Distinguishing lymphoma from reactive lymphoid hyperplasia in children

This chart review found that it can be difficult to determine whether a “salmon patch” lesion in the caruncle region of an adolescent is truly mucosa-associated lymphoid tissue (MALT lymphoma) or simple reactive lymphoid hyperplasia (RLH). Both findings are relatively rare in this population.

Conjunctival RLH may sometimes be a premalignant condition leading to MALT lymphoma, as has been reported in some cases. It presents clinically as a slowly growing pink fleshy mass over the nasal bulbar conjunctiva, with an incidence in the pediatric population equivalent to that of ocular adnexal lymphoma.

Clinically, it is very difficult to distinguish between the two conditions and usually excisional biopsy is performed for diagnosis. However, since RLH is a benign lesion it is important to differentiate it from MALT lymphoma because it can be treated without surgical intervention.

In this study, the authors describe a series of cases of pediatric patients with a similar clinical presentation but a different final diagnosis. Eleven patients aged 6 to 21years presented with an elevated pink conjunctival mass in the plical area of one or both eyes. Nine patients underwent an excisional biopsy that histopathologically disclosed MALT lymphoma in two cases and RLH in seven cases.

Molecular diagnosis showed polyclonal B cells in six patients, monoclonal B cells in two patients and a questionable status in one patient. Systemic examination disclosed localized ocular adnexal disease in the patients with MALT lymphoma, and none had either local or systemic recurrence during follow-up. Two other patients were treated with antiallergic medication with resolution of the lesion, and were therefore diagnosed clinically with RLH.

They conclude that it is reasonable to attempt a trial of anti-allergenic drops prior to surgical excisional biopsy in order to reduce surgeries that often require general anesthesia in this population.

With the relatively rare incidence of ocular adnexal lymphoma and reactive lymphoid hyperplasia, and considering the fact that RLH can sometimes be a pre-malignant condition leading to MALT lymphoma, would you consider a medical trial of anti-allergenic drops prior to surgery with these patients?