Sir,

Lipomas are common benign soft-tissue tumours of adipose tissue.1 Lymphomas are tumours of proliferating lymphocytes and in the adnexal region are commonly non-Hodgkin's B-cell lymphomas.2 We report a patient with multiple lipomas and a suspicious eyelid mass.

Case report

A 58-year-old male was referred to the oculoplastic clinic for assessment regarding left upper lid mass. The mass had been present for 2 years and slowly increasing in size. The patient has a history of multiple lipomas elsewhere on the body and was referred with a provisional diagnosis of left upper lid lipoma (Figure 1). On examination, a firm mass in the medial half of left upper lid with no lymph node enlargement was noted. The visual acuity was 6/9 in both eyes. Biopsy revealed the mass to be confined to the eyelid. Histopathology showed connective tissue infiltrated by small–medium lymphocytes in a follicular pattern (Figure 2). Immunohistochemistry confirmed diagnosis of follicular lymphoma. The patient was referred to haematology team for staging and further treatment.

Figure 1
figure 1

Clinical photographs. (a) Left upperlid mass; and (b) right arm multiple lipomas.

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Figure 2
figure 2

Histopatholgy slides. (a) Follicle centre cells—centrocytes and centroblasts (H&E); (b) lymphoid follicle and interfollicular cells—B-cell marker (CD20); (c) lymphoid follicle—follicle centre cell marker (CD10); (d) neoplastic lymphoid follicle (bcl-2); (e) kappa light-chain negative; and (f) lambda light-chain positive.

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Comment

Ocular adnexal lymphomas represent 6–8% of all orbital tumours.2 Non-Hodgkin's B-cell type constitutes in excess of 95% of adnexal lymphomas with the remaining being T-cell lymphomas, Burkitt's lymphoma, or rarely Hodgkin's lymphoma. Follicular lymphoma is one of the most common variants in adnexal lymphomas after extranodal marginal zone B-cell subtype.3 These lymphomas exhibit a nodular pattern of growth, and on immunohistochemistry neoplastic follicle centre cells are positive for CD10, Bcl-2, and Bcl-6 antigens.4 Follicular lymphomas are often slow growing tumours and indolent in comparison to other lymphoma variants such as mantle cell and diffuse large B-cell lymphomas.2 However, Nicolò et al5 describe a case of follicular lymphoma with an aggressive course resulting in multiple recurrences despite chemotherapy and radiotherapy.

The history of multiple lipomatosis in our patient suggested that the eyelid lesion might represent a lipoma. The appearance and consistency of the lesion, however, suggested the clinical diagnosis of an adnexal lymphoma, which was confirmed on histopathological examination. The implications of the diagnosis of lymphoma are significant in comparison to a lipoma. It is essential to consider the possibility of dual pathology when the clinical picture does not fit with the ‘labelled’ diagnosis.