examination of both eyes revealed no significant abnormalities. CT: computed tomography, OD: oculus dexter (right eye), OS: oculus sinister (left eye)

Figure 2. Orbital MRI images before treatment

(A) Coronal section, (B) sagittal section, and (C-D) horizontal section. An irregular lesion was found in the muscle belly of the left superior rectus muscle. MRI: magnetic resonance imaging

Figure 3. Whole-body CT images of the liver, pancreas, and cardiac sections

Contrast-enhanced CT showed multiple hypovascular lesions in the liver (A), pancreas (B) and heart (C). CT: computed tomography

Figure 4. Microphotograph of liver and pancreas sections

The sections were stained with hematoxylin-eosin (A, C, D, E) and CD20 (B). (A, B) Low-magnification image of the pancreas. The scale bar indicates 250 µm. Green areas indicate necrotic tissue (A). Atypical lymphocytes are diffusely positive for CD20 (B). (C) High-magnification image of the pancreas. The scale bar indicates 100 µm. Proliferation of atypical lymphocytes was observed. (D, E) Proliferation of lymphoma cells in the liver section. The scale bar indicates 100 µm (D) and 50 µm (E).

Figure 5. Ophthalmic examination findings and MRI scanning images after treatment

Six months after treatment, her ptosis and ocular motility disorders had improved (A-B). However, the left optic nerve was atrophied, and visual field defects persisted (C-D). MRI: magnetic resonance imaging, OD: oculus dexter (right eye), OS: oculus sinister (left eye)