|Year : 1961 | Volume
| Issue : 2 | Page : 30-32
Mixed tumours of the lacrimal gland
Eye Infirmary, Medical College Hospitals, Calcutta, India
|Date of Web Publication||31-Mar-2008|
S P Das
Eye Infirmary, Medical College Hospitals, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das S P. Mixed tumours of the lacrimal gland. Indian J Ophthalmol 1961;9:30-2
Diseases of the lacrimal gland are rare. Due to its peculiar situation, it is largely protected from infection and trauma. Tumours are the commonest diseases of this gland. Among them mixed tumours are the most common affections. In 1937 Neely brought the total of reported cases to 267. Since that time various articles on mixed tumours of the lacrimal gland were published and the total came upto 329 in 1951. The total uptil now would be less than four hundred, so any new addition to the literature is of importance.
Since the first study of the histopathology of lacrimal tumour a lot of confusion has been introduced as to the origin of such tumours-epithelial (Verhoeff 1905), endothelial (Warthin 1901) or mixed. Uptil now the origin of these tumours is disputed, but modern trend is towards ectodermal, i.e. epithelial. According to this theory the mesodermal elements that are most often found in these tumours are not really mesodermal, but ectodermal products of epithelial cells. So the term mixed tumours which is also used in this article may not be quite correct, but until definitely proved one way or the other, this term has been retained.
Mixed tumours of the lacrimal gland may be both benign and malignant and different writers state differently about the incidence of malignancy of these tumours. Lane (1922) observed 95 cases and 12 died of the disease. The percentage of recurrence is 20 and metastasis was observed in 7 cases.
Material : The present observation on mixed tumours of the lacrimal gland was carried out in the Eye Infirmary, Medical College Hospitals, Calcutta, over a period of 5 years. Seventy-two cases of primary orbital tumours were recorded within the period of 5 years, nine of which were mixed tumours of the lacrimal gland.
Clinical : No case of bilateral mixed tumour of the lacrimal gland was recorded in the literature and this is true from the present observation. It is said to occur commonly between 35 and 50 years of age, although it has been recorded in the second decade and the sixth decade. The lowest recorded in the present series of cases is 17 years and the highest is 56 years. Sex has no special predilection and either sex was equally affected. The disease occurs either in the right orbit or the left orbit and in the present observation 7 occurred in the right orbit and 2 occurred in the left orbit.
Some of the important data on 9 cases of mixed tumours of the lacrimal gland are given in the table. Proptosis was the constant symptom in all 9 cases. Fall of vision (7 cases) was the second important complaint. Metastatic cervical lymph glands (3 cases), panophthalmitis (I case) etc. were the other complaints.
Onset was gradual in most of the cases, but in one case the rate of growth was so rapid that there developed keratitis elagophthalmos and the patient came to the hospital with the symptoms and signs of panophthalmitis. Visual failure was noted in 7 cases but ophthalmoscopic examination revealed papilloedema (I case) and retinal venous congestion (3 cases). The common clinical finding Was a well localised, firm, sometimes hard mass situated in the superolateral quadrant of the orbit with nodular surface. There was displacement of the globe down and medially and limitation of ocular mobility up and out.
Metastasis in the cervical lymphnodes was observed in 3 out of 9 cases and in one case there was a metastatic tumour mass near the homolateral eyebrow. Mixed tumours of the lacrimal gland has got a great tendency to invade the adjacent bone. X-ray examination to see bony invasion is very important both from the prognostic and therapeutic point of view. In one of the present series of cases, bony invasion was detected during clinical examination; in one case bony invasion was recognised only by X-ray examination. In another case there was no bony invasion both clinically and on X-ray examination, but during operation for the removal of the tumour mass, bony invasion to the lateral wall of the orbit was recognised. In another case X-ray examination showed irregular bony destruction overlying the soft tissue swelling in the zygomaticofrontal region and the lateral wall of the frontal sinus appeared to have been destroyed.
| Pathology|| |
The tumours were definitely encapsulated and the capsule was made of connective tissues running into the substance of the tumour mass. Sometimes compressed tumour tissues were observed in some part of the capsule and this explained the recurrence of the tumour, although histopathologically they appeared to be benign in character, so the capsule should better be called a false one. Histologically both the epithelia: and the connective tissue elements were found in varying proportions in different turnours and even in different parts of the same tumour.
Even normal, abnormal and malignant tissues were noted in the same tumour in different areas. Mucin, said to be secreted by the epithelial cells was present in varying amount. The myxomatous tissues were placed between the epithelial cells. Cartilagenous or bony tissues were not observed in any of the present series. It is said that the mucinous types are more benign and the cellular types are more malignant. In the present series of cases 4 were histopathologically benign and 5 were malignant.
| Discussion|| |
Our knowledge about mixed tumours of the lacrimal gland is inadequate because of its rarity. It is true that the present series of 9 cases is too small to make any deduction, but it offers a histopathological study of uniformly treated cases with a moderate follow-up period.
The incidence of malignant cases in mixed tumours of the lacrimal gland varies according to the different observers. In the present series of 9 cases, 4 were histologically benign and 5 Overt malignant. Of the 4 benign. cases 2 later turned to be malignant with recurrence. So histopathological diagnosis of the benignity of mixed tumours of the lacrimal gland is no sure guide to the prognosis of the patient. Therefore all these tumours should be treated with a suspicious mind of malignancy and the patient should be kept under observation for a long time. Most of these tumours appeared to be well-encapsulated, but complete surgical removal of the tumour mass was often followed by recurrence with increased incidence of malignancy. Lane (1922) observed recurrence as 20%. Verhoeff (1905) reported 5 cases. He followed 3 of the 5 cases and all the three showed recurrence. Whatever may be the views of different observers about the recurrence of these tumours, it seems that if they are followed up for a long time, most of them show either recurrences or metastasis. In the present observation two out of the four histologically benign cases showed recurrence and one of them died. The other one is symptom-free now after deep X-ray therapy. Considering the high incidence of recurrence, all of the present series of cases were subjected to deep X-ray therapy after local excision. Out of the 5 histologically malignant cases, 3 died due to intracranical extension after recurrence; one of them is symptom-free at present and one is living with recurrence.
Fall of vision varying from a small to a marked degree was noted in 7 out of g per cent of cases. Improvement of vision was noted after local excision of the tumour mass. In one case vision did not improve at all. Movements of the affected eye-ball which were hampered before operation, improved after local excision of the tumour.
The prognosis in patients with mixed tumours of the lacrimal gland is poor. The high incidence of recurrence metastasis, and mortality are due to the tendency of the tumour to invade its capsule fairly early, difficulty of the complete removal by the surgical technique and early bony invasive tendency. All of the present series of cases were subjected to irradiation after local removal of the tumour, but this did not prevent recurrence and metastasis.
Although in the present series of cases, the results were not satisfactory, it is to be said that early diagnosis, wide and complete surgical excision, followed by radio-therapy may improve the chances for the patient.
| Summary|| |
A series of 9 cases of mixed tumours of the lacrimal gland are reported with a follow-up period upto 5 years. 4 of them died of the disease. 2 are living with recurrence and 3 are living without recurrence.
| References|| |
Benedict and Broders (1930), Amer. J. Ophthal., 13, 585.
Duke-Elder (1952), Text Book of Ophthalmology, Vol. 5, Henry Kimpton, London, P. 5253.
Godtfredsen (1948) , Brit. J. Ophth., 32, 171.
Lane (1922), Amer. J. Opththal., 5, 425.
Neely (1937), Amer. J. Path., 13, 99.
Sanders (1939), Arch. of Ophthal., 21, 239.
Verhoeff (1905), J. lied. Res., 13, 319.
Warthin (1901), Arch. F. Ophthal. 30, 601.
[Figure - 1], [Figure - 2]
[Table - 1]