Orbital teratoma: late presentation with normal vision

Orbital tooth - not always a teratoma : a case report

A 7-year-old girl presented with a painless firm to cystic mass in the infero-temporal quadrant of her right orbit since birth. The mass had recurred with a cutaneous sinus after initial surgery. Right eye vision was affected by mass induced astigmatism. The anterior and posterior segments were normal. Magnetic Resonance Imaging of the orbit suggested a mature teratoma within the orbital bone. Mass excision showed a fully developed molar tooth within a cyst associated with a cutaneous sinus. Histopathological examination reported odontogenic choriostoma. We report this unique case of orbital odontogenic choristoma in an unusual location, associated with a cutaneous sinus, emphasizing the need for complete excision to prevent recurrence.

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.

Congenital tooth-bearing tumor of the eyelid leading to lacrimal system obstruction

PURPOSE

We present an unusual case of a congenital lesion presenting with concomitant chronic dacryocystitis. The clinical presentation, examination, management, and histopathology are reviewed.

OBSERVATIONS

A healthy male infant born at 37 weeks gestation presented with an isolated painless 5mm congenital mass of the left medial lower eyelid. Parents also reported episodic epiphora and discharge from the left eye. A surgical excision of the mass revealed an underlying dacryocystitis and the presence of a formed tooth. A dacryocystorhinostomy was performed together with a repair of the soft tissue defect. Histopathology revealed components of disorganized epithelial and mesenchymal tissues including a tooth, skeletal muscle, fat, fibrous tissue, nonkeratinized epithelium, and myelinated nerves. A diagnosis of an odontogenic choristoma of the eyelid was made. Furthermore, a lacrimal sac culture was positive for oxacillin-susceptible Staphylococcus aureus with pathological evidence of chronic dacryocystitis.

CONCLUSIONS AND IMPORTANCE

Odontogenic choristoma is a very rare finding in the periocular region with only a few cases reported in the literature. Awareness of clinical findings from this case may allow for a more accurate clinical diagnosis and understanding of the embryologic mechanisms underpinning eyelid and nasolacrimal development. Timely management of this condition is critical to ensure normal oculofacial development and prevent future complications.

Odontogenic choristoma presenting as dermolipoma

A 5-year-old otherwise healthy girl presented to the oculoplastic service with a painless superotemporal subconjunctival mass in the left eye. Visual acuity was within normal limits, and there was no evidence of proptosis or orbital enlargement. Excision was performed to remove the anterior portion of the mass for alleviation of symptoms. On histopathological analysis, the mass was comprised of fibroadipose tissue consistent with dermolipoma and contained a hard nodule found to be a calcified tooth. In the periocular region, odontogenic choristoma (tooth) is a rare lesion, and has been reported to occur within teratomas, dermoid cysts, and displaced oral embryonic epithelium. We describe an unusual case of a tooth occurring within a sporadic dermolipoma. The clinical presentation, examination, management, and histopathology are reviewed.

Congenital Orbital Teratoma

We report a case of congenital orbital teratoma. A 3-day-old male, born at 39 weeks' gestation without relevant prenatal history, presented with a large vascularized proptotic mass distorting the left midface. Laboratory studies showed elevated serum alpha-fetoprotein (12,910 ng/ml). Computed tomography showed a multiloculated heterogeneous lesion composed of hypodense and hyperdense calcified areas encompassing the whole orbital cavity with expansion of the bony walls, as well as forward displacement and compression of the eyeball without extension to surrounding structures. Clinical, imaging and laboratory features were consistent with congenital orbital teratoma. Due to pronounced proptosis with exposure keratopathy and corneal perforation, no motility of the globe and no vision in the affected eye in a resource-limited setting, the patient underwent orbital exenteration. Histopathological examination confirmed the diagnosis of mature cystic teratoma. We describe the clinical course, radiographic and histopathological findings of this rare orbital tumor.

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.

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.

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.