Solitary Fibrous Tumors of the Lacrimal Drainage System With Variable Orbital and Sinonasal Extensions: Combined External and Endoscopic Surgical Approach

A Rare Case of Solitary Fibrous Tumor Involving the Nasolacrimal Duct System in a 12-Year-Old Female: A Case Report and Review of the Literature

We report the youngest case of solitary fibrous tumor (SFT) with extensive involvement of the nasolacrimal duct system and discuss current literature regarding this tumor type. A 12-year-old female presented with a 6-month history of an enlarging right medial orbit mass. CT orbits revealed a well-circumscribed, enhancing lesion adjacent to the right nasolacrimal system. Pathology confirmed SFT (1.2 × 1.1 × 1.1 cm) with spindle cell morphology and a mitotic rate of 5 per 10 high power fields. Immunohistochemistry (IHC) was positive for CD-34 and signal transducer and activator of transcription 6 and negative for S-100, consistent with SFT. Next-generation sequencing confirmed NGFI-A-binding protein 2::signal transducer and activator of transcription 6 gene fusion. To our knowledge, only 17 cases of SFT involving the lacrimal sac have been reported, of which, the average age was 43.5 years. Notably, SFTs with a high mitotic rate carry a heightened risk of malignant transformation. Given our patient's mitotic rate of 5 per 10 high power fields, positive surgical margins, and young age, close follow-up is imperative.

Exclusive or combined endoscopic approach to tumours of the lower lacrimal pathway: review of the literature

A literature review was conducted to assess the role of minimally-invasive endoscopic treatments for lacrimal pathway neoplasms. The study involved the analysis of 316 patients with benign or malignant tumours affecting the lacrimal drainage system. Histologically, the analysis revealed a prevalence of squamous cell carcinoma, followed by lymphatic neoplasms and melanomas. In terms of treatment, minimally-invasive endoscopic approaches, such as endoscopic dacryocystorhinostomy, play a predominant role in managing early-stage tumours, rather than merely obtaining samples for histological analysis. For more extensive tumours, which constitute the majority of cases, more aggressive external approaches are required, along with the use of adjuvant radiotherapy and chemotherapy. The lack of universally shared staging systems poses a limitation in standardisation and comparison of results. Treatment of these tumours remains complex due to their rarity and histological heterogeneity. A multidisciplinary approach is mandatory to optimise outcomes.

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.

A review of solitary fibrous tumours of the orbit and ocular adnexa

Solitary fibrous tumour (SFT) is an uncommon spindle cell tumour of mesenchymal origin characterised by NAB2-STAT6 gene fusion. Although it was first described in the pleura, it can occur in connective tissue in any part of the body, but rarely presents in the orbit and ocular adnexa. SFT, which is part of the same disease spectrum as other fibroblastic tumours such as giant cell angiofibroma, haemangiopericytoma and fibrous histiocytoma, usually presents as a painless, slow-growing mass in any age group and generally follows a benign course, with a good prognosis after complete excision. However, malignant forms rarely occur. Even for benign tumours a more aggressive clinical behaviour is possible, with relentless infiltrative local growth, frequent recurrence following surgery, and malignant transformation with the potential for metastatic spread. Careful long-term follow-up is essential. The published literature on SFTs of the orbit and ocular adnexa is reviewed, and the aetiology, clinical presentation, epidemiology, radiological features, histopathology, immunohistochemistry, risk stratification, clinical management, and prognosis are discussed, reflecting on our own experience.

Bilobed flap reconstruction after en-bloc removal of solitary fibrous tumor of the lacrimal sac

Purpose

To report a rare case of a solitary fibrous tumor (SFT) of the lacrimal sac and discuss considerations for management of similar cases.

Observations

We present the case of a 41-year-old woman who presented with a primary lacrimal sac SFT for which she underwent en-bloc surgical resection. We discuss management options for SFTs and our surgical approach for this case: bilobed flap reconstruction of the medial canthus and inferior orbit.

Conclusions

We present an uncommon presentation of a rare tumor and a successful one-stage reconstruction with a bilobed flap.

Masquerades of Acquired Dacryocystocele

Introduction

Dacryocystocele can be congenital or acquired and acute or chronic, based on underlying pathology. An inferomedial anterior orbital mass lesion can masquerade an acquired dacryocystocele with similar symptomatology; however, the treatment varies. Hence, a careful examination of the swelling to differentiate these masquerades is needed to ensure rightful treatment.

Patients and Methods

A retrospective, interventional study was performed on consecutive patients from January 2017 to October 2019 who presented with swelling in the lacrimal sac area of varying durations. They underwent computed tomography scans followed by surgical intervention. Their relation to the lacrimal drainage apparatus was explored.

Results

During the study period, 5 such patients were found in the records. The radiology was consistent with anterior orbital mass lesions, not involving the lacrimal sac. Histopathology after surgical excision was consistent with three of the lesions being dermoid cysts, one was cavernous hemangioma and one was a solitary fibrous tumor.

Conclusion

Inferomedial anterior orbital mass lesions can present as masquerades of acquired dacrycystoceles. Careful examination and high degree of suspicion is needed to distinguish these lesions and ensure correct treatment.