Lacrimal Drainage System
Neoplastic causes of acquired obstruction of the lacrimal drainage system may be classified into the following groups:
primary lacrimal drainage system tumors (most commonly papilloma and squamous cell carcinoma; Fig 15-26)
primary tumors of tissues surrounding the lacrimal drainage system that secondarily invade or compromise lacrimal system structures (most commonly basal and squamous cell carcinoma of the eyelid skin; others include adenoid cystic carcinoma, infantile [capillary] hemangioma, inverted papilloma, epidermoid carcinoma, osteoma, and lymphoma)
tumors metastatic to the nasolacrimal region
Primary lacrimal sac tumors are rare and should be considered for any mass that presents above the medial canthal tendon. They may be associated with epiphora or chronic dacryocystitis. Some patients report spontaneous bleeding, or blood may reflux from the punctum on irrigation. Tumors that invade the skin may produce ulceration with telangiectasia over the lacrimal sac. Metastasis to regional lymph nodes may also occur. CT and MRI have replaced dacryocystography as the way to identify neoplasms and determine disease extent. CT also has the advantage of facilitating the assessment of bone erosion.
Figure 15-26 Papillary squamous cell carcinoma of the right lacrimal sac. A, Palpable mass over the right lacrimal sac (arrow). B, Magnetic resonance imaging scan shows a mass within the right lacrimal sac (arrow). C, Incisional biopsy through an external approach. D, Lacrimal sac biopsy reveals papillary squamous cell carcinoma.
(Courtesy of Bobby S. Korn, MD, PhD.)
On histologic examination, approximately 45% of lacrimal sac tumors are benign and 55% are malignant. Squamous cell papillomas and carcinomas are the most common tumors of the sac. Many papillomas initially grow in an inverted pattern and into the lacrimal sac wall; consequently, their excision is often incomplete. With recurrence, malignant degeneration may occur.
Treatment of benign lacrimal sac tumors commonly requires a dacryocystectomy. Malignant tumors may require a dacryocystectomy combined with a lateral rhinotomy and medial maxillectomy, sometimes performed in concert with an otolaryngologist. Exenteration, including bone removal in the medial canthal area, is necessary if a malignant epithelial tumor involves bone and the soft tissues of the orbit (see Chapter 8). Radiation is useful for treatment of lymphomatous lesions, as an adjuvant after removal of malignant lesions, or as a palliative measure for unresectable lesions.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.