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    Pathologic findings
    Microscopic desc...
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CASE REPORT
Year : 1996  |  Volume : 44  |  Issue : 4  |  Page : 231-233
 

Mucoepidermoid carcinoma of the lower lid - report of a case


Medical and Vision Research Foundations, Madras, India

Correspondence Address:
Jyotirmay Biswas
Medical and Vision Research Foundations, Madras
India
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PMID: 9251269

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How to cite this article:
Biswas J, Datta M, Subramaniam N. Mucoepidermoid carcinoma of the lower lid - report of a case. Indian J Ophthalmol 1996;44:231-3

How to cite this URL:
Biswas J, Datta M, Subramaniam N. Mucoepidermoid carcinoma of the lower lid - report of a case. Indian J Ophthalmol [serial online] 1996 [cited 2014 Oct 23];44:231-3. Available from: http://www.ijo.in/text.asp?1996/44/4/231/24567


Mucoepidermoid carcinoma is a malignant neoplasm characteristically composed of mucus secreting cells, intermingled with neoplastic squamous cells in variable proportions. The commonest site of occurrence is the salivary glands, although this neoplasm has also been reported in the upper respiratory tract and occasionally in the nasal mucosa, oesophagus, maxilla, mandible, liver, cervix, penis, and anus.[1] Ocular involvement is rare and only few cases have been reported in the conjunctiva and the lacrymal sac.[2][3][4] Conjunctival mucoepidermoid carcinoma does not have a typical presentation and has been reported mostly in the limbal conjunctiva. It can also arise from the bulbar and lower palpebral conjunctiva. Lesions can have variable presentations e.g. leukoplakik lesion, papillomatous or pedunculated mass, or a raised conjunctival ulcer. The tumour can be recurrent and invasive with orbital and intraocular extension.[1],[2]We report a case of histopathologically proven mucoepidermoid carcinoma presenting as a cauliflower-like mass arising from the conjunctiva of the lower eyelid and mimicking squamous cell carcinoma.


   Case report Top


A 51-year-old male presented with a history of swelling in the lower lid, and medial canthus of the left eye since seven years. There was no history of pain, redness or watering and no systemic complaints. The best corrected visual acuity of both eyes was 6/6;N6. Extraocular movements were full. Slit lamp examination revealed a vertically oval cauliflower-like growth which measured 8.5 mm x 11.0 mm in the medial canthus involving the medial one third of the conjunctiva of the lower left eye lid Figure:1]. The puncta was free. The right eye was normal. Intraocular tension and fundus were normal in both eyes. Clinically, a diagnosis of squamous cell carcinoma was made. An excisional biopsy of the mass was done under frozen section control in general anesthesia. The tumour mass was found to be pedunculated with superficial cauliflower like mass. A pedicle of 4 mm was seen at the base of the mass. Conjunctiva 1 mm surrounding the pedicle was excised along with the tumour mass. After frozen section report was obtained that the lateral, medial and deeper margins are free from the tumour, the base of the lesion was heat cauterized. The patient was found to have mild entropion on first postoperative week. The patient was from a distant place and despite repeated reminders did not return for follow up.


   Pathologic findings Top



   Microscopic description Top


Frozen section: Frozen section revealed a portion of the conjunctiva in which the epithelium showed marked acanthosis and dyskeratotic cells. In the stroma, multiple islands of squamous cells and cells containing clear spaces were seen. A definitive diagnosis could not be made on frozen section.

Permanent section: The epithelium demonstrated variable degrees of acanthosis. The acanthotic epithelium revealed dysplastic cell with abnormal nuclei as well as nucleoli.

These epithelial cell were found to be extending to and invading the underlying stroma.

The basement membrane of epithelium was broken at several places. There were multiple islands of epithelial lobules comprising both glandular epithelial cells and squamous cells [Figure - 2]. Multiple elongated infiltrating epithelial cords were seen within the tumour. Cytoplasm of these glandular epithelial cells were often clear. Multiple gland-like spaces were seen within the tumour. Focal lymphocytic infiltration was also seen within the tumour. The tumour and gland-like spaces stained positive with special stain PAS [Figure - 3] and alcian blue; it was diastase resistant indicating mucinous material within the tumour cells, as well as in large glandular spaces lined by the tumour cells. The histopathologic features were consistent with mucoepidermoid carcinoma arising from the conjunctiva of the lower lid.


   Discussion Top


Mucoepidermoid carcinoma is the most common malignant tumour of the salivary gland. It constitutes 10 to 15% of tumours of the minor salivary glands and the palate is the most frequent site. Of the various ocular structures, the conjunctiva is the most common site for mucoepidermoid carcinoma. In a series of five cases reported by Rao et al[1] the tumour was located close to the limbus in three of them, and in two others, in the lower bulbar conjunctiva and lower cul-de-sac. The most common presenting sign in this type of tumour is the presence of conjunctival mass with redness and irritation. Duration of symptoms ranged from 2 to 6 months.[1],[2] In contrast to previous reported cases our case is quite unusual with a history of painless lid swelling for seven years and indicates that this tumour can be slowly progressive without local or systemic spread.

Clinically mucoepidermoid carcinoma may be indistinguishable from squamous cell carcinoma of the conjunctiva, but a histopathologic examination of the tumor would establish the diagnosis. Histologically the tumour exhibits an admixture of epidermoid cells and mucous secreting cells in variable proportions. The cytoplasm of the cells usually appears clear or vacuolated, sometimes like a signet ring. The histochemical stain for mucin (periodic acid schiff, alcian blue, mucicarmine) can confirm the diagnosis. The other cells which can be present are intermediate cells, basal cells and more rarely, hydropic cells and oncocytic cells. Frozen section diagnosis of this tumour can be difficult due to the rarity of its occurrence. The origin of mucoepidermoid carcinomas from the conjunctival epithelium can be readily explained. Normally the conjunctiva is covered by stratified columnar epithelium containing scattered goblet cells, which are mucous secreting cells. This epithelium becomes stratified squamous near the sclero-corneal limbus and the mucocutaneous junction near the margin of the lid. Therefore, it is conceivable that a conjunctival tumour may develop neoplastic differentiation in both directions, forming mucous secreting cells as well as squamous cells, resulting in the mixed pattern seen in mucoepidermoid carcinoma.

The mucoepidermoid carcinoma of the conjunctiva is more locally aggressive than squamous cell carcinoma. In view of the frequent early recurrences and local invasion, these conjunctival tumours should be treated by a wide local excision and the margins should be carefully examined histopathologically, for evidence of residual tumours. An excision with frozen section control is recommended. The patient should be followed-up frequently. In contrast to squamous cell carcinoma which have a recurrence rate of 26% to 40% mucoepidermoid carcinoma of ocular adenexa had a veryhigh recurrence rate. All five cases of conjunctival mucoepidermoid carcinoma has recurred once, one case had two recurrence.[1] Recurrences have been noted with intraocular invasion in another case.[2] Henderson reported that the tumour recurred after orbititomy, in one case, in the lacrimal apparatus and proved fatal within one year of intracranial spread.[5] Bambirra et al in the study of mucoepidermoid carcinoma of lacrimal sac reported no residual tumour after orbital extenteration and post operative radiation, over a period of two years.[3] The prognosis for life in mucoepidermoid carcinoma is reported to be good. Five patients with mucoepidermoid carcinoma of the conjunctiva reported by Rao and Font were alive in a follow-up period ranging from 1.83 years to 7.83 years.[1]Even though the incidence of the mucoepidermoid carcinoma of the conjunctiva is rare, such a tumour should be recognised and differentiated from other conjunctival tumours, especially squamous cell carcinoma,which have a better prognosis and a different biologic behaviour.


   Acknowledgement Top


We acknowledge the kind assistance of Dr. Narsing A Rao, Professor, Department of Pathology, Doheny Eye Institute, for reviewing the histopathology slide of this and confirming the diagnosis[6].

 
   References Top

1.Rao NA, and Font RL. Mucoepidermoid carcinoma of the conjunctiva, a clinicopathologic study of five cases. Cancer 38:1699-1709, 1976.  Back to cited text no. 1    
2.Brownstein S. Mucoepidermoid carcinoma of the conjunctiva with intraocular invasion. Ophthalmology 88:1226-1230, 1981.  Back to cited text no. 2    
3.Bambirra EA, Miranda D, Rayes A. Mucoepidermoid tumour of the lacrimal sac. Arch Ophthalmol 99:2149-2150, 1981.  Back to cited text no. 3    
4.Ni C, Wagoner MD, Wang WJ, Albert DM, Fan CO, Robinson N. Mucoepidermoid carcinoma of the lacrimal sac. Arch Ophthalmol 101:1572-1574, 1983.  Back to cited text no. 4    
5.Henderson JW. Orbital tumour. Philadelphia WB Saunders Co. 1973, pp 440-442.  Back to cited text no. 5    
6.Steward FEW, Foote FW Jr, Becker WG. Mucoepidermoid tumours of salivary glands. Ann Surg 122:810-844, 1945.  Back to cited text no. 6    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]



 

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