Invasive squamous cell carcinoma arising from asymptomatic choristomatous cysts of the orbit. Two cases and a review of the literature

Invasive Orbital Squamous Cell Carcinoma in a Patient with Multiple Myeloma

Background

Orbital squamous cell carcinoma (SCC) is a rare entity. It is often a result of local invasion of SCC originating from the skin, nasopharynx, nasal cavity, paranasal sinuses, conjunctiva, lacrimal glands, or sac or less commonly occurs through hematogenous metastasis. Herein, we report a patient with orbital SCC with a history of multiple myeloma (MM). Case presentation. A 45-year-old woman with a history of MM in the past two years presented to our clinic complaining of gradual right eye proptosis for six months. The relative afferent pupillary defect was detected in the right eye on her examination. Ocular movements of the right eye were limited in all directions. Orbital magnetic resonance imaging demonstrated an infiltrative mass in the right orbit extended from the anterior to the orbital apex and the optic canal. The patient underwent debulking, and a histopathology examination revealed SCC results. No other secondary site was found to be the origin of the tumor.

Result

The patient underwent chemotherapy and subsequent radiotherapy. To our knowledge, this is the first report of concomitant MM and primary orbital SCC.

Differentiating intradiploic orbital dermoid and epidermoid cysts utilizing clinical features and machine learning

Purpose

The purpose of this study was to characterize intradiploic dermoid and epidermoid orbital cysts to determine any differences in clinical, radiographic, or surgical features.

Methods

A retrospective review was performed of patients presenting with intradiplopic dermoid or epidermoid cysts. Additionally, a complete review of the literature was performed to identify cases of intradiplopic orbital dermoid and epidermoid cysts. Data collected included age, sex, presenting symptoms, location of intradiplopic cyst, ophthalmic findings, treatment, and follow-up. Clinical features of dermoid versus epidermoid cyst were compared. Additionally, machine-learning algorithms were developed to predict histopathology based on clinical features.

Results

There were 55 cases of orbital intradiploic cysts, 49 from literature review and six from our cohort. Approximately 31% had dermoid and 69% had epidermoid histopathology. Average age of patients with dermoid cysts was significantly lesser than that of patients with epidermoid cysts (23 vs. 35 years, respectively; P = 0.048). There was no difference between sex predilection, presenting symptoms, radiographic findings, or surgical treatment of dermoids and epidermoids. The majority of patients (64%) underwent craniotomy for surgical removal. Machine-learning algorithms KStar and Neural Network were able to distinguish dermoid from epidermoid with accuracies of 76.3% and 69%, respectively.

Conclusion

Orbital intradiploic cysts are more commonly epidermoid in origin. Dermoid cysts presented in younger patients; however, there were no other significant differences in features including ophthalmic or radiographic findings. Despite similar features, machine learning was able to identify dermoid versus epidermoid with good accuracy. Future studies may examine the role of machine learning for clinical guidance as well as new surgical options for intervention.

Pilosebaceous Malignant Transformation of Dermoid Cyst in the Orbit

Dermoid cysts may occur in the orbit, most commonly in the superolateral area. Malignant transformation of such lesions has been previously reported; however, most turn out to be squamous cell carcinoma. The authors' patient initially presented with mild proptosis and limitation in extraocular movements. Preliminary biopsy showed whitish amorphous material and abundant hairs filling the thin-walled cyst, consistent with dermoid cyst. The patient underwent tumor resection via lateral orbitotomy with bone window and transorbital endoscopic approach for the dural involvement. Final biopsy showed dermoid cyst with pilosebaceous malignant transformation showing p53 expression and 30% of Ki-67 index. Adjuvant radiotherapy was performed. To the best of the authors' knowledge, this is the first reported case of this type. Despite its rarity, there should always be a high index of suspicion and complete work-up for an accurate diagnosis.

Orbital and periorbital dermoid cysts: Comparison of clinical features and management outcomes in children and adults

PURPOSE

To compare differences in clinical presentation and management outcomes of orbital and periorbital dermoid cysts in children and adults.

METHODS

A retrospective interventional comparative consecutive case series. 203 patients in (148 children [Age ⩽18 years] and 55 adults [Age >18 years]), who underwent excision biopsy for orbital/periorbital dermoid cyst were included. Outcome measures included the differences in demography, clinical presentations, radiological features, surgical outcomes and histopathology of cysts between children and adults with dermoid cysts.

RESULTS

The mean age noted at excision was 15 years in this cohort of 148 children and 55 adults. Commonest clinical finding observed was a subcutaneous painless mass (94%) and external angular dermoids were commonest in both groups 1 and 2 (51% and 56%). Diminution of vision (p = 0.007), proptosis (p = 0.008), extraocular motility limitation (p = 0.001), strabismus (p = 0.003) and relative afferent pupillary defect (p = 0.02) were significantly more in adults. Orbital involvement and dumbbell dermoids were not significantly different between children and adults. Radiologically, bony fossa formation (p = 0.03), temporal fossa extension (p = 0.04), full thickness bony defect (p = 0.03) and intraosseous presentation (p = 0.005) were significantly more in adults. Comparison of proportion of lesions having intra-operative rupture of dermoid cyst (p = 0.009) and evidence of inflammation on histopathology (p = 0.01) were significantly more in adults. However, recurrence rates were not different between children and adults.

CONCLUSIONS

Dermoid cysts are commoner in children, but can also present in adulthood. Secondary visual, orbital, radiologic changes and intra-operative rupture of dermoid cyst are more common in adults compared to children.

Case Report: Primary Orbital Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) of the orbit is almost uniformly the result of local invasion from a cutaneous primary, extension by perineural invasion, or the result of metastasis. This is owed to the lack of native squamous epithelium in the orbit. After review of the literature, to date, only 6 reports of 8 patients with primary orbital SCC exist. Of those cases, only 2 reported non-apical orbital SCC. There are 2 reports of orbital SCC after retina surgery with proposed transplanted conjunctival epithelium and subsequent malignant transformation of a conjunctival cyst. The initial signs and symptoms can be vague and lead to delay in diagnosis. We present a case of primary orbital SCC and discuss the workup, imaging, and multidisciplinary management of this rare condition.

Squamous Cell Carcinoma Presenting as an Orbital Cyst with Radiologic Evidence of Perineural Invasion

Purpose

To report clinical and radiologic findings of cystic squamous cell carcinoma (SCC) of the orbit with evidence of perineural involvement.

Methods

Analysis of clinical findings and radiology with a literature review.

Results

A 66-year-old man with SCC of the forehead 8 years prior presented with paresthesias, diplopia, and proptosis. Magnetic resonance imaging showed a well-defined, cystic mass of the orbit with a single, linear structure running through its center. Lateral orbitotomy revealed a cyst adherent to adjacent periorbita containing viscous, clear, yellow substance and a nerve coursing through the center. Histopathology confirmed poorly differentiated spindle cell carcinoma with positive staining for cytokeratin markers, consistent with SCC.

Conclusions

Orbital cysts associated with altered sensation are suggestive of SCC with perineural spread, requiring prompt investigation and treatment to minimize morbidity and mortality. The involved nerve may be seen as a single, linear structure within the mass on imaging.

A clinical update and radiologic review of pediatric orbital and ocular tumors

While pediatric orbital tumors are most often managed in tertiary care centers, clinicians should be aware of the signs of intraocular and orbital neoplasms. In the pediatric population, a delay in diagnosis of orbital and intraocular lesions, even if benign, can lead to vision loss and deformity. Intraocular lesions reviewed are retinoblastoma, medulloepithelioma, and retinal astrocytic hamartoma. Orbital neoplasms reviewed are rhabdomyosarcoma, neuroblastoma metastases, optic pathway glioma, plexiform neurofibroma, leukemia, lymphoprolipherative disease, orbital inflammatory syndrome, dermoid and epidermoid inclusion cysts, and Langerhans' cell histiocytosis. Vascular lesions reviewed are infantile hemangioma and venous lymphatic malformation. In conjunction with clinical examination, high-resolution ophthalmic imaging and radiologic imaging play an important role in making a diagnosis and differentiating between benign and likely malignant processes. The radiologic imaging characteristics of these lesions will be discussed to facilitate prompt diagnosis and treatment. The current treatment modalities and management of tumors will also be reviewed.

[Intraorbital dermoid cyst. Case report and review of the literature]

Periorbital dermoid cysts are benign tumors most often seen in young children. Intraorbital location, though rare, should not be overlooked. Good quality imaging plays a major role in the etiological diagnosis, providing a precise analysis of the location of the lesion, its components, and its effects on adjacent and nearby structures, as well as in planning the surgical approach. The authors report a case of a 46-year-old male with an intraorbital dermoid cyst presenting with progressive left proptosis. Appearance on imaging (CT and MRI) was consistent with intraorbital dermoid cyst. The tumor was extirpated. Histopathologic examination confirmed the diagnosis of dermoid cyst. We also present a review of the literature.

Isolated squamous cell carcinoma of the orbital apex

A 43-year-old woman (Case 1), 63-year-old man (Case 2), and a 67-year-old man (Case 3) presented with diplopia (Cases 1, 2, and 3) and upper-eyelid ptosis (Cases 1 and 3). The cases had preceding cranial nerve V1 disturbances ranging from 3 months to 8 years. Each demonstrated complete internal ophthalmoplegia and external ophthalmoplegia. No case had a cutaneous squamous cell carcinoma (SCC) on presentation or by history. Imaging revealed isolated orbital apex masses. Tumor biopsies revealed SCCs of various differentiations. Systemic workup revealed no extraorbital malignancy. All received radiation therapy, and 2 patients underwent adjuvant chemotherapy. One patient is alive since diagnosis (49 months). In Case 2, SCC developed in the contralateral orbit, and the patient died 19 months after diagnosis; and Case 3 died 12 months after diagnosis. These isolated cases of orbital SCC may have arisen from orbital choristomatous squamous epithelium, may represent de novo or metastatic tumors, or may be manifestations of occult perineural spread.

Uncommon presentation of an intradiploic orbital epidermoid tumor: case report

PURPOSE

Epidermoid tumors are uncommon entities that usually occur intradurally in the cerebellopontine angle and parasellar cisterns. The few cases that have been reported to occur in the intraorbital location involve patients in the first four decades of life. To our knowledge, an elderly person presenting with an orbital epidermoid tumor has never been reported.

METHODS

A 67-year-old man presented with left-sided headache and eye pain. He was found to have a hemorrhagic lesion eroding bone of the greater and lesser wings of the sphenoid that was compressing the frontal and temporal lobes and displacing the globe. Significant edema of the frontal lobe was noted.

RESULTS

Aggressive surgical excision was performed with cranioplasty and orbital reconstruction. Near resolution of the patient's proptosis and eye pain was achieved. Histologic analysis revealed the lesion to be an epidermoid tumor.

CONCLUSIONS

Hemorrhage into a growing intradiploic orbital epidermoid and surrounding frontal lobe edema created an unusual presentation of this rarely occurring entity in an elderly man. Surgical excision allowed appropriate histologic diagnosis and resolution of symptoms. Epidermoid tumor is a rare but possible entity in the differential diagnosis of elderly patients presenting with acute ocular pain and proptosis.

The Bell's toll

A 70-year-old man presented complaining of lid and facial drooping and facial numbness, which progressed over several months. Magnetic resonance imaging of the head showed an enlarged right cavernous sinus. His past medical history was remarkable to squamous cell carcinoma of the face. The patient underwent a craniotomy with biopsy of the cavernous sinus that confirmed malignancy. High index of suspicion in a patient that presents facial drooping and/or numbness should alert ophthalmologists about the occurrence of perineural spread of a previous malignant lesion of the skin.

[Congenital orbital tumors in adults (dermoid cysts)]

The most frequent intraorbital congenital tumors are dermoid cysts, which account for 2-9% of all orbital tumors. Teratomas are also congenital tumors but occur only in children. The revealing clinical sign is a subcutaneous mass along the superior orbital rim if the cyst is superficial or proptosis if the cyst is deep. Neuroradiological work-up provides the preoperative diagnosis. The treatment is solely surgical.

Ocular Adnexal Pseudo-Cyst Formation as a Characteristic Feature of Perineural Spread in Squamous Cell Carcinoma

PURPOSE

To report the clinical features in a series of patients with perineural spread of squamous cell carcinoma involving periorbital nerves that presented with clinical and/or imaging evidence of pseudo-cystic transformation along the involved nerves.

METHODS

A noncomparative, retrospective chart review of the clinical and imaging findings of patients attending a regional orbital surgery department between 1998 and 2005, presenting with a pseudo-cystic orbital mass on clinical examination and/or imaging, which proved to be due to perineural squamous cell carcinoma on histopathology.

RESULTS

The study included 8 male patients with a mean age at referral of 66 +/- 11 years. All cases had associated cutaneous squamous cell carcinoma involving the face or scalp, and, in 4 cases, the primary tumor could be identified in the vicinity of the affected orbit. The duration of the symptoms varied from 5 weeks to 9 years (24 +/- 36 months). Altered sensation, including formication and hypo-esthesia in the V1 and V2 trigeminal division, motor nerve palsies, and ptosis in conjunction with a palpable periorbital mass, were the most common presentations. The cystic tumor deposits were assessed histologically with both hematoxylin and eosin and immunoperoxidase stains (S100 protein for neural structures identification and MNF116 as a keratin marker). This demonstrated malignant squamous epithelium both within and around the wall of the tumor deposit and, in continuity, within the nerve running through the lesion. Some nerves showed substantial areas of fibrosis, representing obliteration of the nerve structure caused by involvement by tumor. Treatment modalities included surgical debulking, exenteration, radiotherapy, and combined chemo-radiotherapy. Mean follow-up was 29 +/- 23 months. Eight patients (87.5%) remain alive, and five of them show no evidence of disease. One patient died after progression of the malignancy.

CONCLUSIONS

The presence of a cystic lesion in association with sensory or motor deficit in the periorbital region should suggest a diagnosis of perineural spread from a cutaneous squamous cell carcinoma. Because these patients may present to the ophthalmologist first, an awareness of this entity is of critical importance to avoid the delayed diagnosis seen in half of our cases.

Primary Squamous Cell Carcinoma Arising From an Epithelium-Lined Cyst of the Lacrimal Gland

A 66-year-old man presented with a slowly enlarging, nontender left orbital mass of 2 months' duration. CT and MRI showed a left lacrimal gland mass with enhancement and internal irregularity of cystic structures. Histopathologic analysis of the biopsy specimen revealed a squamous cell carcinoma arising from an epithelium-lined cyst. The patient underwent left orbital exenteration followed by radiation treatment. No evidence of tumor recurrence was observed after a follow-up of 30 months. We believe this primary squamous cell carcinoma may have arisen either from preexisting lacrimal duct cyst (dacryops) with areas of squamous metaplasia or, less likely, from a choristomatous epithelium-lined cyst of the lacrimal gland. Although rare, this entity should be included in the differential diagnosis of cystic lesions of the lacrimal gland.

The management of perineural spread of squamous cell carcinoma to the ocular adnexae

PURPOSE

To analyze a series of patients with periorbital perineural spread of squamous cell carcinoma and propose treatment guidelines.

METHODS

Retrospective, noncomparative, interventional case series of 17 patients with clinical, radiologic, or histologic evidence of distant perineural spread. Treatment, recurrence, progression, and mortality rates were recorded.

RESULTS

Numbness and pain were the most common symptoms, whereas ophthalmoplegia, ptosis, and facial palsy were the most frequent signs. All cases received wide-field radiotherapy to at least 50 Gy. Chemotherapy and surgery (biopsy, debulking, exenteration) were used in selected cases. Disease progression occurred in 6 patients, 4 of whom died. Median disease-free survival in the remainder was 37.5 months.

CONCLUSIONS

The diagnosis of perineural spread is largely clinical and may be confirmed with imaging findings in the majority of cases. The role of biopsy is usually complementary but may be essential in some cases. In patients with evidence of distant perineural spread, radiotherapy volumes inclusive of potential antegrade and retrograde spread are recommended. Three-dimensional conformal planning or intensity-modulated radiation therapy assists in minimizing damage to adjacent structures. Synchronous chemotherapy should be considered to potentiate the effectiveness of radiation. The place of surgery in the treatment of perineural spread is palliative.

Deep frontotemporal dermoid cyst presenting as a discharging sinus: a case report and review of literature

The commonest location for dermoid cysts in the head and neck is at the frontotemporal or brow region. They usually present as discrete slow growing masses located superficially at the angle of the brow. The presentation as a discharging sinus in the frontotemporal region is rare. In contrast, it is common for nasal dermoids to present as sinuses or fistulae (10-45%) and with a tract extending deep to involve the underlying bone or intracranium. In view of their differences in presentation, preoperative CT scans are generally recommended for the nasal dermoids but not for the frontotemporal dermoids. We report a rare case of a deep frontotemporal dermoid cyst presenting as a discharging sinus at the right temporal region in a girl aged 2 years and 6 months. It had a sinus tract extending deep to form an intraosseous cyst in the frontal and sphenoid bone. The base of the cyst was attached to the dura of the middle cranial fossa. Only a few similar cases were reported in the literature. In the light of our experience with this case, we recommend that this rare type of frontotemporal cyst sinus be operated only after a CT or MRI scan.