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127]

Photo Essay

Solitary Fibrous Tumor of the lacrimal

sac

Avriel I Gudkar, Bipasha Mukherjee,

Subramanian Krishnakumar1

Key words: Epiphora, lacrimal sac, solitary fibrous tumor

Solitary Fibrous Tumor (SFT) was first described as a primary

spindle cell tumor of the pleura.[1] There has been an increase
in its incidence in nonpleural sites. SFTs of the lacrimal sac are Figure 1: Clinical photograph of the patient showing right eye upwards
rare with only six cases reported. We report the first case from and lateral dystopia due to the mass lesion in the lacrimal sac area in
the Indian subcontinent. A 65‑year‑old female presented with the inferonasal quadrant of the orbit
right eye watering for 2  years, associated with painless and
progressive swelling at right medial canthus. Her best corrected
visual acuity was 20/50 in right and 20/20 in left eye. External
examination revealed a firm, well‑circumscribed, nontender
mass in right lacrimal sac region extending above medial canthal
tendon [Fig. 1]. There was no fistula and no regurgitation of fluid
on pressure over lacrimal sac. Anterior segment examination
revealed age‑related immature cataracts in both the eyes while
posterior segment examination was normal.
a b
C o m p u t e d T o m o g r a p h y   ( C T ) s c a n r e ve a l e d a Figure 2: (a) Computed Tomography (CT) scan coronal view showing
well‑circumscribed, homogenous, right medial canthal mass a well‑circumscribed, homogeneous right orbital mass in the region of
of about 2.7  ×  2.1 cms extending into the nasolacrimal duct lacrimal sac. (b) CT scan sagittal view showing the mass extending
with adjacent bone remodeling [Fig. 2a and b]. En bloc excision inferiorly into the right nasolacrimal duct
of the mass along with the nasolacrimal duct was performed
through both external and endonasal approach [Fig. 3a and b]. a b
Histopathology revealed partially capsulated tumor with
hyper and hypocellular areas and scattered thin‑walled blood
vessels [Fig. 4a]. The cells were distributed haphazardly with
spindle‑shaped and epithelioid morphology, mitotic index of
< 4/10 high power field  and absence of necrosis or giant cells
were also noted [Fig. 4b]. Immunohistochemistry was diffusely
positive for CD34 and Bcl‑2 and negative for cytokeratin,

Figure 3: (a) Intraoperative appearance of the mass. (b) Macroscopic

Access this article online appearance of the lacrimal sac tumor after removal along with the
Quick Response Code: Website: nasolacrimal duct
www.ijo.in

DOI: S‑100, smooth muscle actin  (SMA), epithelial membrane

10.4103/ijo.IJO_875_19 antigen (EMA), and desmin thus establishing the diagnosis of
lacrimal sac SFT [Fig. 5a and b]. The patient was asymptomatic
PMID: at 6 weeks follow‑up.
*****

Department of Orbit, Oculoplasty, Reconstructive and Aesthetic

This is an open access journal, and articles are distributed under the terms of
Services, Medical Research Foundation, 1Department of Larsen and
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Toubro Ocular Pathology, Vision Research Foundation, Sankara which allows others to remix, tweak, and build upon the work non‑commercially,
Nethralaya, Chennai, Tamil Nadu, India as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Correspondence to: Dr.  Avriel I Gudkar, Department of Orbit,
Oculoplasty, Reconstructive and Aesthetic Services, Medical Research
For reprints contact: reprints@medknow.com
Foundation, Sankara Nethralaya, Chennai, Tamil Nadu, India.
E‑mail: avi140989@gmail.com
Received: 05-May-2019 Revision: 29-Jun-2019 Cite this article as: Gudkar AI, Mukherjee B, Krishnakumar S. Solitary Fibrous
Tumor of the lacrimal sac. Indian J Ophthalmol 2019;67:2043-4.
Accepted: 04-Sep-2019 Published: 22-Nov-2019

© 2019 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.ijo.in on Friday, January 3, 2020, IP: 122.174.177.127]
2044 Indian Journal of Ophthalmology Volume 67 Issue 12
a b
Figure 4: (a) Microphotograph (Haematoxylin and Eosin staining, 10×)
showing a ‘patternless’ growth pattern with thin‑walled vascular spaces in a
branching pattern (black arrows). (b) Microphotograph (Haematoxylin and
Eosin, 20×) showing spindle cells (black arrowhead) arranged randomly
Lacrimal sac SFTs may present as nasolacrimal duct
obstruction, recurrent dacryocystitis, or as a slow‑growing
mass in the medial canthal region. [2‑4] Complete surgical
excision should be performed. Due to histological diversity,
SFTs can mimic other tumors such as mesotheliomas and
sarcomas. Immunohistochemistry is confirmatory test.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Acknowledgements
Dr Olma Veena Noronha, VRR scans, Chennai.
C onjuncti val ke r a to acantho ma/
keratoacanthoma like squamous cell
carcinoma: Err on the side of caution
Anasua Kapoor, V S Vijitha, Priya Mittal, Ruchi Mittal1
Access this article online
Quick Response Code: Website:
www.ijo.in
DOI:
10.4103/ijo.IJO_314_19
PMID:
*****
The Operation Eyesight Universal Institute for Eye Cancer, Ophthalmic
Plastic Surgery and Ocular Oncology Services, LV Prasad Eye Institute,
Vijayawada, 1Kanupriya Dalmia Ophthalmic Pathology Laboratory,
Mithu Tulsi Chanrai Campus, LV Prasad Eye Institute, Bhubaneswar,
India
Correspondence to: Dr. Ruchi Mittal, Kanupriya Dalmia Ophthalmic
Pathology Laboratory, Mithu Tulsi Chanrai Campus, LV Prasad Eye
Institute, Bhubaneswar, India. E-mail: dr.rmittal@gmail.com.
Received: 15-Feb-2019 Revision: 11-Apr-2019
Accepted: 26-Apr-2019 Published: 22-Nov-2019
a b
Figure 5: (a) Immunohistochemistry showing diffuse positivity for
CD34. (b) Immunohistochemistry showing diffuse positivity for
BCL 2
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Klemperer P, Rabin CB. Primary neoplasms of the pleura. A report
of five cases. Arch Pathol 1931;11:385‑412.
2. Rumelt  S, Kassif  Y, Cohen  I, Rehany  U. A  rare solitary fibrous
tumour of the lacrimal sac presenting as acquired nasolacrimal
duct obstruction. Eye 2003;17:429‑31.
3. Woo KI, Suh YL, Kim YD. Solitary fibrous tumour of the lacrimal
sac. Ophthalmic Plast Reconstr Surg 1999;15:450‑3.
4. Kurdi M, Allen L, Wehrli B, Chakrabarti S. Solitary fibrous tumour
of the lacrimal sac presenting with recurrent dacryocystitis. Can J
Ophthalmol 2014;49:108‑10.
Key words: Conjunctiva, histopathology, keratoacanthoma,
squamous cell carcinoma
A 30‑year‑old immune‑competent Asian woman, coolie
by occupation, presented with painless conjunctival lesion
with progressive enlargement since 1 month. Patient was
a nonsmoker and had significant exposure to ultraviolet
radiation because of her occupation. Examination revealed
a yellowish white, well‑defined conjunctival nodule in
interpalpebral region, 2  mm away from nasal limbus with
a central hyperkeratotic core, and limited mobility [Fig. 1a].
Tumor was excised by “no‑touch technique” with margin
clearance, cryotherapy, and surface reconstruction.
Histopathological examination showed an epithelial lesion
with central keratin‑filled crater surrounded by buttress like
thickened epithelium [Fig. 1b]. Higher magnification showed
irregular epithelial proliferations [Figs. 2 and 3], displaying
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
Cite this article as: Kapoor A, Vijitha VS, Mittal P, Mittal R. Conjunctival
keratoacanthoma/keratoacanthoma like squamous cell carcinoma: Err on the
side of caution. Indian J Ophthalmol 2019;67:2044-5.