Benign mixed tumor or pleomorphic adenomas are the most common benign epithelial tumors of the lacrimal gland. Most of the pleomorphic adenomas arise from the orbital lobe of the lacrimal gland. Herein, we report two cases of pleomorphic adenomas arising from the palpebral lobe in middle-aged males. Both patients presented with a long-standing history of mass lesions in the lateral part of the upper eyelid. Both underwent complete surgical removal of the tumor and histopathological examination was consistent with the findings of a benign pleomorphic adenoma. Only 69 cases of palpebral lobe pleomorphic adenomas have been reported in the literature till date. Our cases document the largest of palpebral pleomorphic adenomas reported till date.
Two males, aged 42 and 59 years respectively, presented with gradually progressive, painless upper eyelid masses since 5 and 15 years, respectively. On palpation, there was a firm, nontender mass arising from the upper lateral part of the left eyelid [Figures 1a, b and 2a]. A computerized tomography scan in patient #1 showed a well-circumscribed homogenous soft tissue lesion in the left upper preseptal area anterior to the orbital rim [Figure 1c]. A magnetic resonance image in patient #2 revealed a large (32 mm × 24 mm) lobulated solid lesion with an isointense signal in T1 and a mixed-signal in T2-weighted images with a normal orbital lobe [Figure 2b and c]. Both the patients underwent complete excision of the lesions through a superior eyelid crease approach and a definitive diagnosis of pleomorphic adenoma was made on histopathological examination [Figure 2d-f].
Figure 1.
(a and b) Clinical photograph of patient #1 showing a mass in the upper lateral part of the left eyelid in a 42-year-old male since 5 years. (c) Computerized tomography scan image showing well-circumscribed homogenous soft tissue lesion in the left upper preseptal area anterior to the orbital rim
Figure 2.
(a) Preoperative clinical photograph in a 59-year-old male with the mass in superotemporal quadrant since 15 years. (b) Magnetic resonance image coronal section showing a large lobulated solid lesion mixed-signal intensity in T2-weighted images. (c) Magnetic resonance image T1W axial image in T1 showing the mass with an isointense signal anterior to the orbital lobe (arrow) of the lacrimal gland. (d) Gross specimen of the excised oval multilobulated mass with intact capsule measuring 32 mm × 24 mm × 18 mm. (e) Postoperative photograph after excision with superior eyelid crease approach. (f) Microphotograph showing benign mixed of lacrimal gland with focal capsular invasion by myxoid component and epithelial component (H and E, ×40)
The lacrimal gland is divided by the levator aponeurosis into an anteriorly situated palpebral lobe from the orbital lobe. Pleomorphic adenomas are the most common benign, slow-growing epithelial tumors of the lacrimal gland that are more common in the orbital lobe.[1] Palpebral lobe pleomorphic adenomas are similar in presentation, histopathology, and prognosis, but are rarer.[2] They have often been misdiagnosed as a dermoid cyst, dacryops, sebaceous cyst, hematoma, lymphoid or inflammatory lesions, or even a large chalazion.[3] It is important to appreciate the characteristic anterior location of the tumor, outside the orbital rim, presenting with mechanical ptosis without any displacement of the globe, bone remodeling or intramural calcification.[4] Palpebral lobe pleomorphic adenomas can be excised by transseptal superior eyelid crease approach leading to a more aesthetic outcome, and avoiding injury to lacrimal ductules or an extensive lateral orbitotomy[2,3] [Figure 2e].
The clinicians must maintain a high index of suspicion as an incisional biopsy or incomplete excision may lead to a recurrence or malignant transformation. Neglected adenomas can attain a giant size as seen in our second patient. The largest palpebral lobe lacrimal gland adenoma had been reported by Jung et al., which was 23 mm × 20 mm in size.[5] Vahdani and Rose has reported the largest series of palpebral lobe adenomas (n = 43), but they have not mentioned the size of the lesions in their article. The gross intact specimen measured 32 mm × 24 mm × 18 mm in patient #2 in our series, making it the largest reported till date [Figure 2d].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Shields CL, Shields JA, Eagle RC, Rathmell JP. Clinicopathologic review of 142 cases of lacrimal gland lesions. Ophthalmology. 1989;96:431–5. doi: 10.1016/s0161-6420(89)32873-9. [DOI] [PubMed] [Google Scholar]
- 2.Vahdani K, Rose GE. Palpebral pleomorphic adenomas of the lacrimal gland. Ophthalmic Plast Reconstr Surg. 2021;37:125–8. doi: 10.1097/IOP.0000000000001682. [DOI] [PubMed] [Google Scholar]
- 3.Ramlee N, Ramli N, Tajudin LS. Pleomorphic adenoma in the palpebral lobe of the lacrimal gland misdiagnosed as chalazion. Orbit. 2007;26:137–9. doi: 10.1080/01676830600985882. [DOI] [PubMed] [Google Scholar]
- 4.Porter N, Sandhu A, O’Connell TB, Selva D, Leibovitch I. Pleomorphic adenoma of the palpebral lobe of the lacrimal gland. Otolaryngol Head Neck Surg. 2007;136:328–9. doi: 10.1016/j.otohns.2006.06.1245. [DOI] [PubMed] [Google Scholar]
- 5.Jung BJ, Cho YK, La TY. A giant pleomorphic adenoma of lacrimal gland involving the palpebral lobe causing severe mechanical ptosis. J Korean Ophthalmol Soc. 2011;52:241–5. [Google Scholar]