Sir,

We congratulate Dr Lai and associates on their excellent and timely review on the role of biopsy in lacrimal gland pleomorphic adenoma (LGPA).1 We would like to further emphasize the distinction between using a fine-needle aspiration biopsy (FNAB) or an incisional biopsy. The first technique includes one or more (usually 25 gauge) transcutaneous or transconjunctival needle passes. For lesions located deep in the orbit, the needle may be guided by computerized tomography. Slides can be immediately assessed for adequacy if the cytopathologist is present at the time of FNAB. The latter technique involves an ‘open’ surgical approach that will necessarily create a significant break of several millimetres in the thin fibrous pseudocapsule surrounding the LGPA. Potentially, this would increase the risk of local tumour seeding and later recurrence. The obvious benefit of the incisional biopsy is that more material will be available for examination.

We recently reported our findings using FNAB for diverse orbital space-occupying masses and were able to make the correct diagnosis in 81/82 (99%) orbital lesions including all three LGPA in this series.2 Since then, we have used FNAB for 12 more patients with LGPA and were able to make a correct pre-operative diagnosis in all cases. All these patients with cytologically confirmed LGPA subsequently had en bloc excision and there have been no tumour recurrence during a median follow-up of 67 months (range: 11–135 months).

On the basis of our experience, we strongly encourage FNAB (and not incisional biopsy) as the routine procedure when lacrimal gland pleomorphic adenoma is suspected. At the hands of a well-trained cytopathologist, the material is usually sufficient for a correct diagnosis and the morbidity is minimal. In the unlikely event of an inconclusive finding, a repeat FNAB or an incisional biopsy may be performed.