Orbital germ cell tumors revisited: a clinicopathological approach to classification

Congenital orbital teratoma: a rare case with intracranial extension

INTRODUCTION

Teratoma is the most common congenital tumor, but the orbital location is rare. It is composed of tissues from ectoderm, mesoderm, and endoderm.

CLINICAL PRESENTATION

Congenital orbital teratoma commonly presents as unilateral proptosis, with rapid growth, leading to exposure keratopathy.

DIAGNOSIS

Prenatal ultrasound may detect the orbital mass, computed tomography (CT) scans, and magnetic resonance (MR) imaging are better in demonstrating multilocular cystic and solid mass, without bone erosion. Laboratory tests should include alfa-fetoprotein (AFP) and B-human chorionic gonadotropin (B-HCG), and histopathologically, it contains all three germ cell layers components. The management is surgical removal of the lesion, the mature teratoma has a benign behavior, and the immature has a poor prognostic. We describe a rare case of congenital orbital teratoma with intracranial extension of the lesion, in which was treated with orbital exenteration. After surgery, AFP levels decreased, the middle face displacement has improved and development milestones were appropriate.

Congenital orbital teratoma: a case report with preservation of the globe and 18 years of follow-up

Background

Congenital orbital teratomas are extremely rare, usually benign neoplasms, comprised of cells originating from all three germ cell layers. Clinically the tumor appears solid, most of the times is intraconal and presents as a rapidly growing mass leading to a massive unilateral axial proptosis, chemosis, exposure keratopathy, markedly distended eyelids and often, loss of vision. To prevent these complications, tumor excision usually involves enucleation or even orbital exenteration.

Case presentation

We report a case of a 1-day old infant who presented with dramatic proptosis at birth due to a true congenital orbital teratoma. We describe the clinical findings, the preoperative neuroimaging, the surgical management which included complete tumor resection with preservation of the globe to allow for optimal orbital growth, the histopathological evaluation, and the clinical course during 18 years of follow up.

Conclusion

Every effort to salvage the globe should be made to achieve the best possible orbito-facial development. Furthermore, the value of prompt surgical management with a less invasive transconjunctival globe sparing procedure can be appreciated in our case.

Prenatal Exophthalmia Revealing a Postnatal Orbital Teratoma

Purpose

Teratomas are congenital tumors of stem cells derived from the three germ layers. They are frequently located in the sacrococcygeal region. Orbital teratoma is rare with less than 70 cases reported until 2016. We report the case of prenatal exophthalmia discovered by ultrasound exam which turned out to be a teratoma postnatally. The newborn in our case was female, just as described in the literature. Treatment consisted of total removal of the teratoma and the eyeball. Reconstructive surgery remains a big challenge since our medical technology is limited.

Conclusion

A prenatal exophthalmia on fetal ultrasound should make us think of a teratoma, even if it is very rare. Fetal orbital teratoma may be associated with fetal survival. The infant will benefit from a reconstructive surgery of the orbit.

Malignant orbital teratoma in a neonate: A clinicopathological case report

Teratoma of the orbit is rare; very few cases have been published in literature. A case of orbital teratoma in a neonate is presented where the proptosis was massive enough to obscure the eyeball. Clinically, the diagnosis of teratoma was considered. As there was no possibility of salvaging the eye, exenteration of the orbit was done. Orbital teratomas are generally benign. Histopathological examination revealed the features of malignant teratoma.

Primary lacrimal gland teratoma in an adult: A clinicopathologic and radiological correlation

A 20-year-old male presented with a gradually growing mass in the left lateral brow region for 2 years. On imaging, the mass appeared to arise from the lacrimal gland, was cystic, without any bony abnormality. With a diagnosis of dermoid cyst, an excision biopsy was performed. The histopathology revealed an epithelium-lined cyst, with the wall of the cyst comprising dermal adnexa and inflammatory cells. The wall also contained fragments of skeletal muscle, nerve bundles, adipose tissue, exocrine and secretory acini, few blood vessels with occasional hair shafts, with the lacrimal gland in the periphery of the tumor. There were no immature elements, atypia, and malignant cells, thus confirming the diagnosis of a mature cystic teratoma. Primary lacrimal gland teratoma is a rare diagnosis and its presentation in adults is extremely uncommon.

A giant dermoid cyst of the orbit

To describe a unique case of a non-germinomatous germ cell tumor, a giant orbital dermoid, present in adulthood. A 31-year-old male presented in our clinic with gradual, painless, progressive proptosis in the left eye since 28 years associated with gradual loss of vision. The left eye showed gross proptosis. Ocular structures could not be made out. Computed tomography scan showed a well-circumscribed oval heterogeneous mixed solid and cystic lesion completely filling the left orbit with calcification. The differential diagnosis was that of either teratoma or optic nerve glioma. The patient underwent excision of the lesion. Histopathology revealed a capsulated tumor with multiple cystic components filled with blood and eosinophilic material suggestive of a dermoid cyst. Non-germinomatous germ cell tumors may present atypically in adults and neglected benign dermoid cysts can attain massive size mimicking malignant lesions.

Congenital orbital teratoma

We present a case of mature congenital orbital teratoma managed with lid-sparing exenteration and dermis fat graft. This is a case report on the management of congenital orbital teratoma. A full-term baby was born in Fiji with prolapsed right globe which was surrounded by a nonpulsatile, cystic mass. Clinical and imaging features were consistent with congenital orbital teratoma. Due to limited surgical expertise, the patient was transferred to Adelaide, Australia for further management. The patient underwent a lid-sparing exenteration with frozen section control of the apical margin. A dermis fat graft from the groin was placed beneath the lid skin to provide volume. Histopathology revealed mature tissues from each of the three germ cell layers which confirmed the diagnosis of mature teratoma. We describe the successful use of demis fat graft in socket reconstruction following lid-sparing exenteration for congenital orbital teratoma.

Ossifying cystic odontogenic and Schneiderian choristoma of the orbit

A 12-year-old girl presented with a left infraorbital lesion, causing upward globe displacement. Imaging confirmed a mass between the globe and the orbital floor. The lesion was removed via a sub-ciliary approach and histology revealed a a mature tooth along with a periodontal ligament, oral-type mucinous glands and bone. Six years later a mass recurred at exactly the same site and on this occasion, revealed cysts containing mucin and lined by Schneiderian type epithelium. A rather complex combination of a tooth, lamellar bone, mucinous oral type glands and Schneiderian cystic epithelium is highly unusual and we have called the lesion "ossifying cystic odontogenic and Schneiderian choristoma of the orbit."

Primary orbital teratoma with tooth in an adult: a rare association with cataract and corectopia

INTRODUCTION

Orbital teratoma is a known cause of proptosis in neonates but it is rare in adults.

CASE REPORT

An adult female presented with primary orbital teratoma with a well formed tooth inside the multicystic mass. Anterior orbitotomy with cyst excision was done with retrieval of a canine tooth.

COMMENT

This report documents a unique case of orbital teratoma presenting in an adult with well formed canine tooth inside. Microcornea, corectopia and cataract were other distinctive coexisting features of our case.

Limbal dermoid epithelium shares phenotypic characteristics common to both hair epidermal and limbal epithelial stem cells

PURPOSE

To determine putative limbal epithelial stem cell marker expression in human limbal dermoids compared to stem cell niches in normal limbus and hair follicles of normal human dermis.

METHODS

Human limbal dermoids (n = 7), normal skin (n = 2) and normal limbal (n = 7) tissue were examined. Immunohistochemistry was performed on paraffin embedded specimens using automated and manual immunostaining with primary antibodies to CK15, CK14, Cadherin-P (CDH3), Wnt-3, Wnt-4, Wnt-5a, Dickkopf (DKK)-3, Sox-2, Sox-10, Sox-13, PEDF, NGFR p75 and β-catenin.

RESULTS

Positive immunostaining was found for CK15, CK14, CDH3, NGFR p75, PEDF, Sox-2, Sox-10 and Wnt 4 in the basal dermoid epithelium, limbus and hair follicles. Suprabasal epithelium was immunostained with PEDF, Sox-2 and Wnt-4 in these tissues. The sebaceous and sweat glands, vascular endothelium and nerves of the limbal dermoid immunostained with PEDF and Sox-2. Sebaceous and sweat glands stained for Sox-10. DKK-3 immunostaining occurred in the dermoids' suprabasal epithelium and vascular endothelium but not in the limbus or hair follicle.

CONCLUSION

Human limbal dermoids share a similar antigenic expression profile similar to the basal limbal epithelium and to the stem cell niche of hair follicles. This supports the notion that limbal dermoids could have properties in common with limbal and/or dermal epithelial stem cells.

Antenatally diagnosed congenital orbital teratoma in which rupture was associated with intrauterine fetal death

We report a case of a fetus with a congenital orbital teratoma (COT), in which rupture of the tumor was associated with an intrauterine fetal demise. An ultrasound scan at 27 weeks' revealed a solid and cystic, complex mass in the orbital region with extensive vascularization suggestive of an orbital cystic teratoma. Magnetic resonance imaging (MRI) supported this diagnosis and clarified tumor localization. At 32 weeks', the patient presented with fetal demise and rupture of the mass was noted. Fetal COTs, like sacrococcygeal teratomas, carry the risk of rupture. MRI in utero is useful for evaluating the extent of disease.

Intraocular teratoma in association with sacrococcygeal teratoma: a clinicopathologic report

A benign sacrococcygeal teratoma was resected from an infant at birth. Four weeks later, intraocular tumors were identified in the right eye. The eye expanded in size and was removed at 16 weeks. A benign cystic intraocular teratoma was identified.

Cranio-orbital teratoma

A new-born baby presented with a large, rapidly growing tumour. The tumour involved the right orbit, the anterior half of the right intracranial space and extended through the skull of the temporal region. The proptotic eye ruptured due to exposure. The tumour was extirpated when the patient was 12 days old. A large recurrence was extirpated two months later. The tumour was firmly bound to the medial aspect of the superior orbital fissure which probably was the location of origin of the tumour. Based on the size of the intracranial-and the orbital part of the tumour, it was classified as a secondary orbital teratoma. The tumour was macroscopically composed of cystic and solid areas. Microscopically it was seen to be a benign teratoma with tissue from all three germinal layers.

Complex palpebral odontogenic choristoma: A reappraisal of the origin of teeth-bearing periocular lesions

PURPOSE

To describe the findings observed in a congenital ectopic tooth of the lower inner eyelid and explain its origin.

DESIGN

Retrospective and interventional clinicopathologic study.

METHODS

Histopathologic evaluation of sequentially excised specimens over 4 years and radiographic study of any associated dental abnormalities, compared with critical reevaluation of similar reported cases in the literature.

RESULTS

The ectopic eyelid tooth clinically created a dome-shaped mass and microscopically displayed advanced cytodifferentiation but incomplete morphogenesis with clearly identifiable ameloblasts, enamel, odontoblasts, and dentin, surrounded by an intact dental sac. Swollen oral mucosal epithelium with associated sebaceous Fordyce nodules, residual ciliated odontogenic epithelium, embryonic epithelial rests, and accessory mucinous and sero-mucinous accessory salivary glands were discovered in place of normal conjunctiva. The tarsus with meibomian glands was absent but islands of cartilage were present.

CONCLUSIONS

Because of the variety of the ectopic tissues that were exhibited, a causative displacement of oral embryonic epithelium with extensive differentiating potentialities is posited. Two previously reported palpebral dental choristomas also had identical locations in the inferomedial eyelid. This is the site where the phakomatous choristoma may be encountered, but this unencapsulated mass creates an eyelid thickening without a globoid configuration and infiltrates the inferior orbit. After a careful re-appraisal of published reports of orbital cysts bearing a tooth that were formerly diagnosed as "teratomas," we have concluded that they developed from similar embryonic oral (buccal) epithelial displacements rather than from aberrant germ cells, based on the cysts' linings and the associated accessory salivary glands in their walls. This view is further supported by the absence of heterologous teratomatous elements of endodermal or neuroectodermal derivation. A clinical and surgical approach to management and a new diagnostic schema for odontogenic choristomas are proposed.

Primary orbital yolk sac tumour in a 14-year-old girl

Yolk sac tumour is a common malignant germ cell tumour, which usually occurs in the testes or ovaries of infants. It can occasionally arise from a number of extragonadal sites. Extragonadal germ cell tumours of the head and neck region account for 5% of all benign and malignant germ cell tumours. The orbit is an extremely unusual location for development of primary yolk sac tumour. The present report concerns the case of a yolk sac tumour in a 14-year-old girl, arising as a primary tumour of the orbit with invasion of periorbital and intracranial spaces.

Perinatal (fetal and neonatal) germ cell tumors

BACKGROUND/PURPOSE

Germ cell tumors are relatively common in the fetus and neonate and are the leading neoplasms in some perinatal reviews. The purpose of this study is to focus on the fetus and neonate in an attempt to determine the various ways germ cell tumors differ clinically and morphologically from those occurring in the older child and adult and to show that certain types of tumors have a better prognosis than others.

METHODS

The author conducted a retrospective review of perinatal teratomas and other germ cell tumors reported in the literature and of patients treated and followed up at Children's Hospital San Diego and Children's Hospital Los Angeles. Only fetuses and infants less than 2 months of age with adequate clinical and pathologic data were accepted for review.

RESULTS

Five hundred thirty-four fetuses and neonates presented with teratomas diagnosed prenatally (n = 226) and at birth (n = 309). The most common initial finding was a mass, noted either by antenatal sonography or by physical examination during the neonatal period, with signs and symptoms referable to the site of origin. Overall polyhydramnios was next followed by respiratory distress and stillbirth. The number of mature and immature teratomas was approximately the same. The incidence of teratoma with yolk sac tumor either at presentation or at recurrence was 5.8%, and the survival rate was 39%. Sacrococcygeal teratomas had the highest incidence of yolk sac tumor at 10%. Recurrent disease in the form of either teratoma or yolk sac tumor developed in 5% of patients. All individuals with teratomas who survived received surgical resection.

CONCLUSIONS

Some germ cell tumors of the fetus and neonate have a better prognosis than others. Neonates with gastric teratomas have the best survival rates, and those with intracranial germ cell tumors the worst. Fetuses with teratomas detected antenatally have 3 times the mortality rate compared with postnatally diagnosed neonates. Although perinatal teratomas have a relatively low recurrence rate of 5%, close follow-up with imaging studies and serum alpha-fetoprotein determinations is is strongly recommended. Surgical resection alone may be adequate therapy for teratomas with nonmetastatic, microscopic foci of yolk sac tumor. In the nonteratoma group, patients with pure yolk sac tumor and gonadoblastoma have a much better outcome than those with choriocarcinoma, which has a very low survival of rate of 12%. Currently, the use of platinum-based combination chemotherapy has significantly improved the survival rate of infants with advanced malignant germ cell tumor disease.

Orbital cysts of childhood—classification, clinical features, and management

There is little in the literature about the clinical spectrum of orbital cysts of childhood and no comprehensive classification has been proposed. The authors propose a classification of orbital cysts of childhood and review their clinical features, pathology, and management. The major categories in the classification include cysts of surface epithelium, teratomatous cysts, neural cysts, secondary cysts, inflammatory cysts, and noncystic lesions with cystic component. Cysts of the surface epithelium are further divided into simple epithelial cyst (epidermal, conjunctival, respiratory, and apocrine gland), and dermoid cyst (epidermal and conjunctival). Epidermal dermoid cyst (dermoid) is by far the most common orbital cystic lesion in children, accounting for over 40% of all orbital lesions of childhood and for 89% of all orbital cystic lesions of childhood that come to biopsy or surgical removal. Neural cysts include those associated with ocular maldevelopment (congenital cystic eye and colobomatous cyst) and those associated with brain and meningeal tissue (cephalocele and optic nerve meningocele). The most important secondary cyst is mucocele that can occur in children with cystic fibrosis. Inflammatory cysts are generally due to parasitic infestations and are more common in tropical areas of the world. Noncystic lesions that can have a cystic component include adenoid cystic carcinoma, rhabdomyosarcoma, lymphangioma, and others. Each type of cyst has rather characteristic, but not pathognomonic, clinical features. Computed tomography and magnetic resonance imaging can help differentiate a cystic lesion from a solid tumor, suggest the type of cyst, and help in planning management. The pathology varies with the cells that line the cyst and with the inflammatory agent. Management varies from local excision to observation, depending on the location and type of cyst. Orbital cysts of childhood can be classified into categories, based mainly on their histopathology. The clinical, radiologic, and histopathologic features can be correlated with the classification in order to better evaluate a child with a cystic lesion in the orbit.

Malignant ectomesenchymoma of the orbit in a child: Case report and review of the literature

Malignant ectomesenchymoma is a rare soft tissue tumor of childhood composed of both mesenchymal and neuroectodermal elements. Reported sites of origin are head and neck, abdomen, perineum, scrotum, and extremities. A new case of an orbital ectomesenchymoma in a 7-year-old boy is presented. The clinical picture of the tumor, radiological findings, and its histopathologic and immunohistochemical characteristics are described. The patient was successfully treated with combined surgical resection and chemotherapy. All the other reported cases of malignant ectomesenchymoma with various sites of origin are also reviewed.

Orbital teratoma: late presentation with normal vision

Orbital teratoma is a rare, rapidly growing tumour that usually presents with congenital proptosis. Visual outcome is usually poor. A case is described of orbital teratoma presenting in an 18-month-old child as an inferior orbital mass with normal vision and intermittent hypertropia. Computed tomography demonstrated a cystic mass containing a tooth adjacent to the inferior orbital fissure. Histology revealed tissues derived from all three germ cell layers. The tumour was removed with preservation of vision and resolution of the strabismus. Late presentation of an orbital teratoma with a good visual outcome is exceptional.

Congenital orbital cyst detected and monitored by prenatal ultrasonography

PURPOSE

High-resolution prenatal ultrasound can allow for early detection and monitoring of many fetal anomalies, including those involving the globe and orbit. We describe a case of a congenital orbital cyst detected and monitored by prenatal transvaginal ultrasonography.

METHODS

After detection of a congenital orbital cyst, serial transvaginal ultrasound examinations were performed through the remainder of the pregnancy to monitor the growth and development of the fetus and the orbital cyst.

RESULTS

A large retrobulbar orbital cyst causing extreme proptosis was detected at 23 weeks of gestation and monitored through the remainder of the pregnancy. Lack of growth, benign behavior, and appropriate interval fetal growth without destruction of adjacent structures was noted. After birth, early surgical intervention allowed for complete surgical excision of the cyst without the need for enucleation or exenteration. Fifteen months after excision, the patient wore a scleral shell and had a good cosmetic appearance with good ocular motility.

CONCLUSIONS

Prenatal ultrasound may allow for early detection of orbital masses. To our knowledge, this report describes the first case of a congenital orbital cyst detected and monitored by prenatal ultrasonography.

Nasolacrimal duct obstruction secondary to ectopic teeth

OBJECTIVE

To describe two patients with nasolacrimal duct obstruction (NLDO) caused by ectopic eruption of teeth. The literature concerning nasal and other unusual ectopic sites of tooth eruption is reviewed.

DESIGN

Two interventional case reports and literature review.

PARTICIPANTS

A 3-year-old girl with epiphora and recurrent dacryocystitis of the right eye. Previous medical and surgical management was unsuccessful. A 32-year-old female with a long history of right eye discomfort and epiphora. Previous examinations and workup were negative.

INTERVENTION

A computed tomographic (CT) scan of the orbits and sinuses was performed in both patients. The ectopic teeth were surgically removed.

MAIN OUTCOME MEASURES

Nasolacrimal system function and response to treatment at the last follow-up were recorded.

RESULTS

In the first patient, CT imaging disclosed two teeth within the right inferior meatus compressing the nasolacrimal duct. In the second patient, CT revealed a large dental structure in the maxillary sinus compressing the nasolacrimal duct. Endoscopic tooth extraction and nasolacrimal duct probing in the first patient and surgical removal of the dental structure in the second patient effected complete resolution of symptoms. Both patients were symptom free at last follow-up.

CONCLUSIONS

These cases suggest that ectopic eruption of teeth should be added to the differential diagnosis of NLDO. Surgical removal of the ectopic teeth compressing the nasolacrimal duct results in resolution of the lacrimal drainage obstruction.

Congenital orbital teratoma

BACKGROUND

The occurrence of proptosis at birth is unusual and may be associated with a variety of tumours and structural abnormalities. Congenital orbital teratoma is a rare cause of congenital proptosis.

METHODS

A case report is presented of a female infant with gross right proptosis.

RESULTS

Computed tomography demonstrated a characteristic multicystic structure with no intracranial involvement. Histological examination found tissues derived from all three germ cell layers, consistent with a congenita orbital teratoma. The tumour was successfully removed preserving the globe and vision.

CONCLUSIONS

This report is an example of how early surgical intervention may allow preservation of the globe and vision in some patients with congenital orbital teratoma.

Congenital malignant teratoid neoplasm of the eye and orbit: a case report and review of the literature

BACKGROUND

Medulloepithelioma is a tumor of the primitive medullary epithelium overlying the ciliary body. Most become evident early in life, and they may be malignant, although distant metastases are rare. The purpose of this report is to describe a unique case of congenital malignant teratoid neoplasm of the eye and orbit.

METHOD

A patient with a congenital malignant teratoid tumor of the eye and orbit is described, and a detailed histopathologic study of the ocular findings with a review of the literature is presented.

RESULTS

Histopathologic study showed that the lesion was a malignant teratoid neoplasm with a large orbital extension. Several intracranial structural abnormalities were identified.

CONCLUSION

The tumor described herein must be added to the differential diagnosis of congenital orbital masses. The clinician should be alert to the association of this lesion with complex intracranial abnormalities.

Orbital coccidioidomyosis presenting as a lacrimal gland fossa mass

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Alpha fetoprotein as marker for a case of orbital yolk sac tumour

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