Clinical and Radiologic Features Correlated with Eye-Sparing Surgery vs. Orbital Exenteration for Lacrimal Gland Adenoid Cystic Carcinoma

Background: To determine if certain clinical and radiologic features of lacrimal gland adenoid cystic carcinoma (LGACC) on pre-operative MRI were associated with the treatment decision to perform orbital exenteration versus eye-sparing surgery. Methods: All consecutive patients with LGACC treated by orbital exenteration (Group 1) versus eye-sparing surgery (Group 2) from June 2007 to March 2024 were identified through a search of the primary author’s patient database. Data analyzed included patient demographics, T category at presentation (using AJCC 8th edition criteria), and magnetic resonance imaging (MRI) features, including T1 post-contrast enhancement patterns and T2 signal characteristics. The MRIs were reviewed by a CAQ-certified neuroradiologist. The location of the LGACC—including the distance of the posterior tumor margin from the superior orbital fissure (SOF), bone remodeling and destruction, involvement of the extra-ocular muscles (EOMs), temporal fossa, pterygopalatine fossa, sinonasal cavity, intracranial compartment, and the presence of perineural tumor spread—were analyzed. Results: The study included a total of 39 patients. A total of 16 patients with a median age of 52.6 years were in Group 1, and 23 patients with a median age of 46.1 years were in Group 2. A greater T-category and larger size of the tumor were significantly more common in Group 1. Smooth tumor margins were significantly more common in Group 2, while irregular margins were significantly more common in Group 1. The distance from the posterior tumor margin to the SOF was significantly less in Group 1. Crossing the vertical midline of the orbit, bone destruction, and the invasion of the EOMs were significantly more common in Group 1. Extension to involve the cavernous sinus, pterygopalatine foramen, and sinonasal cavity, as well as perineural spread, were only present in Group 1. No significant difference was noted between T1 post-contrast patterns and T2 characteristics. Conclusions: MRI features of LGACC more commonly associated with orbital exenteration as opposed to eye-sparing surgery included larger size and irregular margins, as well as the posterior tumor margin being closer to the SOF, crossing the vertical midline of the orbit, bone destruction, and the involvement of the EOMS, cavernous sinus, pterygopalatine foramen, and sinonasal cavity. These MRI features may aid oculoplastic surgeons in determining which patients may be candidates for successful eye-sparing surgery for the treatment of LGACC.