Ophthalmic striated muscle neoplasms

Extraocular muscle enlargement of indeterminate cause in pediatric patients: case series and literature review

PURPOSE

To specify the clinical characteristics of enlarged extraocular muscles of indeterminate cause in pediatric patients based on a case series and literature review.

METHODS

The medical records of pediatric patients who presented between January 2019 and January 2022 with enlarged extraocular muscles, where the underlying cause could not be determined, were retrospectively reviewed.

RESULTS

Four patients were included. The main reason for presentation was evaluation of abnormal head posture. Head tilt or turn with duction deficit was observed in all patients. The age of onset ranged from 6 months to 1 year. Two patients presented with esotropia and hypotropia; the other 2 patients, with large-angle esotropia. Orbital imaging was performed in all cases and revealed unilateral rectus muscle enlargement sparing the muscle tendon. All 4 patients were found to have an enlarged medial rectus muscle. In the 2 patients with hypotropia, the inferior rectus muscle was also involved. No underlying systemic or orbital disease was found. There were no changes in the orbit or extraocular muscles on follow-up imaging test. The intraoperative forced duction test revealed severe restriction in the direction of gaze opposite to the primary field of action of the enlarged muscles.

CONCLUSIONS

Enlargement of extraocular muscles should be considered in the differential diagnosis when large-angle incomitant vertical or horizontal misalignment and abnormal head posture are observed in infancy.

[Diagnostics of benign and malignant tumors of the orbit]

BACKGROUND

Orbital space-occupying lesions can have a significant impact on the quality of life. Depending on the dignity and etiology of the mass, they can even represent a life-threatening process, which must be timely treated in an interdisciplinary cooperation.

OBJECTIVE

To achieve a comprehensive overview about the diagnostics and frequency of malignant and benign masses of the orbit.

MATERIAL AND METHODS

A literature search was carried out in PubMed and Google scholar.

RESULTS AND DISCUSSION

Clinically, orbital lesions can show symptoms, such as exophthalmos with an increase in the vertical lid fissure, visual impairment and motility dysfunction with diplopia. Depending on the extent, an exposure keratopathy can occur due to failure to close the eyelids. For the diagnostics several tests should be carried out. Following a thorough anamnesis and clinical examination, these should include a blood sample to test for various parameters, an ultrasound examination with subsequent computed tomography (CT) in cases of bone involvement or thin slice magnetic resonance imaging (MRI) of the orbit for assessment of soft tissues. In adults an endocrine orbitopathy is the most frequent cause of an inflammatory orbital process, where lymphomas are the most frequent entity among malignant tumors and vascular space-occupying lesions are the most frequent benign tumors. In children the most frequent benign masses are dermoid cysts and rhabdomyosarcoma is the most frequent primary malignant orbital tumor. The multimodal interdisciplinary treatment can include surgical excision and adjuvant radiotherapy or chemotherapy, depending on the entity.

Botryoid Rhabdomyosarcoma of the Conjunctiva in a Young Boy

Primary conjunctival rhabdomyosarcoma (RMS) is a rare entity that can present with or without papillomatous features. A 5-year-old Asian boy was referred for a rapidly growing conjunctival tumor in the superior fornix of the left eye. Surgical excision yielded a 28 mm multilobulated papillomatous specimen that exhibited histopathologic and immunohistochemical features consistent with embryonal (botryoid) RMS. Molecular analysis revealed the absence of the PAX3/FOXO1 fusion gene, indicating favorable prognosis. After surgery, he was promptly treated with systemic chemotherapy and proton beam radiotherapy.

Orbital tumors in USA: difference in survival patterns

INTRODUCTION

There is a wide range of tumors affecting the orbital adnexa. Key such tumors include lymphomas, carcinomas, melanomas and rhabdomyosarcomas. Several studies have proposed that these histological subtypes differ in their survival outcomes. In this study we aim to describe the difference in survival outcomes between such subtypes.

METHODS

The SEER database was used to gather patient information. All 18 SEER registries were used. Patients diagnosed from 1996 to 2005 were included in the analysis. Observed five-year survival rate was calculated using the SEER*Stat software version 8.1.2. Data were extracted into IBM SPSS version 20 to generate Kaplan Meier curve for each group.

RESULTS

There were 2180 patients in the SEER databases who met the selection criteria. Lymphomas were the most common histology in adults. The overall five-year observed survival for all lymphoma patients was 75.9% (95% CI: 73.7-78.1). There was statistically significant difference between observed survival rates of lymphoma subtypes. Carcinomas were the second most common tumors. Their five-year observed survival rate in our study was 60.4%. There was no statistically significant difference between carcinoma subtypes' observed survival rates in the 20-49 age group, while, in the older age group, the difference was found to be statistically significant. Rhabdomyosarcomas were the most common tumors in children. The overall five-year observed survival rate for rhabdomyosarcomas patients was 89.8%. There was no statistically significant difference between observed survival rates of rhabdomyosarcomas subtypes. There was no statistically significant difference between relative survival rates according to gender and treatment received except within melanomas.

CONCLUSION

In adults, lymphomas have better survival rates than carcinomas. Whereas the lymphoma subtype can be used as a determinant prognostic factor in any age, the carcinoma subtype can be used as such a determinant in older age groups only. In children, rhabdomyosarcomas are the predominant tumors affecting the orbital adnexa. Further studies are needed to determine if the difference between embryonal rhabdomyosarcoma and alveolar rhabdomyosarcoma observed survival rates are statistically significant.

Embryonal rhabdomyosarcoma of upper lid in 15-year-old patient

Rhabdomyosarcoma is the most common childhood primary malignant tumor of orbit. Most of patients present between the ages of 7 and 8 years. Pure eyelid rhabdomyosarcoma is a very rare tumor with only a few reported cases in the literature. We introduce a pure embryonal rhabdomyosarcoma of upper lid in 15-year-old patient and demonstrate successful management of it.

Lower eyelid rhabdomyosarcoma in a 3-month-old infant

Rhabdomyosarcoma is the most common childhood primary soft-tissue sarcoma, with ocular lesions representing approximately 10% of cases. Most ocular rhabdomyosarcomas arise in the orbit between 7 and 8 years of age. We present a case of successfully managed rhabdomyosarcoma confined to the lower lid of a 3-month-old boy.

Long-term follow-up and prognosis of orbital apex syndrome resulting from nasopharyngeal rhabdomyosarcoma

PURPOSE

Nasopharyngeal rhabdomyosarcoma may present with a variety of ophthalmic symptoms. Direct extension of the tumor into the orbital apex can lead to ophthalmoplegia and loss of vision. The prognosis for recovery of vision and ocular motility in patients with an orbital apex syndrome due to nasopharyngeal rhabdomyosarcoma is examined.

DESIGN

Retrospective case series.

METHODS

Six eyes from four patients with nasopharyngeal rhabdomyosarcoma who presented to the Children';s Hospital of Philadelphia with a clinical orbital apex syndrome were identified. Complete ophthalmic examination, including visual acuity and extraocular motility at the time of presentation, was reviewed. Tumor extension into the orbital apex was confirmed radiographically. Follow-up ophthalmic evaluations were reviewed for all patients with an average follow-up of 5.5 +/- 3.1 years (range 1 to 8 years).

RESULTS

Six eyes of four patients had limited ocular ductions along with marked loss of vision at presentation. All patients were treated with chemotherapy and radiation, with reduction of tumor mass. Ocular motility recovered in all patients, occurring by an average of 2.2 +/- 1.8 months after initiation of therapy. Four of six eyes had little or no recovery of visual acuity detected at long-term follow-up.

CONCLUSIONS

Patients with ocular motor deficits in orbital apex syndromes caused by extension of nasopharyngeal rhabdomyosarcoma have an excellent prognosis for recovery after treatment of the tumor. The long-term prognosis for visual recovery, however, is poor.

Orbital Rhabdomyosarcoma and Simulating Lesions

The appropriate diagnosis and treatment of orbital rhabdomyosarcoma requires close cooperation and communication between the radiologist, the ophthalmologist, and the medical and radiation oncologists. The clinical presentation, imaging characteristics, and staging of orbital rhabdomyosarcoma are discussed. A discussion of several important simulating lesions and their distinguishing characteristics follows.

Rhabdomyosarcoma: review for the ophthalmologist

Rhabdomyosarcoma is a malignant neoplasm that is composed of cells with histopathologic features of striated muscle in various stages of embryogenesis. It can occur in several sites in the body, including the ocular region. Ocular rhabdomyosarcoma is defined as the occurrence of this tumor in the area of the eye. Most ocular rhabdomyosarcomas arise in the soft tissues of the orbit but they can rarely occur in the other ocular adnexal structures and even within the eye. The purpose of this review is to provide a brief overview of rhabdomyosarcoma and a more detailed review of orbital rhabdomyosarcoma, with emphasis on changing concepts in the diagnosis and management of this ophthalmic neoplasm.

Nonthyroid causes of extraocular muscle disease

Extraocular muscle involvement in orbital disease is most frequently seen as a feature of thyroid orbitopathy (Graves' disease). However, a wide range of other conditions may alter the size, shape, and function of these muscles, with characteristic clinical manifestations or abnormalities visible on orbital imaging. The differential diagnosis of muscle disease can be narrowed by careful analysis of clinical features and ancillary tests. Imaging facilitates recognition in many cases, but in some instances, accurate diagnosis requires biopsy. This review highlights the differential diagnoses for diseases of extraocular muscles based on the clinical and investigative records of 103 patients at our institution combined with data from the world literature. We found that the most common nonthyroid causes of muscle disease were inflammatory, vascular, and neoplastic processes (in decreasing order of frequency). Emphasis is placed on investigations that provide a logical approach to, and appropriate management of, disease of the extraocular muscles.

Orbital rhabdomyosarcomas and related tumors in childhood: relationship of morphology to prognosis--an Intergroup Rhabdomyosarcoma study

Children and adolescents who develop rhabdomyosarcoma (RMS) and related sarcomas in the orbit and treated on Intergroup Rhabdomyosarcoma protocols have had an extremely high cure rate. This study evaluates the possible relationship between their tumor morphologic subtypes and this high cure rate. The histology of tumors was re-reviewed from 229 of the 264 patients with tumors of the orbit, conjunctiva, and eyelids treated on Intergroup Rhabdomyosarcoma Studies (IRS I, II, III, and IV pilot protocols, and followed through July, 1992. Immunohistochemistry was applied in selected cases. Clinical correlations were done on all 264 cases including both the re-reviewed cases and those reviewed only by the IRS Pathology committee. The 5-year survival rate of 24 children with alveolar RMS was 74% (p < .001). All five infants diagnosed to have an alveolar RMS died before the age of one. Two hundred and twenty-one patients (84%) had embryonal RMS. About three-fourths of the re-reviewed embryonal RMS tumors showed only minimal rhabdomyoblastic differentiation. Thirty-one had a spindle cell RMS, two were anaplastic variants. The 5-year survival rate for patients with embryonal RMS subtypes combined was 94%, and 97% for the 144 patients with poorly differentiated embryonal RMS. In contrast, 90 of 432 IRS II patients treated for poorly differentiated embryonal RMS located in extraocular sites had a 66% survival estimate.

Precision radiation therapy for optic nerve sheath meningiomas

A more precise radiation therapy technique to treat unilateral optic nerve sheath meningioma is presented. It uses an immobilization device to align the ipsilateral optic nerve with a vertical axis and employs three small half-beam blocked fields to deliver radiation to a small conformal volume, thereby reducing the dose to the optic chiasm and the contralateral optic nerve. Three patients were successfully treated with this technique, and a fourth patient with optic nerve glioma was also treated in a similar fashion and was included in this study. The new technique irradiates a much smaller volume of tissue to high dose levels: 58 cm3 is irradiated to the 80% isodose level and only 18 cm3 to the 95% level. In contrast, the opposed lateral technique irradiates 171 and 73 cm3 to these levels, respectively. Thus, a considerable reduction in the volume of normal tissue irradiated was accomplished. Doses to the pituitary and contralateral optic nerve were 4% of the treatment dose for the new technique, whereas these doses were 40% and 100% for opposed laterals and 10% and 3% for wedged pair, respectively. The average setup error for this technique was very small, 50% of the setups measured were less than 1 mm off, and 92.5% were less than 3 mm off. However, for the conventional setups without a mask, only 21% of the setups were less than 1 mm off and 55% less than 3 mm off. We recommend this technique for localized unilateral optic nerve sheath meningioma and other optic nerve lesions that may require radiation therapy.

Primary Ewing's sarcoma of the orbit presenting with visual loss

A case of primary Ewing's sarcoma of the orbit and paranasal sinuses in a 6-yearold boy is reported. The child presented with headaches and unilateral visual loss. Loss of vision as a result of optic nerve involvement with primary Ewing's sarcoma is extremely rare.

Orbital lymphoid tumors located predominantly within extraocular muscles

Lymphoid masses can be centered predominantly within an extraocular muscle (EOM), as exemplified by computed tomography (CT) scanning and biopsy confirmation in the seven cases reported in this study. In these patients, an insidious and painless onset of exophthalmos was overshadowed by ptosis or a motility disturbance (particularly limited upgaze) in the absence of chemosis and lid erythema. The lesions were located in the superior rectus-levator complex (6 cases) and in the medial rectus muscle (1 case). One patient, with an exclusive infiltration of the levator, had a complete ptosis, whereas four others had a partial ptosis. Important clinical clues included palpable masses (4 cases) and preserved downward gaze (all cases), the latter suggesting the absence of fibrotic restriction, as is often seen in Graves' myopathy and the idiopathic myositis of pseudotumor. The biopsy specimens showed spill-over of the hypercellular and stroma-free lymphoid tissue into the orbital fat (all cases) and into the lacrimal gland (3 cases). Full extraocular motility on upgaze was restored after local orbital radiotherapy, although a residual ptosis persisted in five cases. Five patients had well-differentiated lesions and nonocular disease did not develop, whereas a widespread disease developed in one of two patients with a cytologically malignant lymphoma; the patient eventually died.

Radiation and chemotherapy of parameningeal rhabdomyosarcoma involving the orbit

Eighteen patients with parameningeal rhabdomyosarcoma (RMS) involving the orbit were treated at Memorial Sloan-Kettering Cancer Center (MSKCC) between July 1971 and October 1983. Fifteen patients were children with a mean age of 6 years and three patients were adults with a mean age of 21 years. In four patients, the primary tumor originated in the orbit, while the remaining 14 had other parameningeal primary sites. The tumors were in a very progressive local stage, with destruction of facial bones in most patients. Six patients were treated with the T2 chemotherapy protocol and 12 received the T6 protocol. The radiation treatment plan for all patients was designed to deliver between 4500 and 7200 rad delivered to the primary tumor over 4 to 16 weeks. Eleven of the 18 patients (61%) are alive and well with a median follow-up time of six years. Two patients died of therapeutic complications and five died of tumor spread with central nervous system involvement. Ocular complications included acute and chronic conjunctival, corneal, lens, and retinal changes, which were less severe than those reported in previous series.

Diagnosis and behavior of juvenile rhabdomyosarcoma

The main problems in the diagnosis of rhabdomyosarcoma are 1) distinction of undifferentiated examples from other small cell malignancies, especially soft-tissue Ewing's tumor and lymphoma; 2) distinction of spindling examples from fibrosarcoma, leiomyosarcoma, malignant fibrous histiocytoma, polyhistioma, and other sarcomas; 3) recognition of minimal criteria on small samples such as needle biopsy specimens or frozen sections; and 4) recognition of rhabdomyosarcoma in uncommon sites such as bone (mandible), perineum, retroperitoneum, and chest. In 95 pediatric cases diagnosed and treated at Royal Alexandria Hospital for Children--45 after the introduction of combined therapy--minimal diagnostic criteria were assessed. Cross-striations were found in only one third of cases; longitudinal myofibrils were more common and more helpful. There was much overlap between histologic types, and the microscopic patterns had little bearing on prognoses in preadolescent children. Fourteen cases could not be further differentiated ("embryonal sarcoma, probably rhabdomyosarcoma")--nine small-cell tumors; four tumors from genitourinary tract or head for which very small biopsy specimens were available, and one spindling retroperitoneal neoplasm. In all, slight evidence suggested embryonal rhabdomyosarcoma; this evidence included oat-shaped nuclei and, in a few cells, deeply eosinophilic cytoplasm, small elongated processes, or myxoid or alveolar foci--features that exclude lymphoma and Ewing's tumor. In six cases that were originally classified as poorly differentiated or undifferentiated, later material confirmed the presence of rhabdomyosarcoma by showing a predominantly well-differentiated (pleomorphic) or alveolar pattern after therapy. In 14 remaining undifferentiated cases, immunoperoxidase staining with antihuman-myoglobin serum was positive in five. With combined therapy there was 100 per cent survival among patients with paratesticular, limb, and stage I and stage II tumors; considerably improved survival among patients with head and neck, pelvic, and stage III tumors; and 100 per cent mortality among patients with intra-abdominal and stage IV tumors.

The use of computed tomography and ultrasonography in the evaluation of orbital masses

The combined use of computed tomography scans with multiplanar reformation and ultrasonography makes it possible to locate orbital masses with a high degree of accuracy, and sometimes even to determine their histological nature without surgical biopsy. One of the unique features of computed tomography is its ability to distinguish both normal and abnormal structures of various tissue densities; this has contributed to very low false positive and false negative rates. Ultrasonography, while of limited use in the detection of posterior orbital lesions or lesions involving the orbital bones, provides an excellent cost-effective screening test for anterior and midorbit disease. It is also useful for the detection of extraocular muscle enlargement secondary to thyroid disease. In this article, a review of the characteristics and techniques of computed tomography and ultrasonography is followed by discussion of the advantages and limitations of each modality in the evaluation of six common types of orbital tumefaction.

Management of neoplasms of the head and neck in children. II. Malignant tumors

The otolaryngologist who treats children must have knowledge of the neoplasms that can occur in childhood. Such tumors are usually mesenchymal in origin and may be benign or malignant. Diagnosis and management of the more common benign tumors are undertaken by the otolaryngologist because local excision is generally curative. The proper treatment of malignant lesions requires a more extensive, multidisciplinary team, which includes a pediatric oncologist, diagnostic and therapeutic radiologist, and pathologist, in addition to the otolaryngologist. This article outlines the types of malignant neoplasms that occur in childhood and discusses current approaches to therapy.

Ocular pathology for clinicians. 8. Orbital cellulitis

Orbital cellulitis secondary to sinusitis has been the most common cause of proptosis in children. A case report is presented which emphasizes that the signs and laboratory findings in orbital cellulitis may be confusing, especially when modified by prior antibiotics. When orbital cellulitis is a possibility, adequate antibiotic therapy should be instituted while diagnostic studies are being performed. CT scanning is a new and useful modality for the evaluation of these patients, but cautious and experienced interpretation is essential. In patients who do not respond promptly to appropriate medical therapy, surgical intervention is indicated for drainage and biopsy.

Extracardiac rhabdomyoma: a clinicopathologic study and review of the literature

Extracardiac rhabdomyomas are rare benign neoplasms that in the past have been divided by histologic criteria into adult and fetal types. In this series, 15 previously unpublished cases are presented and analyzed in combination with 51 acceptable cases from the literature. The adult type of rhabdomyoma occurs almost exclusively in the head and neck region (93% of all cases), particularly in the larynx and pharynx of adult males. The fetal type of rhabdomyoma may be subdivided on histologic grounds into myxoid and cellular variants. The fetal myxoid type usually occurs in the vulvovaginal region of middle aged women or in the postauricular region of male infants. The fetal cellular type has not been previously emphasized. This type tends to occur in the head and neck region of adult males. It may be mistaken for a sarcoma because of its high degree of cellularity. Local recurrence of a rhabdomyoma is rare and has only been occasionally reported in the adult type of rhabdomyoma. In no instance has a rhabdomyoma been shown to possess aggressive local growth or metastatic potential. Therefore, it is essential that these neoplasms be recognized histologically and that they be treated conservatively by local excision.

Polypoid sinusitis mimicking orbital malignancy

A 15-year-old boy developed a rapidly progressive exophthalmos of 6 mm within two months. Radiologic evidence showed bony erosion, a palpable firm mass in the right upper eyelid, and mass blocking the right nares. This tumor was found to be polypoid sinusitis emanating through the lamina papyracea.

Capillary hemangioma of the lids and orbit: an analysis of the clinical features and therapeutic results in 101 cases

The clinical records of 101 patients (biopsies done on 48) with capillary hemangiomas of the orbit, orbit and lids, and lids were analyzed. Lesions predominated in females and typically appeared at birth or within the first two months of life. The superior orbit and lids were definite sites of predilection. Telltale periocular cutaneous involvement occurred in one third of the cases. Pure proptosis caused by a deep orbital tumor without an anterior component was found in seven cases. Proptosis in general was mild, but in two cases was severe enough to cause corneal exposure. Findings suprortive of a diagnosis of an orbital or periorbital hemangioma include (1) change in tumor size on crying (46%); (2) a dark vascular coloration to the subcutaneous tissue (80%); and (3) the existence of nonperiocular strawberry marks (25). Diagnostic tests of most value were plain radiography, ultrasonography, computed axial tomography, and arteriography. The complication rate in the 50 patients followed up over five years was 80% (60% with amblyopia). Present treatment modalities do not appear to be achieving the desired goals of a good cosmetic and functional outcome. Radiotherapy and corticosteroids are both effective in individual cases, but many lesions are resistant to all forms of present treatment. Amblyopia therapy is difficult and often unsuccessful in these patients.

Mesectodermal leiomyosarcoma of the antrum and orbit

A 39-year-old black man developed a left antral leiomyosarcoma that subsequently extended into the ipsilateral orbit. On light microscopic appearance of the antral tumor the presence of a distinctive myxoid and fibrillar cytoplasmic background suggested the diagnosis of a malignant Schwann's cell tumor. A second biopsy of the orbital extension displayed the same fibrillar character, but the emergence of tumor giant cells with cytoplasmic trichrome positivity also raised the possibility of a rhabdomyosarcoma. Electron microscopy demonstrated the smooth muscle derivation of the tumor, which probably originated from vascular smooth muscle elements. The atypical neural appearance of this myogenous tumor may have been caused by the extensive neural crest contribution to the cephalic connective tissues (mesectoderm). Radiation therapy and chemotherapy were ineffective.