1. Michael Stone MD Pranav Doshi MD Henry Ford Hospital Detroit MI
Lacrimal Gland Masses: Multimodality Imaging Appearance and Clinical Features eEdE-121
Michael Stone MD
Pranav Doshi MD
Henry Ford Hospital
Detroit MI

2. The authors have no disclosures

3. Objectives Review anatomy of the lacrimal gland
Review the imaging appearance and clinical features of common and uncommon lacrimal gland masses
Epithelial neoplasms
Lymphoid neoplasms
Inflammatory conditions
Miscellaneous masses

4. Lacrimal Gland
Lacrimal gland tissue present in main and accessory glands
Main gland is located in the superotemporal extraconal orbit and responsible for reflex tear production
Divided 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 fornices

5. Lacrimal Gland On CT the normal lacrimal gland is isodense to muscle
On MRI the normal lacrimal gland typically has intermediate signal (occasionally heterogeneous) on both T1 and T2 weighted imaging
Normal glands show symmetric enhancement post contrast

6. Lacrimal Gland Masses
Broadly speaking, differential considerations for a lacrimal mass or enlargement include:
Epithelial neoplasm
Lymphoproliferative disease
Inflammatory lesions
Miscellaneous masses.

7. Lacrimal Gland Epithelial Neoplasms
Being more common in the orbital lobes, epithelial neoplasms account for about 20-50% of lacrimal masses
50% benign
Pleomorphic adenoma>oncocytoma
50% malignant
Adenoid 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 diplopia

8. 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 T1
T1 GAD

9. 42-year-old male with proptosis
CECT
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

10. 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
NECT

11. Lacrimal Gland Lymphoproliferative disease
In addition to epithelial tissue, the lacrimal glands also contain lymphoid tissue
Primary lymphoma is relatively rare, with involvement most commonly secondary to systemic disease
Typically presents in older patients with bilateral painless masses
Reactive lymphoid hyperplasia (RLH) represents the benign end of the spectrum of orbital lymphoproliferative disease
Both lymphoma and RLH tend to conform to the surrounding structures and are often not readily distinguished on imaging

12. 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
NECT

13. 48-year-old female with headache
T2 FS T1
T1 FS GAD
DWI
ADC
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

14. Inflammatory Lesions of the Lacrimal Gland
Inflammation of the lacrimal gland is termed dacryoadenitis
Infectious causes more common in young patients and show surrounding inflammatory changes and potentially abscess formation, typically presenting with pain
Sarcoidosis is most common inflammatory disease involving the lacrimal gland
Typically bilateral diffuse painless enlargement of the orbital and palpebral lobes
Pseudotumor 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)

15. 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
NECT B
NECT

16. 41-year-old female with pain
NECT
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
CECT
Pseudotumor
CECT

17. 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 T2 T1
IgG4 R>L
T1 GAD

18. 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 T2

19. 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.

20. References
Khoury NJ, Haddad MC, Tawil AN, Ma'luf RN. Ductal cysts of the accessory lacrimal glands: CT findings. AJNR Am J Neuroradiol. 1999;20(6):
Gao Y, Moonis G, Cunnane ME, Eisenberg RL. Lacrimal gland masses. AJR Am J Roentgenol. 2013;201(3):W
Haradome K, Haradome H, Usui Y, et al. Orbital lymphoproliferative disorders (OLPDs): value of MR imaging for differentiating orbital lymphoma from benign OPLDs. AJNR Am J Neuroradiol. 2014;35(10):
Simon EM, Zoarski GH, Rothman MI, Numaguchi Y, Zagardo MT, Mathis JM. Systemic sarcoidosis with bilateral orbital involvement: MR findings. AJNR Am J Neuroradiol. 1998;19(2):336-7.
Prabhakaran VC, Saeed P, Esmaeli B, et al. Orbital and adnexal sarcoidosis. Arch Ophthalmol. 2007;125(12):
Nugent RA, Rootman J, Robertson WD, Lapointe JS, Harrison PB. Acute orbital pseudotumors: classification and CT features. AJR Am J Roentgenol. 1981;137(5):
Patnana M, Sevrukov AB, Elsayes KM, Viswanathan C, Lubner M, Menias CO. Inflammatory pseudotumor: the great mimicker. AJR Am J Roentgenol 2012;198(3):W
Toyoda K, Oba H, Kutomi K, et al. MR imaging of IgG4-related disease in the head and neck and brain. AJNR Am J Neuroradiol. 2012;33(11):
Haik BG, St louis L. Radiologic recognition of orbital dacryops. AJNR Am J Neuroradiol. 1989;10(5 Suppl):S89-90.