The Role of Cervical and Parotid Lymph Nodes in Surgical Management of Malignant Tumors of the Lacrimal Sac

Introduction: Treatment of lacrimal sac malignancies can entail numerous challenging decisions, including the need for orbital exenteration, skull base resection, adequate neck dissection, appropriate adjuvant therapy, and ideal reconstruction. Given the rarity and diversity of these tumors, treatment recommendations are based on small patient series. Lymph node positivity has been predictive of decreased recurrence free and overall survival in one of the lone large series of lacrimal sac tumors. Despite the likely importance of cervical and parotid lymph node status for these tumors, the optimal nodal management has not been described.

Methods: Thirty-one patients with malignant tumors of the lacrimal sac that were treated surgically were identified on retrospective review. Preoperative imaging, surgical treatment, pathology, adjuvant treatment, and recurrence data were collected and univariate analysis was performed.

Results: Forty percent of patients have nodal positivity on preoperative imaging; however, only 60% of these patients had pathologically involved lymph nodes. When pathologically positive nodes were identified, the intraparotid nodes were nearly always involved (6/6 patients in whom parotidectomy was performed, 6/7 patients overall). A majority of recurrences occurred in the neck or parotid lymph nodes (88%), including in 31% of patients with negative preoperative imaging (mean 11 months to regional recurrence). If T1N0 tumors are excluded, failure to perform neck dissection or sentinel lymph node biopsy is associated with regional recurrence (OR: 7.1, 95% CI: 1.02–49.5, p = 0.047).

Discussion: Optimal management of lacrimal sac malignancies remains unclear due to their rarity. Lymph node status appears to play an important role in lacrimal sac tumor spread and recurrence. The intraparotid lymph bed is often involved when lymph node spread is present, and parotidectomy should be considered for high-risk tumors or when there is evidence of cervical lymph node spread. Performing sentinel lymph node biopsy or neck dissection at the time of surgery for tumors larger than T2 decreases regional recurrence rates.

 

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