Lacrimal Gland Masses: Multimodality Imaging Appearance and - PowerPoint Presentation

Slide1

Lacrimal Gland Masses: Multimodality Imaging Appearance and Clinical FeatureseEdE-121

Michael Stone MDPranav Doshi MDHenry Ford HospitalDetroit MISlide2

The authors have no disclosuresSlide3

ObjectivesReview anatomy of the lacrimal gland

Review the imaging appearance and clinical features of common and uncommon lacrimal gland masses Epithelial neoplasmsLymphoid neoplasmsInflammatory conditions Miscellaneous massesSlide4

Lacrimal Gland

Lacrimal gland tissue present in main and accessory glandsMain gland is located in the superotemporal extraconal orbit and responsible for reflex tear productionDivided into the palpebral (superficial) and the larger orbital (deep) lobes by the

levator

palpebrae aponeurosis

Orbital lobe is posterior and superior to the aponeurosis and the palpebral lobe is anterior and inferior

Main gland average size: 20 x 12 x 5 mm

While size varies, asymmetry may signify disease

Accessory lacrimal glands of

Wolfring

and Krause are responsible for basal tear production

Wolfring

: located in the upper>lower tarsal borders

Krause: located in the conjunctiva of the

fornicesSlide5

Lacrimal GlandOn CT the normal lacrimal gland is

isodense to muscleOn MRI the normal lacrimal gland typically has intermediate signal (occasionally heterogeneous) on both T1 and T2 weighted imagingNormal glands show symmetric enhancement post contrastSlide6

Lacrimal Gland MassesBroadly speaking, differential considerations for a lacrimal mass or enlargement include:

Epithelial neoplasmLymphoproliferative diseaseInflammatory lesionsMiscellaneous masses. Slide7

Lacrimal Gland Epithelial Neoplasms

Being more common in the orbital lobes, epithelial neoplasms account for about 20-50% of lacrimal masses50% benignPleomorphic adenoma>oncocytoma50% malignantAdenoid cystic carcinoma> mucoepidermoid carcinoma

Perineural spread common in adenoid cystic carcinoma, rendering complete surgical resection difficult

Typically present with inferomedial globe displacement, proptosis, and occasionally diplopiaSlide8

50-year-old male with proptosis

Pleomorphic

Adenoma

:

Heterogeneous intermediate signal enhancing mass with

internal necrosis

Most common benign lacrimal tumor, representing 57% of epithelial lesions

20

% may undergo malignant degeneration

Commonly intermediate signal on

T2 and T1-weighted MR

as compared to cortical

gray matter

Moderately enhancing

T2

T1

T1 GADSlide9

42-year-old male with proptosis

Pleomorphic Adenoma: Homogeneous left lacrimal gland mass demonstrating slight scalloping of the adjacent orbital margin

Typically

homogeneous on CT and may show smooth bony remodeling reflecting slow growth

Malignant epithelial lesions more commonly show bony destruction

Moderately enhancing

CECT

CECT

CECTSlide10

65-year-old male with proptosis

Undifferentiated carcinoma:Mildly heterogeneous left lacrimal mass with faint internal calcification seen superiorly on the coronal view

In decreasing order of frequency, malignant epithelial neoplasms include: adenoid cystic, pleomorphic, mucoepidermoid, adenocarcinoma, squamous cell and undifferentiated carcinoma.

Often times secondary to degeneration of pleomorphic adenoma AKA carcinoma ex pleomorphic adenoma

Malignant epithelial neoplasms often hypointense on T1 and intermediate to high signal on T2 weighted imaging with diffuse enhancement

NECT

NECTSlide11

Lacrimal Gland Lymphoproliferative disease

In addition to epithelial tissue, the lacrimal glands also contain lymphoid tissuePrimary lymphoma is relatively rare, with involvement most commonly secondary to systemic diseaseTypically presents in older patients with bilateral painless massesReactive lymphoid hyperplasia (RLH) represents the benign end of the spectrum of orbital lymphoproliferative diseaseBoth lymphoma and RLH tend to conform to the surrounding structures and are often not readily distinguished on imagingSlide12

87-year-old male with upper eyelid swelling

Lymphoma: Ill defined right lacrimal mass,

slightly hyperdense to muscle

Most common lacrimal lymphoma is mucosal associated lymphoid tissue

type

Has much better prognosis than less common follicular lymphoma of the orbit

Typically in older patients with painless masses

Homogeneous and well defined

Typically without bony destruction but may show remodeling and sclerosis

Hypercellular

and shows

restricted

diffusion on

DWI

NECT

NECTSlide13

48-year-old female with headache

Reactive lymphoid hyperplasia: T1 and T2 intermediate signal enlargement of the lacrimal glands demonstrating mildly heterogeneous enhancement.

Mild restriction diffusion is present reflecting

hypercellular

nature.

Differentiation of benign lymphoproliferative disease from lymphoma is crucial in planning appropriate treatment, usually requiring biopsy

Lymphomas tend to have lower mean ADC values

Internal flow voids more common in benign lymphoproliferative disorders

Concomitant imaging findings of sinusitis more common in benign lymphoproliferative disorders

T2 FS

T1

T1 FS GAD

DWI

ADCSlide14

Inflammatory Lesions of the Lacrimal Gland

Inflammation of the lacrimal gland is termed dacryoadenitisInfectious causes more common in young patients and show surrounding inflammatory changes and potentially abscess formation, typically presenting with painSarcoidosis is most common inflammatory disease involving the lacrimal glandTypically bilateral diffuse painless enlargement of the orbital and palpebral lobes

P

seudotumor commonly affects the lacrimal glands

Diffuse unilateral >bilateral lacrimal gland enlargement

Typically more T2 hypointense than most other lacrimal gland masses.

Sjögren syndrome is an autoimmune disease affecting the salivary and lacrimal glands

Early in the disease, imaging shows bilateral diffuse enlargement, subsequently progressing to fatty atrophy in chronic disease

Chronic inflammatory conditions may produce firm swelling clinically, mimicking neoplasia (

Küttner

tumor

)Slide15

66-year-old female with eyelid fulness

Sarcoidosis: Diffuse enlargement of the lacrimal glands Ophthalmologic involvement seen in 85% of patients, most commonly uveitis

Lacrimal gland involvement reported in around 7-16% of patients

Lacrimal involvement typically bilateral and diffuse, presenting with painless enlargement or dry eyes

Thoracic imaging often demonstrates adenopathy typical of the disease

B

NECT

NE

CTSlide16

41-year-old female with pain

Pseudotumor: NECT demonstrates enlargement of the right lacrimal gland, isodense to muscle. Avid enhancement is seen on post contrast imaging.

Pseudotumor AKA orbital inflammatory syndrome is the most common noninfectious non-thyroid related cause of orbital inflammation.

Protean in

manifestations and often masquerading as infection or lymphoma. Often diagnosis of exclusion.

Typically

unilateral

involvement

Most

commonly low signal intensity on both T1 and T2 weighted MR, possibly

reflecting fibrotic

nature

NECT

CECT

CECTSlide17

57-year-old male with pain

IgG4 related disease: T1 and T2 hypointense enlargement of the bilateral lacrimal glands

Autoimmune characterized by elevated IgG4 levels and inflammatory masses

Lacrimal involvement reported in 12.5% of patients

Other sites of involvement within the head and neck include the orbit, salivary glands, cranial nerves, pituitary gland, and

dura

.

Multiple foci of head and neck seen in majority of patients (11/15) in one series

Consider IgG4 disease when presented with T2 hypointense lacrimal mass/enlargement

T1

T1 GAD

T2Slide18

80-year-old female with weakness

Ductal cyst: Fluid density and T2 hyperintense lesion in the left lacrimal gland representing an incidental cyst. Benign ductal cysts AKA dacryops

are thought to develop from chronic inflammation or prior trauma. Less commonly from alteration in secretion consistency or congenital anomaly of an excretory duct

Most common clinical presentation is painless unilateral lateral eyelid swelling

NECT

T2Slide19

Conclusion

Lacrimal masses can be categorized as epithelial, lymphoproliferative, or inflammatory in nature. While there is considerable overlap in imaging findings, epithelial based lesions typically present as a circumscribed mass while inflammatory and often times lymphoproliferative processes appear as ill-defined masses or glandular enlargement. Slide20

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