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good faith. Ophthalmologists need to be aware of the syndrome of the battered child, as they may be the first to examine a physically abused child. Prompt recognition is urgent to minimize morbidity and mortality for the child and to initiate therapy for the offending adult.

References 1. Levin, A. V.: Ocular manifestations of child abuse. Ophthalmol. Clin. North Am. 3:249, 1990. 2. Harley, R. D.: Ocular manifestations of child abuse. J. Pediatr. Ophthalmol. Strabismus 17:5, 1980. 3. Harcourt, B., and Hopkins, D.: Ophthalmic manifestations of the battered-baby syndrome. Br. Med. J. 3:398, 1971. 4. Jensen, A. D., Smith, R. E., and Olson, M. 1.: Ocular clues to child abuse. J. Pediatr. Ophthalmol. 8:270, 1971. 5. Friendly, D. S.: Ocular manifestations of physi­ cal child abuse. Trans. Am. Acad. Ophthalmol. Otolaryngol. 750P:318, 1971.

Malignant Myoepithelioma After Radiation for Retinoblastoma Stephen J. Saxe, M.D., Hans E. Grossnikiaus, M.D., and Ayten O. Someren, M.D.

October, 1992

eye was enucleated. The right eye was treated with radiation and chemotherapy. The retino­ blastoma in her right eye regressed and the patient did well until she was 15 years old. She was examined at that time because of a one-month history of an enlarging mass over her right zygomatic bone in the parotid gland and preauricular area. Computed tomography showed that the mass had invaded the inferotemporal wall of the orbit (Fig. 1). A biopsy of the mass showed an invasive, poorly differenti­ ated malignant neoplasm apparently originat­ ing from the parotid gland. Immunohistochemical stains were positive for cytokeratins, vimentin, desmins, S-100 protein, and musclespecific actin in tumor cells (Fig. 2). Electron microscopy showed basement membrane pro­ duction, microvilli, intercellular junctions, and intracytoplasmic actin filaments in tumor cells. The diagnosis was malignant myoepithelioma supported by immunohistochemical and ultrastructural findings similar to previous cases.1,4 The patient was treated with systemic chemo­ therapy that consisted of vincristine, doxorubicin, and cyclophosphamide. She later devel­ oped distant métastases and died 13 months after the malignant myoepithelioma of the pa­ rotid gland was diagnosed. There are two lines of evidence to suggest the tumor in this case was related to radiotherapy and the initial retinoblastoma. First, there is

Departments of Ophthalmology (S.J.S. and H.E.G.) and Pathology (H.E.G. and A.O.S.), Emory Universi­ ty School of Medicine. Inquiries to Hans E. Grossnikiaus, M.D., L. F. Montgomery Ophthalmic Pathology Laboratory, Emory Eye Center, 1327 Clifton Rd. N.E., Atlanta, GA 30322. Salivary gland neoplasms composed of myoepithelial cells, whether benign or malignant, are extremely rare. 1 It is well established that radiotherapy of the head and neck can initiate the development of many neoplastic lesions. 2 There is strong evidence to suggest that the development of a second nonocular neoplasm in patients with heritable retinoblastoma re­ sults from a germinal mutation. 3 We managed a case of malignant myoepithelioma of the parot­ id gland that developed after irradiation for heritable retinoblastoma. A 15-year-old girl had had bilateral heritable retinoblastomas diagnosed when she was 15 months old. At the time of diagnosis, the left

Fig. 1 (Saxe, Grossnikiaus, and Someren). A softtissue mass (arrow) invades the inferolateral wall of the right orbit.

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Arnold, M. J., and Frohman, L. A.: Salivary gland neoplasms as a late consequence of head and neck irradiation. Ann. Intern. Med. 87:160, 1977. 3. Roarty, J. D., McLean, I. W., and Zimmerman, L. E.: Incidence of second neoplasms in patients with bilateral retinoblastoma. Ophthalmology 95:1583, 1988. 4. Tanimura, A., Nakamura, Y., Nagayama, K., Tanaka, S., and Hachisuka, H.: Myoepithelioma of the parotid gland. Report of two cases with immunohistochemical technique for S-100 protein and elec­ tron microscopic observation. Acta Pathol. Jpn. 35:409, 1985. 5. Delbridge, L., Poole, A. G., Ekstein, R., Lim, K., and Posen, S.: Simultaneous presentation of parathy­ roid, thyroid and parotid tumors 44 years after neck irradiation. Aust. N.Z. J. Surg. 59:187, 1989.

Fig. 2 (Saxe, Grossnikiaus, and Someren). Top, The cytoplasm in occasional tumor cells (arrowhead) stains positive for S-100 protein (peroxidase antiperoxidase, x 160). Bottom left, Tumor cells strongly stain for muscle-specific actin (peroxidase antiperoxidase, x 160). Bottom right, Focal intracytoplasmic-positive staining for low-molecular-weight cytokeratins is present in tumor cells (peroxidase antiperoxidase, X 160). strong evidence to suggest the genetic muta­ tion, which results in bilateral retinoblastoma and 15% of unilateral cases, is a major factor that causes an increased incidence of second nonocular tumors. 3 Second, it has been well established that radiotherapy of the head and neck initiates neoplastic lesions. 2 These two factors combined with the findings that the latency period for parotid gland lesions varies from five to 35 years 6 and that the mean latency period for the appearance of a second primary tumor in patients with bilateral retinoblastoma is 13 years 3 support the hypothesis. Possibly radiation to tissue genetically predisposed to develop a neoplasm resulted in the malignant myoepithelioma in our case.

References 1. Singh, R., and Cawson, R. A.: Malignant myoepithelial carcinoma (myoepithelioma) arising in a pleomorphic adenoma of the parotid gland. An immunohistochemical study and review of the litera­ ture. Oral Surg. Oral Med. Oral Pathol. 66:65, 1988. 2. Schneider, A. B., Favus, M. J., Stachura, M. E.,

Periosteal Flap for Lower Eyelid Reconstruction Charles R. Leone, Jr., M.D. Department of Ophthalmology, University of Texas Health Science Center. Inquiries to Charles R. Leone, Jr., M.D., 7950 Floyd Curl Dr., Suite 505, Medical Center Tower 1, San Antonio, TX 78229. When the lateral aspect of the lower eyelid is removed and reapproximation to the lateral rim is impossible, particularly with recurrent tu­ mors, a method must be used to reconstruct the eyelid. To avoid borrowing tarsoconjunctiva from the upper eyelid, a temporal-zygomatic skin flap lined on the inside by conjunctiva can be mobilized, but the eyelid may lack sufficient support and may sag. I have used a technique in which the reconstructed eyelid was connected to the lateral canthus by using the lateral orbital rim periosteum as a sling and a temporal skin flap. With the periosteal flap technique, after it is determined that the medial end of the resected eyelid cannot be approximated to the lateral canthus, the lateral rim is exposed. Just above the level of the lateral canthal angle, perioste­ um is incised on the anterior surface in a rectan­ gular manner with the base at the inner aspect of the lateral rim. The vertical width is at least 5 mm and the horizontal length conforms to the length necessary to reach the eyelid segment, usually 1 cm in length (Fig. 1). This flap is mobilized carefully with sharp and blunt dis­ section by using the tip of a sharp periosteal

Malignant myoepithelioma after radiation for retinoblastoma.

512 AMERICAN JOURNAL OF OPHTHALMOLOGY good faith. Ophthalmologists need to be aware of the syndrome of the battered child, as they may be the first...
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