Epithelial tumours of the lacrimal gland: a clinical, histopathological, surgical and oncological survey

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.

Adenoid Cystic Cancer of the Lacrimal Gland: Management Aspects and Treatment Outcomes

Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common malignant epithelial tumor of the lacrimal gland. The biological behavior of these tumors is characterized by a slow growth with frequent nerve invasion but rare invasion of the neck nodes. Local extension intracranially with bone erosions is seen in locally advanced tumors. Distant metastasis to lungs bone and liver are commonly reported. Treatments using surgery and radiotherapy are generally preferred for adequate tumor control. However there is still no consensus on the best treatment approach.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04426-5.

Diagnostic value of dynamic contrast enhancement combined with conventional MRI in differentiating benign and malignant lacrimal gland epithelial tumours

AIM

To establish the diagnostic value of the quantitative parameters of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) combined with conventional MRI in differentiating of benign and malignant lacrimal gland epithelial tumours.

MATERIALS AND METHODS

A retrospective analysis of primary lacrimal gland epithelial tumours confirmed by histopathology was conducted. Conventional MRI features and DCE-MRI quantitative parameters were collected and subjected to analysis. The diagnostic value was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 53 patients were enrolled of which 29 had malignant, whereas 24 had benign tumours. Conventional MRI revealed statistically significant differences between benign and malignant tumours regarding maximum tumour diameter, posterior margin characteristic, bone destruction, and erosion. The Ktrans and Kep values obtained by DCE-MRI were higher in malignant than in benign tumours, with a statistically significant (p<0.001 and p=0.022). A type I time-signal intensity (TIC) curve was more frequent in benign tumours, whereas a type II TIC curve was prevalent in malignant tumours (p=0.001). ROC analysis showed that Ktrans had the best diagnostic value of the DCE-MRI parameters (area under the ROC curve [AUC] of 0.822, 75.9% sensitivity, and 83.3% specificity, p<0.001). The combination of conventional MRI and DCE-MRI factors had the best diagnostic value and balanced sensitivity and specificity (AUC of 0.948, 93.1% sensitivity, and 91.7% specificity, p<0.001).

CONCLUSIONS

The present findings indicate that the combination of quantitative parameters of DCE-MRI and image characteristics of conventional MRI have a high diagnostic value for the diagnosis of benign and malignant lacrimal gland epithelial tumours.

Incidence, clinical features, and survival outcomes of primary malignant lacrimal gland tumors: A population-based analysis

BACKGROUND

Studies on the epidemiological information and prognosis of primary malignant lacrimal gland tumors (MLGTs) are rare for its low occurrence. The goal of our research was to investigate the epidemiological characteristics and survival outcomes of patients with MLGTs.

METHODS

Incidence and demographic information of patients with MLGTs were collected from the Surveillance, Epidemiology, and End Results (SEER) database. To identify independent prognostic factors for disease-specific survival (DSS) and overall survival (OS), univariate and multivariate Cox regression analysis were performed.

RESULTS

The overall incidence of primary MLGTs from 1975 to 2020 was 0.413/1,000,000 (according to the 2000 American standard population), with a steadily increasing incidence over years. A total of 964 patients with primary MLGTs were diagnosed, with an average age of 59.3 years. Of these, 53.2% were aged ≥60 years, 57.4% were female, and 77.1% were whites. Multivariate Cox regression analysis demonstrated that year of diagnosis, age, sex, histological type, SEER stage, surgery, and chemotherapy were independent prognostic factors of DSS or OS.

CONCLUSIONS

Although primary MLGT is rare, its incidence has steadily increased in the past 46 years, and surgery was related to a better prognosis.

In-Depth Analysis of Incidence and Survival of Lacrimal Gland Malignancies in the United States of America from 1995 to 2018

PURPOSE

To investigate lacrimal gland malignancies' incidence and survival rates in the USA between 1995 and 2018.

METHODS

Incidence and survival data from the North American Association of Central Cancer Registries of lacrimal gland malignancies between 1996 and 2018 were extracted and analyzed.

RESULTS

This study analyzed data pertaining to 3620 patients (females 56.7%, n = 2051). A sizable number of patients were 60-79 years of age (45.1%, n = 1633), with a substantial majority being of the non-Hispanic white ethnicity (82.9%, n = 3002). A little above half of patients (52.1%, n = 1886) had presented with a localized disease. Lymphomas represented 59.3% (n = 2146) of lacrimal gland malignancies, while 37% (n = 1339) were carcinomas. The cumulative age-adjusted incidence rate per million was 0.53 for all malignancies, 0.31 for lymphomas, and 0.2 for carcinomas. While the annual crude incidence rate showed a significant steady increase (average annual change of 1.24%; P < .05), age-adjusted rates did not show a similar trend. The five- and 10-year relative survival rates were 88.64 months (95% confidence interval (CI): 85.81-90.93) and 80.26 months (95%CI: 76.21-83.7), respectively. Older age, non-lymphoma tumors, and advanced stage at diagnosis were significantly associated with worse outcomes. Relative survival rates did not show significant changes from 1995 to 2018, irrespective of gender, race or treatment received.

CONCLUSIONS

Early detection and localized tumor management can improve survival outcomes for patients with lacrimal gland malignancies. Further research is needed to understand these malignancies' risk profiles and develop more effective treatment strategies.

Intraoperative use of electrical impedance spectroscopy for adenoid cystic carcinoma of the lacrimal gland: A case report

Key Clinical Message

Electrical Impedimetric Tumor Detection System is a novel and promising tool for fast intraoperative tumor delineation and accurate safe margin detection in orbital tumors.

Abstract

Adenoid cystic carcinoma (ACC) is a rare malignant tumor of epithelial origin, typically arising from the salivary and lacrimal glands. ACC is notorious for recurrence and a high rate of morbidity and mortality despite therapy. We presented a 48-year-old male patient with lacrimal gland ACC of the right orbit who underwent radical tumor resection and adjuvant radiotherapy. We applied a new diagnostic method, the Electrical Impedimetric Tumor Detection System, during surgery and tested its performance to enhance the precision of tumor resection. Two months after surgery, he underwent external radiation of 58 Gy in 29 fractions. He showed no tumor recurrence or metastasis in the 1-year follow-up visits. ITDS showed a precision of tumor and margin detection consistent with histopathology results. This novel ITDS may be a reliable system for fast intraoperative tumor delineation and accurate, safe margin detection in orbital tumors.

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.

Epidemiology and survival outcomes of patients with orbital region non-cutaneous squamous cell carcinoma: a population-based analysis

Background

Non-cutaneous squamous cell carcinoma (ncSCC) of the orbital region is very rare. Thus, its epidemiological characteristics and prognosis are poorly understood. The aim of the study was to assess the epidemiological characteristics and survival outcomes of ncSCC of the orbital region.

Methods

Incidence and demographic data on ncSCC of the orbital region were extracted from the Surveillance, Epidemiology, and End Results (SEER) database and analyzed. The chi-square test was used to calculate the differences between groups. Univariate and multivariate Cox regression analyses were performed to determine the independent prognostic factors for disease-specific survival (DSS) and overall survival (OS).

Results

The overall incidence of ncSCC in the orbital region from 1975 to 2019 was 0.68/1,000,000, and the incidence showed an increasing trend during this period. A total of 1,265 patients with ncSCC of the orbital region (mean age, 65.3 years) were identified in the SEER database. Of these, 65.1% were aged ≥60 years, 87.4% were White, and 73.5% were male. The conjunctiva (74.5%) was the most common primary site, followed by the orbit (12.1%), lacrimal apparatus (10.8%), and overlapping lesion of the eye and adnexa (2.7%). Multivariate Cox regression analysis revealed that age, primary site, SEER summary stage, and surgery were independent prognostic factors for DSS, whereas age, sex, marital status, primary site, SEER summary stage, and surgery were independent prognostic factors for OS.

Conclusions

The incidence of ncSCC in the orbital region has increased over the past 40 years. It usually affects White people, men, and people aged ≥60 years, and its most common site is the conjunctiva. Orbital SCC has worse survival outcomes than SCC of other sites in the orbital region. Surgery is the independent protective treatment for ncSCC of the orbital region.

Lacrimal Gland Adenoid Cystic Carcinoma with High Grade Transformation: A Case Report and Current Concepts in Multi Modality Management

Lacrimal gland adenoid cystic carcinoma (AdCC) is associated with an aggressive clinical course and grave prognosis. A high grade transformation within adenoid cystic carcinoma of lacrimal gland is a rare condition which is even more locally aggressive with frequent neck and distant metastasis. We present a case of left lacrimal gland adenoid cystic carcinoma with high grade transformation to adenocarcinoma NOS type presenting with orbital pain and proptosis. After thorough evaluation for locoregional and distant spread of the disease, the patient underwent left orbital exenteration with orbitectomy and neck dissection with free flap reconstruction. Patient received adjuvant radiation therapy and is presently disease free for last 6 months. A multi-modality management protocol involving surgery, radiotherapy and chemotherapy has been proposed for management of lacrimal gland AdCC with high grade transformation. We report the 4th case in the literature of lacrimal gland adenoid cystic carcinoma with high grade transformation.

Imaging of Painful Ophthalmologic Disorders

Cross-sectional imaging with computed tomography (CT) and MRI are diagnostic examinations useful in the diagnosis of painful ophthalmologic disorders and their potential complications. CT is a first-line imaging study for suspected orbital infections, particularly useful in differentiating preseptal cellulitis and orbital cellulitis and detecting complications such as orbital abscess. When compared with CT, MRI is better for orbital soft tissue evaluation, particularly useful for optic neuritis, ocular diseases such as endophthalmitis, and invasive fungal rhinosinusitis with orbital involvement. CT angiography is the preferred noninvasive imaging modality for the detection and classification of carotid cavernous fistula.

Metabolic alterations in carcinoma ex pleomorphic adenoma development of lacrimal glands

PURPOSE

To evaluate metabolic alterations along with the carcinoma ex pleomorphic adneoma (CXPA) development of lacrimal glands (LG).

METHODS

Four samples of the normal LG (NLG), 9 of pleomorphic adenoma (PA), 4 of residual PA (rPA), and 4 of CXPA of LG were included. GLUT-1, HIF-1α, FASN, and adipophilin by immunohistochemical stains were performed in the selected cases.

RESULTS

Was observed higher expression of markers associated with glycolytic and lipid metabolism in the tumor tissue samples when compared to the NLG samples. Additionally, GLUT-1, FASN, and Adipophilin were more expressed in CXPA samples while HIF-1α in PA samples.

CONCLUSIONS

In conclusion, our results demonstrate overexpression of FASN and Adipophilin in CXPA which may reflect a metabolic shift toward lipogenesis in cancer cells.

Lacrimal gland adenoid cystic carcinoma: report of an unusual case with literature review

Lacrimal gland adenoid cystic carcinomas are rare, aggressive orbital tumors characterized by poor overall prognosis, tendency for local recurrence and metastasis despite aggressive treatment. Treatment continues to be controversial. Many authorities today will often initiate surgery (orbital exenteration with or without bone removal vs. globe-sparing resection) and adjuvant radiotherapy (external beam or proton beam therapy). We introduce a case of lacrimal gland adenoid cystic carcinoma treated with orbital exenteration and adjuvant volumetric modulated arc therapy, and discuss the related literature.

Epithelial lacrimal gland tumors in dogs and cats: Is the human WHO classification appropriate for animals?

Lacrimal gland tumors (LGTs) in dogs and cats are rare neoplasms that can affect either the nictitans (NLG) or the main lacrimal gland (MLG). A consistent classification scheme for canine and feline LGTs is lacking; however, the importance of a classification scheme for LGTs has been emphasized in the human literature, and an update to the World Health Organization (WHO) classification has recently been published. The aim of this study was to investigate the occurrence of different subtypes of canine and feline LGTs in accordance with the human WHO classification system. Epithelial LGTs (n = 46 tumors; 38 dogs, 8 cats) were reviewed and immunophenotyping for p63, CK14, SMA, calponin, CKAE1/AE3, and CK19 was performed. Consistent with previous literature reports, lacrimal carcinomas outnumbered adenomas in dogs and cats. Based on the WHO classification of human LGTs, the most common subtypes identified in dogs were pleomorphic, ductal, adenoid cystic, and epithelial-myoepithelial carcinoma. In cats, a lower number of subtypes was observed, and adenocarcinoma "not otherwise specified" (NOS) was the most frequent diagnosis. An uncommon case of feline epithelial-myoepithelial carcinoma was also observed. The application of the human WHO-LGT classification scheme to canine and feline tumors increased the diversity of diagnoses and allowed for the identification of numerous subtypes. Further studies to identify possible correlations between pathological subtypes and prognosis are warranted.

Rare Diseases of the Orbit

This article provides an overview of rare orbital diseases. Congenital malformations, inflammatory diseases, benign and malignant neoplasias are described. Although it represents a relatively small area of the body the orbit contains multiple different tissues. Therefore, a great variety of diseases can be found within the orbital space. That is the reason, why both the completeness and the level of detail in the description of particular diseases must be somewhat limited. Nevertheless, clinical manifestations, important aspects of diagnosis, treatment strategies, and, when specific data are available, the prognosis are described. The authors tried to highlight the most characteristic aspects of the different diseases to describe their relevant aspects in spite of the brevity of the subsections.

Retrospective Analysis of Clinicopathological Characteristics of Lacrimal Gland Pleomorphic Adenoma and Mechanism of Tumorigenesis by the Imbalance Between Apoptosis and Proliferation

BACKGROUND Lacrimal gland pleomorphic adenoma (LGPA) is the most common clinically benign epithelial tumor of the lacrimal gland and is predominantly comprised of epithelial cells and interstitial components. At present, the exact pathogenesis of LGPA remains unclear. Previous research has indicated that the occurrence of LGPA may be related to excessive cell proliferation. MATERIAL AND METHODS This study observed the clinicopathological characteristics of LGPA and investigated the tumorigenesis mechanism of cell over-proliferation caused by the imbalance between apoptosis and proliferation. A total of 27 cases were collected from the Department of Ophthalmology of the Affiliated Hospital of Chengde Medical University and the Third Medical Center of Chinese PLA General Hospital from April 2017 to November 2019. Hematoxylin-eosin (HE) staining and immunohistochemical staining were used to observe the pathological characteristics and analyze the expression of bcl-2 and bax in the lacrimal gland. RESULTS Compared with normal lacrimal gland tissues, LGPA tumor tissues had obvious changes in pathological morphology. The expression of bcl-2 in LGPA lesion tissues was dramatically higher (P<0.001), the expression of bax was not significantly different between groups (P=0.25), but the ratio of bcl-2/bax was significantly higher in tumor tissues (P=0.01). CONCLUSIONS We found that the lacrimal gland tumor tissues had obvious excessive proliferation in pathomorphology, which revealed the necessity of complete surgical removal of the capsule from the perspective of pathological morphology and provided a theoretical basis for the hypothesis that the imbalance between apoptosis and proliferation could lead to cell hyperproliferation.

Adenocarcinoma NOS arising from accessory lacrimal glands: A case report and a review of the literature

Primary malignant epithelial tumours arising from accessory lacrimal glands (ALGs) are extremely rare, with only few cases reported in literature. They generally appear as gradually increasing masses of the upper or the lower eyelid. Only one case of primary adenocarcinoma or adenocarcinoma not otherwise specified (ACNOS) from ALGs has been reported in literature. Herein, we describe a case of ACNOS arising from ALGs with an atypical clinical presentation and review prior cases of ALGs epithelial malignancies reported in the literature. A 78-year-old man referred to our Ocular Oncology Unit for adjuvant therapy after the excision of a conjunctival tumour of the left eye with a histological diagnosis of squamous cell carcinoma. He underwent topical chemotherapy with MMC and during follow up he presented a multinodular iris mass in his left eye. The MRI of the orbit showed an ocular mass infiltrating orbital soft tissues of the inferior palpebral region with an involvement of the corresponding zygomatic cutis. We performed orbital exenteration and histological studies revealed an epithelial neoplasm with a solido-glandular growth pattern with lumens containing an eosinophilic material positive for PAS and PAS-D. The immunohistochemical findings confirmed the diagnosis of adenocarcinoma NOS from ALGs. Although ALGs epithelial malignancies are extremely uncommon, they should be considered in the differential diagnosis of ocular tumours. A vigilant approach towards these entities is required, since they can be clinically insidious and locally aggressive.

Ductal Adenocarcinoma Ex Pleomorphic Adenoma of the Lacrimal Gland: a Rare and Morbid Malignancy

Carcinoma ex pleomorphic adenoma (Ca ex PA) is a rare malignant transformation of a benign primary pleomorphic adenoma (PA). We report the case of a 62-year-old male who presented with a swelling over his left temple. Imaging revealed a lytic lesion over the left orbital wall with soft tissue extension suggestive of malignancy. He underwent an en bloc resection of the mass with orbital exenteration, craniotomy, and reconstruction. Pathology demonstrated a lacrimal gland ductal adenocarcinoma arising from a PA which led to the diagnosis of ductal adenoCa ex PA. Postoperatively, he received chemotherapy with 6 cycles of cisplatin and concurrent radiation therapy (RT), but his course was complicated by recurrent bacterial meningitis and abscesses and he ultimately opted for comfort measures. Patients with PA of the lacrimal gland experience an insidiously enlarging painless swelling of the orbit with transformation to Ca ex PA highlighted by a rapid onset of bulbar enlargement, displacement, and often proptosis. Ductal adenoCa ex PA is aggressive with a poor prognosis and has no established standard of care. This case highlights the rarity of this condition and the need for more literature to help direct treatment.

High-risk human papillomavirus positive primary squamous cell carcinoma of the lacrimal gland: a case report

A 78-year-old Caucasian female presented with a painless mass in the right orbit that had progressively enlarged over several months. Computed tomography scan of the orbits showed a right lacrimal gland mass with no bony erosion. Histopathologic analysis of the biopsy specimen revealed invasive squamous cell carcinoma positive via in-situ hybridization for high-risk human papillomavirus. The patient underwent successful removal of the right lacrimal gland tumor en bloc, followed by adjuvant radiotherapy. This is an extremely rare case of primary squamous cell carcinoma of the lacrimal gland and the first report describing human papillomavirus positivity in this tumor location.

Intracapsular High-Grade Ductal Carcinoma In-Situ Ex Pleomorphic Adenoma of the Lacrimal Gland

Primary ductal adenocarcinoma of the lacrimal gland is an aggressive neoplasm and can be seen either as a de novo malignancy or in the setting of a carcinoma ex pleomorphic adenoma. Carcinoma ex pleomorphic adenoma carries an overall unfavorable outcome; however, prognosis depends on the type and grade of the malignant component, presence of retained myoepithelial component, and extend of invasion beyond the capsule. Herein, the authors describe a 78-year-old man diagnosed with an incidental, intracapsular, high-grade ductal adenocarcinoma in situ ex pleomorphic adenoma, who is free of disease at 9 months subsequent to complete resection. It is important to recognize the morphologic features of intraductal and intracapsular neoplasms to prevent unnecessary morbidities due to extensive surgical interventions or radiotherapy.Morphologic features of intracapsular ductal carcinoma in situ ex pleomorphic adenoma, which shows better clinical outcomes with complete excision than its invasive counterpart.

Clinical Management of Acinic Cell Carcinoma of the Lacrimal Gland

To report a case of acinic cell carcinoma occurred in the lacrimal gland. A 59-year-old man was admitted because of sudden blurring of vision, progressive proptosis of the left eye, and mild double vision in left and down directions of the gaze (Hess-Lancaster test). His medical history detailed controlled bilateral keratoconus and open angle glaucoma. On examination, the best corrected visual acuity decreased from 8/20 till 1/50 in one week. There was a swelling of the left upper eyelid. A hard and tender mass was palpated in the superior temporal left orbit. Ultrasound scan showed an extraconal solid mass, situated in the superior lateral corner of the orbit. Computed tomography and magnetic resonance imaging (MRI) revealed a mass of two centimeters in diameter, with round well-defined outline, within the lacrimal gland. We performed an enucleoresection of the mass, via a coronal approach and a lateral orbitotomy by a piezosurgical device. The lesion appeared nodular, brownish, measuring about 2 × 1.5 cm. Histopathological findings were consistent with acinic cell carcinoma with a microcystic, focally papillary-cystic growth of pattern. Follow-up MRI outcomes led to removal of the residual lacrimal gland for suspicion of recurrence. No tumor recurrences where detected at 7-year follow-up.

Immunohistochemical features of carcinoma ex pleomorphic adenoma and pleomorphic adenoma in the lacrimal gland

AIM

To investigate C-myc, Ki-67, pan-cytokeratin, and vimentin immunohistochemical features of carcinoma ex pleomorphic adenoma (Ca-ex-PA) and pleomorphic adenoma (PA) in the lacrimal gland in order to find some clues in the differential diagnosis between them.

METHODS

We reviewed microscopic slides and clinical records of 64 cases of PA and 15 cases of Ca-ex-PA in the lacrimal gland. Immunohistochemical antibodies for C-myc, Ki-67, pan-cytokeratin, and vimentin were employed.

RESULTS

Median age of PA was 43.2y (from 21 to 75). The 35 patients (54.7%) were male and 29 patients (45.3%) were female. For the PAs, the average positivity of C-myc was 4.6%; the average proliferation index of Ki-67 was 3.2%; pan-cytokeratin was positive in ductal cells, and vimentin was positive in myoepithelial cells. Median age of Ca-ex-PA was 54.3y (from 26 to 76). There were 7 male patients (46.7%) and 8 female patients (53.3%). Among 15 Ca-ex-PAs, there were 6 myoepithelial carcinomas, 4 adenocarcinomas, 3 epithelial-myoepithelial carcinomas, and 2 squamous cell carcinomas. For the Ca-ex-PAs, the average positivity of C-myc was 36.4%; the average proliferation index of Ki-67 was 29.2%; pan-cytokeratin was positive in all cases, and vimentin was positive in myoepithelial carcinomas.

CONCLUSION

PA has a lower positivity of C-myc and Ki-67, while Ca-ex-PA had a higher positivity of these two biomarkers. These four biomarkers as a set could provide valuable clues in the differential diagnosis between Ca-ex-PA and PA. Our results indicate that the activation of C-myc could play an important role in the pathogenesis of Ca-ex-PA and PA.

Lacrimal gland pleomorphic adenoma: a review of 52 cases, 15-year experience

BACKGROUND

Lacrimal gland (LG) tumours are rare neoplasms. Pleomorphic adenoma (PA) is the most common histologic variant, representing ∼20% of all LG tumours. PA tends to recur leading to great morbidity.

AIMS

We carried out this study to share our experience and provide recent data on the clinical aspects, radiologic findings, management and outcome after treatment.

METHODS

We realised a hospital-based retrospective case review including data collected from 52 patients, managed over 15 years.

RESULTS

The mean age was 39.8 ± 2 years. Unilateral painless proptosis was the most constant sign (51.9%). CT-scan showed predominantly isodense lesions (96.2%), with regular borders (94.2%), measuring on average 2 cm. MRI showed isointense lesions on T1-weighted images in 96.2% of cases. No pre-operative biopsy was done. Surgical management was mainly external lateral orbitotomy (94.2%). There was no recurrence, considering a mean follow-up period of 12.6 years. Size of tumour at the time of diagnosis increased with age (r = +0.36, p = .01).

CONCLUSIONS

Clinical and radiologic characteristics are consistent with literature. Older patients seem to present larger tumours. We believe that biopsy is not necessary if appropriate imaging is done. Complete, intact resection is generally sufficient to minimise the risk of recurrence.

Primary sebaceous carcinoma of lacrimal gland: A case report and review of literature

BACKGROUND

Primary sebaceous carcinoma of lacrimal gland (SCLG) is extremely rare. Due to its clinical characteristics, it is often misdiagnosed. It is known to be aggressive so delay in diagnosis can increase the chance of local recurrence and metastasis. We report a case of primary SCLG.

CASE SUMMARY

A 75-year-old man was referred with a painful swelling in the right eyelid. Computed tomography scan demonstrates a 2.6 cm mass in upper outer quadrant of right orbit. After the incisional biopsy of the mass, he was diagnosed with squamous cell carcinoma of lacrimal gland. A right orbital exenteration, cervical lymph node dissection was performed. There was no involvement of the overlying periorbital skin, eyelid, or conjunctiva. Histological examination of the exenteration specimen showed tumor arising from the lacrimal gland, which had been entirely replaced by sebaceous carcinoma with sarcomatous and squamous differentiation. Neoplastic cells which were large and contained prominent nucleoli. Focal tumor remained in the posterior resection margin. Patient underwent adjuvant radiotherapy, total dose of 56 Gy with dose-per-fraction 2 Gy to primary lesion. There has been no sign of recurrence until 2-years follow-up.

CONCLUSION

We report a rare case of sebaceous carcinoma arising from the lacrimal gland. Accurate diagnosis of SCLG is important for appropriate treatment and prognosis prediction.

Primary poorly differentiated lacrimal gland adenocarcinoma in left ocular region: A rare case report

RATIONALE

Primary poorly differentiated lacrimal gland adenocarcinoma in the orbital region is an extremely rare type of neoplasm with only 1 related case in the literature. Its high grade of malignancy makes the timely data reported necessary. Hence, we present an extremely rare disease with biopsy results and recommendations on clinical treatment in an elderly male with Chinese descent.

PATIENT CONCERNS

A 66-year-old Chinese man presented with swelling in the left ocular region and eyeball proptosis. On physical examination, the patient had redness, tenderness, and swelling of the left eye. A surgical incision was noted on the left orbital region. Left eye movements were restricted.

DIAGNOSES

Immunohistochemical examination revealed pan-cytokeratin (PCK, +), p63 (partial, +), cytokeratin 7 (CK7, +), cytokeratin 14 (CK14, +), epithelial membrane antigen (EMA, +), protein expressed by erythroblast transformation-specific related gene (ERG, -), S-100 (, -), Epstein-Barr virus-encoded small RNA (EBER, -), smooth muscle actin (SMA, -), and Ki-67 (with a proliferation index approximately 40%). After carefully reviewed the manifestations, imaging findings, and immunohistochemical evidences, a diagnosis of poorly differentiated adenocarcinoma of lacrimal gland was made.

INTERVENTION

Based on the gene sequencing results, we started the patient with an intensive PF chemotherapy including a combination of cisplatine, fluorouracil, and epirubicin. Two months later, radiotherapy was introduced to the therapy regimen.

OUTCOMES

The patient responded well to the treatment without severe adverse events. MRI scan showed remarkable remission.

LESSONS

This rare case report will help raise the awareness of high grade lacrimal gland cancer, and subsequently aid the diagnosis in future cases. Positive immunohistochemical markers of CK7, CK14, EMA, p63, and high proliferation index of Ki-67 can help establishing a diagnosis, and cisplatine-fluorouracil program is proved feasible. We share the difficulties we have encountered, hoping to improve patient care in the future.

Overview of benign and malignant lacrimal gland tumors

PURPOSE OF REVIEW

The goal of this article is to review the key clinical and radiological features, treatment strategies, and prognosis of lacrimal gland tumors.

RECENT FINDINGS

Debulking of the orbital lobe of the lacrimal gland may offer improved control rates in dacryoadenitis without compromise of tear film function. Contrary to previous belief, careful biopsy of the lacrimal gland prior to excision does not appear to increase the risk of recurrence in cases with suspected pleomorphic adenoma. Low-dose radiation (4 Gy) in two 2-Gy fractions appears to be effective and well tolerated in indolent non-Hodgkin lymphoma of the ocular adnexa with high local control rate. Eye-sparing surgery for adenoid cystic carcinoma (ACC) leaving minimal or no tumor residual in the orbit followed by adjuvant radiation therapy or chemoradiotherapy may provide good local control and long-term survival outcomes. Intra-arterial chemotherapy has been found to decrease recurrence and improve survival in ACC and can also be used as part of an eye-sparing treatment strategy. The development of targeted drugs may offer palliation for patients with unresectable or metastatic disease in lacrimal gland carcinoma.

SUMMARY

This article offers an update on diagnosis, management, and prognosis of the major lacrimal gland lesions.

Lacrimal gland adenocarcinoma responding to checkpoint inhibition and androgen deprivation

Although the histologically diverse classification of salivary gland tumors can be successfully applied to the epithelial lacrimal gland neoplasms, it is not clear whether the molecular makeup differs between these two different tumor types. Adenocarcinomas have known to have driver mutations in non-small cell lung cancer, however, besides HER2 expression not much is known regarding molecular drivers in lacrimal tumors. Androgen receptor (AR) expression and deprivation combined with checkpoint inhibition (CPI) have not been described before in lacrimal gland adenocarcinoma. To our knowledge, this is the first case report describing a prolonged response to CPI and AR inhibitors.

Lacrimal gland tumors in Turkey: types, frequency, and outcomes

AIM

To evaluate the clinical, radiological, and treatment features of lacrimal gland tumors.

METHODS

Retrospective review of 99 eyes of 92 patients with lacrimal gland tumors diagnosed and managed in a single institution between January 1999 and March 2017. Clinical and radiological features, histopathology, treatment methods, and prognosis were evaluated.

RESULTS

The mean patient age was 40.3 (range: 7-80)y. The diagnosis was made histopathologically in 91 (91.9%) tumors and on a clinical and radiological basis in 8 (8.1%) tumors. Final diagnoses included idiopathic orbital inflammation (pseudotumor) in 46 (46.5%) lesions, pleomorphic adenoma in 14 (14.1%), adenoid cystic carcinoma in 12 (12.1%), granulomatous inflammation in 10 (10.1%), lymphoma in 5 (5.0%), benign reactive lymphoid hyperplasia in 3 (3.0%), dacryops in 3 (3.0%), carcinoma ex pleomorphic adenoma in 2 (2.0%), adenocarcinoma in 1 (1.0%), dermoid cyst in 1 (1.0%), cavernous hemangioma in 1 (1.0%), and leukemic infiltration in 1 (1.0%). Non-epithelial tumors comprised 64.6% (n=64) of all lacrimal gland tumors, epithelial tumors 32.3% (n=32), dermoid cyst 1% (n=1), cavernous hemangioma 1% (n=1), and leukemic infiltration 1% (n=1). There were in total 78 (78.8%) benign and 21 (21.2%) malignant tumors.

CONCLUSION

Overall, 65% of lacrimal gland tumors were of non-epithelial origin and 32% of epithelial origin. By histopathology and clinical evaluation, 79% of lacrimal gland tumors were benign. The most common lacrimal gland tumors include idiopathic orbital inflammation (46.5%), epithelial (32.3%), and lymphoproliferative (8.1%) lesions.

Low-Grade Mucoepidermoid Carcinoma of the Lacrimal Gland in a Teenaged Patient

Mucoepidermoid carcinoma is the most common malignant, locally invasive tumour of the salivary glands and accounts for approximately 35% of all malignancies of the major and minor salivary glands. Mucoepidermoid carcinoma that originated from the lacrimal gland is exceedingly rare in teenage patients, with only a few cases reported. Herein, we report clinical and radiological findings of a mucoepidermoid carcinoma arising from the lacrimal gland in a 15-year-old boy. We suggest that since preoperative imaging findings are not diagnostic for mucoepidermoid carcinoma, histopathologic examination should be performed for definitive diagnosis. Complete surgical resection is the treatment of choice for low-grade lacrimal gland mucoepidermoid carcinoma.

Lacrimal myoepithelial carcinoma ex recurrent pleomorphic adenoma: A clinicopathological report and review of the literature

Myoepithelial carcinoma is an uncommon malignant tumor of the lacrimal gland, composed of neoplastic myoepithelial cells with an infiltrative growth. The present study describes a unique case of progressive proptosis and blindness of the right eye in a 68-year-old woman following total tumor removal for lacrimal pleomorphic adenoma. Clinical study, surgical exploration, and pathology revealed lacrimal myoepithelial carcinoma ex recurrent pleomorphic adenoma, T2N0M0. In addition, 18 cases of lacrimal myoepithelial tumor that have been previously described in the literature are reviewed. The application of clinical, radiological, histopathologic, and immunohistochemical investigations may help to reach the definite diagnosis. Criteria for malignancy of lacrimal myoepithelial tumor should be the same as salivary myoepithelial tumor diagnosis, until long-term outcome data for a larger number of patients with lacrimal myoepithelial carcinoma become available.

Lacrimal gland ductal carcinomas: Clinical, Morphological and Genetic characterization and implications for targeted treatment

PURPOSE

Ductal carcinomas (DCs) of the lacrimal gland are very rare but aggressive malignancies. We investigated DC of the lacrimal gland for potentially clinically actionable targets in the search for new therapeutic options.

METHODS

Case 1: A 77-year-old man, presented with diplopia and xerophtalmia; case 2: A 53-year-old man, presented with headache, proptosis and chemosis and case 3: A 73-year-old man, presenting with chemosis and a corneal abscess. All three cases were characterized morphologically including immunohistochemistry and genetically with fluorescence in situ hybridization (FISH) and one case with next-generation sequencing (NGS) of cancer relevant genes.

RESULTS

Cases 1 and 3 were composed of large, rounded, irregular cystic nodules of carcinoma cells with prominent central comedonecrosis, whereas case 2 had a scirrhous morphology. High expression of CK7, CK19, EMA, p53 and HER2 was characteristic for all three tumours. Androgen receptor was intensely positive in case 1, in scattered cells in case 2 and negative in case 3, whereas oestrogen and progesterone receptor were consistently negative. Genetically, a hemizygous deletion and a point mutation in PTEN were identified in case 1, whereas HER2 amplification was found in cases 2 and 3.

CONCLUSION

This study identified a spectrum of genetic events and pattern of protein expression in DC of the lacrimal gland similar to a subset of carcinomas of the breast and ductal carcinomas of the salivary glands. For therapeutic purposes, aberrations in several components of especially the HER2 signalling pathway could alleviate the effect of HER2-directed therapy illustrating an inadequacy of isolated HER2 testing.

An Update on Tumors of the Lacrimal Gland

Lacrimal gland tumors are rare and constitute a wide spectrum of different entities ranging from benign epithelial and lymphoid lesions to high-grade carcinomas, lymphomas, and sarcomas with large differences in prognosis and clinical management. The symptoms and findings of a lacrimal gland lesion are a growing mass at the site of the lacrimal gland, including displacement of the eyeball, decreased motility, diplopia, and ptosis. Pain is the cardinal symptom of an adenoid cystic carcinoma. Radiological findings characteristically include an oval, well-demarcated mass for benign lesions whereas malignant lesions typically display calcifications, destruction of bone, and invasion of adjacent structures. The diagnosis ultimately relies on histology, as does the choice of treatment and the prognosis. In recent years, the understanding of the biology of numerous types of lacrimal gland neoplasia has improved and the choice of treatment has changed accordingly and holds further promise for future targeted therapies. Treatment of benign epithelial lesions is surgical excision whereas carcinomas often require adjuvant radiotherapy and/or chemotherapy. In contrast, the cornerstone in management of lymphoid lesions is chemotherapy, often including a monoclonal antibody. This article presents an update on the clinical, radiological, histological, and molecular features, along with treatment strategies for tumors of the lacrimal gland.

Application of Rose and Wright's algorithm in the diagnosis of lacrimal gland masses: a study of 93 cases

OBJECTIVE

To investigate the application of Rose and Wright's algorithm in diagnosing lacrimal gland masses.

DESIGN

Retrospective observational cases series.

PARTICIPANTS

A total of 93 consecutive patients with primary masses within the orbital lobe of the lacrimal gland were reviewed.

METHODS

Before treatment, patients' detailed history was collected verbally and all patients underwent image examination (computed tomography and magnetic resonance imaging). The clinical and radiological features of every patient were evaluated by experienced orbital surgeons. Based on Rose and Wright's criteria, patients were scored and then treated using surgery with radiotherapy and/or chemotherapy. The final diagnoses were based on the histopathologic results. Based on the histopathologic diagnosis, the data from Rose and Wright's algorithm were evaluated.

RESULTS

The accuracy of Rose and Wright's algorithm for benign and malignant tumour diagnoses was 75% and 50%, respectively. The diagnostic sensitivity, specificity, and accuracy of Rose and Wright's algorithm were 64%, 93%, and 86%, respectively. The algorithm demonstrated significant accuracy in the clinicoradiological criterion in differentiating between benign tumours and malignant tumours (p < 0.05).

CONCLUSIONS

Rose and Wright's algorithm has great advantages in distinguishing benign from malignant tumours within the orbital lobe of the lacrimal gland. However, the algorithm should be used with great caution because of its low diagnostic sensitivity for malignant tumours.

A benign presentation of primary ductal adenocarcinoma of lacrimal gland: A rare malignancy

A 34-year-old patient with a swelling over the upper eyelid for nearly 1 year was seen in our clinic. The history, examination and investigations were suggestive of a benign lacrimal gland tumor. The tumor and lacrimal gland were resected. Subsequent histopathological examination revealed the tumor was a primary ductal adenocarcinoma of the lacrimal gland. This is a very rare tumor with less than half a dozen cases reported so far. This case report is being presented to highlight an unusual presentation of this rare malignancy.

The interleukin-6/Janus kinase/STAT3 pathway in pleomorphic adenoma and carcinoma ex pleomorphic adenoma of the lacrimal gland

PURPOSE

Pleomorphic adenoma (PA) is the most common tumour of the lacrimal gland, but very little is known about its biology. It has a tendency to recur and an ability to transform into the high-grade malignancy carcinoma ex pleomorphic adenoma (ca-ex-PA), which is also largely unexplored. In this study, we examine the expression of the interleukin-6/Janus kinase/STAT3 (IL-6/JAK/STAT3) pathway components in PA and ca-ex-PA.

METHODS

Sixteen PAs and two ca-ex-PAs were examined with immunohistochemistry. Seven PAs were subjected to microdissection and subsequent qPCR.

RESULTS

The IL-6/JAK/STAT3 pathway was overexpressed in PA compared to normal lacrimal gland. Overexpression of phosphorylated JAK1 (p-JAK1) and cyclin D1 was significantly overexpressed in ductal cells compared with myoepithelial cells in PA. A shift from p-JAK1 to p-JAK2 and p-Tyk2 overexpression was seen between PA and ca-ex-PA, combined with a high p-STAT3 expression in the latter.

CONCLUSION

The IL-6/JAK/STAT3 pathway is overexpressed in PA, and this overexpression was even more pronounced in ca-ex-PA, with a shift in the JAKs mediating STAT3 phosphorylation. Future studies are needed to clarify whether PA and ca-ex-PA could be treated with targeted therapy directed against components of the IL-6/JAK/STAT3 pathway.

Surgical resection of invasive adenoid cystic carcinoma of the lacrimal gland and wound closure using a vertical rectus abdominis myocutaneous free flap

A 64-year-old man presented with a 3-month history of recurrent conjunctivitis. He was evaluated by an ophthalmologist and submitted to a CT scan that revealed an intraconic mass with invasion of the lateral orbital wall. He was operated, the mass was completely removed (with preservation of the intraorbital structures) and the lateral orbital wall rebuilt. The histopathological analysis revealed an adenoid cystic carcinoma of the lacrimal gland. 4 months later a painful recurrence of the lesion was diagnosed with invasion of the orbital roof and eyelids. After a multidisciplinary discussion and request from the patient, an exenteration of the orbit and removal of the lateral and superior orbital wall and dura mater was performed with the objective of a total resection. The wound and orbit were closed with a vertical rectus abdominis myocutaneous free flap to ensure closure.

Management of Lacrimal Gland Carcinoma: Lessons From the Literature in the Past 40 Years

PURPOSE

To review the published literature on management strategies for lacrimal gland carcinomas.

METHODS

Review of relevant articles in PubMed published in English from the year of 1970 through September 2014.

RESULTS

A review of literature suggests that treatment strategies for adenoid cystic carcinoma of lacrimal gland are varied, but local control does not necessarily prevent future delayed distant relapse. Tumor size and histologic features of lacrimal gland carcinoma seem to be important prognostic features. With improved imaging modalities providing better tumor diagnosis and staging, and availability of more focused radiation delivery techniques, multimodality globe sparing management of lacrimal gland carcinomas may be possible in selected cases. The availability of targeted drugs based on the molecular signature of an individual lacrimal gland carcinoma may offer possible targeted treatments for patients with nonresectable or metastatic disease.

CONCLUSION

Given the rarity of lacrimal gland carcinoma, multi-institutional studies and consistent reporting of size and histologic type of tumors in the literature may be prudent. Particularly, multimodality globe-sparing treatment strategies should be studied further.

Tumors of the lacrimal gland

Tumors of the lacrimal gland comprise a wide spectrum, of which the most common demonstrate epithelial and lymphoid differentiation. The diagnosis of lacrimal gland tumors depends primarily on histological evaluation, as do the choice of treatment and prognosis. For some lacrimal gland neoplasms, such as adenoid cystic carcinoma, the outlook is grave. Optimal treatment for several lacrimal gland tumors is also a matter of controversy. However, recent progress has been made in the molecular and genetic understanding of tumorigenesis for such lesions. This article presents an overview of the histopathology of lacrimal gland tumors, together with their epidemiological features, clinical characteristics, and treatment strategies.

Orbital lobe resection provides a definite diagnosis of lacrimal gland lesions: a report of three cases

BACKGROUND

Entities of lacrimal gland lesions comprise almost inflammatory and lymphoproliferative processes as well as benign and malignant solid tumors and usually cannot be differentiated by magnetic resonance imaging (MRI) exclusively. Hence, representative tissue samples are needed to arrive at sufficient histopathological diagnosis for further treatment decisions.

CASE REPORT

Three women aged between 18 and 67 years were admitted to our center with clinical signs of a space-occupying mass in the lacrimal fossa. MRI revealed a circumscribed lacrimal gland lesion in all three cases. The orbital lobe was resected through a lateral orbitotomy approach for histopathological evaluation. Findings confirmed the diagnoses of pleomorphic adenoma, dacryoadenitis, and low-grade B cell non-Hodgkin's lymphoma. Further surgery was not necessary. No recurrence or symptoms of "dry eye" were observed over the course of a 1-year follow-up.

CONCLUSION

In cases of non-specific masses in the lacrimal gland on MRI, histopathological diagnoses are vital and can be sufficiently provided by resection of the orbital lobe. Symptoms of dry eye are uncommon, and secondary surgical intervention can be avoided in cases of the presented entities. Further studies with larger patient cohorts are warranted to confirm these findings.

Metastatic, her-2 amplified lacrimal gland carcinoma with response to lapatinib treatment

Carcinoma of the lacrimal gland is a rare malignancy, limiting opportunities to develop new therapeutic regimens through clinical trials. There are no standard guidelines on optimal treatment of lacrimal gland carcinoma. In addition, lacrimal gland carcinoma includes several different subtypes with distinct behavior and response to treatment, further complicating treatment. Overexpression of the Her-2/neu protein, a potential target for new therapeutic agents, has previously been described in lacrimal gland carcinoma; however, there are no published reports regarding treatment of lacrimal gland cancer with Her-2 directed medications. This case report describes treatment of a patient with metastatic lacrimal gland carcinoma with lapatinib, an oral agent with activity against Her-2/neu amplified malignancies. In this case, Her-2 overexpression was confirmed by biopsy of a metastatic site. PET imaging obtained 6 months after the initiation of lapatinib showed evidence of a partial response to treatment, although the patient later developed progressive neurologic complications related to her malignancy and ultimately died. Lapatinib and other Her-2 targeted agents may represent an effective therapeutic option for this rare malignancy, in cases of metastatic disease.

Pleomorphic Adenoma With Prominent Clear Cell Myoepithelioma Component of the Lacrimal Gland

A case of a pleomorphic adenoma of the lacrimal gland with a prominent clear cell myoepitheliomatous component was reported. An 81-year-old Caucasian woman experienced a 2-month history of right supraorbital swelling and proptosis. Excisional biopsy revealed a multicomponent lesion including a stromal component featuring glandular structures made of small epithelioid and spindle cells and a trabecular component with small islands of vacuolated cells, displaced nuclei, and clear cytoplasm. Immunohistochemical analysis revealed strong cytokeratin AE1/3 reactivity and focal smooth muscle actin positivity. The pathologic findings including immunohistochemistry results were consistent with a pleomorphic adenoma with prominent clear cell myoepithelioma component.

Postoperative radiotherapy with volumetric modulated arc therapy of lacrimal gland carcinoma: two case reports and literature review

AIMS

To evaluate technical issues and clinical outcomes after postoperative volumetric-modulated arc therapy (VMAT) in two cases of malignant lacrimal gland cancer.

PATIENTS & METHODS

Patients were treated by postoperative VMAT and post-treatment clinical outcomes were followed-up to 18 months.

RESULTS

Dosimetric results were acceptable and acute toxicity was manageable in both patients. No evidence of disease was found at latest follow-up. One patient underwent corneal transplant for central corneal ulceration, experiencing reduction of visual acuity.

CONCLUSION

Postoperative VMAT for treatment of lacrimal gland tumors offers improved outcome, with manageable side effects. In the context of photon beam radiotherapy, VMAT emerged as a valuable treatment option for these malignant tumors.

Adenoid Cystic Carcinoma of the Lacrimal Gland: A Case Report with a Review of the Literature

Adenoid cystic carcinomas, the most common malignancies of the lacrimal gland, are rare overall. We describe a patient who presented with right periorbital swelling developing over 5 months and magnetic resonance imaging findings of a soft tissue mass in the lacrimal fossa with invasion of the adjacent bone. The patient underwent right lateral orbitotomy with tumor debulking. Pathologic analysis showed neoplastic cells in a predominantly cribriform pattern, and the patient was diagnosed with an adenoid cystic carcinoma of the lacrimal gland. We review the clinical, radiographic, and histopathologic features of these rare, aggressive malignancies as well as treatment options with reference to the current literature.

Single bone metastasis from adenocarcinoma of the lacrimal gland: a case report

ABSTRACT 

Malignant tumors of the lacrimal gland are rare, and single bone metastases from lacrimal gland carcinoma are an exceptional event. We present the case of a 71-year-old man with a history of lumbar pain and left exophthalmos. Surgical resection of the lacrimal lesion and a bone biopsy gave a final histopathological diagnosis of primary ductal adenocarcinoma of the lacrimal gland with bone metastasis. The pathological tissue from both procedures was positive for androgen receptor expression. The patient underwent embolization and radiotherapy in association with total androgen blockade. After 20 months, the patient is still asymptomatic and has maintained the partial response at L1 with no progression to other sites. Our patient would appear to have a better prognosis and the disease a more indolent clinical course than the other cases of ductal adenocarcinoma of the lacrimal gland reported in the literature.