Lymphoproliferative tumors involving the lacrimal drainage system: a major review

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.

Delayed Diagnosis and Misdiagnosis of Lacrimal Sac Tumors in Patients Presenting with Epiphora: Diagnosis, Treatment, and Outcomes

BACKGROUND/OBJECTIVES

Epiphora, or excessive tearing, is a common symptom often attributed to benign conditions such as dry eye or nasolacrimal duct obstruction. However, it can also be an early indicator of lacrimal sac tumors, which are frequently misdiagnosed or diagnosed late due to their subtle presentation. This study aims to identify the clinical features that contribute to delays and misdiagnoses of lacrimal sac tumors in patients presenting with epiphora, with the goal of improving early detection and treatment outcomes.

METHODS

This retrospective study reviewed medical records from Taipei Veterans General Hospital between 2007 and 2023, focusing on patients who presented with epiphora and were later diagnosed with pathologically confirmed lacrimal sac tumors. Inclusion criteria were limited to cases that were initially misdiagnosed or had a delayed diagnosis, with imaging and clinical evaluations confirming tumor-related tear drainage obstruction. Patients with non-tumor causes of epiphora were excluded.

RESULTS

Eleven cases of lacrimal sac tumors were identified, including two benign and nine malignant tumors. The average duration from symptom onset to diagnosis was 22.4 months. Common symptoms included epiphora (100%), discharge (54.5%), and hemolacria (18.2%). Subtle clinical signs, such as asymmetry in the medial canthal region and non-tender swelling, were frequently noted. Despite receiving appropriate surgical and adjuvant treatments, the impact of delayed diagnosis was significant. Two patients succumbed to tumor-related disease; one developed lung metastasis 12 years after diagnosis, and another experienced recurrence during a six-year follow-up after undergoing extensive exenteration, adjuvant chemotherapy, and radiotherapy.

CONCLUSIONS

Lacrimal sac tumors can present insidiously with symptoms often mistaken for benign conditions, leading to significant diagnostic delays. Thorough history taking, meticulous physical examination, and timely imaging are crucial for early detection. Increased clinician awareness and a high index of suspicion for lacrimal sac tumors in patients with atypical epiphora are essential to improve prognosis and reduce the risk of severe outcomes.

Primary anaplastic extramedullary plasmacytoma in the lacrimal sac

We report the case of a 60-year-old man diagnosed with unilateral, solitary, extramedullary plasmacytoma located in the right lacrimal sac fossa, with no systemic involvement. This rare plasma cell dyscrasia is usually found in the respiratory tract. Clinical and radiological features of the mass and histopathological results are described. The patient was successfully treated with complete surgical excision. There were no clinical or radiological indications of disease recurrence at 10 months' follow-up.

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.

Primary Canalicular MALT Lymphoma Masquerading as Chronic Canaliculitis

A 67-year-old female presented with chronic canaliculitis and underwent canalicular marsupialization. During the procedure, a fleshy mass was found in the canaliculus, which was excised completely and sent to pathology. Histology confirmed the diagnosis of extranodal marginal zone mucosa-associated lymphoid tissue lymphoma. The patient underwent staging with positron emission tomography/CT scan, which did not show any hypermetabolic foci elsewhere in the body, so the patient elected to undergo close observation without further treatment. At 12 months of follow-up, the patient has remained disease-free.

Diffuse Large B Cell Lymphoma of Lacrimal Drainage System : A Rare Case Report

Tumours of lacrimal drainage system are a rare entity and among these rare tumours lymphomas are a rarity. We report a case of 65 year old male who presented with mass inferior to left lacrimal sac region which was diagnosed as Diffuse Large B Cell Lymphoma on histopathology and immunochemistry. The patient underwent excision biopsy followed by chemotherapy and is disease free till writing of this report.

Radiotherapy of Orbital and Ocular Adnexa Lymphoma: Literature Review and University of Catania Experience

Orbital and ocular adnexa lymphomas are rare neoplasms confined to the orbital region. The prognosis is generally favorable, with a high proportion of localized disease, indolent clinical course, prolonged disease-free intervals, and low lymphoma-related mortality rate. We report our experience on eleven patients with confirmed histological diagnosis of lymphoma stage IE-IIE, treated between 2010 and 2021 with radiotherapy alone or in association with chemotherapy or immunotherapy. Eight patients were treated with primary radiotherapy only, while three received previous systemic treatments. Six patients were treated with Proton beam therapy (PBT), and five with external beam radiotherapy (EBRT). The five-year local control rate was 98%; only one patient developed an out-of-field recurrence. We also conducted a comprehensive literature review using electronic databases (PubMed, EMBASE, and Cochrane Library). Articles were selected based on their pertinence to treatment of the ocular and adnexal lymphoma focusing on radiotherapy techniques (electron beam radiotherapy, photon beam radiotherapy, or proton beam radiotherapy), treatment total dose, fractionation schedule, early and late radio-induced toxicities, and patient's clinical outcome. Radiotherapy is an effective treatment option for orbital lymphoma, especially as standard treatment in the early stage of orbital lymphoma, with excellent local control rate and low rates of toxicity.

Timing of Jones Tube Placement After Excision of Nasal or Lacrimal Drainage System Malignancy: A Survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS)

Purpose

To elicit, from a survey of oculoplastic surgeons, the timing and reason for delaying Jones tube placement after the excision of nasal or lacrimal drainage system malignancy.

Methods

The authors reviewed current literature and distributed an anonymous survey to 627 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) to determine the length of time members wait to perform a Jones tube placement after the removal of nasal or lacrimal drainage system malignancy. The survey also included questions about the rationale for this waiting period.

Results

Fifty-eight members of ASOPRS (9.3%) responded to our survey, 49 (84.4%) of whom had performed Jones tube placement on patients who had an excision of a nasal or lacrimal drainage system malignancy. Nearly 52% of respondents waited one year for Jones tube placement. However, a sizeable number of respondents opted to wait five years (15.1%). The most common rationale for waiting was a concern for tumor recurrence (42 responses).

Conclusion

There is no consensus on when to perform Jones tube placement after the excision of nasal or lacrimal drainage system malignancy. This survey demonstrates a broad array of waiting periods between operations, although most surgeons wait 12 months.

Lymphoma of the Lacrimal Sac: The Massachusetts Eye and Ear Experience With a Comparison to the Previously Reported Literature

PURPOSE

To describe the frequency, clinical features, and histologic subtypes of biopsy proven lacrimal sac lymphomas, and to compare these results to the previously published literature.

METHODS

A retrospective chart review was performed at a single institution from 2004 to 2017. Pathology reports, operative notes, and patients' medical charts were reviewed.

RESULTS

Of 566 lacrimal sacs submitted for routine histopathologic evaluation, 16 cases of lymphoma were identified. All were low-grade, non-Hodgkin B-cell lymphomas, biopsied at an average age of 71 years. Thirteen patients (81.25%) had a pre-existing lymphoma diagnosis; the average interval between the diagnosis of systemic or nonocular adnexal lymphoma and lacrimal sac lymphoma was 7.9 years (range 2-26 years; median 5.5 years). Three cases of primary lacrimal sac lymphoma were identified. Histopathology showed 3 cases (18.75%) of follicular lymphoma, 3 (18.75%) of extranodal marginal zone lymphoma, and 10 (62.5%) of chronic lymphocytic leukemia/small lymphocytic lymphoma. Primary cases presented with epiphora and nasolacrimal duct obstruction, while secondary cases predominantly manifested as dacryocystitis. All lacrimal sac neoplasms were locally responsive (without local recurrence) to chemotherapy, radiation, or both.

CONCLUSIONS

Lacrimal sac lymphoma is uncommon but should be suspected among patients with known lymphoma who develop dacryocystitis. In this series, primary lacrimal sac lymphoma most often presented as a mass or nasolacrimal duct obstruction. Chronic lymphocytic leukemia/small lymphocytic lymphoma was the most commonly identified cause of secondary lacrimal sac lymphoma. Distinguishing primary from secondary lacrimal sac lymphomas is important, as the extent of disease and histopathologic subtypes differ, which may affect patient management.

Primary non-Hodgkin diffuse large B-cell lymphoma of the lacrimal sac: a rare case of aggressive tumor and literature review

Primary malignant lymphomas of the lacrimal sac are rare neoplasms. They are mainly B-cell lymphoma with nonspecific and atypical symptoms, which can lead to misdiagnosis and a delay in the appropriate cure. Early diagnosis made by biopsy and the right choice of treatments can increase the chance of survival. We report a case of a non-Hodgkin diffuse large B-cell lymphoma (DLBCL) of the lacrimal sac, involving also the drainage system, in a 77-year-old female. She presented with an epiphora, swelling and a heavy visual impairment at the left eye successfully treated with cycles of polychemotherapy and radiotherapy.

An Algorithm Recommendation to Detect Specific Pathology of the Lacrimal Sac

ABSTRACT

We aimed to recommend an efficient algorithm to detect the presence of specific pathologies of the lacrimal sac (LS). The charts of 296 patients who had undergone LS biopsy were reviewed retrospectively. The age, gender, history, examination and radiological findings, sac appearance, and pathology results of the patients were recorded. The power of our data to predict the presence of potential specific pathology was identified by regression analysis. After the causality evaluation of the statistical results, an algorithm was created to differentiate specific LS pathologies from chronic dacryocystitis. Our algorithm was mainly formed by deciding on radiological examination and biopsy according to the risk scoring created by the examination findings. A specific LS pathology was observed in 11 (3.7%) patients. When we applied the recommended algorithm to cases with a suspicion of specific pathology and/or found to have a specific pathology, 36.4% of the patients would not require radiological examination and 29.6% of them would not require a biopsy. On the other hand, 80% of the frozen biopsies had been conducted on cases without a specific pathology. Managing the cases according to our algorithm would mean that frozen biopsy would be recommended in only 1 (12.5%) case without a specific pathology. Besides, the detection of cases with a specific pathology would not be prevented and the necessary diagnostic procedures would continue to be performed. Specific LS pathologies can be detected adequately, whereas decreasing unnecessary examinations and procedures in cases without a specific pathology by using our algorithm.

Stenotrophomonas maltophilia-Associated Dacryocystitis in Leukemia-Infiltrated Lacrimal Sacs: Case and Review of Literature

A 91-year-old female with a history of chronic lymphocytic leukemia developed recurrent bouts of bilateral dacryocystitis. She underwent incision and drainage of the lacrimal sac with culture demonstrating the rare bacteria Stenotrophomonas maltophilia. She underwent subsequent dacryocystectomy with biopsy revealing bilateral involvement of chronic lymphocytic leukemia in the lacrimal sac. Stenotrophomonas maltophilia has been associated with immune suppression and is rarely seen in dacryocystitis. Local and/or systemic immune deregulation or suppression may play a role in lacrimal sac infection with this bacterium in some patients.

Clinical profile and management outcomes of lacrimal drainage system malignancies

Purpose: To report the clinical profile and management outcomes of a series of cases of malignant tumors of the lacrimal drainage system (LDS).Materials and Methods: A retrospective analysis of all cases diagnosed with LDS malignancy over the past 24 years (1995-2019) was done. Patient characteristics, tumor types, management, and outcomes were analyzed.Results: A total of 14 patients were included. Thirteen cases were of primary malignancy, while one was a secondary lesion. The mean age was 42.5 years, with males and females being equally affected. A medial canthal mass was the most common (9, 64.2%) presentation. Six patients (42.8%) had undergone one or more dacryocystorhinostomy surgeries for nasolacrimal duct obstruction before presentation. Seven patients underwent wide local excision (50%) while 3 (21.4%) each underwent dacryocystectomy and exenteration. Adjuvant radiation was administered to 4 (28.5%) patients. Thirteen (92.8%) patients were diagnosed with epithelial malignancy while one (7.1%) was a case of small B cell lymphoma. Transitional cell carcinoma was the most common epithelial malignancy (4, 28.5%). Three (21.4%) patients had metastatic disease (2 lymph nodes and one angle of jaw). There was no mortality after a mean follow up of 40.7+_25.1 months (Median 26; Range 4-131).Conclusion: LDS malignancy is rare, with the epithelial variant being far more common than non-epithelial. Wide local excision with adjuvant radiotherapy is the preferred management. Long-term follow-up is essential to manage recurrences and to increase survival.

Mucosa-Associated Lymphoid Tissue and Tertiary Lymphoid Structures of the Eye and Ear in Laboratory Animals

Mucosa-associated lymphoid tissue (MALT) of special senses is poorly described and can be confused with nonspecific mononuclear cell infiltrates and tertiary lymphoid structures (TLS). In the eye, MALT consists mostly of conjunctiva-associated lymphoid tissue (CALT) and lacrimal drainage-associated lymphoid tissue (LDALT). In humans, CALT and LDALT are important components of the normal eye-associated lymphoid tissue (EALT), but EALT is less frequently described in ocular tissues of animals. The EALT are acquired postnatally in preferential mucosal sites, expand with antigenic exposure, form well-developed lymphoid follicles, and are reported to senesce. Lymphoid follicles that are induced concurrently with chronic inflammation are more appropriately considered TLS but must be differentiated from inflammation in MALT. Less understood is the etiology for formation of lymphoid tissue aggregates in the ciliary body, limbus, or choroid of healthy eyes in animals and humans. In the healthy eustachian tube and middle ear of animals and humans, MALT may be present but is infrequently described. Concurrent with otitis media, lymphoid follicles in the eustachian tube are probably expanded MALT, but lymphoid follicles in the middle ear may be TLS. The purpose of this comparative review is to familiarize toxicologic pathologists with MALT in the special senses and to provide considerations for differentiating and reporting eye and ear MALT from immune or inflammatory cell infiltrates or inflammation in nonclinical studies, and the circumstances for reporting TLS in compartments of the eye and ear.

An Unusual Presentation of Large B-cell Lymphoma

Primary Non-Hodgkin's lymphoma of the lacrimal sac is extremely rare. Symptoms are usually atypical and nonspecific, which often leads to the original misdiagnosis of dacryocystitis. The most common presenting features are epiphora, swelling, and acute dacryocystitis. We present a case of a 67-year-old female with primary diffuse large B-cell lymphoma (DLBCL) of the lacrimal sac, which was originally diagnosed as dacryocystitis. This case report adds to the urgency that prompt and precise diagnosis and treatment is key.

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

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