Lacrimal Sac Tumors: A Case Series

Atypical lacrimal sac mucoceles

PURPOSE

To report the clinical features and operative findings of a series of patients with lacrimal sac mucoceles extending above the anatomic level of the medial canthal tendon (MCT).

METHODS

A retrospective chart review of all patients presenting with lacrimal sac mucocele extending above the anatomic level of the MCT over a period of five years from 2019 and 2023. All patients underwent surgical management. Diagnosis of lacrimal sac mucocele was based on clinical examination, imaging where indicated and intraoperative confirmation.  Data obtained include demographics, clinical presentations, duration, imaging features, type of surgical intervention, intraoperative findings, and outcomes.

RESULTS

A total of 62 patients were analyzed, of whom 67.7% were female. The mean age at presentation was 49.11 years. The mean duration of the lacrimal sac swelling was 18.15 months (SD = 21.94). Epiphora, discharge, and dacryocystitis were frequent associations. Regurgitation on Pressure over the lacrimal sac area (ROPLAS) decompressed the swelling   in 35 (56.5%) patients.In 61.3% of patients, the medial canthus remained in its normal position, while the medial canthal tendon (MCT) exerted pressure on the overextending mucocele to varying degrees, resulting in a dumbbell-shaped appearance in certain cases. In 38.7% of patients, the mucocele caused superior displacement of the medial canthus compared to the contralateral side. The surgical interventions were successful in resolving the mucocele.

CONCLUSIONS

Lacrimal sac mucoceles can extend above the level of the MCT. While a lacrimal sac swelling above the MCT should raise suspicion for a mass lesion of neoplastic etiology, it is not a tell-tale sign.

Effectiveness of Nasolacrimal SCC Treatments and Promising Role of Chemo-Induction: A Case Report and Systematic Review

OBJECTIVE

To comprehensively analyze reported cases of nasolacrimal squamous cell carcinoma (NLSCC), focusing on risk factors, treatment modalities, and outcomes. Additionally, investigate the impact of human Papillomavirus (HPV) status and histopathological subtypes' impact on prognosis.

DATA SOURCES

Pubmed, Embase.

REVIEW METHODS

We conducted a systematic literature review to identify relevant studies reporting cases of NLSCC. The review methods adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The final update was performed on May 31, 2023.

RESULTS

The 72 studies included a total of 313 participants (mean age: 55; 60% male). Longer symptom duration (44.1 ± 59.2 months) correlated with recurrence (p = 0.004), and males exhibited higher mortality rates (19.6% vs. 2.4% in females, p = 0.01). The overall survival (OS) rate among all patients was 87.1%. Basaloid NLSCC had a worse death outcome (p ≤ 0.001). HPV-positive cases showed comparable OS, recurrence, and metastasis rates to the general population (p = 0.917, 0.851, 0.07, respectively). Comparing treatment approaches (surgery, surgery with adjuvant radiation, chemoradiotherapy [CRT] followed by surgery), no significant differences in 5 and 10-year OS rates or recurrence were observed (p = 0.4, 0.24, respectively), but 5-year metastasis events were significant (p = 0.024). Eye exenteration rates were 31.1%, 20%, and 0% for the respective treatments (p = 0.089). Induction chemotherapy saved four cases from potential exenteration with favorable prognosis.

CONCLUSION

Early detection and diagnosis are of utmost importance in the management of NLSCC. Regardless of the treatment approach, HPV-related NLSCC demonstrated similar outcomes to the general population. Basaloid histology represents the worst subtype in terms of prognosis. Limited adjuvant CRT cases showed improved outcomes and induction chemotherapy's importance was emphasized in recent literature and our shared experience. Laryngoscope, 134:3892-3902, 2024.

Rare Case of Non-Keratinizing Squamous Cell Carcinoma in the Lacrimal Sac Treated with Surgery

Background and Objectives: The objective of this study was to present a rare case of non-keratinizing squamous cell carcinoma (SCC) of the lacrimal sac (LS). Neoplasms of the lacrimal drainage system are extremely rare. These lesions are predominantly malignant and are associated with a high mortality rate. Case Presentation: A 51-year-old woman was referred to an ophthalmologist with a history of unilateral epiphora, presbyopia, and abnormal eye discharge. Antibiotic therapy was applied and modified later due to persisting symptoms. After five months, edema of the medial left eye angle occurred. A lacrimal sac incision was performed, and a subsequent magnetic resonance imaging (MRI) scan revealed a 2 cm, contrast-enhanced solid tumor. The patient was qualified for dacryocystectomy, which was conducted by the otolaryngology department. Postoperative histopathologic findings indicated the presence of non-keratinizing SCC. During a reoperation, margins were extended, and the surgery was found to be radical. Following the reoperation, no alarming symptoms were observed. However, a follow-up MRI and positron emission tomography (PET) scan six weeks later revealed metastases. Further treatment is being planned. Conclusions: LS tumors are life-threatening conditions that are challenging to diagnose at an early stage. Surgical excision is the preferred treatment option. Imaging studies play an important role in post-operative follow-up because of the possibility of recurrence and metastasis, even after radical surgery.

Non‑Hodgkin's lymphomas of the lacrimal sac: Current insights and future directions (Review)

Non-Hodgkin's lymphoma (NHL) of the lacrimal sac is a rare, yet clinically significant entity within the spectrum of ocular malignancies. While primary lacrimal sac lymphoma is uncommon, it poses unique diagnostic and therapeutic challenges due to its anatomical location and potential for aggressive behavior. Despite advancements being made in the current understanding and treatment of NHL, research that specifically addresses the involvement of the lacrimal sac is currently lacking. Thus, the present review aimed to provide insight into the epidemiology, clinical presentation, diagnostic modalities, histopathological features, treatment strategies and prognosis of lacrimal sac NHL. Through a methodical analysis of previous literature, the present review highlights the diverse spectrum of NHL subtypes that affect the lacrimal sac, including diffuse large B-cell lymphoma, extranodal marginal zone lymphoma, mantle cell lymphoma and follicular lymphoma. Moreover, the present review discusses the role of advanced imaging techniques in accurate staging and treatment planning, including computed tomography (CT), magnetic resonance imaging and positron emission tomography-CT. The present review also discusses evolving treatment approaches, such as surgical intervention, chemotherapy, radiotherapy, immunotherapy, combinations of the aforementioned treatments and targeted therapy. In addition, the present review highlights the significance of multidisciplinary collaboration in attaining optimal outcomes for individuals with lacrimal sac NHL. The present review aimed to provide a basis for 'further investigations into novel treatment modalities and prognostic markers that may aid in guiding personalized management strategies, ultimately improving outcomes for patients with NHL.

From Seed to Spread: Lacrimal Sac Squamous Cell Carcinoma Blossoming Into Orbital Chaos

Non-cutaneous squamous cell carcinoma (ncSCC) is a rare malignancy, especially involving the orbital and lacrimal apparatus. Hereby, we present a case of recurrence of squamous cell carcinoma (SCC) in the left orbit after excision of lacrimal sac SCC and radiotherapy. She presented with acute painful visual impairment with a frontal headache, with imaging showing medial extraconal and intraconal mass. After confirmation of SCC from the biopsy, modified enucleation was done. However, the patient had a recurrence of SCC, and further debulking was performed with palliative measures. Noteworthy, ncSCC is a rare malignancy with an aggressive nature. Orbital SCC has the worst prognosis compared to conjunctiva or lacrimal sac SCC. Surgery remained the mainstay for higher survival, but chemotherapy and radiotherapy were not associated with a better prognosis, yet there is a lack of data regarding recurrence and its management. In conclusion, ncSCC is a rare and challenging disease that requires timely intervention with multiple disciplinary care, especially when it is spread from the lacrimal sac to the orbital.

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.

Lacrimal sac squamous cell carcinoma: From resection to prosthetic rehabilitation. A case report

Key Clinical Message

There is a lack of consensus and evidence on treatment strategies for lacrimal sac carcinomas. Wide en bloc surgical resection with farther prosthetic rehabilitation could be the treatment option in certain cases.

Abstract

Malignant epithelial lacrimal sac tumors are rare cancers with high recurrence rates. Diagnosis of these tumors is often delayed as they are confused with chronic dacryocystitis. There is a lack of consensus and evidence on standard treatment strategies for advanced lacrimal sac carcinomas. A case of advanced lacrimal sac squamous cell carcinoma treated with wide en bloc margin-negative surgical resection with further prosthetic rehabilitation without adjuvant therapy and 38 months of recurrence-free postoperative follow-up is presented.

Investigation of lacrimal sac space-occupying lesions using color doppler ultrasound, computed tomography, and computed tomography dacryocystography

AIM

To observe the imaging features of color Doppler ultrasound (CDU) and computed tomography (CT) or computed tomography dacryocystography (CT-DCG) in different types of lacrimal sac space-occupying lesions (SOLs).

METHODS

This retrospective case series study included 21 patients with lacrimal sac SOLs who underwent lacrimal sac surgery between January 2018 and March 2022. The imaging features of CDU and CT or CT-DCG in these patients were extracted from the examination cloud system. The images were observed and analyzed.

RESULTS

The detection rate of lacrimal SOLs between CDU (21/21, 100%) and CT or CT-DCG (20/21, 95.2%) had no statistically significant difference (P=1.0). CDU could detect the blood flow signals in all SOLs except mucocele and mucopeptide concretion. Among them, polyps had characteristic imaging changes on CDU and CT-DCG. The mucoceles and mucopeptide concretions had characteristic imaging changes on CDU, which could provide more information for differential diagnosis.

CONCLUSION

The morphology and internal blood flow signals of lacrimal sac SOLs can be observed using CDU. CT or CT-DCG has advantages in observing structural damage around the lacrimal sac mass. Therefore, CDU may be used as a routine examination to exclude lacrimal sac SOLs before dacryocystorhinostomy in the absence of preoperative CT or CT-DCG.