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Squamous cell carcinoma of the lacrimal sac


Key points

  • Definition: Squamous cell carcinoma (SCC) of the lacrimal sac is an uncommon but deadly cause of abnormal unilateral tearing, which when not promptly diagnosed and treated can lead to local invasion and death.

  • Classic clue: A patient presents with unilateral epiphora (uncontrolled tearing with tears overflowing onto the face), recurrent dacryocystitis, and imaging showing a lacrimal sac mass.

Imaging

Computed tomography features

  • Computed tomography (CT) shows a lacrimal sac mass that may erode the lacrimal fossa and adjacent structures.

  • Bone destruction suggests a malignant etiology.

  • Carcinomas spread to regional nodes in 27% of cases and distant sites in 9.5% of cases.

  • Lymph node metastasis in SCC occurs late and involves preauricular, submandibular, jugulodigastric, and cervical nodes.

Magnetic resonance features

  • Magnetic resonance imaging (MRI) is the assessment modality of choice.

  • Bone destruction seen on MRI suggests malignancy.

  • Infiltration of a tumor into subcutaneous tissues suggests malignancy

    FIGURE 43-4 ■, Normal anatomy. A, Diagrammatic representation of normal lacrimal drainage system from frontal view of left eye. 1, lacrimal punctum; 2, inferior canaliculus; 3, superior canaliculus; 4, common canaliculus; 5, valve of Rosenmüller; 6, fundus of lacrimal sac; 7, body of lacrimal sac; 8, valve of Krause; 9, interosseous part of nasolacrimal duct; 10, meatal part of nasolacrimal duct; 11, valve of Hasner; 12, anterior lacrimal crest; 13, posterior lacrimal crest; 14, medial canthal ligament; 15, orbicularis oculi. B, Schematic lateral drawing anteromedial orbit. 1, nasal bone; 2, frontal process of maxilla; 3, lacrimal fossa; 4, lacrimal bone; 5, orbital plate of ethmoid bone (lamina papyracea); 6, frontal sinus; 7, frontonasal recess; 8, agger nasi cells; 9, position of uncinate process; 10, position of nasolacrimal duct; 11, maxillary hiatus; 12, inferior turbinate; 13, anterior lacrimal crest; 14, posterior lacrimal crest (bony ridge of lacrimal bone).

    FIGURE 43-5 ■, Nasolacrimal ducts. At the medial rim of the upper and lower lids, the lacrimal puncta open, leading into the lacrimal sac through the upper and lower canaliculi. The lacrimal sac is situated in the orbital lacrimal fossa and proceeds into the nasolacrimal duct. The nasolacrimal duct is surrounded by a bony canal created by the maxillary and lacrimal bones and opens into the inferior meatus of the nose. Both the lacrimal sac and nasolacrimal duct are surrounded by a vascular plexus comparable to a cavernous body that is connected to the cavernous system of the nose.

    (see Figure 43-1 , B ).

    FIGURE 43-1 ■, A, Coronal T1 Gd shows heterogeneously enhancing mass involving medial right orbit displacing right globe laterally. Extends inferiorly into nasolacrimal duct. (Surgically proven benign changes involving right maxillary sinus.) B, Axial T1 Gd shows heterogeneously enhancing mass invading medial right orbit and anterior ethmoid sinus. It extends anteriorly into subcutaneous fat causing skin thickening. Mass epicenter is consistent with lacrimal sac.

  • Thickening of overlying skin suggests malignancy (see Figure 43-1 , B ).

  • Invasion of the orbit and ethmoid sinuses suggests malignancy (see Figure 43-1 , B ).

  • T1 Gd demonstrates moderate heterogeneous enhancement (see Figure 43-1 , A and B ).

  • Carcinomas will spread to regional nodes in 27% of cases and distant sites in approximately 9% of cases.

  • T1 shows an intermediate-signal lesion.

  • T2 shows a hypointense signal. This decreased T2 should serve as a warning sign because inflammatory dacryocystitis has increased T2.

  • Lacrimal sac diverticula and mucoceles may be difficult to distinguish from neoplasms.

Dacryocystography features

  • In 1909 Ewing first reported performing dacryocystography. ,

  • Over the years multiple improvements have been made in technique including catheters, contrast media, and imaging procedures.

  • Currently CT dacryocystography (CTD) has largely replaced plain films and linear tomography.

  • Some suggest MR dacryocystography (MRD) as the next step to eliminate ionizing radiation used in imaging procedures used since their introduction in 1909.

  • Usually with CTD contrast is injected into both the upper and lower lacrimal puncta.

  • With MRI, a dilute solution of Gd is topically applied, similar to a CT technique using iodinated contrast.

  • In 90% of patients the upper and lower lacrimal canaliculi form a common lacrimal canaliculus or sinus of Maier, which enters the lacrimal sac.

  • In 10% of patients, these canaliculi independently enter the lacrimal sac.

  • Complete occlusion, limited filling, or an intraluminal mass suggests neoplasm.

  • CT may demonstrate destruction of adjacent bone.

  • Some suggest performing bilateral exams for comparison with the contralateral ducts. ,

Clinical issues

Presentation

  • SCC lacrimal sac may masquerade as chronic dacryocystitis and receive conservative monitoring until it is far advanced.

  • Symptoms may include bloody tears, frequent nose bleeds, or a medial orbital mass.

Epidemiology

  • SCC lacrimal sac occurs more frequently in the fifth decade.

  • Human papillomavirus (HPV) is associated with approximately 40% of carcinomas and most of the papillomas.

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