Thyroid-associated orbitopathy in patients with thyroid carcinoma: A case report of 5 cases

RATIONALE

Thyroid-associated orbitopathy (TAO) is most often seen in patients with autoimmune thyroid disease. Data about TAO occurred in patients with thyroid carcinoma are rare. We give a report of 5 patients to present the clinical characteristics, treatment, and prognosis of this type of case.

PATIENT CONCERNS

Five thyroid carcinoma patients presented with orbitopathy. Among them, two patients (patient 1 and 4) were hyperthyroid and TSH receptor antibody (TRAb) positive, two patients (patient 3 and 5) were euthyroid and displayed slightly elevated TRAb titres, one patient (patient 2) was euthyroid and TRAb negative.

DIAGNOSES

They were diagnosed as thyroid carcinoma and TAO.

INTERVENTIONS

Patient 1 underwent total thyroidectomy, intravenous glucocorticoids (GCs) therapy, orbital decompression surgery and oral GCs therapy. Patient 2 and 3 only received total thyroidectomy. Patient 4 received sub-total thyroidectomy and oral GCs therapy. patient 5 didn't received thyroidectomy and underwent intravenous GCs therapy for 2 courses.

OUTCOMES

Patient 1,2,3 showed an improvement of TAO at the final follow-up. Patient 4,5 showed no improvement of TAO at the final follow-up.

LESSONS

When TAO present in patients with thyroid nodules, the possibility of thyroid carcinoma should be considered, and the nature of these nodules should be carefully evaluated. In some patients with thyroid carcinoma and TAO, the remission of TAO can be seen post total thyroidectomy. But for other patients, besides thyroidectomy, an adequate dose and course of intravenous GCs treatment and even ocular surgery are also needed.

Clinical characteristics of inflammatory ocular disease in anti-neutrophil cytoplasmic antibody associated vasculitis: a retrospective cohort study

Objective

To characterize the clinical correlates and outcome of inflammatory ocular disease (IOD) among patients with ANCA-associated vasculitides (AAV).

Methods

Medical records of potential cases of AAV seen at Mayo Clinic from 2003 to 2013, inclusive, were reviewed to identify confirmed cases meeting the diagnosis of AAV using the Chapel Hill Consensus Conference 2012 descriptors. Records of confirmed cases of AAV were then further reviewed for IOD, and clinical characteristics, treatment and outcomes abstracted.

Results

A total of 1171 confirmed cases of AAV were identified of which 183 patients (mean age 49.0 years; 51% female; 95% Caucasian) had IOD. The most common manifestation of IOD was injection of the eye (57%) followed by eye pain (46%) and visual acuity loss (18%). Scleritis was the most common type of IOD (22%) followed by episcleritis (21%), orbital inflammation (18%), lacrimal duct stenosis (10%) and uveitis (9%). Oral glucocorticoids were used to treat IOD in the majority of patients (96%). CYC and rituximab were the most frequently used immunosuppressive agents (54 and 36%, respectively). Of those with orbital inflammation, 52% underwent therapeutic surgical intervention. Clinical remission of IOD was achieved in 91% of patients but relapses were seen in 23%. Significant visual acuity loss was observed in only six patients.

Conclusion

IOD is a common manifestation of AAV and seen in about 16% of patients with AAV. Scleritis, episcleritis and orbital inflammation are the most common subtypes. Most patients respond well to glucocorticoids and immunosuppression, but relapse of IOD is common.

Adult Orbital and Adnexal Xanthogranulomatous Disease

PURPOSE

Adult xanthogranulomatous disease of the orbit and ocular adnexa is a rare disease that can cause serious morbidity and mortality. Ophthalmologists are commonly the first clinicians to come in contact with affected patients and an understanding of the clinical features is essential.

DESIGN

We present a retrospective case series of patients seen in the oculoplastic unit of a large tertiary referral hospital over a 20-year period.

METHODS

The clinical files of 7 patients with adult xanthogranulomatous disease of the orbit and ocular adnexa were reviewed. Clinical, radiological, histopathological, and immunohistochemical findings were examined.

RESULTS

Periocular clinical features included cutaneous xanthogranulomatous lesions, decreased visual acuity, proptosis, diplopia, skin ulceration, cicatricial ectropion, and mechanical ptosis. Systemic features included adult-onset asthma, disseminated xanthogranulomatous lesions with long bone involvement, and hematological disturbances such as monoclonal gammopathy and lymphoplasmacytic lymphoma. Lipid-laden macrophages and Touton multinucleated giant cells were histological hallmarks in all subtypes. Most lesions were strongly CD8 positive on immunohistochemistry. Radiologically, the lesions were diffuse and infiltrative in nature. Various treatments were employed with varying success including surgical excision, systemic and intralesional corticosteroids, other immunosuppressants, and systemic chemotherapy.

CONCLUSIONS

Adult xanthogranulomatous disease of the orbit and ocular adnexa, although rare, may be sight or life threatening. Recognition by the ophthalmologist is critical as periocular features often constitute the initial presentation.

Solitary Langerhans histiocytosis of the orbit: case report and review of the literature

Langerhans cell histiocytosis (LCH), previously known as "histiocytosis X", is a clinical entity characterized by abnormal proliferation of Langerhans cells, which exert a mass effect. Orbital involvement due to LCH is rare as a unifocal disease, seldom occurring outside the pediatric population. We report a case of a 21-year-old man with solitary LCH of the orbit depicted by magnetic resonance imaging (MRI) and diagnosed by histopathological examination.

The Role of Fine Needle Aspiration of Orbital Lesions: A Case Series

OBJECTIVE

This paper analyzes a series of ultrasound (US)-guided orbital fine needle aspirations (FNAs) which provide diagnostic information that cytopathologists approaching orbital lesions for the first time can find useful and underlines the importance of teamwork.

STUDY DESIGN

The investigators retrospectively obtained data from 24 consecutive orbital FNAs. For all patients, a complete clinicoradiological database was created. FNAs were performed under US guidance with 25-gauge needles and an aspiration biopsy syringe gun, and sent to the Department of Pathology for examination and data management.

RESULTS

The mean age of the patients was 54 years. Imaging studies included US, magnetic resonance imaging and computed tomography scans; 9 lesions involved the right orbit and 15 the left orbit. The mean lesion size was 23.6 ± 7.2 mm. After microscopic examination, 7 smears were labeled as 'nondiagnostic', while in 17 cases a definitive diagnosis was proposed, which always proved to be correct (70.8%, specificity = 100%).

CONCLUSIONS

The investigators believe that FNA biopsy of orbital masses is a necessary step; its weaknesses lie in the particularly delicate site of sampling and the extreme heterogeneity of lesions. Nevertheless, when orbital FNA is performed within a well-coordinated multidisciplinary team, it is a powerful tool that can be used to define the most appropriate management of these patients.

Partial Removal of Orbital Tumor in Rosai-Dorfman Disease

BACKGROUND

Rosai-Dorfman disease is a rare idiopathic histiocytic proliferation disorder that typically presents with painless cervical lymphadenopathy. We report our experience with the management of a case of Rosai-Dorfman disease with compressive optic neuropathy.

CASE

Rosai-Dorfman disease involving the bilateral orbital and paranasal sinuses was diagnosed in a 14-year-old boy. Diagnosis was based on the characteristic histopathologic features of sinus histiocytosis, composed of large, round S-100 protein-positive histiocytes with striking emperipolesis. The boy received chemotherapy to resolve the bilateral proptosis and compressive optic neuropathy in the right eye, but this treatment failed. Orbital debulking surgery using the Lynch approach was performed.

OBSERVATIONS

Corneal exposure was resolved and visual acuity recovered from 14/20 to 20/20 after partial removal of the tumor mass. There were no complications after surgery. During the 22 months of follow-up, orbital tumor masses redeveloped to cause lagophthalmos again, but did not cause visual impairment.

CONCLUSIONS

Rosai-Dorfman disease is a rare disorder, especially in Asia. The disease is usually chronic with spontaneous remission and is refractory to treatment. Partial removal of tumor masses is a workable way to improve visual acuity and correct corneal exposure. Before carrying out this procedure, we discussed with the parents of the patient the potential complications that might follow surgery and secured their permission before proceeding further.

Solitary Cranial Langerhans Cell Histiocytosis: Two case reports

Langerhans cell histiocytosis (LCH) is a proliferation of Langerhans cells intermixed with inflammatory cells, in particular eosinophils, that may manifest as a unisystem (unifocal or multifocal) or multisystem disease. We describe the clinical and histologic spectrum of LCH of the orbit and skull in our two cases. Both cases had unifocal erosive skull lesions with a history of trauma. Typical histologic features included numerous histiocytes with varying degrees of giant cell formation and scattered eosinophilic granulocytes. The presence of Langerhans cells was confirmed by CD1a and S100 immunohistochemistry. LCH has an excellent prognosis when treated with surgical resection, steroids and radiotherapy or chemotherapy. One of our patients is disease free at 7 year follow-up and one patient had regression of lesion on follow-up.

Electrochemotherapy of a Multirecurrent Dermatofibrosarcoma Protuberans of the Orbital Margin: A Case Report

Dermatofibrosarcoma protuberans (DFSP) is an uncommon cutaneous sarcoma with high recurrence rate. Radical surgery is the treatment of choice, although in cosmetically-sensitive areas such as the head and neck, this option is often not pursued. Electrochemotherapy (ECT) is a minimal invasive anti-tumor modality which is increasingly being used to treat skin metastases from different malignancies. A 31-year-old woman presented with subcutaneous local multirecurring DFSP located at the proximal end of the left eyebrow. ECT was offered as a palliative treatment to avoid radical disfiguring surgery. Two days following ECT, the patient was discharged in good general health. Partial tumor regression was appreciable at two months' follow-up by ultrasound and magnetic resonance imaging. At six months, residual fibrotic tissue was observed; at three years, no evidence of the tumour was detected. In our case, ECT achieved good local tumor control with excellent cosmetic results, preserving the patient's quality of life.

A 10-year review of orbital biopsy: the Newcastle Eye Centre Study

PURPOSE

To review the histopathological diagnoses, visual outcome, and complication rate of orbital biopsy in a UK tertiary referral centre.

METHODS

This was a retrospective, clinical-pathological, interventional, consecutive case series. All orbital biopsies performed between July 2004 and June 2014 in Newcastle Eye Centre (Newcastle upon Tyne, UK) were included in this study. All relevant data collected from the local electronic database and medical records were analysed.

RESULTS

A total of 166 orbital biopsies were identified during the study period: 86 patients (53.1%) were female and the mean age was 53.7 ± 19.7 years. Of all the cases, orbital biopsies were performed unilaterally in 158 (97.5%) patients and bilaterally in 4 (2.5%) patients. The mean follow-up period was 2.2 ± 2.3 years. The two most common histopathological diagnoses were non-specific inflammatory disease (62, 38.3%) and lymphoproliferative disease (40, 24.7%). None of the patients experienced ≥ 2-Snellen line visual loss. There were 7 (4.2%) postoperative complications noted: 1 (0.6%) orbital haemorrhage with no loss of vision, 4 (2.4%) diplopia, 1 (0.6%) short-term symblepharon, and 1 (0.6%) conjunctival granuloma. Postoperative diplopia was associated with lateral orbitotomy (P = 0.044) and excisional biopsy (P = 0.015).

CONCLUSIONS

Orbital biopsy serves as a safe diagnostic tool in managing orbital diseases. Patient should be made aware of the risk of postoperative diplopia. Our data provides useful guidance to clinicians when counselling patients for orbital biopsy.

[Multiple intracranial epidermoid cysts: Case report]

Epidermoid cyst is a benign and rare tumor, that evolves slowly. We describe the case of a 55 years-old woman, who came to our consultation for atypical trigeminal neuralgia of left V1 and V2 nerves. Brain MRI found two tumors: T1W hypointense with no appreciable enhancement after gadolinium injection and T2W and diffusion hyperintense. This last feature was in favour of an epidermoid cyst, but the multiplicity of cerebral lesions was definitely not in favor of such a diagnos­tic. They were located behind the right eye and in the left Meckel’s cave (trigeminal cave). The surgical strategy consis­ted in removal the retro orbital tumor witch was the most acces­si­ble of both the diagnostic of epidermoid cyst was retaned thanks to the anatomopathology report. As these lesions had the exact same characteristics, we concluded that they were simi­lar. The second epidermoid cyst was not removed because of surgical risk, its benign nature and low evolutionary potential.

[Clinicopathologic characteristics of IgG4-related disease in orbital and periorbital tissue]

OBJECTIVE

To study the clinicopathologic characteristics of IgG4-related disease in the orbital and periorbital tissue.

METHODS

The clinical manifestations and pathologic features of 17 cases of IgG4-related disease affecting the orbital and periorbital tissue encountered during the period from 2012 to 2013 were studied.

RESULTS

There were 9 male patients and 8 female patients. The age of patients ranged from 11 to 71 years (mean = 48.5 years). The main clinical manifestation was swelling of the eyelids: bilateral in 11 patients and unilateral in 6 patients. The duration of disease ranged from 5 months to 7 years (more than 2 years in 13 cases). Six patients had history of allergic disorders. In addition to orbital/periorbital involvement, the disease also affected salivary gland, lymph node, lung and kidney. The disease relapsed in 9 patients. Amongst the 8 patients treated with steroids, 5 of them achieved complete remission and the remaining 3 patients had partial remission. The IgG4 level of the 17 cases ranged from 1.49 to 14.88 g/L. Histologic examination showed pseudolymphoma pattern in 8 cases, mixed pattern in 8 cases and sclerotic pattern in 1 case. There were various degrees of lymphoplasmacytic infiltrates (with lymphoid follicle formation) and stromal fibrosis. Classical obliterative phlebitis was absent. Tissue eosinophilia was demonstrated in the 17 cases studied. Immunohistochemical study showed the presence of more than 50 IgG4-positive plasma cells per high-power field, with IgG4/IgG plasma cells ratio more than 40%.

CONCLUSION

There are characteristic clinical manifestations, pathologic features and laboratory findings in orbital and periorbital IgG4-related disease. Thorough understanding is important in arriving at a correct diagnosis.

A clinical, radiologic, and immunopathologic study of five periorbital intraosseous cavernous vascular malformations

PURPOSE

To correlate the clinical, radiographic, histopathologic, and immunohistochemical features of 5 primary periorbital intraosseous cavernous vascular malformations.

DESIGN

Retrospective interventional case series.

METHODS

Clinical and operative records and radiographic images were reviewed. Histopathologic slides were evaluated with hematoxylin-eosin, trichrome, and elastin stains. Immunohistochemical studies were performed with a spectrum of monoclonal antibodies directed at antigens of vascular cells.

RESULTS

Three men and 2 women ranged in age from 36 to 64 years. Vision was unaffected and there was no proptosis or globe displacement. The slow-growing lesions measured 13-25 mm in greatest diameter (mean 16.4 mm). Computed tomographic studies revealed that 2 lesions were situated in the maxillary bone, 2 in the frontal, and 1 in the zygoma, all anteriorly and with circumscribed, lucent, honeycombed, or sunburst characteristics. Histopathologically the lesions were composed of cavernous or telangiectatic channels; 1 showed advanced fibrotic vascular involution. Immunohistochemistry demonstrated CD31/34 positivity for vascular endothelium and D2-40 negativity for lymphatic endothelium. A typically thin mural myofibroblastic cuff was smooth muscle actin positive, weakly calponin positive, and desmin negative. Glucose transporter-1 and Ki-67 were negative in the endothelium.

CONCLUSIONS

Intraosseous vascular lesions resemble orbital cavernous venous malformations (not true hemangiomas), except that their vascular walls are thinner owing to the constraints imposed by neighboring bone spicules, which limit the amount of interstitium from which mural myofibroblasts can be recruited. The bony trabeculae conferred the honeycomb or sunburst appearances observed radiographically. En bloc excision of these lesions was successful and avoided complications (mean follow-up, 46 months).

[Rhinoorbitocerebral zygomycosis caused by Rhizopus microsporus in a roe deer (Capreolus capreolus)]

An one-year-old male roe deer (Capreolus capreolus) with abnormal behaviour was shot in order to exclude rabies virus infection. The 12.8 kg weighing animal was emaciated and revealed an asymmetric head with protruding left eye and expositional keratitis. There was a grey whitish soft mass within the caudal nasal cavity, which had infiltrated the frontal cerebrum through the cribriform plate and the retrobulbar tissue through the orbita. Histologically, the mass consisted of a chronic granulomatous inflammation with plentiful fungal hyphae. Fungal culture revealed mold fungi of the zygomycotic genus Rhizomucor, which were differentiated as Rhizopus microsporus by MALDI-TOF mass spectrometry and DNA-sequencing. Rhinoorbitocerebral zygomycosis has to be considered as a differential diagnosis for nasal and orbital tumour-like lesions and as a cause of abnormal behaviour of roe deer.

Sphenoid sinus dehiscence as a risk for visual consequences in an immunocompromised patient

Isolated sphenoid sinus disease is a rare entity with severe and potentially life threatening sequela. Because of the proximity of the sinus to the orbit, anatomical defects within the surrounding bony structures can facilitate communication with orbital content, predisposing the patient to substantial visual consequences. We report a case of a 51-year-old immunocompromised male who presented with headache and gradual unilateral decreases in vision. Computed tomography revealed opacification of the left sphenoid sinus accompanied by unusual bony dehiscence of the proximal optic canal. Early recognition and treatment of sphenoid sinusitis requires urgent surgical intervention with delay of treatment potentially leading to irreversible blindness or other devastating consequences. Bony dehiscence of the sphenoid sinus overlying the optic nerve has only been found in 4% of cadavers. It is associated with increased risk of orbital complications and predicts a poor prognosis. Immediate intervention is particularly important in immunocompromised individuals who are at greater risk of these severe complications.

Elevated percentage of HLA-DR⁺ and ICAM-1⁺ conjunctival epithelial cells in active Graves' orbitopathy

Background

To evaluate if conjunctival epithelial cells’ expression of HLA-DR and ICAM-1 could be helpful as early topical markers of inflammation in Graves’ orbitopathy (GO).

Methods

The ocular examination evaluated a clinical activity score (CAS) by assessment of clinical features, (e.g., eyelid or conjunctival inflammation, lid width, lid closure, proptosis, ocular motility). Conjunctival epithelial cell specimens for flow-cytometric evaluations of ICAM-I and HLADR expression were collected by impression cytology from ten eyes with active GO (CAS ≥ 4 and duration ≤ 12 months), from 15 eyes with Graves’ disease (GD) without active GO (CAS 0–2) and from 15 normal specimens without any ocular disorders.

Results

The percentage of HLA-DR + conjunctival epithelial cells was significantly elevated in patients with active GO comparing to GD without active GO and healthy controls, 10.7 % (8.5–17.7) and 7.78 % (3.92–10.1) (p < 0.05) vs. control 4.89 % (3.5–5.5) (p < 0.005), respectively. The expression of ICAM − 1+ conjunctival epithelial cells was greater only in patients with GO vs. controls, 5.5 % (4.8–7.03) and 1.46 % (0.69–2.51) (p < 0.005), respectively.

Conclusion

The percentage of HLA-DR⁺ and ICAM-1⁺ conjunctival epithelial cells in patients with the active GO may serve as a topical inflammation marker in Graves’ orbitopathy.

Pseudo third cranial nerve palsy secondary to orbital ectopic lacrimal gland cyst: management with functional endoscopic sinus surgery

An otherwise healthy 13-month-old girl was noted by her pediatrician to have developed a left head turn. The patient was referred to a pediatric ophthalmologist, who noticed signs of incomplete third cranial nerve palsy. Magnetic resonance imaging revealed the presence of an abnormal lesion in the inferonasal orbit that was abutting the ethmoid sinus. After consultation with an ENT specialist, the decision was made to remove the lesion via functional endoscopic sinus surgery because this approach was deemed to provide adequate access while limiting morbidity. Histology of the excised lesion identified it as true ectopic lacrimal gland tissue with cysts. We recognize and comment on the fact that in many reported cases of ectopic lacrimal gland cyst, the tissue was not ectopic at all but instead represented an extension of normal lacrimal gland tissue.

Visual outcomes following orbital biopsy

BACKGROUND

The risks of orbital biopsy depend on the lesion's location and relationship with surrounding structures. Complications include reduced vision, although visual outcomes following orbital biopsy are not widely reported.

AIMS

To determine visual outcomes following orbital biopsy in Gartnavel General Hospital's Oculoplastic and Oncology Service.

METHODS

Case note review of 50 consecutive patients undergoing orbital incision or excision biopsy between January 2006 and December 2010. Data collected included preoperative clinical examination, radiological and histological features, preoperative and postoperative corrected distance visual acuity (CDVA) and surgical complications. The main outcome measure was change in CDVA. Mean follow-up duration was 1.32 years.

RESULTS

Histological diagnoses following biopsy included idiopathic orbital inflammation (n = 13) and lymphoma (n = 9). Of the radiologically defined lesions, 86.7% were extraconal (13.3% intraconal). Extraconal lesions were anterior in 59.0% (41.0% posterior). Mean preoperative LogMAR CDVA was 0.10 which was maintained at day one post-biopsy, indicating the absence of immediate sight-threatening complications such as retrobulbar haemorrhage or optic nerve compression, and there was no significant reduction at one-year follow-up (p = 0.239). Further analysis of change in CDVA showed no difference between: anterior and posterior lesions; extraconal and intraconal lesions; incision and excision biopsies; anterior and lateral surgical approaches.

CONCLUSIONS

CDVA is retained for one year following orbital biopsy. Significant visual loss is a very rare complication of this procedure.