Lacrimal sac adenocarcinoma

Case contributed by Dr Amy Wong

Presentation

Right anteromedial orbit / lacrimal gland mass and epiphora.

Patient Data

Age: 60 years
Gender: Male
MRI
  • Contrast-enhancing soft tissue lesion measuring 33x20x29 mm (AP x transverse x craniocaudal) within the right orbital cavity centered on the lacrimal sac (inferomedially)
  • The lesion extends within the pre- and postseptal cavity, compressing medial and inferior rectus muscles laterally, and has minor extension into subcutaneous area of the right nasal root at the naso-orbital corner. 
  • The lesion extends medially into the lateral aspect of the anterior ethmoidal air cells and occupies the right nasolacrimal sac and duct
  • No evidence of intracranial extension and no extension into the right maxillary sinus.
  • The lesion is hyperintense on FLAIR. 
  • There are some internal foci of diffusion restriction suggestive of invasive nature. 
Nuclear medicine
  • A 33x20x29 mm mass metabolic primary involving the medial right orbital cavity centered on the lacrimal gland. 
  • At the inferior border of this lesion along the lacrimal duct, there is linear extension inferiorly with a small separate nodule which involves and seems to invade the medial aspect of the right maxillary sinus
  • Nodal metastases: There is a small metabolic node within the superficial anterior aspect of the right parotid and several metabolic right level 2 nodes with a combined diameter of 5.21 x 1.75 x 2.32 cm (CC x AP x TR).
  • Distant metastases: There is a small area of increased metabolic activity on the right and a metabolic medial right upper lobe apical segment lung lesion 2.39 cm in diameter with an appearance consistent with a metastasis (not shown).

Case Discussion

The patient underwent right extended orbitomaxillectomy, right parotidectomy, right neck dissection and locoregional reconstruction, followed by a staged right upper lobectomy.

Histology: Poorly differentiated adenocarcinoma invading lacrimal sac and sinonasal mucosa and 5/28 lymph node involvement. 

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