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Inverted Papilloma of the Lacrinial Sac

A case report and discussion are presented covering a rare case of lacrimal sac tumor showing the features of an inverted papilloma.

DEBA P. SARMA, MD New Orleans

r-piumors of the lacrimal sac are JL relatively rare. The epithelial tumors constitute about 50 percent of all neoplasms of the lacrimal sac.1 Similarity between the histologic appearance and natural course of the epithelial tumors of the lacrimal sac and those of the nose and the paranasal sinuses has been emphasized.1 I am reporting a rare case of lacrimal sac tumor showing the features of an inverted papilloma. Case Report
A 69-year-old man was admitted to the hospital with a 3-month history of pain, epiphora, and swelling of the left side of the nose in the area of the lacrimal fossa. On examination, a hard non-reducible mass was felt over the left canthus. Roentgenologic studies of the orbits did not show any abnormality. A dacryocystogram could not be ob"tained because of obstruction of the canaliculi. The patient underwent a left dacryocystectomy with the placement of Quicken Tubes. The tumor was confined to the lacri.mal sac which was dissected out in its entirety leaving only a small portion of the nasal wall of the sac. The postoperative course was uneventful. The excised tissue measured 1 x 0.5 x 0.3 cm. Microscopic examination revealed a lacrimal sac showing denuded epithelium and

fibrotic wall containing epithelial structures with inverted pattern and marked lymphocytic and plasmacytic infiltration of the stroma (Fig 1). The epithelial cells formed solid nests as well as tubules that also displayed papillary infoldings. Epithelial cells were in multiple layers with scattered goblet cells and microcysts containing eosinophilic material as well as aggregates of polymorphonuclear leukocytes. The basal epithelial cells were basophilic, but the cells closer to the tubular lumen exhibited eosinophilic cytoplasm. No squamous metaplasia was noted. No cytologic atypia or mitosis was noted. The dense plasmacytic infiltrates were most prominent around the epithelial nests. No lymphoid follicles were present. The tubular lumina contained degenerated epithelial cells and polymorphonuclear leukocytes.

Discussion
In a study of 27 primary epithelial tumors of the lacrimal sac, Ryan and Font2 noted 11 benign papillomas of which 3 displayed inverted growth pattern and 2 others displayed a mixed inverted and exophytic growth pattern. In another seven cases of papilloma with carcinoma, they noted inverted growth patterns in three cases. One must carefully search for any evidence of carcinoma in a case of inverted papilloma. I did not find'any evidence of invasive carcinoma in this case. The most common presenting signs and symptoms occurring with lacrimal sac neoplasms are epiphora,

mass or inflammation. Pain and bleeding are usually observed in the patients with carcinomas. Papillomas of the lacrimal sac, like those of nose and paranasal sinuses, are known to recur. This recurrence should not be misinterpreted as carcinoma, particularly in the cases of inverted papillomas. However, with repeated recurrences, there is a tendency toward malignant change.2 In a large series of 315 papillomas of the nose and paranasal sinuses,3 20 papillomas developed into invasive squamous cell carcinomas. Interestingly, 19 of these 20 papillomas displayed an inverted pattern. Complete surgical removal is the treatment of choice for the tumors of the lacrimal sac. For the inverted papillomas, such as this case, a close follow-up is indicated because of their potential for recurrence. During the follow-up period of three months the patient is asymptomatic and is free of recurrence.

Summary
A case of lacrimal sac tumor is described in which the tumor showed features of an inverted papilloma. Natural course and prognosis of such a tumor are discussed.

From the Department of Pathology, Veterans Administration Medical Center and Louisiana State University Medical Center, New Orleans, Louisiana.

INVERTED PAPILLOMA - SARMA

References
'Ashton N, Choyce DP, Fison LG: Carcinoma of the lacrimal sac. Brit J Ophthalmol 35:366-376, 1951 2 Ryan SJ, Font RL: Primary epithelial neoplasms of the lacrimal sac. Am J Ophthalmol 76:73-88, 1973 3 Hyams VJ: Papillomas of the nasal cavity and paranasal sinuses. Ann Otol Rhinol Laryngol 80:192-206, 1971

Fig 1. Photomicrograph showing denuded epithelium of the lacrimal sac on the top. Underlying tissue shows epithelial islands displaying inverted pattern. (H&E, Original magnification X 24)

Sarma DP (1981): Inverted papilloma of the lacrimal sac. J La State Med Soc 133:22-23. PMID: 7276690 [PubMed - indexed for MEDLINE]