Primary orbital tumors: a review of 122 cases during a 23-year period: a histo-clinical study in material from the ENT Department of the Medical University of Silesia

A retrospective analysis of the management and surgical treatment of orbital lesions: Outcomes and rationale

The orbital cavity is a subject of interest for various specialists, and achieving optimal outcomes requires comprehensive, multidisciplinary management. This study aims to report 10 years of experience in the preoperative, surgical, and postoperative care of patients with orbital lesions, examining their clinical, radiological, and anatomopathological features and outcomes. A retrospective review of 125 patients who underwent surgical treatment for intraorbital masses between January 2012 and December 2021 was performed. Outcome measures included postoperative diplopia, exophthalmos, decimal visual acuity, eyeball position, ocular motility, operative time, complications, and aesthetic results. A total of 107 patients were included. All cases were discussed with a neuroradiologist to determine the best therapeutic approach based on preoperative imaging. Preoperative diplopia was linked to extraconal (p = 0.03) and anterior (p = 0.001) lesions, and exophthalmos and visual acuity deterioration were associated with intraconal (p = 0.02; p = 0.03) and retrobulbar (p = 0.001; p = 0.02) lesions. Complications (11.2%) included diplopia, worsened visual acuity, postoperative blepharoptosis, and postoperative ectropion. Of the patients, 80.4% reported an "excellent" aesthetic outcome. This study underscores the importance of a multidisciplinary approach based on a thorough analysis of preoperative imaging. Periorbital approaches tailored to the lesion's three-dimensional location enables safe access to most intraorbital lesions, resulting in minimal complications and good aesthetic results.

Modified Orbitozygomatic Craniotomy Approach for a Recurrent Orbital Tumor in a Pediatric Patient

Background: This report aims to present the case of a pediatric patient with a recurrent tumor in the superolateral orbit. Clinical Presentation: An 8-year-old patient was initially treated for a tumor in the superolateral orbit via a transconjunctival approach. The histopathological diagnosis was epidermoid cyst. Postoperatively, chronic inflammation and fistula developed in the lateral canthus area. Magnetic resonance imaging revealed a residual tumor posterior to the original tumor location. The patient was treated via a modified orbitozygomatic (mOZ) craniotomy approach that was originally applied in neurosurgery, and complete tumor removal was achieved. A temporary paralysis of the frontotemporal branch of the facial nerve was observed and fully resolved within one month following surgery. At the 18th month of follow-up, the visual, neurological, and cosmetic results were found to be satisfactory. Conclusions: mOZ craniotomy can be used to access and operate on recurrent orbital tumors in pediatric patients where other more aggressive surgical approaches should be avoided.

Global incidence and prevalence of malignant orbital tumors

Purpose

Aims to provide an overview of the contemporary epidemiology of malignant orbital tumors by analyzing population-based incidence patterns across various regions worldwide.

Methods

In this article, we retrieved orbital malignancy data from the MEDLINE database and analyzed the incidence and prevalence of orbital malignancies worldwide. We performed the literature search by searching on the Mesh terms for malignant orbital tumors ("orbital", "tumor", "lymphoma", "malignant", "cancer", "incidence", and "epidemiology"). All included studies were published between 1993 and 2023 and were written in English.

Results

Ocular or ophthalmic lymphoma most frequently occurred in the orbit, with a prevalence ranging from 47% to 54%. The incidence of malignant orbital tumors was increasing in the USA (2.0 per million (1981-1993), Netherlands (0.86 (1981-1985) to 2.49 (2001-2005) per million) and South Korea (0.3-0.8 per million (1999-2016)), respectively. Ophthalmic lymphoma which includes orbit lymphoma was increasing in Canada (0.17-1.47 per million (1992-2010)), Denmark (0.86 per million (1981-1985) to 2.49 per million (2001-2005)), respectively.

Conclusions

The predominant primary malignant orbital tumor in adults was lymphoma. Ocular or ophthalmic lymphoma most frequently occured in the orbit. The limited data available suggested an increasing trend in the incidence of malignant orbital tumors in each country included, which were mainly attributed to the increase in lymphoma. Generally, incidence rates were found to increase with advancing age, with no difference between males and females.

Do Minimally Invasive Approaches to Pediatric Orbital Tumors Provide an Advantage on Outcome and Efficiency?

OBJECTIVE

The present study evaluated whether minimally invasive approaches to orbital lesions could improve surgical, clinical, and aesthetic outcomes compared with more invasive ones. This is the first study specifically addressing this topic in children.

METHODS

Children consecutively operated on from January 2010 to January 2020 were analyzed. Thirty patients matched the inclusion criteria and were divided into group A: 14 cases treated with traditional surgical approaches; and group B: 16 cases managed by minimally invasive approaches.

RESULTS

There were no significant differences between the 2 groups in terms of demographic data and extent of tumor resection. Mean surgical time for the approach (40 minutes vs. 70 minutes, P < 0.0001), surgical complication such as periorbital edema (37% vs. 78%, P = 0.02) and dural tear (0 vs. 21%, P = 0.05), and procedures cost (P < 0.0001) were significantly reduced in group B. Regarding clinical outcomes, group B showed a significant reduction both in terms of postoperative pain (mean score based on visual pain scale was 2.9 vs. 4.1 P = 0.003) and mean hospitalization time (4.5 days vs. 5.5 days, P = 0.0004). The cosmetic outcome according to the Sloan classification was significantly better in group B as well (81% vs. 36% class I patients, P = 0.005).

CONCLUSIONS

The use of mini-invasive approaches to orbital tumor has clear advantages in terms of surgical, clinical, and cosmetic outcomes in comparable patients; therefore, they should be preferred whenever feasible. Craniotomic approaches remain necessary for very large tumors.

Surgical treatment of orbital tumors in a single center: Analysis and results

Background

Orbital tumors, arising within the bony orbit and its contents, present diverse challenges due to their varied origins and complex anatomical context. These tumors, classified as primary, secondary, or metastatic, are further subdivided into intraconal and extraconal based on their relationship with the muscle cone. This classification significantly influences surgical approach and management. This study highlights surgical experiences with orbital tumors, underscoring the importance of tailored surgical approaches based on the lesion's site and its proximity to the optic nerve.

Methods

This retrospective study at the National Institute of Cancer's Head and Neck Department (2005-2014) analyzed 29 patients with orbital tumors treated with surgery, radiotherapy, chemotherapy, or combinations of them. Patient demographics, tumor characteristics, and treatment responses were evaluated using computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT imaging. Malignant tumors often required orbital exenteration and reconstruction, highlighting the study's commitment to advancing orbital tumor treatment.

Results

29 patients (18 females and 11 males, age 18-88 years, mean 53.5 years) with orbital tumors exhibited symptoms such as decreased vision and exophthalmos. Tumors included primary lesions like choroidal melanoma and secondary types like epidermoid carcinoma. Treatments varied, involving a multidisciplinary team for surgical approaches like exenteration, with follow-up from 1 to 9 years. Radiotherapy and chemotherapy were used for specific cases.

Conclusion

Our study underscores the need for a multidisciplinary approach in treating orbital tumors, involving various surgical specialists and advanced technologies like neuronavigation for tailored treatment. The integration of surgery with radiotherapy and chemotherapy highlights the effectiveness of multidimensional treatment strategies.

Surgical Treatment of Intraorbital Lesions

BACKGROUND

Resection of pure intraorbital tumors is challenging owing to the nearness of the optic apparatus. The objective of this article was to report our experience with different intraorbital tumors and discuss classic approaches and obstacles.

METHODS

A retrospective case series of patients who underwent surgery for intraorbital tumors at a tertiary neurosurgical center between June 2007 and January 2020 was performed.

RESULTS

The study included 34 patients (median age 58 years; range, 18-87 years; 55.9% [19/34] female, 44.1% [15/34] male). Preoperative proptosis was observed in 67.6% (23/34); visual impairment, in 52.9% (18/34); diplopia, in 41.2% (14/34); and ptosis, in 38.3% (13/34). Intraconal tumors were found in 58.8% (20/34). The most common lesions were cavernous hemangiomas in 26.5% (9/34) and metastases in 14.7% (5/34). Gross total resection rate was 73.5% (25/34). Planned biopsy was performed in 14.7% (5/34). Median follow-up time was 15.5 months (interquartile range: 0-113 months). Surgical approaches included supraorbital approach (23.5% [8/34]), pterional approach (52.9% [18/34]), lateral orbitotomy (14.7% [5/34]), transnasal approach (5.9% [2/34]), and combined transnasal approach/lateral orbitotomy (2.9% [1/34]). Excluding planned biopsies, gross total resection was achieved in 80.0% (12/15) with pterional approach, 100% (7/7) with supraorbital approach, 80.0% (4/5) with lateral orbitotomy, and 100% (1/1) with transnasal approach/lateral orbitotomy. Complication rate requiring surgical intervention was 11.8% (4/34).

CONCLUSIONS

Considering the low operative morbidity and satisfactory functional outcome, gross total resection of intraorbital lesions is feasible. We support use of classic transcranial and transorbital approaches. More invasive and complicated approaches were not needed in our series.

Adult Orbital Lesions in Saudi Arabia: A Multi-centered Demographic Study with Clinicopathological Correlation

The demographics, clinical features, and histopathological classification of orbital space-occupying lesions in adults have not been widely described in our part of the world except for the pediatric population. In this retrospective study, we collected 110 consecutive adult patients (18 years and older) with orbital lesions (excluding lacrimal gland lesions) that were diagnosed histopathologically in two tertiary eye centers in Riyadh, Saudi Arabia (January 2000 to July 2017). Patients with thyroid-related orbitopathy, infectious, and inflammatory/pseudo-inflammatory lesions were excluded. We had 60 males (54.5%) and 50 females (45.5%). The mean age at presentation was 51.4 years (range 19-99). Proptosis was the most common clinical presentation (mean duration 15.4 months). The orbital lesions in order of increasing prevalence were: lymphoproliferative lesions in 26.4%; vascular in 21.8%; secondary tumors in 14.6%; neurogenic in 13.6%; structural in 10.0%; soft tissue tumors 8.2%; then metastatic tumors (2.7%) and others (extramedullary leukemia, fibrous dysplasia, and histiocytic lesion: Rosai-Dorfman disease): one case each. Gender distribution was varied in lymphoproliferative disorders compared to vascular lesions. Cavernous hemangioma was the most common vascular lesion (83.3%) and schwannoma was the most common neurogenic tumor (60%). Secondary lesions extended to the orbit mostly from eyelids in nine out of 16 or conjunctiva in four out of 16 cases. A favorable outcome was observed in about 80% of patients who underwent excisional biopsy. The rest encountered local recurrence of the tumors, growing of residual lesions, and recurrence with further invasion to nearby structures. We concluded having a similar demographic pattern of orbital lesions in adults as has been universally reported. We have fewer secondary tumors. We have summarized the pathological profile of adult orbital lesions according to patients' age, gender, symptoms, and location of the lesion as a baseline guide for proper diagnosis of any orbital mass prior to surgical management planning and for future prognostic studies.

Orbital metastasis diagnosed by ultrasound-guided fine-needle aspiration biopsy: Case report of unknown primary site

Twenty five percent of orbital metastasis is usually of unknown primary origin and it requires histopathological and immunohistochemical confirmation. The fine-needle aspiration biopsy of the orbit is an alternative procedure to conventional orbitotomy. The case is presented of a 60 year-old woman with a right orbit tumour mass and neoplastic lesions in her brain and cranium. As an incidental finding, she had a thrombus in her left atrium, and so an orbitotomy procedure was ruled out. An ultrasound-guided fine-needle aspiration biopsy was performed instead with rapid on-site evaluation of biopsy samples. These showed malignant cells of a lung adenocarcinoma, which was confirmed with immunohistochemistry and chest diagnostic images. In conclusion, biopsy samples obtained by fine-needle aspiration biopsy, together with cytopathological and immunohistological analysis, enabled orbital metastasis to be identified in the case described, and showed that fine-needle aspiration biopsy is a safe, effective, and minimally invasive alternative.

Orbital Tumors: Report of 70 Surgically Treated Cases

OBJECTIVE

The orbital cavity is an anatomically complex region and an area of interest of many specialists, each of whom is familiar with specific surgical approaches.

METHODS

We retrospectively reviewed clinical and outcome data of 70 patients who underwent surgery for resection of an orbital tumor with a mean follow-up of 111.9 ± 79.6 months. The clinical outcome was reported and the role of sex, age, histology, tumor location, tumor size, and surgical approach on the extent of tumor removal was assessed.

RESULTS

Total removal was achieved in 74.3%, subtotal removal in 20%, and partial removal in 5.7% of patients. A fronto-orbital craniotomy was used in 57.1% of cases, frontal approach in 17.1%, fronto-orbit-zygomatic approach in 10%, and endoscopic endonasal approach in 11.4%. Complications included visual acuity decrease (4.3%), cerebrospinal fluid leak (4.3%), nerve palsy (10%; supra-orbital nerve 4.3%; frontal branches of facial nerve 2.9%, third cranial nerve 2.9%), and enophthalmos (1.4%). Lateral orbitotomy, combined fronto-orbital and maxillotomy, and trans-eyelid approaches were used in the remaining cases. The fronto-orbital, frontal, and lateral orbitotomy approaches were associated with greater rates of total resection as compared with the fronto-orbit-zygomatic approach, which was used in difficult cases in which the tumor involved several regions.

CONCLUSIONS

We recommend, 1) the endoscopic endonasal approach for primary orbital tumors located in the medial or inferior orbital walls without extra-orbital extension; 2) the trans-eyelid approach for tumors of the upper and upper-lateral quadrants extraconally located, and 3) the fronto-orbital approach for intraconally located tumors involving more than one quadrant.

C-reactive protein may be useful to differentiate idiopathic orbital inflammation and orbital cellulitis in cases with acute eyelid erythema and edema

Purpose

Idiopathic orbital inflammation (IOI) and orbital cellulitis can present similar clinical features, and the diagnoses of these two disorders are sometimes confused. The purpose of the present study was to determine whether or not inflammatory markers in the blood can be useful to differentiate between IOI and orbital cellulitis in cases with acute eyelid erythema and edema.

Subjects and methods

In this retrospective single-institute study, we reviewed the medical records spanning the past 10 years at the Department of Ophthalmology, Osaka Medical College Hospital, Takatsuki, Osaka, Japan, and found 45 cases, with patients >15 years of age, with presumed IOI. Their blood samples were obtained within 5 days after the onset of IOI. Of those cases, 15 patients (10 males, 5 females, mean age of 56.9 years; range 38–76 years) presented acute eyelid erythema and edema, and were initially misdiagnosed as orbital cellulitis. Thus, inflammatory markers in the blood (ie, white blood cells [WBCs] and C-reactive protein [CRP]) of those 15 patients were analyzed with 17 patients (10 males, 7 females) having orbital cellulitis. The receiver operating characteristic curve analysis was performed to determine the optimal cut-off values.

Results

The mean ± standard error (SE) levels of the WBC were 6.80±0.70×10³/μL in the IOI patients, and 8.54±0.91×10³/μL in the orbital cellulitis patients, and no significant differences were observed (P=0.15, Student’s t-test). However, the mean ± SE levels of CRP were 1.04±0.43 mg/dL in the IOI patients, yet were significantly increased to 4.65±1.21 mg/dL in the orbital cellulitis patients (P=0.01, Student’s t-test). The area under the curve value was 0.80 and the optimal cut-off value was 0.43 for orbital cellulitis, with sensitivity and specificity being 82% and 73%, respectively.

Conclusion

The findings of this study indicate that CRP may be useful in distinguishing patients with idiopathic orbital inflammation from those with orbital cellulitis.