Benign mixed tumor of the palpebral lobe of the lacrimal gland. Clinical diagnosis and appropriate surgical management

A swinging upper eyelid approach for excision of lacrimal gland masses

PURPOSE

To describe a novel transconjunctival technique for excision of well-defined masses of the orbital lobe of the lacrimal gland.

METHODS

Case series of three patients undergoing excision of a well-defined mass of the orbital lobe of lacrimal gland using a swinging upper eyelid flap. This technique entails a supratarsal conjunctival incision combined with lateral canthotomy and superior cantholysis.

RESULTS

Complete removal of the mass without visible scars was achieved in all cases. There were no complications related to this approach.

CONCLUSION

The swinging upper eyelid approach produces a wide exposure of the superolateral orbit. It allows safe removal of large lacrimal gland masses without the need for bone removal, while affording acceptable cosmesis.

Palpebral Pleomorphic Adenomas of the Lacrimal Gland

AIMS

To report the characteristics and management for patients with palpebral pleomorphic adenoma of the lacrimal gland.

METHODS

The records for patients with palpebral pleomorphic adenoma seen at Moorfields Eye Hospital between 1978 and 2019 were reviewed for demographics, presentation, imaging, histopathology, management, and outcome.

RESULTS

Forty-three patients (25 male; 58%) with palpebral pleomorphic adenoma were identified, presenting at a mean age of 46 years (median 46.4 years; range 24-81 years) with symptoms for an average of 31 months (median 18.0 months; range 1 month to 17 years). The commonest symptom was a painless upper lid lump (37 patients; 86%), although 4 patients (9%) had a localized ache, and 1 (2%) had episodic epiphora. A moderately-mobile, firm round mass (like a "chick-pea") was readily palpable in 39/43 (91%) patients, and significant ptosis and upper lid swelling was noted in 6 cases (14%). Imaging was reviewed in 35 patients, 28 (80%) having a well-defined homogeneous mass in front of the orbital rim, on the anterior pole of the lacrimal gland. With the exception of 8 tumors removed from the actual palpebral lobe using a conjunctival incision, all others were excised intact through an upper eyelid skin-crease incision. Histopathology confirmed an intact pseudocapsule in 39/43 (91%) and 10 (23%) had a mild chronic lymphocytic inflammation within the tumor and/or neighboring lacrimal gland. There were no tumor recurrences at an average follow-up of 40 months (median 9.1; range 2 weeks to 230 years).

CONCLUSION

Most palpebral pleomorphic adenomas are discovered as an upper lid lump and a few first become manifest as upper lid swelling with ptosis. To avoid inadvertent incisional biopsy, they should be recognized preoperatively-especially as most are readily palpable as a hard lump superotemporally, often freely mobile in the suborbicularis plane (anterior to the tarsus and main lacrimal gland). Excision, generally easiest through a transcutaneous route, was judged intact in all cases and confirmed in 91% of histological reports, with no recurrent tumors.

Orbital Lobe and Palpebral Adenomas of the Lacrimal Gland Behave as Distinct Entities

AIMS

To assess whether orbital lobe and palpebral adenomas of the lacrimal gland are biologically similar, based upon a comparison of the age at presentation and at first symptom. The size of the excised tumor in the 2 groups is also examined and considered in relation to age at surgery.

METHODS

Review of clinical details and histopathology reports for patients with biopsy-proven lacrimal gland pleomorphic adenomas, under the care of Moorfields Eye Hospital. The age at presentation and at earliest symptoms were calculated for each patient. Where available, estimates of tumor volume were obtained from the 3 orthogonal measurements taken during histopathological examination.

RESULTS

One hundred eighty-seven patients (100 male patients; 53%) presented at an average age of 48 years (median, 46.8; range, 11-88): the average age for 144 patients with orbital lobe tumors (mean, 48 years; median, 47.8; range, 11-88) was similar to that for 43 patients with palpebral tumors (mean, 46 years; median, 46.8; range, 24-81) (p = 0.45). The average age at first symptom(s) in the 2 groups is similar (orbital 45 years, palpebral 44 years; p = 0.63). In contrast, there is a very highly significant difference in estimated tumor volumes, with the mean for orbital lobe pleomorphic adenomas being 5.4 ml (median, 4.9 ml; range, 1.5-13.6) and that for palpebral being 0.91 ml (median, 0.7 5 ml; range 0.11-3.61) (p = 1.42 × 10-25).

CONCLUSIONS

As expected, excised palpebral adenomas-readily palpable in the eyelid-are very much smaller than orbital lobe tumors, that tend to be impalpable. If pleomorphic adenomas in the 2 locations were biologically identical, they should arise at the same time and have similar growth rates-which would mean that orbital pleomorphic adenomas ([PAs] being, on average, 6 times the size of palpebral PAs) should present several decades later. The age at presentation and age at first symptom are, however, almost identical in the 2 groups. These observations provide incontrovertible evidence that, in their biological behavior, palpebral and orbital PAs are distinct entities-either arising at different ages (with orbital tumors arising much earlier in life) or having different growth rates (palpebral PAs being slower).

Adenoid cystic carcinoma of the palpebral lobe of the lacrimal gland - case report and literature review

Epithelial tumors of the lacrimal gland are rare and usually develop in the orbital lobe. We report the exceedingly rare occurrence of a primary adenoid cystic carcinoma in the palpebral lobe of the lacrimal gland. A 26-year-old female was referred for evaluation of a gradually enlarging mass in the lateral upper eyelid, previously diagnosed as a chalazion. Computed tomography revealed a heterogeneous round lesion anterior to the orbital rim. Excisional biopsy was compatible with an adenoid cystic carcinoma. After excluding distant metastasis, and as the patient refused adjuvant radiotherapy, a second surgical procedure, with wide local excision, was indicated. Follow-up showed no recurrence. This case highlights the importance of performing a thorough clinical examination when diagnosing any lateral upper eyelid mass. A high index of suspicion for malignant tumors of the lacrimal gland should always be maintained, and a complete excision with histological analysis should be preferred whenever possible.

[Pleomorphic adenoma of the lacrimal gland in a young girl: a case report]

We present a case of a 13 year old girl with a diagnosis of Pleomorphic Adenoma (PA) located in the lacrimal gland of the left upper eyelid. The patient had a very satisfactory recovery after surgical excision of the tumor, with no recurrence after a two year follow-up. The clinical, radiological and histopathological characteristics of PAs are discussed.

Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions

OBJECTIVE

To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions.

METHODS

Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination.

RESULTS

The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %.

CONCLUSION

CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management.

KEY POINTS

• CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

A misleading frozen section in a lacrimal gland pleomorphic adenoma of a nine-year-old

INTRODUCTION

Benign pleomorphic adenomas of the lacrimal gland usually present as a painless, slow growing mass in healthy adults and rarely present in childhood. This report describes a pediatric patient found to have a lacrimal gland pleomorphic adenoma that mimicked rhabdomyosarcoma on frozen section.

REPORT

A nine-year-old African American male presented with two months of unilateral proptosis and was found to have a left orbital mass on computed topography. Through a lateral orbitotomy, the mass was excised, but noted to appear distinct from the lacrimal gland. An intraoperative frozen section demonstrated a myxoid matrix with scattered cells mimicking rhabdomyoblasts. Because this sample lacked additional elements, the diagnosis of rhabdomyosarcoma could not be excluded, especially considering the patient's age, short time course of symptoms, and the tumor's intraoperative appearance. Permanent sections of the whole lesion provided definitive diagnosis.

CONCLUSIONS

In the rare pediatric presentations, pleomorphic adenomas of the lacrimal gland can be difficult to quickly and definitively differentiate from a rhabdomyosarcoma. The unusual age of presentation and the misleading frozen section appearance in this case demonstrate the intricacies of managing pediatric orbital tumors and highlight the importance of permanent sections for definitive diagnosis.

Space-occupying lesions of the lacrimal gland at one tertiary eye center in China: a retrospective clinical study of 95 patients

AIM

To investigate the treatment status and prognosis of space-occupying lacrimal gland lesions at one tertiary eye center in China.

METHODS

A retrospective clinical study was performed on 95 patients with space-occupying lesions of the lacrimal gland surgically treated at the Eye & ENT Hospital of Fudan University from 2003 to 2007. The reviewed clinical data included age, gender, side of the lesion, duration of signs and symptoms, histopathological diagnosis, treatment modality, recurrence (local, regional, and distant metastasis) and survival.

RESULTS

Of the 95 cases (99 eyes), pleomorphic adenomas were the most common lesions (43 cases), followed by lymphoid disorders (14), inflammatory pseudotumors (11), carcinoma ex-pleomorphic adenomas (11), and adenoid cystic carcinomas (ACC, 6). There were 8 patients with relapsed pleomorphic adenomas. Five of these 8 cases had malignant pathological changes. All patients with ACC had metastasis and three of them died during their follow-up.

CONCLUSION

Our study indicated that the most common lacrimal gland lesions were pleomorphic adenomas. Multiple recurrence and surgical procedures may increase the risk of tumor progression. ACC had a high incidence of tumor metastasis and a poor prognosis.

[Lacrimal gland epithelial tumors]

Epithelial tumors of the lacrimal gland account for 50% of the expansive lesions of the lacrimal fossa. Pleomorphic adenomas have a good prognosis if surgery achieves en bloc removal distant from the tumoral capsule. Nevertheless, despite more severe treatment, the average survival remains limited for adenocarcinomas and cylindromas.

Pleomorphic adenoma in the palpebral lobe of the lacrimal gland misdiagnosed as chalazion

We reported a case of pleomorphic adenoma of the lacrimal gland involving the palpebral lobe in young teenage girl of Asian origin. The presentation at young age group is rare, which initially misdiagnosed as a large chalazion. The benign tumor with its intact pseudocapsule was removed through lateral orbitotomy together with the suspicious looking orbital lobe.

Pleomorphic Adenoma Arising in an Accessory Lacrimal Gland of Wolfring

PURPOSE

To describe a patient with pleomorphic adenoma arising in an accessory lacrimal gland of Wolfring in the lower lid and to illustrate the immunohistochemical and molecular cytogenetics.

DESIGN

Single interventional case report.

METHODS

A 62-year-old man presented with a 20-year history of a painless slowly growing mass at the temporal part of the right lower eyelid. Histological, immunohistochemical, and fluorescence in situ hybridization studies of the excised tumor were performed.

RESULTS

Histological evaluation showed many glandular elements embedded in a myxoid stroma. The tumor was situated beneath an area of a normal accessory lacrimal gland of Wolfring and in close association with normal meibomian glands. Myoepithelial tumor cells in the myxoid stroma reacted strongly with an antibody against glial fibrillary acidic protein, which did not bind to normal lacrimal gland tissue. Tumor cells with both epithelial and myoepithelial morphologies reacted positively for both pleomorphic adenoma gene-1 and high-mobility group A2 proteins. Fluorescence in situ hybridization analysis showed no evidence of clonal translocations or numerical abnormalities involving chromosome 8 or 12.

CONCLUSIONS

Pleomorphic adenoma of the accessory lacrimal gland is an exceedingly rare tumor of the ocular adnexa. Glial fibrillary acidic protein seems to be a tumor-associated antigen. Genetically, this case of pleomorphic adenoma arising from an accessory lacrimal gland of Wolfring is identical with those originating from salivary glands.

Pleomorphic adenoma of the lachrymal gland: presentation of a clinical case of relapse

Pleomorphic adenoma affecting the lachrymal gland requires a well-grounded clinical and therapeutic protocol to avoid the risk of malignant transformation or disease recurrence, which is quite dangerous at this site. The authors present a clinical case of pleomorphic adenoma recurrence affecting the right lachrymal gland in a patient who first underwent a biopsy, with subsequent resection of the neoplasm. The authors also review the clinical and radiological features enabling a differential diagnosis and describe the radical "exenteratio orbitae" surgery for pleomorphic adenoma recurrence 7 years after the first operation, which was performed because of total derangement of the orbital cavity. The patient remains disease-free 5 years after this surgical treatment. Therefore, it turns out that an incisional biopsy carries a higher biological cost for the patient.

Pleomorphic adenoma of the lacrimal gland: case report

Lacrimal gland tumours are rare. We present a case of a lacrimal gland pleomorphic adenoma in a 19-year-old man. The tumour was removed and he has made an uncomplicated recovery, with no sign of recurrence after nine months of follow-up. We will keep him under long-term review.

Epithelial tumors of the lacrimal glands: a clinicopathologic study

We report the clinicopathologic features of epithelial tumors of the lacrimal gland apparatus, which are rare and therefore represent a major challenge for diagnosis and treatment. Histologic material from 22 lesions was studied by light microscopy, histochemistry, and immunohistochemistry. A comparison with major and minor salivary gland tumors was performed to analyze the relative distribution of these tumors and to establish whether salivary glands and lacrimal gland tumors are similar or different in their pathologic appearance and clinical behavior. There were three benign pleomorphic adenomas and 19 malignant tumors. The gender distribution was equal. The ages of the patients ranged from 10 to 73 years (mean age, 46 years). Among the malignant tumors, adenoid cystic carcinoma was the most common (nine cases), followed by mucoepidermoid carcinoma (three cases). There were two cases each of malignant mixed tumor and adenocarcinoma. All mucoepidermoid carcinomas and the adenocarcinomas were histologically high grade. There also was one case each of salivary duct carcinoma, spindle cell carcinoma, and oncocytic adenocarcinoma. Of 14 patients in whom clinical follow-up was available, seven had distant metastases and four died of their disease. The only case occurring in a child was an adenoid cystic carcinoma that recurred locally after 14 years. The clinical and pathologic features of lacrimal gland tumors resemble those lesions that arise in the intraoral minor salivary glands. The greater relative proportion of malignant cases in this series probably reflects a selection bias.

Tumors arising in the palpebral lobe of the lacrimal gland

PURPOSE

Tumors arising in the palpebral lobe of the lacrimal gland are uncommon. There have been only eight reported patients, all of whom had pleomorphic adenomas. The authors present another six patients with primary palpebral lobe tumors.

METHODS

The clinical presentation, computed tomographic, and pathologic findings of these six patients were reviewed.

RESULTS

Tumor types include three pleomorphic adenomas, one well-differentiated adenoid cystic carcinoma, one carcinoma in pleomorphic adenoma, and one carcinoma ex pleomorphic adenoma. All six patients presented with a painless mass in the upper outer eyelid without significant displacement of the globe, but the superficial location of these lesions led to early detection. The tumors were localized to the lacrimal gland, predominantly anterior to the orbital rim. In all six patients, the involved palpebral lobe was removed, five via a direct anterior subcutaneous approach and one by superolateral orbitotomy. In two patients (adenoid cystic carcinoma and carcinoma ex pleomorphic adenoma), repeat surgery via superolateral orbitotomy was necessary to achieve complete removal of the lacrimal gland and surrounding tissue. No recurrences were detected during follow-up (range, 6 months to 7 years; mean, 26 months).

CONCLUSION

Palpebral lobe tumors of the lacrimal gland are more common and consist of a greater variety of histologic types than previously described. In our series, these tumors comprise 17% of all epithelial lacrimal gland lesions. These are the first reported cases of malignancy in this location. A longer follow-up period is necessary to determine the true recurrence rate of these tumors.

Pleomorphic adenoma of the lacrimal gland

To reduce the risk of recurrence and malignant transformation, pleomorphic adenomas of the lacrimal gland should be removed intact, without prior biopsy. Seventy one of the 78 patients in this series were referred without previous surgery, and, on clinical or radiological evidence, 63 (89%) tumours were correctly diagnosed and totally excised, with preservation of a margin of the surrounding normal tissue. Sixty three patients had tumour within the body of the gland and 55 (84%) had radiological signs or satisfied clinical criteria for pleomorphic adenoma that we suggested previously; that is, over 1 year of symptoms and absence of pain. Eight (16%) orbital lobe tumours were misdiagnosed preoperatively and biopsied; in all these patients symptoms had been present for less than 1 year, and four patients had pain. Eight patients with tumours arising in the palpebral lobe had a short history of an upper lid mass, and their tumours were excised without biopsy. With the surgical techniques described in this paper, there has been no recurrence of tumour in patients with follow-up as long as 21 years. A modification of surgical technique, with preservation of the palpebral lobe of the gland, has reduced the incidence of postoperative dry eye and distortion of the upper eyelid.

Benign mixed tumors arising in the palpebral lobe of the lacrimal gland

The accurate clinical diagnosis of benign mixed tumors of the lacrimal gland is imperative for proper therapeutic management. Although benign mixed tumors of the orbital portion of the lacrimal gland have an established identity, those tumors arising in the palpebral lobe are unusual. Four patients with benign mixed tumors of the palpebral lobe are presented, emphasizing the confusion that exists in making the diagnosis. Palpebral lobe benign mixed tumors should be strongly considered in the differential diagnosis of upper outer eyelid masses. En bloc resection avoids the risk of tumor spillage, recurrence, and/or malignant transformation caused by preliminary biopsy or incomplete resection.