|  | | Orbital Tumors - Lacrimal Gland Tumors |
| General - look for fullness of upper lid, asymmetry of superior sulcus, abnormal lid contour
- majority lacrimal gland masses are idiopathic inflammatory dacryoadenitis
- especially S-shape, often palpable
- check for mobility, smooth, rubbery or nodular
- proptosis is evidence of posterior growth, otherwise globe is down and media
Imaging - CT very good for differentiating inflammation from tumor: inflammation and lymphoid with in gland cause diffuse enlargement, elongated shape, contour around globe; neoplasms are isolated, globular, displace & indent globe
- Pathology
- Epithelial Tumors
- 50% benign mixed
- Benign Mixed Tumor (Pleomorphic Adenoma)
- most common epithelial tumor
- 30-50 year old, M sl>F
- palpable, painless, slow (history often reveals symptoms > 1 year) growing with globe dispalced down, medial, axial proptosis
- incites bony cortication, enlargement/expansion lacrimal gland fossa, firm lobular mass
- CT
- lacrimal gland is oblong if inflammatory, globular if malignant
- pathology
- metaplasia of epithelial cells to form stroma, cartilage
- benign epithelial cell nests with loose mesenchymal connective tissue
- variability of above is mixed tumor
- microscopic extension into pseudocapsule causes recurrence if margins not adequate at excision
- treatment
- must excise it all with lateral orbitotomy with en bloc excision including pseudocapsule
- don’t biopsy b/c of 1/3 chance of recurrence, significant risk of malignant degeneration
- 50% carcinomas (50% of these are adenoid cystic, remainder: malignant mixed, 1o adeno carcinoma, mucoepidermoid carcinoma, squamous carcinoma)
- Malignant Mixed Tumor
- often arise from 1o benign mixed or from recurrent benign mixed if incomplete excision
- path
- similar to benign mixed but with malignant change
- least common epithelial tumor
- treatment
- frequent exenteration, bone removal necessary
- fatality rate of 50%
- Adenoid Cystic Carcinoma (Cylindroma) (25% if epithelial lacrimal gland tumors)
- most common (highly) malignant tumor of lac gland
- PAIN from bone destruction, perineural invasion, rapid course differentiates from benign mixed
- pathology
- swiss cheese appearance, stain with mucicarmine, looks benign, infiltration of orbital tissue, incl. perineural invasion
- basaloid pattern worst prognosis
- treatment
- radical orbital exenteration (of roof, lateral wall, floor, orbital soft tissue, anterior temporalis muscle), with XRT
- death from intracranial extension or systemic metastisis after multiple recurrences
- Non-Epithelial Lacrimal Gland Tumors
- Orbital inflammatory syndrome
- Sarcoidosis
- African or Scandinavian descent, systemic disease, non-caseating granuloma with monocytes, typical bilateral lacrimal gland involvement, conj. biopsy or lac gland biopsy or gallium scan may establish diagnosis, ACE, lysozyme, chest x-ray for hilar adenopathy, anergy on skin test
- benign lymphoproliferative lesions of lacrimal gland middle aged F, dry eye, if with rheumatoid arthritis, then classic Sjogren’s
References
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