A 65 year old female presents with increasing epiphora and a fusiform, firm swelling over the right lacrimal sac area. On examination, the fusiform swelling projects above the medial canthal ligament. imaging confirms that the mass doe snot extend beyond the confines of the lacrimal sac. Complete excision of the sac is undertaken and submitted to histopathology.
1-low power H&E.
2. Higher power H&E of Fig 1
3. Melan A immunohistochemistry.
1. The diagnosis is fairly straightforward. What other factors must be considered when liaising with the clinicians?
1. The diagnosis is invasive melanoma. The question is whether this is a primary of the lacrimal sac or spread from the conjunctiva or nasal mucosa into the sac. In this case an in-situ component was present supporting the interpretation of a lacrimal sac primary. Biopsies of the conjunctiva and nasal mucosa were unremarkable.
Malignant melanoma of the lacrimal sac. Levine MR, Dinar Y, Davies R.Ophthalmic Surg Lasers. 1996 Apr;27(4):318-20
Malignant melanoma of the lacrimal sac complicating primary acquired melanosis of the conjunctiva. McNab AA, McKelvie P. Ophthalmic Surg Lasers. 1997 Jun;28(6):501-4
Lacrimal sac melanoma.Sitole S, Zender CA, Ahmad AZ, Hammadeh R, Petruzzelli GJ. Ophthal Plast Reconstr Surg. 2007 Sep-Oct;23(5):417-9
Epistaxis or epiphora as a sign for extension of a conjunctival melanoma. A series of six patients with nasolacrimal recurrence. Missotten GS, Gambrelle J, de Wolff-Rouendaal D, de Keizer RJ.Br J Ophthalmol. 2010 Oct;94(10):1328-31
Pigmentation of the Lacrimal Sac Epithelium. Jakobiec FA, Stagner AM, Sutula FC, Freitag SK, Yoon MK. Ophthal Plast Reconstr Surg. 2016 Nov/Dec;32(6):415-423