A case of primary adenocarcinoma of the lacrimal sac

Primary Lacrimal Sac Tumors with Extension into Vicinity: Outcomes with Endoscopy-Assisted Modified Weber-Ferguson's Approach

PURPOSE

To evaluate the outcomes of endoscopy-assisted modified Weber-Ferguson's approach in the management of primary lacrimal sac tumors with extension into the neighboring tissues.

METHODS

A retrospective interventional study was performed on all patients with lacrimal sac tumors treated with the endoscopy-assisted modified Weber-Ferguson approach between January 2010 and June 2022 at the Shanghai Ninth People's Hospital, China. Data assessed include demographics, clinical presentations, imaging features, surgical techniques, histopathology, adjuvant modalities of management, complications, and outcomes.

RESULTS

A total of 13 patients were included in the analysis. Epiphora and palpable mass lesion were the presenting complaint in 84.6% (11/13) of the patients. Nearly half of the patients (46.1%, 6/13) were misdiagnosed as lacrimal duct obstruction. All the lacrimal sac tumors in the present series showed uneven enhancement on T1-weighted MRI imaging. Postoperatively, 84.6% (11/13) patients recovered well with excellent esthetics and were disease-free after a mean follow-up of 58.6 months. Two patients who underwent additional exenteration developed recurrence and succumbed (at 41 and 96 months follow up) while they were on palliative chemoradiation.

CONCLUSION

The endoscopic-assisted modified Weber-Fergusson surgical approach is effective in providing better visibility and accessibility to lacrimal sac tumors with extension into neighboring tissue.

Lacrimal Sac Tumors: A Case Series

Objective

The aim of the study was to describe the clinical presentation, management strategies, and outcomes in a case series of primary lacrimal sac tumors.

Methods

This retrospective study was conducted in Sheikh Fajilatunnessa Mujib Eye Hospital and Training Institute, Bangladesh, from July 1 to December 31, 2020, and included all patients who were evaluated, treated, and followed up for at least 6 months from January 2013 to October 2020. One patient developed a recurrence of the adenocarcinoma of the lacrimal sac after 1 year of primary treatment. Patients' demographic data were analyzed and reviewed from published articles on lacrimal sac tumors. We assessed patients clinically, followed by radiological evaluation. We also analyzed the biopsy technique, treatment modality, and recurrence. An oncologist reviewed all patients to prepare a plan for adjuvant treatment.

Results

Ten patients with lacrimal sac tumors were included in this study. Swelling in the medial canthal region was the most common presenting feature (100%), followed by epiphora (60%) and pain (30%). Open biopsy was preferred over fine-needle aspiration biopsy. Incisional biopsy or complete excisional biopsy was performed for all suspected malignancies. Malignant tumors were found in 7 (70%) cases, and benign tumors in 3 (30%) cases. Non-Hodgkin's lymphoma (NHL) (40%) was the most common malignant lacrimal sac tumor. Mucosa-associated lymphoid tissue lymphoma was 75%, and diffuse large B-cell lymphoma was 25% among the cases of NHL. Patients with epithelial malignancy were treated with external beam radiation therapy, while NHL patients were treated with chemotherapy (CHOP regimen). Recurrence was noted in 1 case (10%) of epithelial malignancy after 1 year of treatment.

Conclusion

Successful management of lacrimal sac tumors requires a high index of suspicion, as these are fatal tumors, often misdiagnosed as dacryocystitis. Nonepithelial malignancies are more predominant than epithelial malignancies, and hematolymphoid tumors are most frequent.

Lacrimal sac adenocarcinoma managed with androgen deprivation

Purpose

To describe a case of primary lacrimal sac adenocarcinoma treated primarily with androgen deprivation therapy (ADT) with good clinic response.

Observations

An 82-year-old male presented with a painless right orbital mass. Pathology following partial resection was consistent with primary lacrimal sac adenocarcinoma positive for androgen receptors (AR). Magnetic resonance imaging (MRI) scan showed an orbital mass with extension into the nasolacrimal apparatus and intraconally between the medial and inferior recti. Staging positron emission tomography/computed tomography (PET/CT) showed one hypermetabolic right sided lymph node in addition to the known orbital mass. Orbital exenteration and external beam radiation therapy were offered as the primary treatment modality however the patient refused. He subsequently received four years of androgen deprivation monotherapy, before stopping due to sexual side effects, with no progression of local or metastatic disease and some local regression documented on MRI at 5 years.

Conclusions and Importance

Lacrimal sac adenocarcinoma is commonly found to be AR positive on pathology. Our case shows that ADT can serve as an effective treatment modality for those patients that defer primary surgical management.

Primary Malignant Epithelial Tumors of the Lacrimal Drainage System: A Major Review

Purpose: To perform a literature review on the primary malignant epithelial tumors (PMET) involving the lacrimal drainage system (LDS).Methods: The authors performed a PubMed search of all articles published in English on primary malignant epithelial tumors of the lacrimal sac and the nasolacrimal duct. Data analyzed include prevalence, demographics, clinical presentation, histopathological subtypes, management modalities, outcomes, and recurrence rates.Results: Malignant epithelial tumors of the lacrimal sac are commonly diagnosed in the fifth to seventh decades of life (mean age: 58 years) and have no gender predilection. Typical clinical presentation includes epiphora (84%) and lacrimal fossa mass lesion (78%). Pain (9%) and blood-stained epiphora (4%) were inconsistent findings. Among the PMET, squamous cell carcinomas (SCCs) were the most common (61%) followed by transitional cell carcinomas (TCC; 15%), and mucoepidermoid carcinoma (MEC; 7%). Complete surgical excision followed by radiotherapy (59%) was the preferred modality of management, and only 18% required orbital exenteration. Of the 331 tumors with available treatment details, 85% survived at a mean follow-up of 33 months. The overall recurrence rate following treatment was 20% (65/331). MECs of the lacrimal sac had the best while adenoid cystic carcinoma had the worst prognosis.Conclusion: Blood-stained epiphora was not the classical presentation for primary epithelial malignancies of the LDS. No validated staging system exists for lacrimal drainage tumors. There is a need for consistent and detailed reporting in the literature, more so on the histological subtypes and their management.

Carcinomas of the lacrimal drainage system

Malignant tumors of epithelial origin are the most frequent neoplasms of the lacrimal drainage system (LDS). A total of 539 cases are reported in the literature from 1960 to 2019. LDS carcinoma is a disease of the middle-aged and elderly population, with a median age at diagnosis of 57 years. Overall, there is a slight male predominance. Reported risk factors are chronic inflammation, LDS papilloma, and infection with oncogenic viruses. Symptoms of an LDS carcinoma resemble those of benign, inflammatory diseases, with epiphora from obstruction of the LDS as the most frequently encountered symptom. The median time from symptoms to diagnosis is 12 months and even longer for patients reporting epiphora as the only initial symptom. This diagnostic delay leads to a substantial fraction of patients with locally advanced tumors and lymph node spread at the time of diagnosis. Surgery with adjuvant radiotherapy is the treatment of choice for most patients; however, the extension and aggressiveness of the disease and the patient's general health and preferences determine the definite treatment. Five-year overall survival is reported to range from 61 to 87.6%. A large tumor size and positive lymph node status correlate with a decreased overall and disease-free survival.

Poorly differentiated primary adenocarcinoma of the lacrimal sac and the nasolacrimal duct

Primary adenocarcinoma of the lacrimal drainage system is a rare malignancy. Poorly differentiated subtypes of this tumor demonstrate aggressive behaviors, and metastasis is not uncommon. We present a patient with poorly differentiated adenocarcinoma of the lacrimal sac and nasolacrimal duct with an orbital extension. The case was managed by a combined external and endoscopic approach excision followed by adjuvant radiotherapy.

Lacrimal Sac Tumors--A Review

Tumors of the lacrimal sac are rare but their recognition and early management are imperative, as they are locally invasive and potentially life-threatening. Because of their rarity, large clinical studies with statistically significant data on the natural course, management, and prognosis of these neoplasms are unavailable. Current practices are therefore based on a few case series and a small number of isolated case reports. Most tumors are primary and of epithelial origin (60-94%), of which 55% are malignant. Lacrimal sac tumors typically present with epiphora and a palpable mass over the medial canthus and are thus often erroneously diagnosed as chronic dacryocystitis. A full history with clinical and diagnostic workup is essential to plan treatment, which is often multi-disciplinary. Statistically significant associations have been shown with higher tumor staging and size with increased metastatic risk and lower survival rates. Management usually involves complete surgical resection with adjuvant radiotherapy and/or chemotherapy for malignant lesions. Long-term follow-up is required, as recurrences and metastases can occur many years after initial treatment.

Androgen-Receptor Positive Lacrimal Sac Adenocarcinoma Demonstrating Long-Lasting Response to LHRH Analog Plus Abiraterone Treatment

Tumors arising at the lacrimal sac are extremely rare, as a limited number of cases have been reported worldwide. They are commonly primary and the majority of them are malignant and epithelial in origin. Adenocarcinomas account for a small percentage of these tumors. Treatment of local disease mainly includes complete surgical resection. However, metastatic disease has a poor prognosis and the development of new treatment strategies is highly important. Research efforts mainly focus on the identification of molecular targets for therapy. Herein, we describe for the first time a case of a patient with an androgen receptor expressing adenocarcinoma of the lacrimal sac that had an impressive response to abiraterone.

Nasolacrimal duct tumours in the era of endoscopic dacryocystorhinostomy: literature review

Background:

Nasolacrimal duct tumours are rare and are often found inadvertently during dacryocystorhinostomy. Anecdotal case reports have been published, mostly in ophthalmology journals. Since the era of endoscopic dacryocystorhinostomy, such cases are more frequently encountered by ENT surgeons.

Method:

This paper reports a retrospective chart review of patients who underwent endoscopic dacryocystorhinostomy over the last 10 years in our dedicated epiphora clinic. It also provides a systematic literature review of nasolacrimal duct tumour cases published in English over the last 16 years.

Results:

Four of 525 endoscopic dacryocystorhinostomy procedures exposed a tumour (inverted papilloma, oncocytoma, lymphoma and solitary fibrous tumour). The literature review revealed 118 published case reports. Papilloma was the most frequently reported benign tumour and lymphoma was the most common malignant tumour.

Conclusion:

Since the advent of endoscopic dacryocystorhinostomy, tumours are being diagnosed relatively early when smaller in size. Because of the rarity of this condition, it is advisable that such cases are managed through a dedicated epiphora service framework.

Les tumeurs malignes primitives des voies lacrymales

OBJECTIVES

To assess the clinical characteristics, the workup, therapeutic approach and pathological findings of primitive tumors of the lacrimal sac.

MATERIAL AND METHODS

Three cases were retrospectively reviewed from the database of our ENT department. They were analyzed and compared to cases reported in the literature.

RESULTS

One adenoid cystic carcinoma and two adenocarcinomas were observed, all were adults and the sex ratio was one man for 2 women. Clinically they presented neither significant lacrimal or rhinologic sign. A CT-scan and a MRI were performed along with a physical examination. An entire surgical resection was done with subsequent postoperative radiotherapy. Two patients died, and one is alive, free of disease.

CONCLUSION

Lacrimal tumors should be considered in the differential diagnosis of a banal chronic epiphora. The ENT practitioner must associate this factor to any clinical evaluation. The management of these lesions requires a complete surgical resection, routinely associated with postoperative radiation.

Salivary duct carcinoma in the sinonasal tract

Salivary duct carcinoma (SDC) is an uncommon malignant tumor, characterized by aggressive behavior and poor prognosis. SDC usually arises from ductal epithelium of the major salivary glands, and it is quite infrequent elsewhere. We present a rare case of a 73-year-old man with SDC, which is possibly originated from the paranasal sinuses or the lacrimal system. Microscopic evaluation revealed that the tumor cells, with pleomorphic nuclei and abundant eosinophilic cytoplasm, formed cell nests and duct-like structure. A cribriform growth pattern was also seen. Immunohistochemical staining was positive for cytokeratins (CAM 5.2 and 34betaE12), gross cystic disease fluid protein 15 (GCDFP-15), and androgen receptor protein, while p63 and involucrin were negative. The patient already had multiple metastasis of the tumor in the lung at diagnosis, and he could not undergo definitive surgical procedures, because of severe restrictive lung disease. Although SDC in the sinonasal tract is quite rare, SDC should be in the differential diagnosis in these regions, due to its aggressive behavior and poor prognosis.