Fabrication of orbital prosthesis by two different methods in patients with post-COVID-19 rhino-orbital maxillary mucormycosis: A case series

Neoplasms, congenital disorders, fungal infections, and traumatic injuries are the predominant causes of orbital defects. Various retentive mechanisms such as application of adhesive, utilization of mechanical undercuts, and implant-supported attachments are generally used in the maxillofacial prosthesis. In the orbital region, the result of magnet-retained attachments is favorable compared with other mechanisms. Different advantages of the magnet-retained prosthesis are less manual dexterity needed during insertion or removal and better maintenance of hygiene. The skin-implant interface and thick tissues in the maxillofacial region are the critically important points that should be given importance during the planning and placement of implants. Ideally, implant sites for orbital prosthesis are the lateral, infra-, and supraorbital rims of the orbital region. The following case series describes two different methods to rehabilitate patients with an exenterated eye due to mucormycosis by individually designed implant with magnetic attachment and mechanical undercut-retained orbital prosthesis.

Feasibility of robotic platform to perform R0 resection for locally advanced multi-visceral pelvic malignancy: an institutional experience on outcomes of robotic pelvic exenteration

BACKGROUND

Exenteration surgery for multi-visceral pelvic malignancy is a complex life-changing operation with high perioperative morbidity and mortality. Traditional open surgery has long been the standard approach for pelvic exenteration for achieving Ro resection which is the main aim of surgery. In the current era of minimally invasive surgery, robotic-assisted pelvic exenteration has provided a promising alternative, offering potential advantages in terms of improved oncological outcomes and enhanced postoperative recovery. This study aims to explore the feasibility of a robotic platform for locally advanced multi-visceral pelvic malignancy.

METHODS

A retrospective review from the prospectively maintained robotic colorectal surgery database at University Hospital Coventry and Warwickshire (UHCW) Trust was performed. Demographic details and clinical and surgical details were documented from the case records. Data was analysed using SPSS version 22.

RESULTS

Thirteen female patients diagnosed with primary or recurrent pelvic malignancy who underwent robotic pelvic exenteration at UHCW between February 2019 and April 2023 at UHCW were included. The mean age of our patients was 60.4 (± 10.1) years. Complete Ro resection was achieved in all 13 (100%) cases on final histopathology. The median length of hospital stay was 15 days after this extensive surgery. Grade 3 morbidity on Clavien-Dindo classification was observed in four (30.7%) patients, while zero percent 30-day mortality was experienced in this study. At a median follow-up of 21 (3-53) months, we observed tumor recurrence in three (23.7%) patients, while death in four (30.7%) patients. Only few studies have highlighted outcomes of robotic pelvic exenteration, and our results were quite comparable to them.

CONCLUSION

Robotic-assisted pelvic exenteration for primary or recurrent pelvic malignancy is feasible with improved oncological and acceptable postoperative outcomes.

Radiotherapy in combination with exenteration and partial orbitectomy for orbital multilobular tumor of bone in a Cocker Spaniel

Background

Multilobular tumor of bone or multilobular osteochondrosarcoma is a tumor of flat bone in the skull. The treatment of choice for a multilobular tumor of bone is local aggressive surgical excision.

Case Description

A female Cocker Spaniel dog aged 11 years presented with a history of globe displacement of the right eye for 3 months. Ophthalmic examination revealed exophthalmos, third eyelid protrusion, and slightly increased intraocular pressure OD (oculus dexter; right eye). Computed tomography (CT) revealed a mass effect in the right retrobulbar, maxilla, zygomatic, and temporal areas. Right zygomatic and temporal bone lysis were observed. Physical examination, hematology, and blood chemistry results were within normal limits. Exenteration with zygomatic arch removal was performed. During surgery, a firm 2-lobed mass (4.8 × 3.7 and 1.6 × 1.4 cm) adhered to the mandible was found in the retrobulbar area OD. Histopathological findings revealed a multilobular tumor of bone. CT imaging was performed for the remaining tumor and an extended part of the right retrobulbar mass was found. Hypofractioned radiotherapy with 6 fractions of 6 Gy was performed on days 0, 7, 14, 21, 28, and 35. At 1-month and 4-month follow-up inspections, the mass gradually reduced in size. At 8 months and 11 months after radiotherapy, the mass was unremarkable. The dog was alert during all follow-up periods to 1 year and 8 months after hypofractioned radiotherapy combined with exenteration and partial orbitectomy.

Conclusion

Hypofractioned radiotherapy combined with exenteration and partial orbitectomy extended the patient's survival and decreased the size of the remaining tumor for the management of orbital multilobular tumor of bone in this dog for at least 1 year and 8 months.

Intensification of Local Therapy With High Dose Rate, Intraoperative Radiation Therapy (HDR-IORT) and Extended Resection for Locally Advanced and Recurrent Colorectal Cancer

BACKGROUND

We report our long-term experience with high dose rate intraoperative radiotherapy (HDR-IORT) in a single, quaternary institution.

PATIENTS/METHODS

From 2004 to 2020, 60 HDR-IORT procedures for locally advanced colorectal cancer (LACC) and 81 for locally recurrent colorectal cancer (LRCC) were done in our institution. Preoperative radiotherapy was done prior to majority of the resections (89%, 125/141). Sixty-nine percent (58/84) of the resections involving pelvic exenterations had >3 en bloc organs resected. HDR-IORT was delivered using a Freiburg applicator. A single 10 Gy fraction was delivered. Margin status was R0 and R1 in 54% (76/141) and 46% (65/141) of the resections, respectively.

RESULTS

With a median follow-up time of 4 years, 3-, 5-, and 7- year, overall survival (OS) rates were 84%, 58%, and 58% for LACC and 68%, 41%, and 37% for LRCC, respectively. Local progression-free survival (LPFS) rates were 97%, 93%, and 93% for LACC and 80%, 80%, 80% for LRCC, respectively. For the LRCC group, an R1 resection was associated with worse OS, LPFS, and progression-free survival (PFS), preoperative EBRT was associated with improved LPFS and PFS, and ≥2 years disease-free interval was associated with improved PFS. The most common severe adverse events were postoperative abscess (n = 25) and bowel obstruction (n = 11). There were 68 grade 3 to 4 and no grade 5 adverse events.

CONCLUSIONS

Favorable OS and LPFS can be achieved for LACC and LRCC with intensive local therapy. In patients with risk factors for poorer outcomes, optimization of EBRT and IORT, surgical resection, and systemic therapy are required.

Large extraocular extension of a choroidal melanoma with orbital inflammation

Purpose

To describe an atypical case of a choroidal melanoma presenting with eyelid edema, chemosis, pain and diplopia and demonstrating significant extraocular extension on ultrasonography and neuroimaging.

Observations

A 69-year-old woman presented with a headache, eyelid edema, chemosis and pain in the right eye. Upon subsequent onset of diplopia, MRI of the orbits was performed and demonstrated a predominantly extraocular, intraconal mass with a small intraocular component. She was started on corticosteroids and referred to the ocular oncology service for evaluation. On fundus examination, she was noted to have a pigmented choroidal lesion consistent with melanoma, and ultrasound showed a large area of extraocular extension. Enucleation, enucleation with subsequent radiation and exenteration were discussed, and the patient requested an opinion from radiation oncology. A repeat MRI obtained by radiation oncology demonstrated a decrease in the extraocular component after corticosteroid treatment. The improvement was interpreted as suggestive of lymphoma by the radiation oncologist who recommended external beam radiation (EBRT). Fine needle aspiration biopsy was insufficient for cytopathologic diagnosis, and the patient elected to proceed with EBRT in the absence of a definitive diagnosis. Next generation sequencing revealed GNA11 and SF3B1 mutations, which supported the diagnosis of uveal melanoma and led to enucleation.

Conclusion and Importance

Choroidal melanoma may present with pain and orbital inflammation secondary to tumor necrosis, which may delay diagnosis and decrease the diagnostic yield of fine-needle aspiration biopsy. Next generation sequencing may aid the diagnosis of choroidal melanoma when there is clinical uncertainty and cytopathology is unavailable.

Robotic pelvic exenteration in males: systematization of the technique

Male pelvic exenteration is a challenging procedure with high morbidity. In very selected cases, the robotic approach could make dissection easier and decrease morbidity due to the better vision provided and higher range of movements. In this paper, we describe port placement, instruments, minilaparotomy location, and the stepwise sequence of these procedures. We address 3 different situations: total pelvic exenteration with abdominoperineal resection, colostomy and urostomy; pelvic exenteration with colorectal/anal anastomosis and urostomy; and pelvic exenteration with abdominoperineal resection, colostomy and urinary tract reconstruction.

Orbital ophthalmomiasis due to Dermatobia hominis in an immunosuppressed patient from the ecuadorian andean area

An 83-year-old Ecuadorian male, indigent with a history of malnutrition and chronic alcoholism, presented with a clinical feature characterized by progressive growth of larvae at the left eye level (LE), associated with areas of ocular tissue putrefaction. Upon admission, his vision in the right eye (RE) was of hand movement and no light perception in LE, the anterior segment of the RE showed a brunescent cataract, with no other alteration, while the LE presented edema, bipalpebral erythema and an abundant number of mobile larvae distributed throughout the orbit, associated with areas of necrosis, putrefaction and distortion of the anatomy of the ocular tissues. Orbital tomography showed a significant compromise of the orbit, indicating surgical management by left orbital exenteration with taxonomic identification of the larvae as Dermatobia hominis associated with it, antibiotic treatment was implemented and a frontal fasciocutaneous flap was performed by the plastic surgery department.

Is mucormycosis the end? A comprehensive management of orbit in COVID associated rhino-orbital-cerebral mucormycosis: preserving the salvageable

BACKGROUND

Rhino-orbital-cerebral mucor mycosis (ROCM) is a relatively rare opportunistic infection caused by the Mucorales species. While ROCM suggests involvement of the paranasal sinuses, orbit and brain ROM (rhino-orbital-Mucormycosis) stands for the fungal invasion in sinuses and orbit sans cerebral involvement. In India with the outbreak of the second COVID wave and the delta variant of the virus, there has been a steep increase in this opportunistic fulminant fungal infection, named COVID-associated Mucor mycosis (CAM). The most critical question in orbital management is when to go ahead with an exenteration. Our study aims to design a pertinent minimal invasive surgical protocol for surgeons to manage such cases based on our surgical experience and mitigate the need for exenteration and save the eyes wherever possible.

METHODS

The study is a retrospective analysis of patients of ROM with and without brain involvement, who underwent minimal surgical management between March 2021 to March 2022 along with their follow-up.

RESULTS

There were 184 eyes of 148 patients diagnosed with CAM. The mean age was 51.7 years with a male predominance of 103 (70%). All patients developed ROM following the COVID-19 infection and the duration between diagnosis of COVID-19 and ROM was 36 ± 23 days. 18 cases (12%) were bilateral. 76 eyes (41%) had no vision at the presentation. Imaging revealed paranasal sinus involvement (100%), orbital apex involvement (61%), cavernous sinus involvement (53%), and central nervous system (CNS) involvement (47%). All the patients (100%) were treated with systemic Liposomal amphotericin-B and sinus debridement. Endoscopic debridement of the orbital disease was performed in 45 (30.4%) cases, 15(8.1%) eyes underwent exenteration and were later rehabilitated with a customized ocular prosthesis, 103 (56%) eyes underwent transcutaneous retrobulbar amphotericin-B. At a mean follow-up of 13.1 months; the complete resolution was seen in 25 (17%) cases, the residual stable lesion was seen in 77(52%) of the cases and new lesions were developed in 13(9%) of the cases. Mortality was seen in 33 (22%) patients and all of them had CNS involvement.

CONCLUSIONS

Systemic and protocol-based management can save the life and salvage the eyes.

Total Pelvic Exenteration surgery - Considerations for healthcare professionals

BACKGROUND

Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and with the view of achieving the best outcomes and lessen short and long-term morbidities, a well-thought-out and coordinated multidisciplinary team approach, is crucial to the provision of safe and high-quality care.

METHOD

Using a nominal group technique and qualitative methodology, this article explores the current practices in the care of oncology patients who undergo TPE surgery, in a tertiary cancer centre, by highlighting considerations of a collaboratively multi-disciplinary team.

RESULTS

This article provides guidance on the multi-disciplinary team approach, relating to TPE surgery, with discussion of clinical concerns, and with the goal of high patient satisfaction, provision of effective care and the lessening of short and long-term morbidities.

CONCLUSION

Oncology patients that undergo TPE surgery benefit from the contribution of a diversified multidisciplinary team as skilled and competent care that meets patient's health and social care needs is provided in a holistic, comprehensive, and timely care manner. Improving patient's care, pathway and postoperative outcomes, with the use of clinical expertise and support from professionals in the multidisciplinary team, can maximise care.

Trends in Eye Removal Surgeries at a Tertiary Care Hospital Over Three Decades

PURPOSE

To determine the trends in eye removal surgeries at a tertiary hospital in Nigeria over 26 years.

METHODS

A retrospective comparative review of clinical records of all patients who had eye removal surgery at a tertiary hospital in Ile-Ife, Nigeria, between 2014 and 2019 was done. Patients' demographic and clinical data, including indication for eye removal and type of surgery were analysed and compared with two earlier studies at the same hospital between 1994 and 2013.

RESULTS

There was an average of 14.3 surgeries per year between 2014 and 2019. Patients' ages ranged from 2 to 102 years, M:F was 1.5:1, the commonest indication for eye removal was infection (n=30, 34.9%), and the most common surgery was evisceration (n=70, 81.4%). Studies from 1994 to 2003 and 2005 to 2013, reported an average of 9.2 and 10 surgeries per year; ages ranging from 4 days to 88 years and 3 months to 88 years; with a M:F of 2.1:1 and 3.4:1 respectively. In both studies, the commonest indication for eye removal was trauma (43.4% and 43.8% respectively) and the most common surgery was enucleation (57.6% and 55% respectively). Trend data showed a progressive increase in eye infections (12% vs 15% vs 34.9%) and eviscerations (19.6% vs 31.2% vs 81.4%) over time.

CONCLUSION

There was a change in trend towards an increase in eviscerations and infective indications for eye removal at the hospital over three decades. Prompt and optimal treatment of orbito-ocular infections is recommended to reduce the incidence of eye removal surgeries.

A systematic review of the pathological determinants of outcome following resection by pelvic exenteration of locally advanced and locally recurrent rectal cancer

BACKGROUND

Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery.

METHODS

A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool.

RESULTS

Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report.

CONCLUSION

Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.

Experience on rhino-orbital mucormycosis from a tertiary care hospital in the first wave of COVID-19: An Indian perspective

Background

To highlight the clinical presentations and management outcomes of rhino-orbital mucormycosis during first wave of COVID-19 pandemic in North India.

Methods

A retrospective observational study. 15 patients with mucormycosis (orbital disease) who presented during short span of 3 months (October-December 2020) in a tertiary-care referral institution were analysed.

Results

At presentation, 13 of 15 patients had uncontrolled diabetes. Four had history of COVID-19 infection. All patients had advanced orbital disease with sinusitis; cavernous sinus involvement was in nine and intracranial spread in three patients. Liposomal amphotericin-B was started and prompt orbital exenteration with sinus surgery was performed in 12 patients. All 12 patients survived with an average follow-up of 4.8 months.

Conclusion

In the present series, cases with orbital spread of mucormycosis were mostly found in non-COVID uncontrolled diabetics. Exenteration was done in 80% of cases with advanced orbital disease. Prevention and early detection of infection at the stage of sino-nasal involvement might help to prevent spread and/or halt the orbital disease.

Neoadjuvant Intra-Arterial Cytoreductive Chemotherapy for Lacrimal Gland Adenoid Cystic Carcinoma: A Long-Term Follow-up Study of a Trimodal Strategy

PURPOSE

To report the therapeutic efficacy of integrating neoadjuvant chemotherapy with conventional bimodal therapies for lacrimal gland adenoid cystic carcinoma by providing an additional 8 years of follow-up data on the same cohort of patients whose cumulative 10-year disease-free survival outcomes were reported in 2013.

DESIGN

Non-randomized, retrospective, interventional case series.

METHODS

Nineteen consecutive patients treated with neoadjuvant intra-arterial cytoreductive chemotherapy (IACC), orbital exenteration, chemoradiotherapy, and adjuvant intravenous chemotherapy at a single institution were included. Analyses were undertaken of locoregional recurrences and distant metastases, disease-free survival time, TNM tumor stage at presentation, response to IACC, and prognostic impact of positive resection margins. The main outcome measures were overall survival, disease-free survival, disease relapse, positive tumor resection margins, and tumor stage at presentation.

RESULTS

Eight patients with an intact lacrimal artery (group 1), 7 with AJCC stage T4a-c, had significantly better overall survival (87.5% versus 14.3% at 15 years), disease-specific mortality, and recurrences (all < .001, log-rank test) than prior conventionally treated patients from the Bascom Palmer Eye Institute. Group 1 was superior to group 2, patients lacking an intact lacrimal artery, concerning overall survival (P = .042) and recurrence (P = .017), but with no significant difference in disease-specific mortality (P = .23). Group 2 was associated with a significantly lower cause-specific mortality than the institutional comparator group (P = .039). Prior tumor resection with lateral wall osteotomy and failure to adhere to all protocol elements were adverse prognostic factors for suboptimal outcomes. Positive tumor margins increased the risk of all-cause mortality 4.1 times (P = .036, stratified Cox proportional hazards regression) and disease-specific mortality 8.0 times (P = .043, stratified Cox proportional hazards regression) than a patient with negative margins.

CONCLUSIONS

Extended follow-up supplemented with AJCC staging data supports neoadjuvant IACC as an integral component of a trimodal treatment strategy in patients with an intact lacrimal artery. Protocol elements implemented as designed appear to have improved overall survival and decreased disease relapse in this cohort. This extended long-term IACC dataset suggests that a critical bar of at least 15 years of follow-up is appropriate for assessing the efficacy of current conventional and future globe-sparing bimodal therapies.

Scoring system evaluation for orbital exenteration in patients with rhino-orbito-cerebral mucormycosis

PURPOSE

To evaluate our patients with rhino-orbito-cerebral mucormycosis according to a new scoring system and to compare those who underwent orbital exenteration persuant to a new threshhold.

METHODS

Mucormycosis is a fungal disease that can be of acute onset, aggressive, and angioinvasive. Aggressive surgical debridement, long-term systemic antifungal therapy, and treatment of underlying predisposing factors are essential to the treatment. However, orbital exenteration is a very difficult decision to make, particularly in patients with orbital involvement, because there is little information in the literature, resulting in limited support for making this aggressive surgical decision. In this study, our 43 cases of mucormycosis were evaluated in terms of orbital exenteration using a scoring system (including clinical signs and symptoms, ophthalmoscopic findings, and radiologic results) developed by Shah et al., which establishes indications for orbital exenteration in mucormycosis.

RESULTS

According to our study, if the threshold score for exenteration is 19.0, the sensitivity was 100% and specificity was 97%, providing better results than the 23.0 threshold score determined by the reference study for exenteration. When these two score thresholds were compared, there was a statistically significant difference.

CONCLUSION

We believe that this scoring system may be beneficial to use for orbital exenteration in patients with mucormycosis. Prospective studies in large case series are required to determine the most appropriate threshold score.

Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction - a supraregional experience

BACKGROUND

Vertical rectus abdominis myocutaneous (VRAM) flap has proven to be a robust reconstruction method following radical pelvic surgery. Radical pelvic surgery is associated with high morbidity due to pelvic complications and non-healing perineal wounds, as a result of non-collapsible pelvic dead space and pre-operative adjuvant radiotherapy insult. VRAM flap reconstruction addresses both issues by obliterating the dead space and introducing healthy non-radiated tissue. However, flap reconstruction complications can include donor site hernias (abdominal wall), perineal hernias, and flap-specific complications. This study aimed to evaluate the abdominal and perineal hernia rates as well as radiological evidence of flap vascularity post-operatively.

METHODS

We conducted a retrospective analysis of patients who underwent a VRAM flap reconstruction following radical pelvic surgery at Christchurch hospital over a 10-year period. We identified the presence of donor site hernias (abdominal wall hernias), perineal hernias, and flap vascularity on post-operative radiological imaging performed within 48 months.

RESULTS

Seventy-seven patients underwent a VRAM flap reconstruction of which 60 patients met the inclusion requirements for the study (mean age was 60.3 years [range 26-89]; 31 were male and 29 were female). Eighteen patients underwent an APR and 42 underwent a partial or a complete pelvic exenteration and the majority of them (75.0%) were for rectal cancers. Available imaging was on average 21.6 months post-operatively (IQR 11.8-31.3 months). The donor site hernia rate was 16.7%, and the perineal hernia rate was 3.3%. VRAM flap appeared to have DIEA flow in 98.3% of the patients.

CONCLUSION

VRAM flap reconstruction of complex pelvic defects remains a robust method of choice in complex pelvic reconstruction with little morbidity.

State-of-the-art surgery for recurrent and locally advanced rectal cancers

Extended and beyond total mesorectal excisions (TME) for advanced and recurrent rectal cancers are increasingly performed with acceptable oncological and functional outcomes. These are undoubtedly due to better understanding of tumor biology and improved patient selection rather than surgical valor and technical refinements alone. In the present review, we attempt to present the current surgical standards for advanced and recurrent cancers requiring surgery outside the TME planes based on involved pelvic compartments. The available procedures, their indications, and extent of resection and reconstruction are highlighted. Emphasis is on formation of dedicated exenteration teams, structured training, and referral systems that increase hospital and surgeon volume to improve patient outcomes and reduce morbidity. Areas of deficiencies in literature were recognized with regards to factors influencing recurrences, patient selection, and quality of life. Finally, the most appropriate preoperative therapy for these tumors is unclear in both the primary and recurrent settings.

Advanced ocular surface squamous cell carcinoma (OSSC): long-term follow-up

PURPOSE

To analyze the clinical characteristics and long-term follow-up of patients with advanced ocular surface squamous cell carcinoma (OSSC) involving periocular tissues and/or orbit. Primary outcomes were overall survival (OS), disease-free survival (DFS), and overall recurrence rate (RR). Secondary outcomes were a correlation between primary outcomes and tumor location, American Joint Committee on Cancer Classification (AJCC) staging system, histological results, surgical margins, and type of treatment.

STUDY DESIGN

a retrospective case series.

METHODS

The medical records of patients affected by OSSC involving periocular tissues and/or orbit referring, from 01/2011 to 01/2020, to our tertiary referral center were reviewed.

RESULTS

Thirty-six eyes of 36 patients were included. The mean age was 68.2 years; 18 (50%) patients were males. The mean follow-up was 40 months. The RR was 64%. The OS at 12, 24, 36, and 60 months was respectively 97.1%, 92.7%, 92.7%, and 92.7%. The DFS at 12, 24, 36, and 60 months was respectively 62.9%, 50.8%, 41.6%, and 29.7%. Multicentric disease (p = 0.0039), inferior tarsus localization (p = 0.0428), histological diagnosis of high-risk SSCs (p = 0.0264), positive surgical margins (p = 0.0434), and excisional biopsy (EB) alone (p = 0.0005) were associated with an increased risk of recurrence. A shorter OS was observed in patients who underwent EB alone (p = 0.0049).

CONCLUSION

OSCC involving periocular tissues and/or orbit is an aggressive disease with a high recurrence rate. Multicentric disease, positive surgical margins, inferior tarsus localization, and surgery without adjuvant therapies are strong predictors of recurrence and are the main factors affecting prognosis.

Medical and surgical treatment of rhino-orbital-cerebral mucormycosis in a child with leukemia

PURPOSE

Rhino-orbital-cerebral mucormycosis (ROCM) is a rare opportunistic infection with a high mortality despite relevant treatment.

OBSERVATIONS

A 3-year-old girl under treatment for acute lymphoblastic leukemia developed periorbital swelling, ophthalmoplegia and a necrotic palatal lesion during a period of neutropenia. Imaging revealed sinusitis, pre- and postseptal cellulitis. The disease later progressed to cerebral involvement and orbital apex syndrome with complete ophthalmoplegia, ptosis and loss of vision. The patient was treated with systemic antifungal therapy, hyperbaric oxygen and extensive surgery. This included orbital exenteration, skull base resection, cerebral debridement with placement of an Ommaya reservoir for intrathecal administrations of amphotericin B (AmB) and in addition endoscopic sinus surgery with local AmB installation. Chemotherapy was safely continued after resolution of the ROCM and the patient remains in complete remission after 5 years.

CONCLUSION AND IMPORTANCE

Patients with ROCM can be cured with aggressive multimodality treatment, including surgical intervention, even if in myelosuppression.

Orbital Apex Syndrome due to Orbital Mucormycosis after Teeth Infection: A Successful Case Report

Rhino-orbital-cerebral mucormycosis is a severe and rapidly progressive fungal infection associated with low survival rates. Early diagnosis and proper management are mandatory. We report the case of a 20-year-old female with diabetic ketoacidosis and teeth infection, who presented with sudden orbital apex syndrome. Several surgical procedures were necessary to provide a definite histopathological diagnosis of the fungal infection. Ultimately, given the progressive aggravation of the infection and the ineffectiveness of antifungal and antibiotic agents, an orbital exenteration was performed. A mycobacteriological examination revealed a polymicrobial culture with Mucorales. One year after the initial presentation, the patient is alive and with a good general health condition.

Secondary orbital exenteration for conjunctival melanoma: A study of 25 cases

INTRODUCTION

The treatment of conjunctival melanoma is most often conservative, but exenteration is sometimes necessary in order to achieve local control of the disease. It can be performed as a primary procedure in cases of locally advanced disease or as a secondary procedure after one or more recurrences. No benefit to secondary exenteration on patient survival has been demonstrated to date for conjunctival melanoma, and it is generally considered a palliative procedure.

PATIENTS AND METHODS

Single-center retrospective study performed in the ocular oncology department of the Institut Curie (Paris, France). We included all patients who underwent secondary orbital exenteration for conjunctival melanoma between January 2008 and January 2016.

RESULTS

Twenty-five patients underwent secondary exenteration for conjunctival melanoma. The maximum number of local recurrences prior to exenteration was six. Metastases occurred in 11 patients after exenteration and were more common when there was a greater tumor thickness on histology, if the tumor had not been treated initially in an ocular oncology center, or if there had been a greater number of local recurrences before the secondary exenteration was performed. Seventy-five percent of patients developed metastases when the exenteration was performed after 5 or 6 local recurrences.

CONCLUSION

This study suggests that early secondary exenteration (i.e. after a number of local recurrences less than or equal to 4) may reduce the occurrence of metastases (and therefore improve patient survival) in conjunctival melanoma. Thus, secondary exenteration might be a curative surgery in some patients with recurrent disease.

Sinonasal cancer encroaching the orbit: Ablation or preservation?

BACKGROUND

Encroachment on the orbital cavity represents a challenge in the management of sinonasal cancer. Criteria guiding orbital preservation lack univocal consensus. Stage of orbital involvement is best assessed through magnetic resonance imaging (MRI).

METHODS

Patients affected by orbit-encroaching sinonasal cancer with available preoperative MRI, receiving surgery-based treatment at the University of Brescia between May 2005 and October 2018 were included. All cases were reviewed by expert radiologists and pathologists. Diagnostic performance of MRI was calculated using pathological information as reference. Survival analysis was performed.

RESULTS

The study included 123 patients. The orbit was abutted in 53 (43.1%) patients, whereas orbital invasion reached the periorbit in 18 (14.6%), extraconal fat and/or medial lacrimal sac in 29 (23.6%), extrinsic ocular muscles in 7 (5.7%), intraconal compartment in 4 (3.3%), and orbital apex in 12 (9.8%). Seventy-six (61.8%) patients received orbit-sparing surgery, 47 (38.2%) underwent orbital ablation (OA). Accuracy of MRI in detecting involvement by cancer was ≥80.0% for the orbital wall, extraconal fat, and muscles, and <80.0% for the periorbit and intraconal compartment. Previous surgery, neoadjuvant chemotherapy, and perineural invasion decreased MRI accuracy. Age, histology, tumor grade, pT category, N status, perineural invasion, orbital invasion stage, and need for OA were found to affect prognosis. Five-year orbital dysfunction-free survival was 92.8%.

CONCLUSION

Conservative management of sinonasal cancers encroaching the orbit is feasible. MRI is essential to preoperatively stage orbital invasion, yet with some limitation. Given the dismal prognosis despite aggressive surgery, neoadjuvant non-surgical therapies should be considered in patients requiring OA.

Orbital exenteration: A 20-year experience from a tertiary center in Taiwan

PURPOSE

To describe the prognostic factors and survival outcomes in patients who underwent orbital exenteration surgery at a tertiary center over a 20-year period.

METHODS

This institutional retrospective study reviewed all patients who underwent orbital exenteration between January 1999 and January 2019 at Department of Ophthalmology, National Taiwan University Hospital. Patient demographics, tumor site, histopathology, status of surgical margins, additional resection, local recurrence, metastases, survival, and treatment data were recorded. Log-rank tests were used to verify the difference in survival curves among various potential prognostic factors.

RESULTS

Thirty patients (27 with malignancy, 1 with hybrid neurofibroma/schwannoma, and 2 with mucormycosis) were included. Malignant melanoma (n = 11) and sebaceous gland carcinoma (n = 8) were the most common indications for exenteration. Survival rates were 83% at 1 year, 42% at 3 years, and 33% at 5 years. Among patients with malignancies, 71% patients had clear margins after exenteration. All the incidences of local recurrence developed in the first 2 years postoperatively. Postoperative survival was significantly related to lymphovascular invasion (p = 0.018), but was independent from surgical margins, presence of metastasis, local recurrence, or perineural invasion.

CONCLUSION

We found worse prognosis with positive lymphovascular invasion. Although not significant, malignant melanoma showed poorer survival times compared to sebaceous gland carcinoma. Close follow-up, especially in the first 2 years after orbital exenteration, is crucial to identify disease recurrence.

Cannibalistic bilateral orbital trauma

Purpose

To describe the details of a unique case of cannibalistic orbital trauma and the oculoplastic reconstruction approach.

Observations

A 65-year-old homeless man survived a disfiguring cannibalistic facial and bilateral orbital injury that included bilateral loss of all adnexal structures, partial exenteration of the left orbit, and severe damage to the right globe and anterior orbital structures. The patient's extensive facial and orbital tissue damage required emergent surgery, which included left exenteration and right eyelid reconstruction.

Conclusions

This is the first report of cannibalistic evisceration in a live victim who survived the attack, posing a unique reconstructive challenge. Bilateral globe removal was avoided to provide time for the patient's emotional recovery. Although this was an exceptional surgical scenario, traditional oculoplastic principles remained crucial to achieving a successful outcome. The patient survived and was pleased with his surgical outcome, refusing further reconstruction or prosthesis fitting.

Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: A systematic review

BACKGROUND

The vertical rectus abdominis myocutaneous (VRAM) flap is an established technique employed to reconstruct pelvic and perineal defects not amenable to primary closure. The aim of this study was to systematically review the morbidity of VRAM flap reconstruction following exenterative pelvic surgery.

MATERIALS AND METHODS

A systematic literature search was conducted by using Medline, EMBASE, and Cochrane databases. Abstracts of all studies published from inception to November 2019 were identified. Search terms used included 'vertical rectus abdominis myocutaneous', 'vertical rectus abdominis musculocutaneous' and 'VRAM'. Only studies that described outcomes when a VRAM flap was used during exenterative pelvic surgery were included; case reports were excluded. The primary outcome measure was VRAM flap morbidity. Secondary outcome measures included donor site morbidity and hospital length of stay.

RESULTS

Sixty-five studies with a total of 1827 patients were identified and included. Perineal reconstruction was most commonly performed following abdominal perineal excision of the rectum (APER) (n = 636 and 34.8%). Median patient age at surgery ranged from 38 to 78 years. Mean perineal flap morbidity was 27%, with a complete flap loss rate of 1.8% and a perineal hernia rate of 0.2%. Mean donor site morbidity was 15%, with an abdominal dehiscence rate of 5.5% and an incisional hernia rate of 3.3%.

CONCLUSIONS

While overall morbidity after VRAM flap reconstruction in pelvic visceral surgery is high; the risk of major complications remains low. These data are important when counselling patients for surgery.

Modified types of orbital exenteration, survival, and reconstruction

PURPOSE

This study aims to analyse the various modifications of orbital exenteration.

METHODS

Patients undergoing orbital exenteration from March 1978 to October 2019 were included in this retrospective study. The patients were evaluated on the basis of the indication, type of exenteration, reconstruction technique, overall survival (OS), and disease-free survival (DFS).

RESULTS

In total, 300 patients were enrolled in this study. As many as 24 patients had lid and conjunctiva sparing anterior exenteration, 16 had lid sparing anterior exenteration, 83 had anterior exenteration, 14 had lid and conjunctiva sparing total exenteration, seven had lid sparing total exenteration, 44 had total exenteration, one had lid and conjunctiva sparing extended exenteration, 23 had lid sparing extended exenteration, and 88 had extended exenteration. As many as 39 patients had a primary wound closure. Six patients underwent reconstruction with a split-thickness skin graft, 177 patients with a local or regional flap, and 40 patients with a microvascular flap. A total of 38 patients did not undergo reconstruction. The mean follow-up was 40 months (range 6-216 months). The OS rate was 82.2% after 1 year, 58.5% after 5 years, and 49% after 10 years for all patients with malignant tumours. The DFS rate was 67.7% after 1 year, 45.6% after 5 years, and 31.7% after 10 years.

CONCLUSION

Individual types of orbital exenteration allow patient-adapted therapies. The preservation of uninvolved orbital tissue facilitates orbital reconstruction. The type of exenteration did not have any influence on overall survival.

Orbital exenteration and reconstruction in a tertiary UK institution: a 5-year experience

PURPOSE

Orbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach.

METHODS

We performed a clinicopathological review of patients referred to Guy's and St Thomas' NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed.

RESULTS

27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects.

CONCLUSIONS

A multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.

Orbital exenteration: Symptoms, indications, tumour localizations, pathologies, reconstruction, complications and survival

OBJECTIVE

This study aims to evaluate malignant and benign diseases that lead to orbital exenteration.

PATIENTS

From December 1999 to September 2017, patients undergoing orbital exenteration were included in this retrospective study. All of them were evaluated on clinical symptoms, indications, tumour localizations, pathologies, reconstruction techniques, complications, recurrences, and survival.

RESULTS

Of the 205 patients enrolled in this study, 94 had a carcinoma, 73 melanoma, 9 a sarcoma, 14 some other malignant disease, and 15 a benign medical condition. Sixteen patients underwent reconstruction using a local eyelid skin flap (7.8%), 6 with a split-thickness graft (2.9%), 144 with a local flap (70.2%), and 25 with a microvascular graft (12.2%), whereas 14 patients did not undergo reconstruction (6.8%). The most common complications were wound dehiscences (25 cases), pain (17 cases), and partial flap necroses (13 cases). Moreover, 62% of the patients were treated with different facial prostheses or artificial eyes. Given these results, it appears that lymph nodes and distant metastases, as well as lymphatic invasion into vessels, perineural invasion, and non-cleared resection margins, seem to affect overall survival after orbital exenteration.

CONCLUSION

Different reconstruction techniques can be used to provide the patient with maximum functionality and aesthetics after orbital exenteration. Individual concepts should be discussed at the beginning of the treatment. Using primary reconstruction and providing osseointegrated implant-retained prostheses remain the gold standard.

[Advanced periocular basal cell carcinoma-a therapeutic challenge]

BACKGROUND

Basal cell carcinomas are the most common periocular malignant tumor. In advanced periocular basal cell carcinoma, vismodegib is a new treatment option which might potentially avoid surgical eye removal.

CASE REPORT

We treated a 76-year-old patient unwilling to consent to surgery with vismodegib for advanced periocular basal cell carcinoma on the left forehead that had already undergone several previous treatments. After initial partial remission, the tumor regrew under ongoing therapy, so that radical surgical excision including orbital exenteration was performed. Unfortunately, the patient died thereafter due to septic multi-organ failure.

CONCLUSION

Basal cell carcinoma and its new treatment options are gaining importance for ophthalmology due to rising incidence and prevalence rates. Vismodegib is a new encouraging option. However, for advanced tumors, it must be resolved whether complete histological remission may be achieved to avoid surgical intervention, or whether the area of resection can be significantly reduced. Current multicenter studies investigate these aspects further (ClinicalTrails.gov identifier: NCT03035188).

The effect of preoperative nutritional status on postoperative complications and overall survival in patients undergoing pelvic exenteration: A multi-disciplinary, multi-institutional cohort study

INTRODUCTION

Optimization of preoperative nutritional status has been recommended and associated with improved outcomes for other oncologic procedures, but has not been studied in patients undergoing pelvic exenteration.

METHODS

A retrospective chart review of 199 patients was conducted. Overall survival (OS) was calculated using the Kaplan-Meier method and multivariate analysis was performed with Cox proportional hazards.

RESULTS

199 patients underwent PE with 61 (31%), 78 (40%) and 58 (29%) patients having colorectal, gynecologic and urologic histological diagnoses, respectively. Median OS following PE was 25 months. Preoperative serum albumin <3.5 g/dL was associated with worsened OS (HR 1.661; 95% CI 1.052-2.624) as well as increased incidence of any postoperative complication (85.9% vs 72.3%, p = 0.034), but was not associated with 90-day mortality (11.3% vs 7.9%, p = 0.457).

CONCLUSION

Poor preoperative nutritional status is associated with increased complications and decreased OS. Surgeons should maximize preoperative nutritional status to improve perioperative outcomes and long-term survival.

Regression of Sebaceous Carcinoma of the Eyelid after a Small Incisional Biopsy: Report of Two Cases

Purpose

To report 2 cases of regression of sebaceous carcinoma of the eyelid after a small incisional biopsy.

Methods

Clinical, imaging, and histopathological findings are presented, with a literature review on regressing ocular tumors.

Results

Our first patient was a 79-year-old man who presented with a 10-month history of progressive left upper eyelid ptosis caused by an eyelid tumor with orbital involvement and confirmed on magnetic resonance imaging. Our second patient was a 70-year-old woman who presented with ptosis with a left upper eyelid mass. Both patients underwent a small incisional biopsy of their lesion. The histopathological diagnoses in both cases were consistent with sebaceous carcinoma. Both patients refused exenteration. Follow-up clinical examination and imaging disclosed total regression of the ptosis and of the neoplasm with no sign of recurrence in both patients over a 4-year period for Case 1 and a 7-year period for Case 2.

Conclusion

Regression following incisional biopsy of basal cell, squamous cell, and Merkel cell carcinoma, including of the eyelid, is well documented. To the best of our knowledge, our 2 cases of sebaceous carcinoma are the first to be reported with total involution clinically and on imaging of the tumor following partial incisional biopsy.

Transperineal retropubic approach in total pelvic exenteration for advanced and recurrent colorectal and anal cancer involving the penile base: technique and outcomes

BACKGROUND

Complete pathological resection of locally advanced and recurrent anorectal cancer is considered the most important determinant of survival outcome. Involvement of the retropubic space with cancer threatening or involving the penile base poses specific challenges due to the potential for margin involvement and blood loss from the dorsal venous plexus. In the present study we evaluate a new transperineal surgical approach to excision of anterior compartment organs involved or threatened by cancer which facilitates exposure and visualisation of the bulbar urethra and the deep vein of the penis caudal to the retropubic space and penile base.

METHODS

A retrospective study was performed on male patients with tumour extension into the penile base treated at our institution using the transperineal surgical approach. Descriptive data for patient demographics, radiology, operative details, postoperative histology, complications and outcomes were collated.

RESULTS

Ten male patients with tumour extension into the penile base were identified. Two patients had recurrent anal cancer, 6 had locally advanced primary rectal cancer and 2 had recurrent rectal cancer. All patients had exenterative surgery with excision of the penile base utilising the transperineal approach. All patients had R0 resection. No local recurrence developed after a median follow up period of 15 months.

CONCLUSIONS

The transperineal approach to the penile base and retropubic space allows for high rates of R0 resection margin status with direct visualisation of the dorsal venous plexus, thereby minimising blood loss. In our experience, this technique is the preferred approach to excision of cancers threatening and involving the penile base and also for most male patients requiring total pelvic exenteration.

Orbital exenteration: Institutional review of evolving trends in indications and rehabilitation techniques

PURPOSE

To determine the changes in indications for orbital exenteration over 20 years and to assess its impact on patient survival. Evolving techniques of rehabilitation of the orbit in our institution were also evaluated.

METHODS

This was a retrospective review of hospital records of patients who underwent orbital exenteration from 1995 to 2015 in a tertiary care center. Data extracted included primary location of the tumor, preoperative treatments, interval between initial diagnosis and exenteration, status of surgical margins, presence of metastatic disease, and postoperative survival. The types of prosthesis utilized over the years were also reviewed. Cox regression analysis was performed for categorical variables. Kaplan-Meier analysis was used to estimate post-exenteration survival.

RESULTS

Over a 20-year period, orbital exenteration was performed on 100 orbits of 100 patients. The mean age was 39.4 years (range: 2 months to 90 years). The most common indications among 98 malignant causes were retinoblastoma, squamous cell carcinoma, basal cell carcinoma, extraocular extension of uveal melanoma, and conjunctival melanoma. Postoperative survival was significantly related to age and tumor location but independent from gender, surgical margin, histopathological diagnosis, previous treatment modality, and preoperative interval. In the whole cohort, 1-year and 5-year survival rates were 97% and 84%, respectively.

CONCLUSIONS

Exenteration appears to be life-saving in children with orbital extension of retinoblastoma. While patients exenterated for malignant eyelid tumors have the best chance of survival, those with orbital extension of uveal melanoma and adenoid cystic carcinoma of the lacrimal gland have the worst prognosis.

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.

Aggressive Ciliary Body Adenocarcinoma with Bilateral Lung Metastases: Histological, Molecular, Genetic and Clinical Aspects

Purpose of the Study

To describe the clinical and histopathological features of an aggressive ciliary body adenocarcinoma with pulmonary metastases and skull base spread.

Procedures and Results

A 45-year-old female patient presented with a post-traumatic phthisical eye that was eviscerated. This showed an unexpected carcinoma (positive for cytokeratins and melanocytic markers), the histological differential diagnosis for which included a primary ciliary body adenocarcinoma or a metastasis. The patient developed rapid post-surgical localized recurrence that required an orbital exenteration. This showed identical tumour to the evisceration specimen, with vascular invasion in orbital blood vessels and a contaminated orbital soft tissue margin. Staging imaging revealed multiple lung metastases, which were biopsied and shown to be a disseminated ciliary body adenocarcinoma rather than a disseminated primary lung carcinoma. The tumour spread locally to the skull base for which radiotherapy was given. Unfortunately, the patient passed away a few weeks later.

Conclusions

To our knowledge, this is the first case of ciliary body adenocarcinoma with bilateral lung metastases. The malignant potential of these tumours should be considered as a possibility, and appropriate screening and staging tests should therefore be considered to guide appropriate management.

Malignant Orbital Meningioma Originating from the Frontal Lobe

PURPOSE OF THE STUDY

Orbital meningiomas are typically benign tumors, most commonly originating from the dura of the sphenoid wing or the optic nerve sheath.

PROCEDURES

We describe an unusual case of a malignant meningioma originating from the frontal lobe that ultimately produced orbital and distant metastases.

RESULTS AND CONCLUSIONS

Orbital invasion by the meningioma was preceded by multiple incomplete resections, which may have facilitated access to the orbit. The present case serves to remind clinicians that surgical resection of aggressive, recurrent frontal lobe meningiomas may facilitate subsequent penetration of surrounding structures, particularly by tumors that demonstrate bone-destructive properties.

Use of bilayer matrix wound dressing in the exenterated socket

To describe the novel use of a bilayer dermal substitute to reconstruct exenterated orbits. A retrospective chart review was performed in the practices of two surgeons (RET and PDL) of all patients who had undergone orbital exenteration between April 2014 and June 2016 and whose subsequent reconstruction included lining the socket with Integra bilayer. Patient demographics, pathologic diagnoses, surgical and post-operative complications, graft integrity, and patient acceptance were recorded. The charts of 7 patients (4 men and 3 women, ages 60-87 years) were reviewed. In all cases, the Integra graft had taken well to the socket bed at the time of silicone removal 3-4 weeks after surgery. Epithelialization of the socket occurred rapidly over the Integra graft (within several weeks) without incident in each case and with minimal postoperative management. No intraoperative or postoperative complications were noted. Integra dermal substitute is an ideal graft for the lining of an exenterated orbit. It is readily available in large quantities, handles easily, lines the socket smoothly, epithelializes rapidly, and requires minimal postoperative care. It offers minimal morbidity compared to skin grafting or free flap reconstruction, but greatly speeds epithelialization compared to laissez faire management. Surgeons should consider reconstructing exenterated orbits with the Integra matrix, both for its ease of use and its ability to epithelialize rapidly.

Microcystic adnexal carcinoma of the orbit mimicking pagetoid sebaceous gland carcinoma

Microcystic adnexal carcinoma (MAC) is a rare malignancy of sweat glands that has been reported most often on the face in the form of a cutaneous lesion, with the potential for deeper invasion. The synonyms of MAC include sclerosing sweat duct carcinoma, syringomatous carcinoma, and malignant syringoma. Clinically, MAC in the periocular area has been misdiagnosed as basal cell carcinoma, squamous cell carcinoma, or even chalazia. We report a case of MAC presenting clinically as sebaceous gland carcinoma with pagetoid spread for the first time in literature.

The intraoperative use of polydioxanone foil to reduce the risk of sino-orbital fistula formation in orbital exenteration

BACKGROUND

Orbital exenteration is a radical surgical procedure resulting in deformity. It involves removal of the globe, optic nerve, extra-ocular muscles, orbital fat, lacrimal gland, and peri-osteum. Sino-orbital fistula (SOF) formation is a common documented post-operative complication, usually connecting the orbit and the ethmoid sinus. SOFs can cause leaks of serous fluid, and act as an entry site for pathogens into the orbit leading to socket infection and breakdown.

METHODS

This retrospective study analyzed exenterations performed over a 22-year period (1993-2015) at the National Ocular Oncology Service Centre for Scotland. PDS is a crystalline, biodegradable polyether-ester that is strong with good shape-memory and flexibility. Orbital exenterations with and without the use of PDS foil were compared in terms of SOF formation.

RESULTS

A total of 30 exenterations were performed during the study period. A total of 29 were analyzed. Choroidal malignant melanoma was the most common indication for performing orbital exenteration (n = 7, 24.14%). The most common post-operative complications seen were SOF (n = 8, 27.59%). A total of 8 out 21 (38.10%) cases not using PDS developed SOFs. By contrast, none of nine patients receiving PDS plates developed SOFs (p = 0.0332).

CONCLUSIONS

This is the first study to compare SOF rate in patients undergoing exenteration with and without the use of PDS foil. PDS foil is a safe material, which has effectively reduced the incidence of SOF formation.

[Laparoscopic anterior pelvic exenteration in a patient with locally advanced melanoma]

BACKGROUND

Pelvic exenteration is one of the most mutilating surgical procedures with high post-operative morbidity. The laparoscopic technique aims to reduce perioperative complications and reduce post-surgical recovery.

OBJECTIVE

We present the first case of laparoscopic anterior exenteration for locally advanced melanoma, held at the National Cancer Institute and published in Mexico.

CASE REPORT

Patient 60 years of age diagnosed with invasive vulvar melanoma with bladder extension upon whom laparoscopic anterior pelvic exenteration with external urinary reconstruction was performed. Time in surgery was 505minutes and estimated blood loss was 400ml. No complications occurred during or immediately after surgery. The final histopathological study reported: nodular lesion that completely replaces the clitoris and spreads to the left labia majora, measures 3×2.5×2cm and is located relative to the free margins with perineural invasion intraepithelial spread in space and urethra and bladder trigone.

CONCLUSIONS

The laparoscopic anterior pelvic exenteration is a safe alternative in well-selected patients, with acceptable time in surgery, surgical complications and recovery time.

Locally advanced vulva cancer: A single centre review of anovulvectomy and a systematic review of surgical, chemotherapy and radiotherapy alternatives. Is an international collaborative RCT destined for the "too difficult to do" box?

INTRODUCTION

Treatment of locally advanced vulva cancer (LAVC) remains challenging. Due to the lack of randomised trials many questions regarding the indications for different treatment options and their efficacy remain unanswered.

METHODS

In this retrospective study we provide the largest published series of LAVC patients treated with anovulvectomy, reporting oncological outcomes and morbidity. Additionally, a systematic literature review was performed for all treatment options 1946-2015.

RESULTS

In our case series, 57/70 (81%) patients were treated in the primary setting with anovulvectomy and 13 patients underwent anovulvectomy for recurrent disease. The median overall survival (OS) was 69months (1-336) with disease specific survival of 159months (1-336). Following anovulvectomy for primary disease, time to progression and OS were significantly higher in node negative disease (10 vs. 96months; 19 vs. 121months, p<0.0001). Post-surgical complications were observed in 36 (51.4%), the majority of which were Grade I/II infections. There was one peri-operative death. Review of the literature showed that chemotherapy, radiotherapy or combination treatments are alternatives to surgery. Evidence relating to all of these consisted mostly of small retrospective series, which varied considerably in terms of patient characteristics and treatment schedules. Significant patient and treatment heterogeneity prevented meta-analysis with significant biases in these studies. It was unclear if survival or morbidity was better in any one group with a lack of data reporting complications, quality of life, and long term follow-up. However, results for chemoradiation are encouraging enough to warrant further investigation.

CONCLUSIONS

There remains inadequate evidence to identify an optimal treatment for LAVC. However, there is sufficient evidence to support a trial of anovulvectomy versus chemoradiation. Discussions and consensus would be needed to determine trial criteria including the primary outcome measure. Neoadjuvant chemotherapy or radiotherapy alone may be best reserved for the palliative setting or metastatic disease.

Locally Recurrent Disease Related to Anal Canal Cancers

Surgery for anal cancer is usually reserved for patients with persistent disease or local recurrence after definitive chemoradiation therapy. Patients with local recurrence should be re-evaluated for evidence of metastatic disease using positron emission tomography-computed tomography, and the local anatomy should be delineated with MRI. Eligible patients should undergo tailored surgery with the aim of achieving an R0 resection. Management is best undertaken within a specialized multidisciplinary setting. Careful patient selection and shared decision making are paramount for achieving acceptable patient-centered outcomes.

Organ preservation with neoadjuvant chemoradiation in patients with orbit invasive sinonasal cancer otherwise requiring exenteration

Purpose

We sought to determine if organ preservation (OP) with neoadjuvant chemoradiation (CRT) was feasible in patients with sinonasal cancer determined to require exenteration.

Materials and Methods

Twenty patients were determined to require exenteration for definitive treatment from 2005 to 2014. Fourteen patients underwent OP and 6 patients received exenteration with adjuvant CRT. Exenteration free survival (EFS), locoregional control (LRC), progression-free survival (PFS), and overall survival (OS) were estimated.

Results

Five patients (36%) receiving OP had complete disease response at time of surgery. With a median follow-up of 18.8 months, EFS was 62% at 2 years for patients undergoing OP. At 2 years, there were no significant differences in LRC, PFS or OS (all all p > 0.050) between the groups. Less grade 3 or greater toxicity was seen in patients undergoing OP (p = 0.003). Visual function was preserved in all patients undergoing OP.

Conclusion

For patients with sinonasal cancer, OP may avoid exenteration, offering similar disease control and improved toxicity.

Restoration of vaginal anatomy after extensive posterior wall resection utilizing human acellular dermal matrix

•

Pelvic tumor debulking encompassing the vaginal wall can preclude simple closure.

•

Current repair options that maintain sexual function and anatomy are limited.

•

This is the first published case of an acellular matrix used for such reconstruction.

•

This technique presents a new & superior option for vaginal preservation.

Abdominoperineal Excisions in the Treatment Regimen for Advanced and Recurrent Vulvar Cancers-Analysis of a Single-Centre Experience

Vulva cancer is the fourth leading gynaecological malignancy, accounting for approximately 4 % of all gynaecological cancers. Surgery represents the treatment of choice, and cases of advanced or recurrent vulvar cancers are to date a major challenge to multidisciplinary teams. Abdominoperineal excision (APE) in combination with vulvectomy and inguinal lymphadenectomy is the only curative treatment option. Patients' files of all women with squamous cell carcinoma of the vulva who underwent abdominoperineal resection were retrospectively reviewed with special regards to technical challenges the general surgeon will face. Seven women were enrolled in this retrospective study with a median age of 71 years (range 56-79 years). In six patients, the pelvic floor after abdominoperineal excision could be closed by direct suture of the levator muscles. One woman underwent abdominoperineal resection with closure of the defect using a vertical rectus abdominis myocutaneous (VRAM) flap. All women underwent radical vulvectomy, in five patients in combination with bilateral inguinal lymph node dissection. Operation time was 377 min (range 130-505 min). The median overall survival after surgery was 27 months (range 4-84 months), with a calculated 5-year survival rate of 42 %. Women with negative lymph nodes revealed a longer survival time after surgery compared to women with lymph node metastases (15.5 vs. 72 months; p = 0.09). Abdominoperineal excisions represent a powerful tool in the multidisciplinary treatment regimen of advanced or recurrent vulvar cancer. Reconstruction of the pelvic floor usually does not require myocutaneous flaps, even when facing large tumours. Despite high complication rates, radical surgery was a feasible treatment with long-term survival potential without mortality.

Reconstruction of orbital exenteration defects with bilobed forehead flap

To describe the use of bilobed forehead flap for reconstruction of orbital exenteration defect. The medical records of 2 patients in whom orbital exenteration defect repair was performed with bilobed forehead flap were reviewed. In both patients (male, ages 74 and 65 years), extended exenteration was performed because of basal cell carcinoma infiltrating the upper and lower eyelids and orbit. One patient had a history of multiple eyelid surgeries and periorbital radiotherapy. In the other, the tumor also involved the maxillary and ethmoid sinuses and nasal dorsum. The bilobed flap was combined with a cheek advancement flap in 1 patient. The excisional defect could be primarily covered in both patients. In 1 patient, a skin graft was needed to cover the forehead donor area defect. In both patients, transient, distal flap ischemia developed after surgery and, in 1 patient, eyebrow malposition required surgical correction at the late period. No other complication developed during follow-up (18 and 26 months). The bilobed forehead flap can be effectively used to reconstruct total or extended orbital exenteration defects.

Macroscopic techniques for ophthalmic tumor specimens

This article explores the range of tumor specimens that may be submitted to ophthalmic pathology. The handling of complex enucleation and exenteration is described along with smaller eyelid, conjunctival and corneal specimens. The importance of a good understanding of the unique anatomy of the ocular region and detailed clinical information is emphasized as this results in the taking of appropriate blocks for histology and consequently clinically helpful reports. Recommendations for handling specimens where further tissue is required for molecular studies is discussed.

Eye Removal Surgeries in Exotic Pets

This article covers considerations and techniques of eye removal surgeries in exotic pets. After issues including surgical indications, anesthesia, patient preparation, and instrumentation are explored, surgical techniques are described. Enucleation/exenteration and modified evisceration are discussed, with species-specific nuances of small mammals, birds, reptiles, snakes, amphibians, and fish highlighted.

Naso-orbital fistula and socket reconstruction with radial artery forearm flap following orbital mucormycosis

Invasive mucormycosis is an uncommon cause of orbital exenteration. Reconstruction of an exenterated orbit is a surgical challenge. The loss of eyelids, adnexal structures, and even surrounding skin causes significant facial disfigurement. The goal for reconstruction demands a symmetrical orbital cavity with good prosthetic rehabilitation. Multiple reconstructive options in the form of skin grafts, local flaps, and free flaps are available. However, none of them provide ideal reconstruction. Our patient not only had extensive soft-tissue loss and unstable lining but also a large naso-orbital fistula. Reconstruction for this complex defect was done using an adipofascial radial artery flap which not only closed the fistula but also provided soft-tissue bulk and good skin match. Radial artery forearm flap provides a simple, stable, and good reconstructive option postorbital exenteration.

Orbital Extension of an Unsuspected Choroidal Melanoma Presumably through an Aqueous Tube Shunt

AIMS

To report a patient with unrecognized small macular melanoma, who gradually developed neovascular glaucoma that was treated with an Ahmed valve. We presume that tumor cells gained access to the orbit through this aqueous drainage device.

METHODS

The medical records pertaining to 5 different centers, the results of imaging studies, the clinical course of the patient and histopathological findings were retrospectively reviewed.

RESULTS

A 61-year-old man presented with a blind and painful proptotic right eye. Retinal hemorrhage had been suspected 3 years earlier and followed accordingly thereafter. Yearly performed MRI studies demonstrated the steady growth of the hemorrhagic lesion/tumor. Meanwhile, he developed neovascular glaucoma first treated unsuccessfully with cyclocryotherapy then with implantation of an Ahmed valve. Right proptosis became evident within a year, and a final MRI study revealed a large retrobulbar mass. Orbital exenteration was performed and histopathological examination showed intraocular and orbital epithelioid cell melanoma. Tumor cells were also found within the reservoir of the Ahmed valve. The patient died of widespread metastases 1 year later.

CONCLUSIONS

Ahmed valve implantation in an eye with unsuspected macular choroidal melanoma may ultimately be associated with extraocular extension and orbital tumor formation.

Clinicopathological profile of orbital exenteration: 14 years of experience from a tertiary eye care center in South India

This study aims to describe the clinicopathological features and outcomes of patients who underwent orbital exenteration at a tertiary eye care center in south India. Retrospective chart reviews were performed on all patients undergoing orbital exenteration from January 1999 to December 2012. Parameters recorded include demographic data, clinical presentations, past medical or surgical interventions, exenteration notes, histopathological diagnosis, adjunctive treatment, follow-up examination findings, recurrences, complications, and their management. Orbital exenteration was performed on 119 orbits of 119 patients over a 14-year period. The mean age was 48.9 years (range 1-82 years). The indications were malignancies in 90.7 % (108/119), while 9.3 % (11/119) of cases were exenterated for non-malignant indications. Among the malignancies, the commonest tissue of origin was conjunctiva, noted in 45.4 % (49/108), followed by eyelids (25.9 %, 28/108), orbit (19.4 %, 21/108), and intraocular tissues (9.3 %, 10/108). The commonest malignancies noted in this series were an extensive ocular surface squamous neoplasia (OSSN) (44.4 %, 48/108) and sebaceous gland carcinoma of eyelids with an orbital involvement (18.5 %, 20/108). Extensive fungal granuloma (mucormycosis-4, aspergillosis-4) was the commonest (81.8 %, 9/11) indication among the non-malignant group. All complications were wound related, and none had a recurrence at a mean follow-up of 12.8 months. Extensive orbital involvement with OSSN and SGC were the commonest indications for exenteration. There is a need of creating awareness among general ophthalmologists in specific geographical regions regarding early diagnosis, standardized protocols of management, and appropriate referral.