Squamous cell carcinoma in the lacrimal sac presenting as proptosis: a case report.

Dear Editor, Recently, we experienced two cases of lacrimal sac tumors discovered in patients who presented with persistent epiphora after receiving dacryocystorhynostomy (DCR). A 75-year-old female visited the clinic complaining persistent epiphora in the right eye for 5 years. The patient was diagnosed with nasolacrimal duct obstruction in the right eye and received a DCR twice 2 years ago at a local hospital, but epiphora persisted post operation. Lacrimal irrigation test revealed a reflux through contralateral puncta in the right eye. There was a protrusion superior to medial canthus and a mass was palpable at the medial side of the right orbit. Computed tomography (CT) scan confirmed a 3-cm-sized mass involving the right lacrimal sac and surrounding soft tissue of inferomedial orbit (Fig. 1A and 1B). An excisional biopsy was performed and diagnosed as invasive squamous cell carcinoma from lacrimal sac. Wide resection of lacrimal sac and nasolacrimal duct via anterior orbitotomy and medial maxillectomy via lateral rhinotomy was performed (Fig. 1C). The patient received adjuvant radiotherapy and is under observation. Fig. 1 Computed tomography (CT) scan and operation images of epiphora patients diagnosed with tumor in lacrimal duct (A,B). Preoperative orbital CT images of the 75-year-old female patient show a 3-cm mass at the right lacrimal sac. (C) An excisional biopsy ... The second case presents a 51-year-old female whose history included a DCR received at a local hospital for epiphora in the left eye. She was complaining of persistent epiphora and swelling of upper and lower eyelids. The slit lamp examination and lacrimal irrigation test was normal. Sinus endoscopy showed intact bony opening from the previous DCR. A CT scan was done and a mass occluding the lacrimal sac and invading the inferomedial orbit was observed (Fig. 1D and 1E). An excisional biopsy was performed and the pathology report diagnosed a papilloma with mild nuclear dysplasia, which has a risk of advancing into a squamous carcinoma. Wide resection of inferomedial orbit including lacrimal sac and endoscopic medial maxillectomy was performed (Fig. 1F). Pathology report diagnosed a carcinoma arose from papilloma, and the patient received adjuvant radiotherapy. This is the first case series of lacrimal sac tumors discovered in patients with persistent epiphora after receiving DCR in Korea. A tumor originating from the lacrimal sac is a rare cause of epiphora [1], but a half of the cases turn out to show malignancy with a high mortality rate, which raises a need for precaution. Tumors of lacrimal sac can be categorized into three types. The first type is a primary tumor in the lacrimal sac, in which 72% of the cases are malignant. The second type is a tumor invading from the nearby tissue such as eyelids, paranasal sinuses or orbits. The third type is an inflammatory tumor such as sarcoidosis or Wegener's granulomatosis, which may require an internal medical approach to evaluate systemic symptoms. Epithelial tumor is the most common type of primary tumor in the lacrimal sac. Benign epithelial tumors include papilloma and oncocytoma, and can be treated with surgical resection [2,3]. Malignant epithelial tumors include squamous cell carcinoma and transitional cell carcinoma, and a wide resection including lacrimal canaliculi, sac and nasolacrimal duct with lateral rhinotomy is needed with preoperative and/or postoperative radiotherapy. If the tumor is invasive, an orbital exenteration including wide resection, lymphadenectomy and paranasal sinus resection is required. The local recurrence rate is 50% and the mortality rate is 50% for invasive squamous cell carcinoma and 100% for transitional cell carcinoma. Non-epithelial tumor includes mesenchymal tumor and lymphoproliferative tumor [2,3]. Because recent DCRs are performed using sinus endoscopes to avoid scar formation, it is more difficult to find tumors than in conventional DCRs. The possibility of a tumor in the lacrimal sac must be ruled out in the patients with a palpable mass superior to the medial canthus, a bloody reflux and/or a simultaneous exophthalmos [3,4]. Palpation around the medial canthal area and pathologic confirmation of tissue whenever discovering any sign of abnormality is important, especially when eyelid swelling or epiphora persist after DCR. Imaging study of the lacrimal drainage system using CT scan is also a good screening process.

OBJECTIVE. The aim of the study was to evaluate the endoscopic dacryocystorhinostomy (DCR) with some particularities and its advantages over external DCR. MATERIAL AND METHODS. We evaluated 3 female patients (age range 35-84 years) diagnosed with chronic dacryocystitis - lacrimal sac abscess (2 cases) and lacrimal sac fistula (1 case). All patients presented a history of repeated episodes of acute dacryocystitis initially treated with broad spectrum antibiotics by the ophthalmologist. The evaluation protocol consisted in cranio-facial CT scan or MRI for the evaluation of the lacrimal sac and nasal structures, an ophthalmologic examination with the catheterization of the superior and inferior lacrimal punctum with a light probe to verify the permeability of the lacrimal pathway, and the Jones test with fluorescein to receive information about the common lacrimal path. Lacrimal syringing with regurgitation of fluid from the opposite punctum was the only criteria to decide the surgery. In all three cases we performed an endoscopic DCR, with stent insertion in two cases and a laco-dacryo-rhinostomy in one case. In only one case a reintervention was needed 12 months later. CONCLUSION. The endoscopic DCR, with its different particularities, is a safe surgical procedure with a low rate of complications, being the treatment of choice for the treatment of nasolacrimal duct obstruction.

Objective To study the suitability of MeroGel sticking as a new way of a flap anastomosis in entranasal endoscopic dacryocystorhinostomy(EES-DCR)for chronic dacryocystitis.Methods Two hundred seventy patients with purely chronic dacryocystitis were randomly and equally divided into 3 groups:MeroGel stickinggroup(groupA),silver folder holding group(groupB)and negative control group(group C).All patients received conventional EES-DCR,during which the lacrimal sac and nasal mugosa was sticked and adhered and the wound surface around the lacrimal ostium was surrounded by the biological gel of Merogel in group A,and mucosa of the lacrimal sac and nose were held with a silver folder in group B,and the valve of the lacrimal sac was only adequately extended after removing the nasal mucosa valve in group C.The postoperative follow-up was periodically performed.When followed up,whether the ostium was patent and whether the wounded surface around the ostium was healed and covered by a perfect epithelial mucosa or not were observed under the endoscope.Success rate of ostium patency was recorded and used as standard for therapeutic outcome evaluation.Results All operations were completed uneventfully.The patients Were folowed up for 6 to 12 months(mean:8.6±2.2)months after operation.Two hundred twenty-eight patients(228 eyes) having completed throughout follow-up time and with total clinical data were included in this study,in which group A had 78 patients,group B had 69 patients,group C had 81 patients.The success rate of lacrimal system reconstruction was 94.9%(74/78)in group A,75.4%(52/69)in group B and 76.5%(62/81)in group C.There was significant statistical differencebetween groupA and B or between group A and C(P＜0.01),however,there was no meaningful statistical difference between group B and C(P＞0.05).The average time for mucosa epithelization of the wound surface around the lacrimal ostium was 9.1±1.4 days in group A,significantly shorter than that in group B and C(P＜0.01).And meanwhile,there were less scars and granulation formation around the lacrimal ostium in group A than group B or C(P＜0.05).Conclusionsmonths Mucosa sticking by MeroGel is an efficient method for the flap anastomosis of the lacrimal and nasal mucosa during EES-DCR for treatment of chronic dacryocystitis mainly because of its significant facilitating mucosa epithelization of the lacrimal ostium and its surroundings,inhibiting scarring or granuloma formation,and increasing success rate of lacrimal system reconstruction. Key words: Chronic dacryocystitis; Hyaluronic acid; Entranasal endoscopic dacryocystorhinostomy; Wound healing; Therapeutic efficacy

The authors evaluated the risk factors for regional lymph node recurrence and the prognosis of patients with regional nodal recurrence after breast conservation therapy for Stage I-II breast carcinoma. Between 1977 and 1995, 1293 women with pathologic Stage I and II (T1-2, N0-1) breast carcinoma were treated with breast-conserving therapy including lumpectomy, axillary lymph node dissection, and definitive breast irradiation. A total of 39 women (3%) had any regional lymph node recurrence. The median follow-up was 8.5 years (range, 1.5-24 years). Among 39 patients with a regional lymph node recurrence, 10 women had regional recurrence only, 16 had simultaneous locoregional recurrence, and 13 had simultaneous regional and distant recurrence. Regional recurrence occurred in the axillary lymph nodes only (n = 21; 51%), supraclavicular lymph nodes only (n = 8; 23%), internal mammary lymph nodes only (n = 3; 8%), infraclavicular lymph nodes only (n = 3; 8%), or multiple lymph node sites (n = 4; 10%). The median time to regional lymph node recurrence was 3.1 years (range, 0.2-20.9 years). Overall survival after regional-only disease recurrence was 44%, locoregional disease recurrence was 26%, and regional with distant disease recurrence was 12%. Cause-specific survival rates at 10 years for the 3 groups were 44%, 40%, and 12%, respectively. For patients who presented with simultaneous regional and distant metastases, the median survival period was 1.1 years, compared with 5.2 years for women who developed distant disease subsequent to regional recurrence. Regional lymph node recurrence after breast conservation therapy may be salvaged, but is associated with a high rate of either simultaneous or subsequent distant metastatic dissemination and poor overall prognosis.

The aim was to clarify the distributions of bacteria in the conjunctival sac and lacrimal sac in patients with chronic dacryocystitis. In total, 297 (322 eyes) chronic dacryocystitis patients who underwent nasal endoscopic dacryocystorhinostomy (EN-DCR) were included. Conjunctival sac secretions from the affected eye were collected preoperatively, and lacrimal sac retention fluid from the affected side in the same patient was collected intraoperatively. Bacterial culture and drug sensitivity testing were performed to determine bacterial distributions. In total, 127 bacterial isolates (49 species) were detected in 123 eyes in the conjunctival group, with a positivity rate of 38.2% (123/322); 85 bacterial isolates (30 species) were detected in 85 eyes in the lacrimal sac group, with a positivity rate of 26.4% (85/322). The positivity rates were significantly different (P = 0.001) between two groups. The gram-negative bacilli proportion in the lacrimal sac group (36/85, 42.4%) was significantly higher than that in the conjunctival sac group (37/127, 29.2%) ( P = 0.047). Positive conjunctival sac secretion culture (123/322) was significantly associated with increased ocular secretion (281/322, 87.3%) (P = 0.002). Among the culture-positive bacteria in the conjunctival sac group and the lacrimal sac group, 30/127, 23.6% and 43/127, 26.7% and 21/85, 24.7% and 20/85, 23.5% were resistant to levofloxacin and tobramycin, respectively. This study illustrated differences in bacterial distributions between conjunctival sac secretions and retained lacrimal sac fluid in chronic dacryocystitis patients, with a higher proportion of gram-negative bacilli in lacrimal sac secretions. The ocular surface flora in chronic dacryocystitis patients is partially resistant to levofloxacin and tobramycin, which need to be considered by ophthalmologists.

Dacryoliths are concretions formed in the lacrimal sac from cellular debris and proteins, which may calcify and cause further obstruction of the nasolacrimal pathway. Dacryoliths are often underlying contributors in cases of intermittent or chronic dacryocystitis (i.e. nasolacrimal sac inflammation, characterised by epiphora, pain, erythema, sac dilation and lacrimal punctum swelling). We report an unusual case of dacryolith resulting in obstructive epiphora, managed via an endonasal endoscopic approach. Case report and literature review pertaining to dacryolith. A 54-year-old man attended the multidisciplinary nasolacrimal clinic due to recurrent epiphora. Obstructive epiphora secondary to chronic dacryocystitis was diagnosed. He underwent endonasal endoscopic dacryocystorhinostomy. Intra-operatively, a large dacryolith was found to be the cause of epiphora. Dacryolith is an unusual cause of nasolacrimal duct obstruction. This case highlights this unusual cause, and the relevant diagnostic investigations. This case also illustrates successful endonasal endoscopic management, rather than an external, open approach.

Objectives:Chronic dacryocystitis is usually seen in middle-aged or older women, suggesting that decreased estrogen and progesterone serum levels may be a causative factor in the disease pathology. However, the occurrence of the disease in premenopausal females and males suggests that there may be more to the explanation than the level of female sex hormones. The purpose of the present study was to investigate estrogen and progesterone receptor positivity in the lacrimal sacs of individuals with and without chronic dacryocystitis.Methods:The study group included 50 female and 20 male patients diagnosed with chronic dacryocystitis. Lacrimal sac samples were taken during a dacryocystorhinostomy. The control group comprised 29 cadavers with no evidence of lacrimal system pathology in the health records. The samples were obtained transconjunctivally. Lacrimal sac samples from both groups were stained with the estrogen and progesterone receptor protein antigen. Fisher’s exact test and a chi-square test were used to compare the receptor positivity results of premenopausal and postmenopausal women, and samples of those with dacryocystitis and cadaver sacs without the disease.Results:In the control group, estrogen receptor positivity was observed in the samples of 2 premenopausal females. In the study group, estrogen receptor positivity was seen in 4 premenopausal females. There was no significant difference in estrogen receptor positivity between the premenopausal and postmenopausal female groups (p=0.41). A similar result was not established between the premenopausal and postmenopausal females in case group (p=0.056). No comparison was made of the progesterone receptor because only 1 example of progesterone receptor positivity was found in a premenopausal female in the dacryocystitis group.Conclusion:Estrogen receptor positivity did not seem to be a factor in chronic dacryocystitis physiopathology.

The aim of this study was to identify the organisms responsible and to determine the antibiotic susceptibility pattern of the bacterial isolates from conjunctiva and nasal mucosa in cases of chronic dacryocystitis and comparing with lacrimal sac specimen. Prospective longitudinal study. A prospective analysis of 44 lacrimal sac contents of patients with chronic dacryocystitis conducted during the period from April 2012 to March 2013. Material was obtained directly from the lacrimal sac while making sac flap during external dacryocystorhinostomy for chronic dacryocystitis. Samples were also collected from ipsilateral conjunctiva and inferior meatus of nose. The specimens were cultured and results analyzed. The results were analyzed by using Chi-square (χ(2)) test. All the patients were in age group of 30 and above. Gram positive bacteria i.e., Coagulase negative staphylococci and Staphylococcus aureus were the most common isolates (71% and 14% respectively). Vancomycin, amikacin, 3(rd) generation cephalosporins and amoxyclav were most sensitive antibiotics (100%, 89%, 83%, and 78% respectively). Comparison between lacrimal and nasal/conjunctival isolates showed high degree of identicalness between the isolates of two sites (p< 0.05). Majority of the chronic dacryocystitis cases are caused by Coagulase negative Staphylococci and Staphylococcus aureus. Amoxyclav and 3(rd) generation cephalosporins can be used to treat chronic dacryocystitis. Commensal flora of nose and conjunctiva have a direct role in pathogenesis of chronic dacryocystitis.

Cervical cancer is one of the most common malignancies affecting women worldwide, but its occurrence during pregnancy remains rare, affecting only 1%-3% of pregnant women. Managing cervical cancer in pregnancy poses significant clinical and ethical challenges, as treatment must balance maternal oncologic outcomes with fetal safety. We report a case of a 38-year-old woman, gravida 3 para 2, diagnosed with stage IB1 cervical squamous cell carcinoma at 30 weeks of gestation, who presented with postcoital bleeding and lower abdominal pain. Clinical, ultrasound, and MRI assessments revealed a 2 cm cervical mass without evidence of local invasion or lymphadenopathy. Histopathology confirmed moderately differentiated non-keratinizing squamous cell carcinoma. Respecting the patient’s strong desire to continue the pregnancy, a multidisciplinary team opted for delayed treatment. After fetal lung maturation, cesarean section was performed at 36 weeks followed by radical hysterectomy with left salpingo-oophorectomy and right ovarian transposition. The neonate, delivered with transient respiratory complications, was managed in the neonatal intensive care unit. Postoperative recovery was stable, and adjuvant chemoradiation was planned. This case highlights the importance of individualized care, taking into account gestational age, tumor characteristics, and patient preferences. In select early-stage cervical cancer cases, deferred definitive treatment until fetal maturity followed by radical surgery may offer favorable outcomes for both mother and fetus. Keywords Cervical cancer; Pregnancy; Stage IB1, Cesarean section, Radical hysterectomy; Squamous cell carcinoma

Ethmoid Sinus Cancer: Experience and Oncological Outcomes at Memorial Sloan-Kettering Cancer Center (MSKCC): Non-Squamous Cell Malignancies of the Head and Neck (thyroid, skin cancers, salivary gland and sinus cancers)

This research was designed to make a comparison of the treatment outcomes of endoscopic dacryocystorhinostomy (En-DCR) in nasolacrimal duct obstruction (NLDO) with and without chronic dacryocystitis. NLDO (obstruction group) and chronic dacryocystitis (dacryocystitis group) patients treated with En-DCR in the Eye Hospital of Wenzhou Medical University from March 2021 to February 2022 were retrospectively analyzed. According to CT dacryocystography, patients in each group were assigned into the high obstruction group (obstruction located in the lacrimal sac) and the low obstruction group (obstruction located at or below the junction of the nasolacrimal duct and dacryocystis). The surgery outcomes of patients in the 2 groups were compared 12 months postoperation. One hundred four patients (104 eyes: obstruction group: 49 eyes; dacryocystitis group: 55 eyes) were recruited. Patients with high obstruction accounted for 61.2% in the obstruction group and 32.7% in the dacryocystitis group. There were significantly more high obstruction patients in the obstruction group versus the dacryocystitis group ( P <0.05). At 12 months postoperative follow-up, the total anatomic and functional success rate was 83.7% and 80.8%, respectively. Higher anatomic success rate (90.9%) and functional success rate (89.1%) were noted in the dacryocystitis group versus the obstruction group (75.5% and 71.4%, respectively, P <0.05). The obstruction site is higher in the obstruction group in comparison to that in the dacryocystitis group. En-DCR is effective in the treatment of NLDO and chronic dacryocystitis, and its efficacy on chronic dacryocystitis is better than that on NLDO.

A 71-year-old Caucasian female with a history of a right conjunctival intraepithelial neoplasia (CIN) presented with an expanding right lacrimal sac mass. Pathology from the lacrimal sac biopsy revealed invasive, moderately differentiated, non-keratinizing squamous cell carcinoma (SCC) that stained positive for p63 and p40 and negatively for CEA. The conjunctival and lacrimal sac masses were noncontiguous and found to be HPV-positive SCCs after definitive surgery. Whole exome sequencing demonstrated distinct, shared deletions and gains in both tumors, with the lacrimal sac SCC having more genetic mutations than the conjunctival tumor, suggesting that the lacrimal sac SCC evolved from the conjunctival SCC. The pathology and sequencing data show a shared genetic and histopathologic heritage between the conjunctival and lacrimal sac SCCs, suggesting the potential for conjunctival tumor cells to spread to the lacrimal sac in a non-contiguous manner.

Loco (regional)-recurrence rate after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC) remains high, and the efficiency of adjuvant chemoradiotherapy is still debated. We aimed to assess predictors of loco-recurrence in order to tailor the indications for adjuvant chemoradiotherapy. Patients who underwent PD for PDAC between January 2001 and December 2010 were retrieved from a prospective database. Tumor recurrence was categorized as either loco-recurrence or distant recurrence. Clinicopathological characteristics and survivals were compared between patients with different recurrence patterns. The predictors for loco-recurrence were assessed. Seventy-nine patients were included. Loco-recurrence alone was identified in 22 patients (27.8%), distant recurrence alone in 33 (41.8%), both loco- and distant recurrences in 17 (21.5%) and no recurrence in 7 (8.9%). Median survival after recurrence (SAR) was significantly better in patients with loco-recurrence alone than in those with distant recurrence alone (10.4 vs. 5.0 months, P = 0.002) or in those with both loco- and distant recurrences (10.4 vs. 5.8 months, P = 0.044); the survival for patients with distant recurrence alone and those with both patterns was identical. Patients with early recurrence had a significantly poorer SAR than those with late recurrence (median, 5.5 vs. 9.0 months, P = 0.001). Logistic regression analysis revealed that positive resection margin (P = 0.001, HR = 14.532; 95% CI 7.399-38.466), early T stage (P = 0.018, HR = 0.014; 95% CI 0.000-0.475) and large tumor size (P = 0.030, HR = 4.345; 95% CI 1.152-16.391) were the determinant factors directly related to loco-recurrence alone. Patients with PDAC loco-recurrence alone had a significantly better SAR than those with distant recurrence. Adjuvant chemoradiotherapy should be considered to reduce loco-recurrence further and improve long-term survival.

IMPACT OF SURGICAL MARGINS AND THEIR LOCALIZATION ON LOCAL RECURRENCE IN DUCTAL CARCINOMA IN SITU OF THE BREAST: RETROSPECTIVE TRIAL IN A TERTIARY ONCOLOGY CENTRE

BackgroundRectal squamous cell carcinoma (SCC) is a rare tumor. The incidence of this malignancy has been reported to be 0.25 to 1 per 1000 colorectal carcinomas. From a review of the English literature 55 cases of SCC of the rectum have been published. In this study we report a rectal metastatic SCC to the liver, discussing the efficacy of aggressive adjuvant and neo-adjuvant therapies on survival and prognosis.Case presentationA 39-year-old female patient with a pure SCC of the rectum diagnosed endoscopically is presented. The patient underwent initially neoadjuvant chemo-radiotherapy and then abdominoperineal resection with concomitant bilateral oophorectomy and hysterectomy, followed by adjuvant chemo-radiotherapy. Five months after the initial operation liver metastasis was demonstrated and a liver resection was carried out, followed by adjuvant chemotherapy. Eighteen months after the initial operation the patient is alive.ConclusionAlthough prognosis of rectal SCC is worse than that of adenocarcinoma, an aggressive therapeutic approach with surgery as the primary treatment, followed by combined neo- and adjuvant chemo-radiotherapy, may be necessary in order to improve survival and prognosis.