Running Header: FOLLICULAR LYMPHOMA OF THE EYE

Follicular Lymphoma of the Eye

Amanda Sperling
Argosy University, Twin Cities
RTH290 Clinical Training II
Julie Yasgar

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February 27, 2016Consultation

John Smith is a 66 year old Caucasian male who was diagnosed with follicular lymphoma
of the lower eyelid. Mr. Smith has a history of skin cancer, both basal and squamous cell
carcinoma, all which have been removed. He also has type 2 diabetes, hypertension and
hyperlipidemia. Prior surgeries include a tonsillectomy. He has no history of smoking and does
not currently drink any alcohol. His maternal grandmother and mother died of breast cancer, his
father had colon cancer that spread to his liver and his brother had liver cancer from hepatitis C.
He is recently retired, has a 30 year old son and a 9 year old son. He is accompanied by his wife
for his consult appointment. John consulted his primary doctor and believed he had pink eye.
After a work up, his doctor prescribed him antibiotic eye drops to eliminate the symptoms. After
three weeks post medication, Mr. Smith still presented with inflammation, itchy eye and redness.
His wife noticed there was rapid spread of erythematous modularity along the medial border of
the right lower lid as well as eye protrusion. His wife had worked for an optometrist for 25 years,
so she directed he see his eye doctor immediately due to these symptoms. After seeing his
optometrist, he was referred to a plastic surgeon for surgical excision. His biopsy results came
revealed he had follicular lymphoma in his lower eyelid. He has been referred to our clinic for
treatment options. We discussed radiation treatment options with Mr. Smith and his wife, went in
detail about specific side effects that could occur during the course of treatment and what to
expect. His side effects that were discussed included skin irritation, redness and inflammation in
the area of treatment, possible losing the lower eye lashes, blocking of the tear duct and dry eye.
If the tear duct does end up being blocked, there is a potential for surgery to insert a tube for
proper drainage. The doctor explained this is rare due to the type of treatment, but wanted to

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make the patient aware that it could be a side effect. Mr. Smith and his wife are very eager to
start treatment and thankful to have caught this in the early stages.
Diagnosis
After the biopsy was completed, John was diagnosed with Stage II, 1E follicular
lymphoma. He was also scheduled for an MRI of the brain and a PET scan. In the consultation,
we reviewed Mr. Smiths PET scan results, but did not have his MRI results back for review. His
PET scan showed no sign of enlarged lymph nodes or areas of suspicion. His MRI results were
reviewed prior to simulation and all results came back negative with no signs of metastasizes to
the brain. Since his lymphoma occurs above the diaphragm and has no nodal involvement, his
staging follows the guidelines for an NHL diagnosis.
Treatment
John was set up in our treatment room for a clinical electron setup. He was supine, we
used a B headrest on a frame indexed to the table at F1, he had a small knee wedge positioned
under his knees for back support and was holding an O ring on his chest. After positioning the
patient, we placed an internal eye shield in his right eye. His left eye was blocked with a lead
shield lined with wax, to block and absorb any scatter. The treatment area was too small to make
a custom block, so we used a 3.0 circle block with lead shielding to block areas that did not need
treatment. We also used a lead cutout on the lateral part of his under eye, since we are not
treating the whole lower lid. Our doctor verified the treatment setup to ensure we had the correct
borders and margin for residual disease.
After the clinical set up was completed, our doctor and physicist completed the treatment
planning and calculations. Since the cancer was superficial, the doctor decided to treat with
electrons, treating to the 90% isodose depth line with an energy of 6 MeV.

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A 6x6 electron cone was used with a 3.0cm circle cerrobend block. The gantry, collimator and
couch kick were all set at 180 degrees. Wet gauze was used as bolus, measuring .5cm and was
placed over the treatment area daily. The SSD was set to 102cm for treatment. The doctor
prescribed a dose of 180cGy per day for 17 fractions, totaling a dose of 3060cGy. The cerrobend
block has a cutout factor of .8651, totaling the daily monitor units to 231 MU. After the first
week of treatment, Mr. Smith presented with mild erythema and had no complaints otherwise.
He maintained his daily lifestyle, had no eye irritations and continued with treatment. His weekly
follow up appointments were usually very quick because he didnt have any concerns or change
in vision/side effects. Mr. Smith finished all of his treatments without breaks and seemed to
handle the process quite well. His last day of treatment he did communicate having a drier eye
than usual, but he started using drops that helped keep the eye moisturized.
Follow Up
Mr. Smith followed up with our clinic two weeks after completing treatment. He still
presented with mild erythema, but according to the Doctor it was healing properly. He stated he
hasnt had any vision changes. He has been using eye drops due to irritation and dry eye, but
otherwise feels good following treatment. He has scheduled a follow up appointment with his
eye doctor for this June. Our doctor recommended self-exams around his eye and if any
suspicious bumps or redness appears to make an appointment immediately. Mr. Smith came back
for another follow-up appointment two months post treatment. His lower eyelid had very
minimal erythema, according to the patient it had returned to its normal state. Due to surgical
resection, his right eyelid looks different than his left, but the skin itself was similar in color and
texture to his left (untreated) eye. Patient has a six month follow up appointment scheduled with
our clinic as well as his optometrist appointments in June.

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Follicular Lymphoma
Lymphoma is the most common blood cancer, two main forms are Hodgkins lymphoma
and non-Hodgkins lymphoma (NHL). Follicular lymphoma is the most common occurrence of
NHL, accounting for about 20-30% of all NHL (Lymphoma Research Foundation, 2012).
Etiology & Epidemiology
Follicular lymphoma is a type of non-Hodgkins lymphoma arising from the B-cells. Bcell lymphomas make up most (about 85%) of non-Hodgkin lymphomas in the United States.
About 1 out of 5 lymphomas in the United States is follicular lymphoma (American Cancer
Society, 2016). Follicular means the cells grow in a circular pattern in the lymph nodes. This type
of lymphoma is typically slow growing and radiosensitive. However, they tend to be harder to
cure due to regrowth of diffuse B-cell lymphoma, which is a faster growing lymphoma. 1 in 3
follicular lymphomas will return with diffuse B-cell lymphoma (Washington & Leaver, 2010).
Average age of onset is about 65 years old, peaking at 80-84 years old and very rare in younger
ages. This type of cancer typically arises in the lymph nodes and bone marrow. Follicular
lymphoma occurs most commonly below the diaphragm and mesenteric lymph nodes and least
common site is in the Waldeyer ring (Washington & Leaver, 2010).
Signs & Symptoms
The most common signs of NHL are enlarged lymph nodes, fever, night sweats, fatigue,
itching and weight loss (Washington & Leaver, 2010). NHL differs from Hodgkins in pattern of
spread and occurrence. The most common site of NHL is in the lymph nodes. Symptoms can
differ depending on the site of tumor growth. Shortness of breath or cough can indicate lung
involvement, abdominal pain or change in bowel habits will indicate a pelvic involvement. Brain
symptoms could include headaches, seizures and vision changes.

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Detection and Diagnosis

The first step in diagnosis is a physical exam and history of the patient, which is typically
standard procedure. Blood tests are taken, including a complete blood count (CBC), an HIV test,
blood chemistry, urinalysis, serum lactate dehydrogenase (LDH), liver function tests and a serum
alkaline phosphatase. Bone marrow biopsy is taken due to the incidence of bone marrow
involvement. MRIs can be used to detect bone marrow involvement and CNS involvement and
are sometimes more sensitive to detect the extent of involvement (Washington & Leaver, 2010).
Diagnostic imaging includes a chest x-ray, CT of the abdomen, pelvis, neck and chest, PET scans
have been used more commonly for staging. Depending on the extent of spread, testing may
include a gallium whole body scan, upper GI or small bowel series and CT scan of the brain. If
the CT comes back with unfavorable results, a lymphangiogram of the pelvis and abdomen will
be performed as well (Washington & Leaver, 2010).
Pathology and Staging
Lymphomas occur in the primary (central) or the secondary (peripheral) tissues. Primary
harbors the lymphoid precursor cells, both B and T, whereas the peripheral tissue is where the
antigen-specific reactions occur. The size, shape and pattern of the cells best predict prognosis.
Lymphocytes arrange themselves in similar circle patterns called follicular or nodular. These tend
to be slow growing and of low grade. Follicular lymphomas are more often of B-cell origin and
have a prolonged survival rate. Most of these lymphomas appear below the diaphragm and
involve the mesenteric lymph nodes. Lymphatics are the most common site for reoccurrence.
Staging lymphomas is complex due to accounting for the bulky part of the disease and the
random spread patterns associated with NHL. Ann Arbor staging system is most commonly used,
but is not accurate to account for the advanced disease. The diaphragm plays an important role in

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the staging of Hodgkins and Non-Hodgkins, but is insignificant in the staging of lymphomas
(Washington & Leaver, 2010).
Treatment Techniques
Due to the wide variety of lymphomas, treatment techniques vary greatly. Treatment
choices are based on specific subtype, extent of disease, age and general health. There are five
categories for treatment: no initial treatment, chemotherapy, radiation therapy, biologic therapies
and stem cell transplants.
Overall, the most common treatment technique is chemotherapy with or without radiation.
Chemotherapy is given to reduce the risk of distant failure and is usually given as the sole
treatment or prior to radiation treatments. If chemo is combined with radiation both doses will be
reduced by half. Chemo is given in multi-agent due to its proven effectiveness over single-agent
chemo. CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone) is the
most common chemo regimen is the most common for Stage I and II NHL, given in three or for
cycles followed by radiation therapy.
Lymphomas are sensitive to radiation, but few patients obtain a cure from local or regional
radiation treatments due to the likelihood of disease spreading to other lymphatics. Since
lymphomas tend to spread randomly, radiation more than likely will be combined with
chemotherapy treatments. Radiation is the treatment choice of treatment for Stage I and II
follicular lymphoma. They can be curatively treated with 30-36Gy followed by a boost up to 3640Gy total. The five-year survival rate is 80% for patients with limited disease (Washington &
Leaver, 2010).

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Analysis
Based upon researching follicular lymphoma, followed by discussions with the radiation
oncologist, Mr. Smith was treated appropriately. Since the area of spread was so small and
caught early on, surgery was the best initial option for treatment. Due to the rate and
reoccurrence of spread with follicular lymphoma, treating the area post-surgery with radiation,
was the next step. Due to the location and size of his lesions, electrons were the optimal
treatment choice for radiation. Chemotherapy was an unnecessary treatment because of the
extent and staging of his cancer. He had no evidence of spread or metastasizes, therefore ruling
out chemotherapy at this point in time. Biotherapy is used in some types of lymphoma,
monoclonal antibodies (MAB) are the most common type. Rituximab is the most common MAB
used in follicular lymphoma (Cancer Research, 2014). Prior to remission, it is given concurrently
with chemo and once announced in remission it can be given for up to two years, post treatment.
Mr. Smith did not received chemotherapy and caught his disease very early on, making
biotherapy an unnecessary treatment option at this point.
Mr. Smith has been announced disease free and received the recommended dose of
radiation for cure. He followed his care regimen as suggested by the Doctor and used eye drops
2-3 times a day to help alleviate his dry eye symptoms. Post treatment, his dry eye has subsided
and his erythema in his inner lid is gone. John is scheduled to follow up with his eye doctor,
medical oncologist and radiation oncologist every 3-6 months for eye exams, imaging tests and
general follow up. I believe Mr. Smith will remain cancer free due to the early detection,
treatment and continued follow up from treatments.

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9
References

American Cancer Society. (2016). Types of non-Hodgkin lymphoma. Retrieved March 18, 2016,
from http://www.cancer.org/cancer/non-hodgkinlymphoma/detailedguide/non-hodgkinlymphoma-types-of-non-hodgkin-lymphoma
Cancer Research, UK. (2014, September 26). Biological therapy for non-Hodgkin lymphoma
Retrieved March 21, 2016, from http://www.cancerresearchuk.org/about-cancer/type/nonhodgkins-lymphoma/treatment/biological-therapy-for-non-hodgkins-lymphoma
Lymphoma Research Foundation. (2012). Follicular Lymphoma. Retrieved March 18, 2016,
from http://www.lymphoma.org/site/pp.asp?c=bkLTKaOQLmK8E&b=6300155
Washington, C., & Leaver, D. (2010). Principles and practice of radiation therapy. (3rd Ed.). St.
Louis, MO: Mosby Elsevier.