|Year : 1961 | Volume
| Issue : 4 | Page : 87-90
Primary epithelial tumour of the lacrimal gland
BN Consul, OP Kulshrestha, Subhash Gupta
Department of Ophthalmology, S. M. S. Medical College, Jaipur, India
|Date of Web Publication||7-Apr-2008|
B N Consul
Department of Ophthalmology, S. M. S. Medical College, Jaipur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Consul B N, Kulshrestha O P, Gupta S. Primary epithelial tumour of the lacrimal gland. Indian J Ophthalmol 1961;9:87-90
The classification of Primary epithelial tumours of the lacrimal gland has been the subject of much discussion. Sheldon (1943) separated four closely related and overlapping groups among these salivary type of tumours. They were regarded as variations of the type of neoplasm commonly called "Mixed tumours". The four categories were : Adenoma, mixed tumours, Myo-epithelioma and carcinoma.
This distinction between adenoma, carcinoma and the so called "Mixed tumours" is considered to be an artificial one by Willis (1948). All of the categories are different variations of the same types of epithelial tumours with wide range of structure and behaviour merging imperceptably with the simple adenoma on one hand and anaplastic carcinoma on the other. It may be felt convenient to continue using these names for descriptive purposes understanding them as variations of a single histogenic group.
By designating these tumours as pleomorphic adenomas and adenocarcinomas, the variable structure and behaviour of tumours, ranging from benign adenomas to malignant adenocarcinomas and merging into anaplastic carcinoma is expressed. These terms originally expressed by Willis have also been used by Duke Elder (1952) to designate the same meaning. The great majority (about 90%) of lacrimal gland tumours fall in this category.
Milan & Heath (1956) has divided these tumours into 4 sub-groups. In the first group are simple adenoma by which is meant'a uniform proliferation of the normal structure of the lacrimal gland. Such simple benign adenomas showing within the tumour the structure of fibro-myxo-epithelium are exceedingly rare.
In the second group are included the growths showing the structure of the so called mixed tumours (Fibro myxo-epitheliomas according to him). Two types of tumour cells, one derived from the epithelium and the other from the myo-epithelium like myxo-matous, cartilagenous and other mesodermal elements are found. The growth is lobulated with an apparent connective tissue capsule. Areas of squamous metaplasia with prickle cells and epithelial pearl formation are sometimes found.
In the third group is basiloma, because of histological similarity to basal cell carcinoma of the skin. It may be sub-divided into cystic and solid groups. The cystic form also called as cylindromas, have, well developed acini with few layers of cells. In the solid forms the cystic spaces are inconspicuous but it is rich in cells.
In the last group these authors have included "Other Carcinomas". This includes various adeno and squamous cell types and undifferentiated carcinomas. The tumours of the latter group are highly malignant, not well encapsulated, tend to invade the adjoining bones soon and are followed invariably by recurrences.
Clinically the usual site of the tumour mass is in the upper temporal quadrant of the orbit in the region of the lacrimal gland but mass may be felt at other abnormal situations which is possible because lacrimal gland tissue is found not only in the lacrimal fossa but also at almost any site in the lateral half of the orbit.
The tumour has a ready access to the adjoining bones which are sooner or later invaded in a majority of cases. Bone invasion is characteristic of the epithelial type of tumour and can be appreciated by palpation before it is demonstrable by roentgenographic changes. It must be noted that an invasive growth into the bone may be found at operation after roentgen examination has given negative results.
The present proven case of primary epithelial tumour of the lacrimal gland showing malignant characteristics is interesting because of its very short duration and occurring at such a young age.
| Case Report|| |
Patient R. S., 12 years old, male child was admitted complaining of gradually increasing proptosis of the right eye since the last 3-4 months. Since two weeks, he also had pain in the right eye and occasional diplopia.
His right eye showed marked proptosis. the upper lid showed heaviness and some chemosis of the conjunctiva of the upper fornix. The whole eye-ball was displaced downwards and medially. The movements of this eye were to some extent restricted in the upper and outer quadrant. But Hess's chart did not show weakness of any particular extraocular muscle.
A firm mass could be palpated in the outer and upper part of the orbit. It was felt to be lying a little anterior to the usual position of the lacrimal fossa in the bony orbit and the mass was free of the orbital rim. The posterior boundary of the growth towards the orbit could not be defined.
Exophthalmometry (Hertel's) showed proptosis of this eye by 9 mm. The external eye, the media and fundus were normal. Vision was 6/6 partial in this eye. There was no enlargment of preauricular or cervical lymph nodes.
Left eye and the orbit showed no abnormality. Investigations : Total leucocyte count was 8800 per cmm. Differential white cell count showed Polymorphs 74%, Lymphocytes 22;%, Monocytes 3%, Eosinophils 1% Haemoglobin was 10 Gms per cent. and the erythrocyte count was 3.9 million per c.m.m. E.S.R. was 12 m.m. per hour.
Blood for Kahn's was negative. On screening chest was normal.
Skiagram of the orbits did not show any bony involvement or any other abnormality.
Under general anaesthesia, after incising the periosteum, the lateral orbital wall was resected out by means of an electrically driven circular saw (Striker Saw). The eye ball was protected by means of a retractor and the tumour was palpated. It was firm lying anterior to the lacrimal gland with which it had formed one mass.
The growth was removed enmass along with the lacrimal gland. It consisted of a greyish, firm, slightly irregular and a well encapsulated mass which was not adherent to the adjoining bones.
The patient had an uneventful recovery. The right eye had no proptosis 3 weeks after the operation.
Post-operatively, the orbital region was treated with deep X-ray therapy. A total of 2400r. was administered in 10 sittings. About a year has passed since the initial operation and he has no recurrence of the growth so far.
Histological Report of the Tissue.
Lacrimal gland is seen at the periphery of the capsulated tumour tissue, composed of the stellate cells, chondromatoid tissue, acini containing eosinophilic stained cells irregularly arranged in sheets.
The acinar lining and the cells show prominent nucleii, showing hyperchromatism, mitotic figures and other nuclear aberrations. The capsule is infiltrated at places. Histological diagnosis of mixed tumour of the lacrimal gland is obviously malignant.
| Comments|| |
Mixed tumours of the lacrimal glands have been reported in only 335 cases so far and are rare. The rarity of such growths may also be judged by the fact that in our institution with 72 indoor eye beds and about 16,18,000 new eye patients seen every year, this is the first case seen by us during the last 10 years.
The common age for such tumours is the 3rd or 4th decade and this patient may be considered to be the third youngest patient reported, the other two being by Milan & Heath (1956) and Rubin (1947) in patients aged 18 months and 10 years respectively.
Because of rarity of such growths only a few authors have been able to study adequately a significant series of cases. Some observers particularly Forrest and Reese have attempted to correlate the histologic types with clinical course including response to treatment and prognosis. But the number of such cases reported by them is not large enough.
In considering prognosis, it is well to note the recordings of Milan & Heath. Out of 15 cases of fibromyxo-epitheliomas (mixed tumour type), seven cases had recurrences of their tumour. Recurrence was noted 10, 11, 26 years after the operation. Five of them died of their tumour. For this reason a five-year or even 10-year follow up may be of little significance. Only a year has elapsed after removal of the tumour in our patient and there has been no recurrence so far.
The clinical course of the other two varieties is much more rapid. Of the rich ocular epitheliomas (basiloma group) of eight patients, seven of their cases died of their tumour on an average 4 years after the onset of symptoms. Of six cases of other varieties of carcinomas (undifferentiated carcinomas) 3 patients died of their tumour in about 2½ years after the onset of symptoms. The other two were living with inoperable metastasis.
The prognosis of all types is poor. especially for the basiloma group. All of the primary epithelial tumours of the lacrimal gland should therefore be considered as clinically malignant. In some cases recurrences appear to be histologically more malignant. Metastasis in regional lymph nodes are found in some cases and occasionally in the lungs.
| Summary and Conclusions|| |
A case of primary malignant epithelial tumour of the lacrimal gland in a boy aged 12 years is presented here. Clinically it appeared like the so called "Mixed Tumour" and histologically, was showing carcinomatous characteristics. The tumour was of very short duration.
| References|| |
Benedit, WV. L. (1939) Arch. Ophthal. 21 : 258.
Duke-Elder, S., Text Book of Ophthal. Vol. V. 5253-64, (1952), Henry Kimptom, London.
Fleeting (1949) Brit. J. Ophthal. XXXHI, 763.
Forrest, A. W. (1949), Arch. Ophthal, 41 :198.
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Irving, A. R., Roberts, W. L. and Souda Koff, P. S. (1951) Am. J. Oph. 34 :1511.
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Sheldon, W. H. (1943), Arch. Path. 35:1-2o (Jan).
Willis, R. A.; Pathology of tumours (1918) Butterworth, London.
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]