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

Ocular and orbital tumors in childhood

Pediatric tumors of the eye and orbit can be benign or malignant as well as congenital or acquired and are usually distinctively different than those seen in adults. Although most of these neoplasms are benign (eg, dermoid cyst, chalazion, molluscum), their location near and within a vital organ can result in serious dermatologic and ophthalmologic sequelae. Lesions discussed include vascular lesions, retinoblastomas (the most common primary pediatric intraocular malignancy), rhabdomyosarcoma (the most common primary pediatric orbital malignancy), Langerhans cell histiocytosis, and metastatic lesions to the orbit (neuroblastoma, Ewing sarcoma). Although cysts and ocular melanoma can occur within the pediatric population, these conditions are covered in other contributions in this issue of Clinics in Dermatology.

Juvenile Xanthogranuloma of the Head and Neck: Imaging Findings in 11 Cases

BACKGROUND

Juvenile Xanthogranuloma (JXG) is a non-Langerhans cell histiocytosis, occurring mainly in infancy. With an extracutaneous lesion, its diagnosis is difficult, because of a wide clinical spectrum. Here we demonstrate and characterize imaging features of 11 patients with JXG of the head and neck in various locations.

MATERIAL AND METHODS

We recorded clinical data and reviewed all imaging studies of 11 patients with JXG of the head and neck. Ultrasonography (US) alone was performed in 1 patient; MRI alone in 6 patients; US and MRI in 1 patient; and US, CT, and MRI in 3 patients. We evaluated the following characteristics in all studies: location and number of lesions, echogenicity and vascularization on US, density on CT, signal intensity on T1- and T2-weighted images, ADC and enhancement on MRI, and tumor boundaries and bone involvement.

RESULTS

Lesions were well-defined in 9 cases, and bone erosion was present in 2. On US, lesions were hypoechoic or hyperechoic and with or without vascularization. On CT, lesions were hyper-dense, with no calcification. On MRI, lesions were mildly hyper-intense or iso-intense on T1-weighted images in 8 of 9 patients, hypo-intense on T2-weighted images in 7 of 10, low ADC in 7 of 9, and enhancement in 7 of 7.

CONCLUSIONS

The diagnosis of extra cutaneous JXG may be proposed, with the following suggestive criteria: age < 1 year, well-defined lesion, mild hyper-intensity on T1-weighted images, hypo-intensity on T2-weighted images, low ADC, enhancement, and possible adjacent bone involvement.

Gastric Ganglioneuroblastoma in an Elderly man: A Case Report and Literature Review

Background. Ganglioneuroblastoma is a borderline tumor of sympathetic origin that is considered a childhood disease, with the majority of patients occurring in children less than five years old and few patients occurring in adults. There are no treatment guidelines for adult ganglioneuroblastoma. Here, we report a rare patient of adult gastric ganglioneuroblastoma that was completely resected by a laparoscopic approach. Case presentation. A 73-year-old man presented with dull pain in the upper abdomen along with abdominal distension for one month. Gastroscopy examination revealed chronic gastritis and submucosal tumors of the gastric antrum. Endoscopic ultrasonography showed a hypoechoic mass in the gastric antrum arising from the muscularis propria. An abdominal computed tomography scan revealed an irregular soft tissue mass in the gastric antrum with heterogeneous enhancement in the arterial phase. The mass was completely resected by laparoscopic surgery. Postoperative histopathology revealed that the mass contained differentiated neuroblasts, mature ganglion cells and ganglioneuroma components. The pathological diagnosis was ganglioneuroblastoma intermixed, and the patient was determined to be in stage I. The patient received no adjuvant chemotherapy or radiotherapy. At his two-year follow-up, the patient was doing well and showed no signs of recurrence. Conclusion. Despite the rarity of gastric ganglioneuroblastoma as a primary site of origin, it should be considered in the differential diagnosis of gastric masses in adults. Radical surgery is sufficient for the treatment of ganglioneuroblastoma intermixed, and long-term follow-up should be performed.

Assessing the Usefulness of Ultrasonography for the Diagnosis and Evaluation of Intra-Orbital Lesions in Pediatric Patients: A Retrospective Analysis

OBJECTIVES

To assess the usefulness of ultrasonography in the diagnosis and evaluation of extraocular intra-orbital lesions in pediatric patients.

METHODS

Twenty-three pediatric patients with intra-orbital lesions who underwent both ultrasound and computed tomography/magnetic resonance imaging (CT/MRI) were included. The following parameters were evaluated using ultrasound: 1) lesion detection rate (presence or absence of lesions), 2) lesion characteristics, 3) lesion location (extraconal or intraconal), and 4) the lesion longest linear dimensions, and these were compared using Fisher's exact test and Mann-Whitney U test.

RESULTS

Two lesions could not be detected using ultrasound; in the other 21 cases, the lesion characteristics diagnosed by ultrasound were correct. Diagnostic accuracy of detection and characteristics assessment using ultrasound were 91.3% and 91.3%, respectively. The lesion location was not significantly different between the two groups (intraconal/extraconal in those detected using ultrasound versus those in the absence on ultrasound = 7/14 versus 0/2, P > .999); however, in two cases that were not detected on ultrasound, the lesions were located at extraconal. Lesions that were small in longest linear dimensions on CT/MRI were not detected using ultrasound (the longest linear dimensions in lesions detected using ultrasound versus that in the absence of ultrasound: 29.5 ± 8.2 [range, 13-46] versus 10 and 11 mm, P = .043).

CONCLUSIONS

Ultrasonography proved to be useful for visualizing and evaluating intra-orbital lesions except for lesions that were relatively small in size. Therefore, although ultrasound could not detect lesions located behind bone and bone invasion, it could be used for diagnosing and selecting treatment strategies for intra-orbital lesions.

[Embryonic development and congenital diseases of the orbit]

Many neuroradiologists focus primarily on the central nervous system and give little attention to other regions like the eye/orbit. It is easy to be deceived by the pitfall called satisfaction of search (also abbreviated SOS), despite most congenital eye diseases being easily recognized if one is aware of them. In this article, the most common congenital orbital abnormalities are described, and their basic prenatal causes are summarized.

New-Onset Vision Impairment in Children: Magnetic Resonance Imaging Findings by Age Groups

INTRODUCTION

Non-traumatic visual impairment is rare in the pediatric population, but early diagnosis and treatment of the cause is crucial to prevent long-term consequences affecting children's neurocognitive development. The authors aim to determine the most common causes of non-traumatic visual impairment in pediatric patients according to age groups by magnetic resonance imaging (MRI).

METHODS

Images of patients who underwent contrast-enhanced cranial and orbital MRI for new-onset visual impairment between June 2019 and June 2022 were retrospectively reviewed. MRI findings were categorized as tumors, idiopathic intracranial hypertension, demyelinating disorders, infections, isolated optic neuritis, and others. The patients were grouped according to age as preschoolers, schoolchildren, and adolescents. Demographic features of patients and MRI findings were collected and compared among age groups.

RESULTS

One hundred seventeen of the 238 patients had pathologic MRI findings. The most common pathologies were tumors (26.4%), idiopathic intracranial hypertension (24.7%), demyelinating disorders (18.8%), infections (11.1%), and isolated optic neuritis (7.6%). Tumors (69.2%) in preschool children, idiopathic intracranial hypertension (36.3%) in schoolchildren, and demyelinating disorders (32.7%) in adolescents were the most common cause of vision impairment by age group.

CONCLUSION

Children with acute vision impairment could have severe pathologies. Tumors in preschool children, idiopathic intracranial hypertension in schoolchildren, and demyelinating disorders in adolescents were the most common causes of new-onset vision impairment detected with MRI. Because of the difficulty of performing optimal ophthalmologic and neurologic examinations, especially in young children, cranial and orbital MRI should be considered to detect life-threatening pathologies.

Genetic Risk Factors and Clinical Outcomes in Childhood Eye Cancers: A Review

Childhood eye cancers, although rare, present substantial health challenges, affecting the pediatric population with a remarkable impact on their lives and families. This comprehensive review provides insights into the various types of ocular tumors, primarily focusing on malignant eye tumors, their genetic predispositions, and advancements in managing these conditions. Understanding the genetic risk factors is crucial for early detection, risk assessment, and the development of targeted therapies. This review discusses genome-wide association (GWAS) and next-generation sequencing (NGS) studies to find common and rare genetic variants. Furthermore, it also explores the outcomes and implications of these genetic discoveries in treating pediatric ocular cancer. These findings underscore the significance of genetic research in guiding early interventions and improving outcomes in children with ocular cancers.

An advanced case of pediatric ciliary body medulloepithelioma with detailed literature review

INTRODUCTION AND IMPORTANCE

Medulloepithelioma is the second most common primary intraocular malignant tumor in children but is often diagnosed late, which worsens the prognosis.

CASE PRESENTATION

We are reporting a 6-year-old boy presenting with a ciliary body (CB) teratoid malignant medulloepithelioma (TMM), which was missed at the initial presentation. We added our case to the 97 previously reported cases in our literature review that were confirmed by cytological or histopathological examination.

DISCUSSION

Medulloepithelioma has a wide age range at presentation with a mean of 5.3 ± 4.1 years, and slight male predominance (M: F ratio of 1.15). Clinically, the main symptoms/ signs are reduced visual acuity, lens changes, or a pupil "mass." Almost all reported medulloepitheliomas were unilateral (98 %). Histopathologically, non-teratoid malignant medulloepithelioma (NTMM) (35.7 %) and TMM (34.5 %) were the commonest. Enucleation was the main treatment modality because of the large tumor size of 72.7 %. A combination of chemotherapy and/or radiotherapy was used in 15.1 % and brachytherapy for small lesions in 14.1 %. Orbital exenteration was needed in 3 cases because of orbital invasion.

CONCLUSION

A CB medulloepithelioma tumor can be easily missed, diagnosed late, with less chance for globe salvaging. The malignant types are more common and may result in orbital invasion, requiring even more extensive surgery. Therefore, when facing a child with lens changes, a pupil "mass," or raised intraocular pressure, pediatricians and general ophthalmologists must have an earlier suspicion and be aware of this rare entity to improve outcomes and reduce loss of vision or other disease-related morbidity.

Orbital manifestations of B-cell acute lymphoblastic leukemia/lymphoma

A 2-year-old boy presented with left periorbital edema, proptosis, hyperglobus and esotropia. Imaging revealed an inferotemporal orbital mass with adjacent bony erosion. Histological evaluation of an orbital biopsy revealed B-cell acute lymphoblastic leukemia/lymphoma (B-ALL/BLL). The patient was subsequently treated with chemotherapy. Although orbital involvement in acute myelogenous leukemia has been well-described, orbital manifestations of B-ALL/BLL are uncommon, with only a limited number of previous reports in the literature.

Orbital Rhabdomyosarcoma Masquerading as a Dermoid Cyst: A Case Report and Review of the Literature

The purpose of this report is to present a case of orbital rhabdomyosarcoma (RMS) masquerading as a dermoid cyst. A six-year-old boy with an unremarkable medical history presented in the outpatient department with a palpable mass in the superonasal region of the right orbit, which had rapidly grown in the past month. The most likely diagnosis was dermoid cyst and the patient was scheduled for surgical excision. A high index of suspicion was raised intraoperatively based on the appearance of the lesion due to the presence of a feeder vessel. The histopathology examination identified alveolar RMS. The patient was referred to a pediatric oncology department and commenced intravenous chemotherapy. RMS may masquerade as various conditions, including dermoid cysts and chalazion. A high index of suspicion should be raised in cases with rapidly growing lesions.

Prevalence and clinical features of orbital vascular anomalies in children

PURPOSE

To report the prevalence, clinical characteristics, and natural history of orbital vascular anomalies diagnosed among children over a 50-year period.

METHODS

The medical records of all patients <19 years diagnosed with any form of an orbital vascular anomaly (OVA) at Mayo Clinic, Rochester, Minnesota from January 1 1966, through December 31 2015, were retrospectively reviewed.

RESULTS

A total of 109 children were diagnosed with OVA during the 50-year period, of which 24 were from Olmsted County, MN, yielding a birth prevalence of 1 in 4,305 live births. The median age at diagnosis for the 109 patients was 1.2 years (range, 0-17.9 years) and 67 (61.5%) were female. Common presenting symptoms included proptosis in 80 (73.4%) patients, abnormalities in skin color in 45 (41.3%) patients, and pain in 18 (16.5%) patients. There were 55 (50.5%) vascular malformations [50 (91%) low-flow lymphatic malformations, 3 (5.5%) high-flow arteriovenous malformations, and 2 (3.5%) low-flow venous malformations] and 54 (49.5%) vascular tumors [53 (98%) capillary hemangiomas and 1 (2%) kaposiform hemangioendothelioma]. During a mean follow-up of 5.95 years (range 0-27.7 years), amblyopia and/or strabismus were diagnosed in 46 (43.4%) patients.

CONCLUSIONS

Capillary hemangiomas and low-flow lymphatic malformations comprise most of the orbital vascular anomalies in this cohort of children. Amblyopia and strabismus are common sequelae, highlighting the importance of early diagnosis and appropriate management.

Orbital rhabdomyosarcoma in a 19-year-old male patient: A case report and literature review

Rhabdomyosarcoma (RMS) is the most common mesenchymal tumor in children and adolescents, with 10% of cases occurring in the orbits. RMS should be suspected whenever children present with rapidly progressing unilateral exophthalmos. Its symptoms depend on the lesion's origin and location. We report the clinical case of a 19-year-old male patient admitted to the hospital because of blurred vision and bulging eyes that gradually increased over several months. Magnetic resonance imaging showed a mass located mainly in the left orbit, pushing and deforming but not invading the eyeball. The lesion had grown into the left ethmoid sinus wall. The histopathological incisional biopsy results were with alveolar RMS.

Imaging of pediatric calvarial and skull base tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee/ASPNR White Paper

A standardized imaging protocol for pediatric oncology patients is essential for accurate and efficient imaging, while simultaneously promoting collaborative understanding of pathologies and radiologic assessment of treatment response. The objective of this article is to provide standardized pediatric imaging guidelines and parameters for evaluation of tumors of the pediatric orbit, calvarium, skull base, and temporal bone. This article was drafted based on current scientific literature as well as consensus opinions of imaging experts in collaboration with the Children's Oncology Group Diagnostic Imaging Committee, Society of Pediatric Radiology Oncology Committee, and American Society of Pediatric Neuroradiology.

Orbital rhabdomyosarcoma in children

Purpose. To analyze the results of treatment and active monitoring the children with orbital rhabdomyosarcoma (RMS) with an emphasis on vital prognosis. Material and methods. We examined 32 children with RMS (18 boys, 14 girls) aged 2 months to 12 years, whose case history ranged from 1 week to 16 weeks (median, 5 weeks). The median follow-up was 60 months. The tumor was localized in the upper (n = 13), upper internal (n = 9), lower (n = 4), internal (n = 3), and external (n = 3) quadrants. The patients underwent primary surgical treatment: orbitotomy using transcutaneous (n = 26), transconjunctival (n = 2) and subperiosteal access (n = 4) followed by cytological, histological and immunohistochemical tissue verification in all cases. Results. The highest number of RMS cases was noted in in the 2- to 7-year-old group (66 % of patients). All patients were treated in in-patient settings. Complete macroscopic removal of tumor was performed in 17 cases, partial removal in 9 cases, and biopsy sampling in 6 cases. The embryonic type of RMS accounted for 87 % (n = 28), and the alveolar type, for 13 % (n = 6). In the postoperative period all children received combined therapy (systemic polychemotherapy and distant radiation therapy) in in-patient facilities of special oncological and radiological clinics. The survival rate of the whole group was 100%. In the long-term follow-up period (after 3 to 5 years), reconstructive surgeries were performed to correct ptosis and strabismus, and/or spectacle or prismatic correction of complex or mixed astigmatism. In cases of “dry” eye syndrome, conservative local therapy was offered. After orbital exenteration, ectoprosthesis procedures was applied. Conclusion. The analysis of our observations of 32 children with orbital rhabdomyosarcoma showed a 100 % survival rate, which testifies to the importance of timely diagnosis and combined treatment of the tumor.

Paediatric orbital ultrasound: Tips and tricks

Background

The orbital structures are ideally suited for ultrasound examination due to their superficial location and cystic composition of the eye. However, orbital ultrasound remains an underutilised modality due to preference for other cross-sectional modalities in general practice.

Aim

In this article, we review the basic principles, clinical uses and technique of orbital ultrasound in peadiatric patients.

Materials and methods

The clinical utility of orbital ultrasound in peadiatric patients is demonstrated using selected cases.

Results

Ultrasound is useful in the diagnosis of various posterior segment pathologies, especially in conditions causing opacification of light-conducting media of the eye. It is also beneficial in diagnosing various orbital pathologies, particularly in differentiating solid from cystic lesions.

Discussion

The added advantages of its use in children include lack of ionising radiation and reduced requirement of sedation or general anesthesia. Ultrasound is the most practical initial investigation in cases where ophthalmoscopy is limited by opacification of ocular media. The addition of color Doppler on ultrasound can give additional information about the vascularity of the lesion.

Conclusion

Use of ultrasound can be streamlined into the workup of various orbital and ocular pathologies either as an initial investigation or as a problem-solving tool in cases with a diagnostic dilemma on other modalities.

Imaging Findings of Pediatric Orbital Masses and Tumor Mimics

Pediatric orbital masses are not common but encompass a wide spectrum of benign and malignant entities that range from developmental anomalies to primary and secondary orbital malignancies and metastatic disease. Certain orbital tumors are unique to pediatric patients, such as retinoblastoma and neuroblastoma. Clinical symptoms and signs are often insufficient to differentiate between orbital lesions, and imaging is essential for narrowing the diagnostic considerations and determining the most appropriate management strategy. MRI is the primary imaging modality for evaluating orbital masses in children, with US and CT playing complementary roles. The authors review a spectrum of masses and tumor mimics that affect the pediatric globe and orbit. The shared and differentiating characteristics of pediatric orbital lesions are reviewed. Emphasis is placed on utilizing an orbital compartment-based approach to narrow the differential diagnosis. By using this organizational scheme, the authors describe intraocular processes (retinoblastoma, persistent fetal vasculature, and Coats disease), intraconal lesions (lymphatic malformation, schwannoma, optic nerve sheath meningioma, and optic pathway glioma), extraconal lesions (infantile hemangioma, rhabdomyosarcoma, idiopathic orbital inflammation, lymphoma, venous varix, plexiform neurofibroma, and pleomorphic adenoma of the lacrimal gland), and lesions involving the bony orbit (dermoid cyst, metastatic neuroblastoma, and Langerhans cell histiocytosis). The authors describe the basic management of each entity. Orbital infections and traumatic lesions are beyond the scope of this article. ^©RSNA, 2022.

Pediatric Oculo-orbital Tumor Characteristics, Imaging and Histopathology Agreement in a Tertiary Level Teaching Hospital, Ethiopia

BACKGROUND

Oculo-orbital tumors are frequently encountered pathologies and late diagnosis results in high morbidity and mortality in developing countries. This study aims to assess the computed tomography and magnetic resonance imaging patterns of pediatric oculo-orbital tumors with particular emphasis on retinoblastoma and compare agreement between imaging and histopathology diagnosis.

METHODS

A retrospective analysis of 101 pediatric patients with oculo-orbital lesions from February 2017 to January 2020 at Tikur Anbessa Specialized Hospital oncology center. Medical records were reviewed for clinical data, history, physical examination, pretreatment eye exam under anesthesia (EUA), computed tomography (CT) magnetic resonance imaging (MRI) and histopathology reports. The agreement between imaging and histopathology diagnosis was analyzed.

RESULTS

Malignant oculo-orbital tumors represented 97 (96.1%) cases. Age group 2-5 years had 56 (55.4%) cases of oculo-orbital tumors. Retinoblastoma accounted for 78 (77.2%) followed by rhabdomyosarcoma in 8 (7.9%) patients. The primary patient complaint was proptosis in 78 (77.2%) followed by leukocoria in 16 (15.8%). In 88 (89.7%) cases, there was agreement between imaging and histologic findings with 72 out of the 75 histopathology confirmed cases of retinoblastoma showing an agreement. Retinoblastoma patients presented at an advanced stage with orbital and intracranial extension.

CONCLUSIONS

In conclusion, patients with oculo-orbital tumors presented with advanced stage of disease. Excellent imaging and histopathology agreement was demonstrated.

Acute myeloid leukaemia presenting as proptosis in an infant

Paediatric patients with acute myeloid leukaemia (AML) often present with symptoms associated with the disruption of normal haematopoiesis and subsequent cellular deficiencies. Periosteal reactions are common in paediatric leukaemia, but typically manifest as a thin, laminated pattern along long bones. Aggressive periosteal reactions are much less frequently seen. Here, we report a case of paediatric AML initially presenting with proptosis and periorbital swelling caused by aggressive, sunburst periosteal reactions surrounding the sphenoid and zygomatic bones. This unique presentation emphasises the importance of considering leukaemic infiltration in the differential for sunburst periosteal reaction in paediatric patients.

Rare neonatal malignant primary orbital tumors: Three case reports

BACKGROUND

Aggressive malignant primary orbital tumors are extremely rare in newborns. The current cases further clarify the clinical features of malignant primary orbital tumors in neonates.

CASE SUMMARY

At the time of presentation at the Seventh Center of People’s Liberation Army General (PLAG) Hospital, the children were 1-, 2- and 5-mo-old, respectively, and included 2 boys and 1 girl. All three cases had unilateral proptosis at birth, and underwent mass excision and histopathologic examination. A peripheral primary neuroectodermal tumor, an aggressive infantile fibromatosis and an embryonic rhabdomyosarcoma were diagnosed, respectively. The first case underwent routine chemotherapy following surgery but died within three months due to worsening condition as the tumor spread throughout the body. The other two children were treated by surgery, and at the follow-up visits 6 mo and 1 year after surgery, respectively, the wound was completed healed, and they had normal growth and development without radiotherapy or chemotherapy. A review of highly uncommon orbital tumors in newborns is also provided.

CONCLUSION

Malignant primary tumors should be considered in the presence of unilateral proptosis in newborns.

Primary ectopic orbital craniopharyngioma

Craniopharyngiomas (CP) ectopic localizations off the midline outside the sellar-suprasellar region are very rare and most often associated to secondary tumor dissemination, being primary ectopic CPs extremely unusual. We herein report the first case of a primary ectopic craniopharyngioma within the orbit. A 15-year-old patient presented with progressive right ptosis, proptosis, and retro ocular pain. Magnetic resonance imaging (MRI) showed a predominantly cystic lesion, occupying the superolateral right corner of the orbit, outside the intraconal space with no evidence of intracranial involvement. An endoscopic transorbital eyelid approach was adopted. Pathology report disclosed a primary ectopic craniopharyngioma.

Extramedullary manifestations in acute lymphoblastic leukemia in children: a systematic review and guideline-based approach of treatment

OBJECTIVE

Acute lymphoblastic leukemia (ALL) may present with signs and symptoms related to extramedullary involvement, therefore, leads to delayed diagnosis of ALL in children. This study aims to consider the extramedullary manifestations of ALL in children and their proper treatment.

METHOD

The databases were searched for all relevant subjects including "acute lymphoblastic leukemia", "clinical presentation", "unusual presentation", "childhood acute lymphoblastic leukemia", "presenting features of ALL", "extramedullary presentation", and "atypical presentation" from April 1968 to June 2020. The Inclusion criteria for this review study were all cases reported, case series, and studies about extramedullary presentations of ALL in pediatrics. Eighty-seven studies had inclusion criteria. All reported studies were analyzed given their extramedullary presentations, age, sex, treatment option, and prognostic factors. A two-sided P-value less than 0.05 was considered statistically significant.

RESULT

In this review study, the extramedullary initial signs and symptoms of ALL were related to musculoskeletal system 17 (19.5%) especially bony symptoms and hypercalcemia. The additional extramedullary presentations of ALL in order of frequency include; renal involvement, 17 (19.5%), hepatic symptom 12 (13.8%), orbital presentation 10 (11.5%), neurologic signs 8 (9%), dermatological manifestations 5 (5.8%), oral presentations 5 (5.8%), hypereosinophilia 5 (5.8%), abdominal manifestation 3 (3.5%), pericardial involvement 2 (2.3%), and the other miscellaneous presentations 3 (3.5%).

CONCLUSION

The clinicians must become familiar with these extramedullary presentations of ALL in pediatrics to avoid the delayed diagnosis of this disease and increase the probable chance of survival by early detection.

Spotlight on the pediatric eye: a pictorial review of orbital anatomy and congenital orbital pathologies

Orbital lesions in the pediatric population vary from adults in terms of their presentation, unique pathology, and imaging characteristics. The prompt and accurate diagnosis of these lesions is imperative to prevent serious consequences in terms of visual impairment and disfigurement. Along with dedicated ophthalmologic examination, imaging is instrumental in characterizing these lesions, both for accurate diagnosis and subsequent management. In our pictorial essay, we provide a basic review of orbital embryology, anatomy, and congenital orbital pathologies, with emphasis on radiological findings.

Clinical correlation recommended: accuracy of clinician versus radiologic interpretation of the imaging of orbital lesions

Purpose: To assess the accuracy of radiographic interpretation between the clinician and radiologist when compared to histopathology of orbital lesions. Methods: A retrospective chart review of patients at the University of California Davis Eye Center who underwent orbitotomy from 1/1/2000 to 5/22/2019 was performed. Charts with a preoperative imaging report, preoperative clinical assessment including the clinician's interpretation of imaging, and histopathologic diagnosis were included. The specific diagnoses were grouped into related classes of pathology for the analysis. The clinical and radiologic assessments were compared against the final histopathologic diagnosis for concordance. A concordance analysis was performed. Results: 242 patients (mean age 49 years, 53.5% female) were reviewed. Of these records 185 documented the clinician's clinical impression, the radiology report, as well as the histopathology report. The clinician's preoperative assessment had substantial agreement [kappa = 0.72 (0.65,0.79)] with the final histopathologic result and was correct in 75.7% (140/185) of cases whereas the radiology report was correct in 52.4% (97/185) with a moderate level of agreement [kappa = 0.47 (0.39, 0.55)]. In 49.2% (91/185) of cases the final histopathology correlated with both the clinical impression and radiology report [kappa = 0.58 (0.55, 0.61)]. Conclusions: The accurate interpretation of orbital imaging is a challenge and histopathologic examination remains the gold standard for diagnosis. While orbital imaging is a valuable diagnostic tool the interpretation of these studies is most accurate when conducted in the context of the patient's medical history, clinical exam, and with the physician most familiar with various orbital lesions.

Large Orbital Pediatric Intraosseous Hemangioma

A five-year-old male presenting with progressive right facial swelling underwent multiple biopsies before being diagnosed with a polyostotic frontal-zygomatic primary intraosseous hemangioma. Intraosseous hemangiomas are rare, more frequently afflict adult females, and very rarely involve the orbit. Our case with bony destruction and surrounding soft tissue mass measured 5.3 cm in a child mimicked a more ominous malignancy. This case is unique with its rapid progression and largest reported size, leading to additional challenges such as difficulty in achieving an adequate tissue sample and in the surgical management with respect to significant blood loss in a small child.

Orbital cellulitis clinically mimicking rhabdomyosarcoma

Introduction

Proptosis in children with acute-onset accompanied by signs of inflammation is commonly caused by orbital cellulitis, however, the possibility of rhabdomyosarcoma should always be considered by the clinician. This is a case report of a five-year-old boy presenting with an acute-onset of proptosis without a history of trauma and systemic infection. Our clinical differential diagnosis included orbital cellulitis and orbital rhabdomyosarcoma.

Purpose

To report a case of orbital cellulitis that clinically and radiologically mimics rhabdomyosarcoma.

Case presentation

A five-year-old boy presented with rapid-onset proptosis, periorbital edema, pain and visual loss in the left eye for two weeks without a history of trauma, upper respiratory tract infection, sinusitis or immunosuppression. Our clinical differential diagnosis includes rhabdomyosarcoma and orbital cellulitis. Complete blood count reveals a leukocytosis. Multislice computed tomography (MSCT) scan shows lesions involving the lateral orbit and the retro bulbar space. Antibiotics combination and adjunct anti-inflammatory intravenously shows excellent clinical resolution.

Conclusions

The study demonstrates difficulty in differentiating acute orbital cellulitis from rhabdomyosarcoma based on clinical findings. In addition, the case highlights that antibiotic combination of cephalosporin and aminoglycosides together with an adjuvant corticosteroid as an anti-inflammatory was effective in the case of acute orbital cellulitis.

Orbital neuroblastoma metastasis: A case report and literature review

RATIONALE

Neuroblastoma is one of the most common tumors found in children, and mostly arises in the adrenal gland and paravertebral regions. Orbital neuroblastoma metastasis is relatively rare, and is associated with poor prognosis. Since the symptoms and signs of orbital neuroblastoma are not specific, its diagnosis remains challenging.

PATIENT CONCERNS

A 3-year-old girl presented with periorbital ecchymoses (raccoon eyes) and proptosis for 40 days.

DIAGNOSES

Abdominal magnetic resonance imaging (MRI) and sonography analysis revealed a large mass in the left adrenal gland (primary tumor). The computed tomography and MRI further revealed multiple soft tissue masses in the skull and both orbits with erosion of the adjacent bones (the metastasis). The histological analysis of the tumor removed from the right orbit confirmed the diagnosis of neuroblastoma.

INTERVENTIONS

The mass on the right face was surgically removed.

OUTCOMES

The patient exhibited no deteriorative signs at the 6-month follow-up.

LESSONS

Clinical manifestations, such as periorbital ecchymoses and proptosis, in combination with radiological analysis and histological findings, are important for the diagnosis of orbital neuroblastoma metastasis.

MRI of Pediatric Orbital Masses: Role of Quantitative Diffusion-weighted Imaging in Differentiating Benign from Malignant Lesions

PURPOSE

To systematically evaluate the utility of different magnetic resonance imaging (MRI) features, including quantitative diffusion-weighted imaging, in differentiating benign from malignant pediatric orbital masses.

METHODS

The use of MRI in 40 pediatric patients with orbital masses was retrospectively reviewed. Multiple subjective and objective MRI parameters, including lesion mean apparent diffusion coefficient (ADC) values and lesion-to-thalamus ADC ratio were recorded. Bivariate analysis was done to identify parameters that were significantly different between benign and malignant subgroups. Receiver operating curves were used to establish optimal cut-off values for lesion mean ADC and lesion-to-thalamus ADC ratio for predicting benign versus malignant lesions.

RESULTS

Lesion mean ADC, lesion-to-thalamus ADC ratio and extent of contrast enhancement showed statistically significant differences between the two subgroups. For distinguishing benign from malignant lesions, a lesion mean ADC cut-off value of 1.14 × 10^-3 mm²/s provided a sensitivity of 84% and specificity of 100%, while an ADC ratio of 1.4 provided a sensitivity of 81% and specificity of 89%.

CONCLUSION

Quantitative diffusion-weighted imaging can be a useful adjunct in characterizing pediatric orbital masses by MRI, and thus help in clinical decision making.

Congenital Orbital Rhabdomyosarcoma

Rhabdomyosarcoma (RMS) is the most common malignant tumor of the orbit in children, but it is rarely present at birth. We report a large congenital orbital RMS with intracranial extension in a newborn baby. A newborn baby girl was referred to our hospital due to severe right-eye exophthalmia. Imaging studies showed an orbital mass with intracranial extension. Treatment was started with a course of neoadjuvant chemotherapy followed by right orbital exenteration and intracranial resection of the tumor. Histologic examination of the mass showed undifferentiated malignant small-cell tumor. Immunohistochemical study proved it to be RMS. The patient was categorized as intermediate-risk RMS and chemotherapy was continued accordingly with VAC regimen. In spite of treatment, the infant developed intracranial recurrence at the age of 6 months and died 1 month later. Congenital orbital RMS has a poor prognosis. Reconstruction surgery should be deferred due to high rate of recurrence and low chance of survival. A multidisciplinary approach might increase the survival of these patients.

[Imaging of orbital tumors in children]

Orbital tumors in children are characterised by a wide histological diversity due to the architectural complexity of the orbit. Several classifications may be proposed according to their location, histologic type and malignant or benign character. The most common clinical manifestation is the leukocoria. Diagnostic delay of these tumors, even if they are benign, may affect prognosis and lead to a loss of vision and/or a morphological deformation. Imaging plays an important role in positive diagnosis, in the differentiation between benign processes and potentially malignant processes, in the assessment of local and loco-regional staging and in follow-up monitoring under treatment. This study aimed to highlight the radiological features of primary intra-orbital tumors in children which are, in general, different from those of adults, by conducting a retrospective study of 40 medical records whose data were collected in the Division of Pediatric Radiology at the Mohammed VI University Hospital in Marrakech, Morocco over a period of 4 years (2014-2017).

Diagnostic imaging in neuro-ophthalmology

Neuro-ophthalmology is a field combining neurology and ophthalmology that studies diseases that affect the visual system and the mechanisms that control eye movement and pupil function. Imaging tests make it possible to thoroughly assess the relevant anatomy and disease of the structures that make up the visual pathway, the nerves that control eye and pupil movement, and the orbital structures themselves. This article is divided into three sections (review of the anatomy, appropriate imaging techniques, and evaluation of disease according to clinical symptoms), with the aim of providing useful tools that will enable radiologists to choose the best imaging technique for the differential diagnosis of patients' problems to reach the correct diagnosis of their disease.

Esthesioneuroblastoma Presenting with Bilateral Proptosis and Blindness in a Child: A Case Report

Esthesioneuroblastoma is a rare malignant tumour of the olfactory epithelium. The most common symptom is related to unilateral nasal obstruction. It rarely presents with bilateral proptosis and blindness. We report a 21-month-old girl with esthesioneuroblastoma in sphenoid and ethmoid sinus in a child presenting with bilateral proptosis, blindness, and irritability. The diagnosis was confirmed by histopathology.

A Rare Cause of Proptosis in Childhood: Langerhans Cell Histiocytosis

A three-year-old male patient was admitted to the clinic with proptosis in his right eye. He had a history of fever with an unknown etiology. In examination, right proptosis was observed and an immobile mass was palpated at the lateral wall of the right orbita. Eye movement was unrestricted in all directions and anterior and posterior segment examination was normal in both eyes. On computed tomography, diffuse bone destruction and expansion was observed in the right orbital lateral wall and other cranial bones. Langerhans cell histiocytosis was diagnosed by bone biopsy. Malignancy is an important cause of proptosis in childhood. Pediatric patients who are admitted to clinic with proptosis should be carefully examined and Langerhans cell histiocytosis should also be considered as an etiology.

Syndrome-Associated Tumors by Organ System

Certain tumors suggest the possibility of a patient harboring a genetic syndrome, particularly in children. Syndrome-associated tumors of the gastrointestinal tract, genitourinary tract, gynecologic tract, heart, lungs, brain, eye, endocrine organs, and hematopoietic system will be briefly discussed.

Orbital tumours and tumour-like lesions: exploring the armamentarium of multiparametric imaging

Although the orbit is a small anatomical space, the wide range of structures present within it are often the site of origin of various tumours and tumour-like conditions, both in adults and children. Cross-sectional imaging is mandatory for the detection, characterization, and mapping of these lesions. This review focuses on multiparametric imaging of orbital tumours. Each tumour is reviewed in relation to its clinical presentation, compartmental location, imaging characteristics, and its histological features. We herein describe orbital tumours as lesions of the globe (retinoblastoma, uveal melanoma), optic nerve sheath complex (meningioma, optic nerve glioma), conal-intraconal compartment (hemangioma), extraconal compartment (dermoid/epidermoid, lacrimal gland tumours, lymphoma, rhabdomysarcoma), and bone and sinus compartment (fibrous dysplasia). Lesions without any typical compartmental localization and those with multi-compartment involvement (veno-lymphatic malformation, plexiform neurofibroma, idiopathic orbital pseudotumour, IgG4 related disease, metastases) are also reviewed. We discuss the role of advanced imaging techniques, such as MR diffusion-weighted imaging (DWI), diffusion tensor imaging, fluoro-2-deoxy-D-glucose positron emission tomography CT (FDG-PET CT), and positron emission tomography MRI (MRI PET) as problem-solving tools in the evaluation of those orbital masses that present with non-specific morphologic imaging findings. Main messages/Teaching points • A compartment-based approach is essential for the diagnosis of orbital tumours. • CT and MRI play a key role in the work-up of orbital tumours. • DWI, PET CT, and MRI PET are complementary tools to solve diagnostic dilemmas. • Awareness of salient imaging pearls and diagnostic pitfalls avoids interpretation errors.

Ectopic cilia associated with an orbital dermoid cyst and sinus tract: case report

Ectopic cilia are extremely rare congenital anomalies in which eyelash follicles appear in an abnormal place on the eyelid, most typically on the lateral quadrant of the anterior surface of the upper eyelid. In the majority of cases, simple surgical excision of ectopic cilia is indicated because of its cosmetic aspect. There is usually no associated medical co-morbidity with this anomaly. The authors report an unusual case of ectopic cilia associated with an orbital dermoid cyst and sinus tract. A 3-year-old boy was initially diagnosed with ectopic cilia on the left upper eyelid. There was no history of inflammation or swelling of the eyelid. An ophthalmological examination revealed only 1 mm of ptosis; no proptosis, inferior displacement, or palpable orbital mass was present. During surgical excision of the ectopic cilia, a thin sinus tract was identified, leading posteriorly to the orbit. Magnetic resonance imaging performed after the excision showed a supraorbital extraconal mass just below the roof of the left orbit. A supraorbital 2-piece craniotomy was performed with total extirpation of the dermoid cyst. The cyst was removed en bloc without damage to the extraocular muscles, but the sinus tract could no longer be identified. Follow-up MRI was performed 6 months after surgery and showed no evidence of recurrence. A follow-up ophthalmological examination showed no signs of inferior displacement or proptosis. To the best of the authors' knowledge, this case is the first reported instance of ectopic cilia associated with a dermoid cyst and sinus tract in which no typical clinical signs and symptoms of possible orbital pathology were present. This case highlights the value of radiological examination in all cases of ectopic cilia prior to surgical excision.

Magnetic resonance imaging of sellar and juxtasellar abnormalities in the paediatric population: an imaging review

The sellar and juxtasellar regions in the paediatric population are complex both anatomically and pathologically, with magnetic resonance imaging (MRI) being the "gold standard" imaging modality due to the high contrast of detail. Assessment requires a detailed understanding of the anatomy, embryology, pathophysiology and normal signal characteristics of the pituitary gland and surrounding structures in order to appropriately characterise abnormalities. This article aims to provide an overview of the imaging characteristics of developmental/congenital and acquired disease processes which affect the sellar and juxtasellar region in the paediatric population. Main Messages • The sellar region is anatomically complex and covers a wide pathology spectrum. • MRI is the key imaging modality to assess sellar and juxtasellar pathology. • Numerous developmental anomalies may not be discovered until adulthood. • Knowledge of pathology alerts and guides the clinician towards appropriate management.

Intracranial Extension of an Orbital Epidermoid Cyst

Epidermoid and dermoid cysts represent the most common cystic lesions of the orbit and commonly arise from bony sutures or the intradiplpoic space of orbital bones. Massive intracranial extension of an epidermoid cyst arising from the intradiploic space of an orbital bone is very rarely seen. We present a case of a 55-year-old male who was incidentally found to have massive intracranial extension of an intradiploic epidermoid cyst of the superolateral orbital bone with minimal symptoms. The cyst was completely excised via a pterional craniotomy and lateral orbitotomy by neurosurgery and oculoplastic surgery teams. The patient suffered no complications and is doing very well.

Systemic abnormalities in children with congenital optic disc excavations

PURPOSE

Together with optic disc hypoplasia, excavated optic disc anomalies represent the most frequent congenital abnormality involving the optic nerve head. The purpose of the present study was to retrospectively review the results of a screening for extraocular abnormalities in children presenting with congenital optic disc excavations.

MATERIALS AND METHODS

The medical records of 37 patients diagnosed with a unilateral or bilateral non glaucomatous optic disc excavation were retrospectively reviewed to analyze the result of the extra ocular evaluation and to report the associated ocular abnormalities.

RESULTS

An ocular abnormality was observed in conjunction with the excavated optic disc in 31% of the eyes. The systematic investigations revealed the presence of at least one extra-ocular disorder in 48% of the cases, and the optic disc excavation could be considered as syndromic in 30% of patients. The prevalence of extraocular malformations was significantly higher in infants presenting with associated ocular malformations or abnormal vision/development.

CONCLUSIONS

The present study suggests that a systematic approach to search for any associated systemic abnormalities could be envisioned in patients presenting with congenital excavated optic discs, and particularly those presenting with abnormal vision, associated ocular defects or abnormal development.

Orbital rhabdomyosarcomas: A review

Rhabdomyosarcoma (RMS) is a highly malignant tumor and is one of the few life-threatening diseases that present first to the ophthalmologist. It is the most common soft-tissue sarcoma of the head and neck in childhood with 10% of all cases occurring in the orbit. RMS has been reported from birth to the seventh decade, with the majority of cases presenting in early childhood. Survival has changed drastically over the years, from 30% in the 1960's to 90% presently, with the advent of new diagnostic and therapeutic modalities. The purpose of this review is to provide a general overview of primary orbital RMS derived from a literature search of material published over the last 10 years, as well as to present two representative cases of patients that have been managed at our institute.