Purpose

Routine histopathological examination of lacrimal sac specimens during dacryocystorhinostomy (DCR), in patients without suspicion of malignancy, has a low diagnostic yield (approximately 0.44%). Selective biopsy is recommended when suspicious findings are identified. The authors report a case in which violaceous discoloration and friability of the lacrimal sac prompted histopathological analysis.

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Methods

Clinical-pathological case report on a patient with nasolacrimal duct obstruction and acute exacerbation of chronic dacryocystitis.

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Results

A 74-year-old male with mild macrocytic anemia (Hb 11.9 g/dL; MCV 102.9 fL) and normal leukocyte differential underwent external DCR. Intraoperatively, the lacrimal sac walls appeared violaceous and markedly friable. The posterior flap was submitted for histopathological analysis. Microscopy showed tissues consistent with lacrimal sac origin densely infiltrated by small lymphocytes with a focally nodular and diffuse pattern, without large cells or necrosis. Immunohistochemistry revealed diffuse CD20, BCL2, and CD43 positivity; CD3/CD5 in reactive T cells in the background; rare CD21/CD23-positive dendritic meshworks; negativity for CD10, BCL6, Cyclin D1, and LEF1; polytypic Kappa/Lambda expression; an estimated proliferative index (%Ki-67) of 20-30%; and CAM5.2 without lymphoepithelial lesions. Findings favored a CD5-negative small B-cell non-Hodgkin lymphoma, consistent with extranodal marginal zone lymphoma (EMZL). Flow cytometry disclosed disclosed a small B-cell lymphoma. PET revealed a widely spread lymphoproliferative disease, confirmed by bone marrow biopsy. The patient started R-CHOP.

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Conclusion

Despite the low yield of routine sampling, selective biopsy in suspicious cases is essential for diagnosis and prognosis, and should be routinely performed.

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Additional Authors

First name	Last name	Base Hospital / Institution
Pedro	Baptista	Department of Ophthalmology. Clinic of Neurosciences. Unidade Local de Saúde de Santo António (ULSSA). Porto, Portugal. University of Porto, ICBAS-School of Medicine and Biomedical Sciences. Porto, Portugal
Beatriz	Costa Vieira	Department of Ophthalmology. Clinic of Neurosciences. Unidade Local de Saúde de Santo António, Porto (ULSSA). Porto, Portugal
Francisca Emanuel	Costa	Anatomic Pathology Service, Pathology and Genetics Clinic, Unidade Local de Saúde de Santo António (ULSSA)/University of Porto, Laboratory of Cell Biology, Department of Microscopy, ICBAS-School of Medicine and Biomedical Sciences; UMIB/ITR Laboratory for Research in Population Health, Porto, Portugal.
Nuno	Lamas	Anatomic Pathology Service, Pathology and Genetics Clinic, Unidade Local de Saúde de Santo António (ULSSA). Porto, Portugal. School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho. Braga, Portugal.

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