Masses of the Lacrimal Gland: Evaluation and Treatment

Advances in lacrimal gland organoid development: Techniques and therapeutic applications

The human lacrimal gland (LG), located above the outer orbital region within the frontal bone socket, is essential in maintaining eye surface health and lubrication. It is firmly anchored to the orbital periosteum by the connective tissue, and it is vital for protecting and lubricating the eye by secreting lacrimal fluid. Disruption in the production, composition, or secretion of lacrimal fluid can lead to dry eye syndrome, a condition characterized by ocular discomfort and potential eye surface damage. This review explores the recent advancements in LG organoid generation using tissues and stem cells, highlighting cutting-edge techniques in biomaterial-based and scaffold-free technologies. Additionally, we shed light on the complex pathophysiology of LG dysfunction, providing insights into the LG physiological roles while identifying strategies for generating LG organoids and exploring their potential clinical applications. Alterations in LG morphology or secretory function can affect the tear film stability and quality, leading to various ocular pathological conditions. This comprehensive review underlines the critical crosslink of LG organoid development with disease modeling and drug screening, underscoring their potential for advancing therapeutic applications.

A novel case of recurrent cylindroma of the orbit

Cylindroma is a rare benign tumour of eccrine origin that has not been previously reported within the orbit. We report a case of a recurrent orbital cylindroma following incomplete excision. A 75-year-old female presented with a recurrent left inferomedial orbital mass. Seven years prior a mass of the same location was excised and on histology at the time resembled a cylindroma. The patient had a history of lung adenocarcinoma. Magnetic resonance imaging (MRI) found the recurrent mass to be a well-circumscribed lesion anterior to the inferior oblique. The mass was subsequently excised. Histological analysis found a well-circumscribed neoplasm with a characteristic jigsaw pattern of nested cells, consistent with cylindroma. This case demonstrates the possibility for cylindromas to occur within the orbit and their ability to reoccur if incompletely excised.

Optimizing surgical approaches for lacrimal gland adenoid cystic carcinoma to minimize cross-organ invasion

AIM

To evaluate the outcomes of eye-sparing surgery for lacrimal gland adenoid cystic carcinoma and the impact on tumor recurrence and orbital integrity.

METHODS

The study enrolled four patients with recurrent lacrimal gland adenoid cystic carcinoma. The outcome focused on the relevance of the integrity of the lateral orbital wall to the occurrence of extraorbital metastasis in the local recurrence of lacrimal gland adenoid cystic carcinoma.

RESULTS

Three patients underwent eye-sparing surgery via lateral orbitotomy without postoperative radiotherapy, and one patient who underwent eye-sparing surgery via sub-brow approach. These four patients all demonstrated a recurrence involving the invasion of extraorbital tissues as metastatic form through surgical bone seams.

CONCLUSION

Preserving intact orbital bone tissue is crucial for mitigating direct cross-organ metastasis of lacrimal gland adenoid cystic carcinoma. The findings suggest avoiding the lateral orbitotomy approach with no or limited orbital bone wall invasion.

Prognostic factors for lacrimal gland adenoid cystic carcinoma: a retrospective study in Chinese patients

AIM

To explore the prognostic factors for lacrimal gland adenoid cystic carcinoma (LGACC) in Chinese patients.

METHODS

Clinical and histopathological data were reviewed in patients with pathologically confirmed LGACC. Local recurrence, metastasis, and disease-specific death were the main outcome measures. Univariate and multivariate analyses were performed by the Kaplan-Meier method and a Cox proportional hazard model.

RESULTS

This retrospective cohort study included 45 patients with pathologically confirmed LGACC between January 2008 and June 2022. Tumor (T) classification (P=0.005), nodal metastasis (N) classification (P=0.018) and positive margin (P=0.008) were independent risk factors of recurrence; T (P=0.013) and N (P=0.003) classification and the basaloid tumor type (P=0.032) were independent risk factors for metastasis; T classification (P<0.001) was an independent factor of death of disease. In the further analysis, the durations from first surgery to radiotherapy is correlated with metastatic risk in LGACC patients with basaloid component (P=0.022).

CONCLUSION

Histological subtype should be emphasized when evaluating prognosis and guiding treatment. Timely radiotherapy may reduce the risk of metastasis in patients with basaloid component.

Recurrence rate of pleomorphic adenoma of the lacrimal gland: systematic review and meta-analysis

PURPOSE

The aim is to increase the understanding of lacrimal gland pleomorphic adenoma's recurrence rate and the factors that influence it.

METHODS

A systematic search of PubMed, SCOPUS, Cochrane Library, and CINAHL was conducted following PRISMA guidelines. The data in the included studies were extracted and analyzed.

RESULTS

Twenty-two studies were included representing 963 patients from 12 different countries. The pooled analysis of the recurrence rate was 8.83% (95% CI: 5.08-13.50). In the event of recurrence, there was a 75.17% (95% CI: 65.98-82.94) chance of benign recurrence and a 28.35% (95% CI: 19.66-38.41) chance of malignant recurrences, with malignant recurrence occurring almost exclusively after a benign recurrence. The results showed that 47.09% (95% CI: 24.60 to 70.22) of recurrent tumors had a ruptured pseudocapsule and 6.35% (95% CI: 0.82 to 16.54) had an intact pseudocapsule with a significant difference between the two. Of the recurrent tumors, 51.50% (95% CI: 9.28 to 92.39) were biopsied compared to 8.83% (95% CI: 3.40 to 16.49) of the total; the difference between these two proportions was also found to be significant.

CONCLUSION

There was a statistically significant difference in the rates of recurrence between tumors that were either biopsied or had a ruptured pseudocapsule compared to those that did not. This evidence adds additional support for excisional biopsy being the procedure of choice for LGPA and reinforces the importance of keeping the pseudocapsule intact during surgical resection.

Molecular characterisation of tumours of the lacrimal apparatus

AIMS

Malignant tumours of the lacrimal apparatus are rare and frequently show a poor prognosis, with no clear therapeutic standards. Characterisation of the genetic landscape of these rare tumours is sparse, and therefore therapeutics generally follow those of their common salivary gland counterparts. To further clarify the pathophysiology and discover potential therapeutic targets, we investigated the genetic landscape of eight tumours of the lacrimal apparatus.

METHODS AND RESULTS

DNA and RNA sequencing were performed to identify genetic mutations and gene fusions. Immunohistochemistry, fluorescence in-situ hybridisation and reverse transcription-polymerase chain reaction followed by Sanger sequencing were performed to confirm the identified molecular alterations. Genetic alterations were detected in six tumours. Among five adenoid cystic carcinomas (ACC), four had confirmed alterations of MYB or MYBL1 genes, including a MYB::NFIB fusion, a MYBL1::NFIB fusion, a MYB amplification and a novel NFIB::THSD7B fusion. Mutations in genes encoding epigenetic modifiers, as well as NOTCH1, FGFR2 and ATM mutations, were also identified in ACCs. A carcinoma ex pleomorphic adenoma showed TP53 and CIC mutations and an amplification of ERBB2. A transitional cell carcinoma was associated with HPV16 infection. No genetic alteration was found for one adenocarcinoma, not otherwise specified.

CONCLUSIONS

Our study highlights the variety of molecular alterations associated with lacrimal system tumours and emphasises the importance of molecular testing in these tumours, which can reveal potentially targetable mutations. Our results also reinforce the hypothesis of a common physiopathology of all ACCs, regardless of their primary location.

Correction of Lacrimal Gland Ptosis in Blepharoplasty: A Systematic Review

PURPOSE

Lacrimal gland ptosis has a prevalence of 10% to 15% in Caucasian patients, reaching up to 60% in older age. Its involuntary resection during blepharoplasty carries the potential risk of compromising corneal lubrication. The purpose of this systematic review is to check whether there is a consensus in the literature regarding the surgical procedure of choice and which outcomes and complications have been observed.

METHODS

A systematic review was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A search was carried out in the Medline, Scopus, and Cochrane databases in March 2022.

RESULTS

A total of 16 studies involving 483 patients with lacrimal gland ptosis have been included. In 90.06% of patients, resuspension or direct refixation of the gland to the lacrimal fossa with suture to the orbital periosteum was performed. Follow up has been inconsistent, with an average of 18 months. Regarding complications, 5 recurrences and only 2 patients with persistent dry eye were observed.

CONCLUSIONS

In general, the evidence is sparse. Nevertheless, repair of lacrimal gland ptosis is a relatively simple, reproducible, and safe surgical technique, with a low likelihood of recurrence, severe, or persistent complications. A classification is proposed for both the grading of ptosis and its treatment.

Advances in clinical examination of lacrimal gland

In humans, the lacrimal gland is located in the socket of the frontal bone above the outer orbital area. As an essential part of the eye surface, the gland is fixed to the orbital periosteum by connective tissue. The lacrimal gland passes through the outer tendon membrane, which divides the gland into larger orbital and minor eyelid glands. The lacrimal glands are the main contributors to tear film. They secrete electrolytes, proteins, and water to help nourish and protect the eye's surface. Furthermore, clinically, lacrimal glands are associated with a variety of inflammatory reactions and immune factors and are also vulnerable sites for tumors. Changes in tear gland morphology or secretory function affect tear film stability and tear secretion quality. Various technological devices have been developed and applied to lacrimal glands. This article systematically reviewed the clinical examination of the lacrimal gland to help inform personalized strategies for the diagnosis of lacrimal gland-related diseases.

A case report: An unusual presentation of adenoid cystic carcinoma of the lacrimal gland

RATIONALE

Adenoid cystic carcinoma (ACC) is the most common malignant epithelial tumor of the lacrimal gland with the highest malignant degree. ACC of the lacrimal gland is characterized by symptoms of <1 years duration. We present a 38-year-old male patient who complained of an enlarging mass in the left lacrimal fossa for almost 10 years previous to the diagnosis of ACC.

PATIENT CONCERNS

A 38-year-old male patient visited our ophthalmology clinic with a chief complaint of a mass in his left upper lid, which had enlarged significantly over the previous months.

DIAGNOSES

Magnetic resonance imaging with intravenous Gadobutrol showed moderate and homogenous mass enhancement. Bone destruction is found. The periosteum is not eroded. The magnetic resonance imaging finding was supportive for malignancy. Histopathological examination of the specimen revealed solid tumor showing a cribriform pattern mixed small amount of basaloid cell proliferation. Therefore, the final diagnose was Adenoid cystic carcinoma of the lacrimal gland.

INTERVENTIONS

The treatment included en bloc resection of the mass and adjacent bone and radiotherapy.

OUTCOMES

In 1 year follow-up after operation, there is no recurrence. Visual acuity is 30/30. The left eye shows limitation on abduction.

LESSONS

The present case demonstrates an unusual progression of ACC of the Lacrimal Gland.

Delineation of the lacrimal vein: a magnetic resonance imaging study

PURPOSE

To our knowledge, anatomical knowledge about the lacrimal vein (LV) is missed. Therefore, this retrospective study aimed to explore them using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Eighty-one patients who underwent contrast-enhanced MRI and three donated bodies to science were enrolled.

RESULTS

On the sagittal images, the measured mean right long (LD) and short diameters (SD) of the lacrimal gland (LG) were 17.3 ± 2.4 mm and 13.7 ± 2.1 mm, while the left LD and SD were 17.0 ± 2.6 mm and 13.6 ± 2.6 mm, respectively. Laterality or sex differences were not found in the LD and SD groups. In addition, no specific age range was associated with a significantly longer LD or SD. LVs were identified in 94% of axial images. Their course was classified into as follows: three types: connecting to the superolateral cavernous sinus (CS), to the superior ophthalmic vein (SOV), and the diploic channels of the greater wing of the sphenoid bone (DCGW). The CS type was the most frequently identified, followed by the SOV and DCGW types. In dissected specimens, the LVs consistently coursed between the posterior margin of the LG and the superolateral part of the CS, above the upper margin of the lateral rectus muscle.

CONCLUSIONS

The LV may consistently emerge from the upper posterior margin of the LG. It commonly pours into the SOV or superolateral part of the CS.

Stereotactic radiosurgery for recurrent pleomorphic adenoma of the lacrimal gland: a case report

Lacrimal gland pleomorphic adenomas (LGPAs) are common, benign, and intraorbital tumours that cause exophthalmos, ptosis, and visual disturbances. The curative treatment for LGPAs is gross total resection, and radiotherapy is considered adjunctive for recurrence or an alternative for inoperable LGPAs. Stereotactic radiosurgery (SRS) can be used for precise delivery of high radiation doses to the tumour, crucial in the treatment of intra-and extracranial neoplasms. Here, we present a 95-year-old woman who had a rapidly growing, recurrent LGPA and was successfully treated with SRS. The tumour was controlled without any adverse events over 21 months following SRS. SRS is a potential alternative treatment for recurrent LGPA.

Orbital Infiltration in a Patient with Waldenström Macroglobulinemia: Need for Multidisciplinary Approach and Comparison with the Literature

The use of specific inhibitory drugs of intracellular signalling pathways (such as Bruton-Kinase inhibitors) for the treatment of Waldenström's macroglobulinaemia (WM) is a recognised risk factor for Aspergillus spp. infections. The overlapping clinical manifestations of the two diseases may require the involvement of different medical specialities. We describe the clinical course of a patient with pulmonary and encephalic aspergillosis, with concomitant orbital infiltration, which represented a difficult diagnosis: the case required a multidisciplinary approach to define the ocular lesions and an in-depth study of the literature.