Lacrimal fossa lesions: pictorial review of CT and MRI features

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.

Advances in clinical examination of lacrimal gland

In humans, the lacrimal gland is located in the socket of the frontal bone above the outer orbital area. As an essential part of the eye surface, the gland is fixed to the orbital periosteum by connective tissue. The lacrimal gland passes through the outer tendon membrane, which divides the gland into larger orbital and minor eyelid glands. The lacrimal glands are the main contributors to tear film. They secrete electrolytes, proteins, and water to help nourish and protect the eye's surface. Furthermore, clinically, lacrimal glands are associated with a variety of inflammatory reactions and immune factors and are also vulnerable sites for tumors. Changes in tear gland morphology or secretory function affect tear film stability and tear secretion quality. Various technological devices have been developed and applied to lacrimal glands. This article systematically reviewed the clinical examination of the lacrimal gland to help inform personalized strategies for the diagnosis of lacrimal gland-related diseases.

Lacrimal gland biopsies—results from a tertiary centre in the UK

Purpose

To report the histopathological results of lacrimal gland biopsies over a 21-year period in a tertiary referral centre in the United Kingdom. To the best of our knowledge, this represents the largest series to be published in the United Kingdom.

Methods

A retrospective observational review was carried out for patients who underwent lacrimal gland biopsies in a tertiary referral centre at the University Hospitals of Leicester, United Kingdom between the years of 2000 and 2021.

Results

Lacrimal gland biopsies were performed on 248 patients during the specified 21-year period. They comprised 157 (63.3%) females and 91 (36.7%) males. The mean age at presentation was 50.8 years (range 15–94 years). The majority of patients were Caucasian (69.4%, n = 172) followed by Asians (25.0%, n = 62), African/Afro-Caribbean (4.8%, n = 12) and other ethnicities (0.8%, n = 2). The most common histopathological diagnosis was chronic inflammation dacryoadenitis (69.0%, n = 171) followed by lymphomas (15.3%, n = 38).

Conclusion

Our study shows that chronic inflammation accounts for the majority of histopathological diagnosis followed by lymphoproliferative disorders.

Differentiation of lacrimal gland tumors using the multi-model MRI: classification and regression tree (CART)-based analysis

BACKGROUND

Little is known about the value of dynamic contrast-enhanced (DCE) in combination with diffusion-weighted imaging (DWI) for the differentiation of lacrimal gland tumors.

PURPOSE

To evaluate the ability of DCE and DWI in differentiating lacrimal gland tumors.

MATERIAL AND METHODS

DCE and DWI were performed in 72 patients with lacrimal gland tumors. Time-intensity curve (TIC) patterns were categorized as type A, type B, type C, and type D. Apparent diffusion coefficient (ADC) was measured on DWI. Then, the diagnostic effectiveness of TIC in conjunction with ADC was assessed using classification and regression tree (CART) analysis.

RESULTS

Type A tumors were all epithelial; they could be further separated into pleomorphic adenoma sand carcinomas. Type B tumors were all non-epithelial tumors, which could be further separated into benign inflammatory infiltrates (BIIs) and lymphomas. Type C tumors contained both carcinomas and non-epithelial tumors, which could be diagnosed into carcinomas, BIIs and lymphomas. Type D tumors were all PAs. The mean ADC of epithelial tumors was significantly higher than that of non-epithelial tumors, and the mean ADC values were significantly different between PAs and carcinomas. Besides, the mean ADC value of BIIs was higher than that of lymphomas. Therefore, the CART decision tree made by ADC and TIC had a predictive accuracy of 86.1%, differentiating lacrimal gland tumors effectively.

CONCLUSION

Combined DCE and DWI-MRI can efficiently differentiate lacrimal gland tumors which can be of help to ophthalmologists in the diagnosis and treatment of these tumors.

Recurrent Oncocytoma of the Lacrimal Sac

Oncocytoma of the lacrimal sac is an extremely rare tumor. In this report, we present the case of an 82-year-old woman who presented with swelling in the region of the lacrimal sac. Systemic examination and ophthalmic examination of both eyes were unremarkable. Computed tomography of the brain and orbits revealed a mass lesion involving the right lacrimal sac with expansion of the related nasolacrimal duct. Neither bone destruction nor tissue invasion was observed. Right external dacryocystectomy and debulking of the tumor were performed. Histopathological examination of the surgical specimen showed oncocytic cells arranged in an adenomatous fashion, and a diagnosis of benign oncocytoma was made. Three years later, the same patient presented with a similar complaint that was pathologically proven to be a recurrent benign oncocytoma of the lacrimal sac.

Non-infectious Dacryoadenitis

Dacryoadenitis is an inflammation of the lacrimal gland that may have various etiologies with similar presentations. Despite more recent elucidation of specific causes, the management has remained largely unchanged. Hence, the condition remains under biopsied with the rationale that empirical treatment with corticosteroids is effective for many of the causes. Dacryoadenitis, however, dacryoadenitis can be the presenting sign of an undiagnosed systemic disease and a mimick for lymphoma; hence, tissue diagnosis and systemic investigations play a vital role. A significant proportion of dacryoadenitis has a specific etiology, and IgG4-related dacryoadenitis is more frequently identified as a cause. We summarize the different types of immune-mediated dacryoadenitis, their clinical findings, histopathology, management, and prognosis. We have also highlighted and formulated practice guidelines for diagnosis and effective treatment based on the underlying systemic disease.

Masses of the Lacrimal Gland: Evaluation and Treatment

Lacrimal gland lesions account for approximately 9 to 10% of all biopsied orbital masses. Potential causes include nongranulomatous and granulomatous inflammation, autoimmune disease, lymphoproliferative disorders, benign epithelial proliferation, malignant neoplasia, and metastatic disease. Inflammatory lesions and lymphoproliferative disorders are the most common and may be unilateral or bilateral; they may also be localized to the orbit or associated with systemic disease. Both benign and malignant epithelial lacrimal gland masses tend to be unilateral and involve the orbital lobe, but a more rapid onset of symptoms and periorbital pain strongly suggest malignant disease. On orbital imaging, both inflammatory and lymphoproliferative lesions conform to the globe and surrounding structures, without changes in adjacent bone, whereas epithelial lacrimal gland masses often show scalloping of the lacrimal gland fossa. Malignant epithelial lacrimal gland tumors can also have radiographic evidence of bony invasion and destruction. Masses of the lacrimal gland may be due to a broad range of pathologies, and a good working knowledge of common clinical characteristics and radiographic imaging findings is essential for diagnosis and treatment. All patients with inflammatory, lymphoproliferative, and epithelial neoplastic lesions involving the lacrimal gland require long-term surveillance for disease recurrence and progression.

Adenoid Cystic Carcinoma of Lacrimal Gland with Bone Remodeling

Adenoid cystic carcinoma is the most common type of malignancy seen in the lacrimal glands and is generally characterized by invasive malignant appearance with irregular margins and associated bone erosion or destruction. The authors report an unusual patient with a large expansile, well-circumscribed lacrimal adenoid cystic carcinoma with adjacent bone remodeling, radiologically mimicking a benign lesion.

Value of quantitative multiparametric MRI in differentiating pleomorphic adenomas from malignant epithelial tumors in lacrimal gland

PURPOSE

To evaluate the diagnostic performance of the quantitative parameters derived from diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI in differentiating lacrimal gland pleomorphic adenomas (LGPAs) from lacrimal gland malignant epithelial tumors (LGMETs).

METHODS

Seventy-seven cases with LG epithelial tumors confirmed by histopathology (47 LGPAs and 30 LGMETs) underwent DWI and DCE-MRI. The quantitative parameters including the apparent diffusion coefficient (ADC), the volume transfer constant (K^trans), the efflux rate constant from the extravascular extracellular space (EES) to blood plasma (K_ep), and the extravascular extracellular volume fraction (V_e) were used to differentiate LGPAs from LGMETs. Independent-samples t test was conducted to compare these parameters. The diagnostic performance was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

Compared with LGPAs, LGMETs had significantly lower ADC value (1.090 ± 0.169mm²/s) (P < 0.001), higher K^trans value (0.892 ± 0.517/min) (P = 0.001), and K_ep value (1.300 ± 1.131/min) (P = 0.002). ADC as a diagnostic index showed a better diagnostic efficacy in predicting malignant tumors (AUC 0.914, sensitivity 90.0%, specificity 85.1%, and accuracy 87.0%) than K^trans and K_ep alone. The combination of ADC and K^trans presented the optimal diagnostic performance for the differentiation (AUC 0.938, sensitivity 93.3%, specificity 87.2%, accuracy 89.6%).

CONCLUSION

The quantitative parameters including ADC, K^trans, and K_ep derived from DWI and DCE-MRI might be potential imaging biomarkers in differentiating LGPAs from LGMETs. The combination of ADC and K^trans is superior to other quantitative parameters in distinguishing LGPAs from LGMETs.

Sarcoidosis presenting as lacrimal gland enlargement: Eyes speak the truth

Bilateral lacrimal gland enlargement is uncommon; however, its presence induces brainstorming process and intensive discussion between a clinician and an imaging specialist, leading to exploration of multiple systemic disease patterns such as lymphoproliferative disorders, sarcoidosis, Sjögren's syndrome, and tuberculosis. Thoughtful analysis and diagnostic work-up are required to confirm the diagnosis. Sarcoidosis is a rare systemic disease, with ocular involvement being still rarer. Here, we report a case of a young male presenting with nodular swelling over lateral aspects of both the eyes. The imaging study revealed bilateral lacrimal gland enlargement. Further work-up revealed mediastinal and hilar lymphadenopathy with pulmonary nodules which along with biochemical tests lead to the diagnosis of sarcoidosis. The case highlights the ocular symptoms in sarcoidosis and clinicoradiological approach to bilateral lacrimal gland enlargement.

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.

Lacrimal gland pleomorphic adenoma and malignant epithelial tumours: clinical and imaging differences

AIMS

To investigate the clinical and imaging features of primary and recurrent lacrimal gland pleomorphic adenoma (LGPA), as well as lacrimal gland malignant epithelial tumours (LGMET).

METHODS

Retrospective comparative case series from September 2000 to September 2016 in a single tertiary institution. Medical records of cases with histopathologically proven primary LGPA (PLGPA), recurrent LGPA (RLGPA) and LGMET were reviewed.

RESULTS

Sixty-four patients with LGPA (55 primary and nine recurrent) and 36 patients with LGMET underwent surgical excision in the study period. There was no significant difference in terms of age, gender or laterality. In terms of symptom duration, that of LGMET (7.1 months) was significantly shorter than PLGPA (23.9 months), which in turn was significantly shorter than RLGPA (127.1 months). Proptosis was the most common presenting symptom among all three groups. On CT, LGMET and RLGPA were significantly more likely to have ill-defined margins (p<0.001) and be heterogeneous (p<0.001) than PLGPA. RLGPAs (56%) were significantly more likely to have calcification than LGMET (34%), which in turn was more likely to have calcification than PLGPA (13%); LGMET (40%) and RLGPA (33%) were significantly more likely to have bony invasion than PLGPA (2.2%). On MRI, LGMETs (55%) were significantly more likely to have a tail or wedge sign indicating infiltration into the posterior orbit than PLGPA (0%) or RLGPA (0%).

CONCLUSION

Our study adds important information regarding differentiating clinical and radiological features between malignant and benign epithelial lacrimal gland tumours that would aid in their management.

A new cause of lacrimal gland calcification: Retained metallic foreign bodies

A 49-year-old male presented with a 4 month history of dysaesthesia in the left periorbital region. A CT scan showed a lacrimal gland mass with areas of dense calcification. Biopsies of the left lacrimal gland revealed a silver material with associated chronic granulomatous inflammation and secondary calcification. The histological specimen was sent for X-ray microanalysis. This confirmed the silver material to be aluminium. The metal fragments were subsequently discovered to be from a car aerial, which caused an orbital impaling injury 20 years prior to presentation. This is the first reported case of lacrimal gland calcification secondary to chronic metal foreign body exposure. The case is presented alongside literature reviews of lacrimal gland calcification and associated radiological findings.

The "Wedge Sign": An Imaging Sign for Aggressive Lacrimal Gland Disease

PURPOSE

Lacrimal gland carcinoma can form a triangle of tissue back to the orbital apex, intraconal spread apparently being prevented by the intermuscular septum. The "wedge sign" frequency is assessed in lacrimal carcinoma, lacrimal lymphoma, or dacryoadenitis.

DESIGN

Retrospective masked review of images from patients with biopsy-proven lacrimal gland pathology.

METHODS

For each patient, the presence of a triangle of tissue between the lateral rectus and lateral orbital wall and the superior rectus and the orbital roof was assessed by masked review of computed tomography or magnetic resonance imaging. For the lateral compartment, the wedge was classified as "grade 1" if it just reached the sphenoidal trigone and "grade 2" if it was a complete triangle reaching the orbital apex. Comparison of proportions was made using the Fisher exact test, using an α risk of 0.05 as clinically significant.

RESULTS

Imaging for 116 patients was reviewed: 39 with lacrimal gland carcinoma, 37 with lymphoma, and 40 with dacryoadenitis. The lateral wedge (grade 1 or 2) was most common in patients with carcinoma (16/39; 41%), was present in 11 of 37 patients (30%) with lymphoma, and was rarest in patients with dacryadenitis (6/40; 15%) (P = 0.033). The proportion in patients with carcinoma (41%) was similar to that in patients with lymphoma (30%) (P = 0.345); the proportion in patients with lymphoma (30%) was similar to that in patients with dacryoadenitis (15%) (P = 0.170), but carcinoma (41%) was significantly different from dacryoadenitis (15%) (P = 0.013). The proportions for malignant lesions (carcinoma and lymphoma; 27/76, 36%) and benign dacryoadenitis (15%) were significantly different (P = 0.029). Likewise, a superior wedge, of any extent, was present in 10 of 39 carcinomas (26%), 2 of 40 dacryoadenitis (5%), and 6 of 37 lymphomas (16%) (P = 0.033).

CONCLUSIONS

The "wedge sign" is most common in lacrimal gland carcinoma, but can occur in patients with severe forms of dacryoadenitis or lymphoma and generally indicates life-threatening lacrimal gland pathology that requires urgent biopsy. It is significantly more common in lacrimal gland carcinoma compared with dacryoadenitis and in malignancy (lymphoma and carcinoma) compared with inflammation.

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.

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.

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.

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.

Lacrimal fossa lesions: a review of 146 cases in Egypt

Purpose

The incidence and clinical and imaging criteria of different pathological forms of lacrimal fossa lesions in the Delta region of Egypt were studied.

Methods

A retrospective study of patients with lacrimal fossa lesions for the past 10 years was conducted. A total of 146 cases were identified. Their medical records were reviewed for clinical and imaging data (computed tomography scan, magnetic resonance imaging scan, or both). A definitive diagnosis based on pathological examination of biopsies was also reviewed.

Results

Among the patients reviewed, 43.15% had inflammatory lacrimal gland lesions, 26.71% had lymphoproliferative lesions, and 21.92% had epithelial lesions; 8.22% had rare lesions (5.48% were dacryops and 2.74% had hemangioma). The study included 71.92% benign lesions and 28.08% malignant lesions, which were distributed between 19.18% malignant lymphoma and 8.9% malignant epithelial tumors. According to the pathological origin of the lesions, they may be classified into 78.08% nonepithelial lesions and 21.92% epithelial lesions (16.44% epithelial tumors, and 5.48% dermoid cysts).

Conclusion

Lacrimal fossa lesions show a wide pathological range. Inflammatory lesions are most frequent, followed by lymphoproliferative and epithelial lesions. Analysis of clinical and radiological criteria is helpful in the differential diagnosis of lacrimal gland lesions.

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.

Tumours of the lacrimal gland. Epidemiological, clinical and genetic characteristics

Tumours of the lacrimal gland are rare, but the prognosis may be grave. To date, no population-based incidence and distribution data on lacrimal gland tumours exist. In addition, almost nothing is known about the genetic profile of epithelial tumours of the lacrimal gland. We collected specimens and clinical files on all biopsied lacrimal gland lesions in Denmark over a 34-year period and re-evaluated the diagnosis to provide updated population-based incidence rates and epidemiological characteristics. Clinical data regarding symptoms, clinical examinations, treatment and follow-up were collected for patients with adenoid cystic carcinoma (ACC), pleomorphic adenoma (PA), carcinoma ex pleomorphic adenoma (Ca-ex-PA) and mucoepidermoid carcinoma (MEC). Using RT-PCR, FISH, immunohistochemistry, Q-PCR and high-resolution array-based comparative genomic hybridization (arrayCGH) we explored the genetic characteristics including copy number alterations (CNA) in ACC, PA, Ca-ex-PA and MEC. The incidence of biopsied lacrimal gland lesions was 1.3/1,000,000/year, and ~50% were neoplastic lesions. Of these, 55% were malignant tumours with epithelial tumours as the most frequent. The overall incidence was increasing, and this was caused by an increase in biopsied non-neoplastic lesions. We found that 10/14 ACCs either expressed the MYB-NFIB fusion gene and/or had rearrangements of MYB. All ACCs expressed the MYB protein. ACC was characterized by recurrent copy number losses involving 6q, 12q and 17q and gains involving 19q, 8q and 11q. ArrayCGH revealed an apparently normal genomic profile in 11/19 PAs. The remaining 8 PAs had recurrent copy number losses involving 1p, 6q, 8q and 13q and gain involving 9p. PA expressed PLAG1 in all tumours whereas only 2/29 tumours expressed HMGA2. Ca-ex-PA was characterized by recurrent copy number gain involving 22q. PLAG1 was expressed in 3/5 Ca-ex-PA whereas none of these tumours expressed HMGA2. MEC expressed the CRTC1-MAML2, and this fusion was found to be tumour-specific for lacrimal gland MEC. In conclusion, lacrimal gland lesions that require pathological evaluation are rare in the Danish population, and the incidence rate of biopsied benign lesions is increasing. Epithelial tumours of the lacrimal gland are molecularly very similar to their salivary gland counterparts in the expression of the tumour-specific fusion genes and in their genomic imbalances as demonstrated by arrayCGH. MYB-NFIB is a useful biomarker for ACC and MYB, and its downstream target genes may be potential therapeutic targets for these tumours.

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

Epithelial tumours of the lacrimal gland represent a large spectrum of lesions with similarities in clinical signs and symptoms but with different biological behaviour and prognosis. They are rare, but with aggressive malignant potential. Tumours of the lacrimal gland may present with swelling of the lacrimal gland, displacement of the eyeball, reduced eye motility and diplopia. Pain and symptoms of short duration before the first ophthalmic consultation are characteristic of malignant tumours. The histological diagnosis determines the subsequent treatment regimen and provides important clues regarding the prognosis. The purpose of this paper is to describe the various primary epithelial tumours of the lacrimal gland. In the first part of the review, the frequency, demographics, clinical presentation and diagnostic features are described. In the second part, primarily tumour-specific histological characteristics are given. Finally, treatment modalities including surgical procedures and medical oncology as well as prognosis are discussed.

[Clinical and neuroradiological diagnostics of orbital tumors]

Exophthalmus is the leading sign of space-occupying lesions of the orbit. Patients may further present with lid swelling, impaired ocular motility and optic neuropathy including a relative afferent pupillary defect, compressive optic disc edema or optic atrophy. Orbital tumors can be classified into various categories depending on the etiology, as lymphoproliferative lesions (in particular non-Hodgkin's lymphoma as the most common malignant orbital tumor of adulthood), optic nerve and meningeal lesions, lacrimal gland lesions, secondary orbital tumors which extend to the orbit from neighboring structures and metastases. Slightly less common are vasculogenic and cystic lesions including cavernous hemangioma as the most common benign orbital tumor of adulthood and dermoid cysts as the most common benign orbital tumor of childhood. Rhabdomyosarcoma is the most common malignant orbital tumor of childhood but has a low total incidence. Orbital tumors might not only cause symptoms like pain, diplopia and loss of visual acuity but may also lead to esthetically disfiguring changes. Particular attention should be paid to underlying systemic diseases and generalized tumor diseases. This article illustrates the approach to a detailed clinical and neuroradiological assessment which is mandatory for the care of orbital tumor patients.

Adenoid cystic carcinoma of the lacrimal gland: CT and MRI findings

Purpose

To highlight the computed tomography (CT) and magnetic resonance imaging (MRI) characteristics of lacrimal gland adenoid cystic carcinoma.

Methods

We reviewed the clinical records and imaging findings of 17 patients who were histopathologically diagnosed with primary adenoid cystic carcinoma of the lacrimal gland between August 1998 and November 2010. Orbital CT scans were performed in 17 patients and MRI scans were obtained in 13 patients.

Results

On the CT scans, out of 4 cases of adenoid cystic carcinoma, 3 showed characteristic features of a soft tissue mass with poorly enhancing areas representing cystic changes, and 4 of 17 cases had contiguous bony erosion. On the MRI scans, all cases had mixed signal intensity on T2-weighted images, and 6 cases showed poorly enhancing areas.

Conclusions

Enhanced CT and MRI (including T2-weighted) are helpful in the diagnosis of primary adenoid cystic carcinoma of the lacrimal gland.