Primary orbital leiomyosarcoma. A case report and review of the literature

Primary Leiomyosarcoma of the Orbit and Conjunctiva: A Report of Four Cases With a Review of the Literature

Leiomyosarcomas (LMS) are common soft tissue tumors in the body. Primary orbital and conjunctival LMS are, however, rare. Herein, we describe the diverse clinical presentations, histopathological features, and management outcomes of three cases of primary LMS of the conjunctiva and one case of primary orbital LMS. The first patient was a 40-year-old female with primary orbital LMS who developed recurrence following wide local excision. The remaining three cases were primary conjunctival LMS. All four patients underwent orbital exenteration and were disease-free at a mean follow-up period of 18.64 months. LMS is known for local recurrences and metastasis. Complete surgical excision and prompt adjuvant radiotherapy can improve the prognosis.

Primary Orbital Leiomyosarcoma in an Adult Male

A 71-year-old male presented with a history of noticing gradual painless progressive proptosis along with a pinkish mass seen on the outer aspect of his left eyeball. Orbital CT revealed a fairly defined homogenous lesion, abutting the left eyeball and involving the lateral orbit reaching almost till orbital apex. Histopathology analysis aided with immunohistochemistry after an incision biopsy was consistent with leiomyosarcoma. Positron emission tomography scan ruled out presence of any distant primary or metastatic tumor. He underwent eyelid sparing total orbital exenteration with confirmed tumor free soft-tissue margins. He is doing well at 5 months of follow-up with no sign of local recurrence or distant metastasis. Primary orbital leiomyosarcoma is a rare tumor. It is mainly found in older woman; it is even rarer in males. Complete surgical excision with tumor free margins is the recommended treatment. Histopathology and immunohistochemistry are valuable in diagnosis and management.

Conjunctival Leiomyosarcoma, a Rare Neoplasm Always Originating at the Limbus? Report of a New Case and Review of 11 Published Cases

PURPOSE OF THE STUDY

To describe the differential diagnosis and management of a rare conjunctival malignancy.

PROCEDURES

A 79-year-old man presented with a conjunctival mass at the limbus. Excisional biopsy revealed a malignant mesenchymal tumor with myogenic differentiation. Six months later, three suspect lesions developed at the border of the previous excision. Pathological diagnosis pointed to a leiomyosarcoma. Adjuvant radiotherapy with strontium-90 brachytherapy was applied. After 3 years, there was neither recurrence nor distant metastases. A literature review revealed 11 cases of conjunctival leiomyosarcoma.

RESULTS

All 12 cases seemed to originate at the limbal conjunctiva. Scleral invasion was found only in one patient with multiple previous resections. Corneal invasion was reported in two patients. Four patients had a globe-sparing resection. In two of them, margins were not tumor free and additional brachytherapy gave a tumor-free follow-up of 1 and 3 years. Four cases underwent an exenteration.

CONCLUSION AND MESSAGE

Primary conjunctival leiomyosarcoma is a rare tumor with a favorable prognosis due to early detection and consequently limited size. Diagnosis involves histopathological investigation including immunohistochemistry. If possible, complete resection has the best prognosis. Adjunctive radiotherapy can be effective when the margins are not free and should be considered.

Conjunctival leiomyosarcoma: A fairly common tumour in an uncommon site

BACKGROUND

Leiomyosarcomas of soft tissue are malignant tumours that are not infrequently encountered in clinical medicine and histopathology. Such sarcomas of the eye are, however, a rare occurrence.

PURPOSE

Herein, the histopathological features of a case of conjunctival leiomyosarcoma are described. A 38-year-old HIV-positive male, who was otherwise fit and healthy, presented with redness of his right eye and a mass of the conjunctiva. Clinically, he did not have any soft-tissue masses elsewhere in the body.

METHOD

He underwent monoblock excision of the conjunctival mass which was confirmed histologically to be a leiomyosarcoma. Unfortunately, the patient had not returned for follow-up examination.

CONCLUSION

The differential diagnosis of a conjunctival spindle cell neoplasm is broad. While a spindle cell carcinoma is the most likely tumour, other tumours must be borne in mind so as not to misdiagnose primary sarcomas in this unusual location.

MRI and FDG PET/CT Findings of Primary Orbit Leiomyosarcoma

Primary leiomyosarcoma of the orbit is extremely rare. Here we report the case of a 32-year-old woman who presented with proptosis and diplopia of the left eye. MRI examination showed a solid mass in the left orbit with invasion to adjacent tissue, and the lesion had intense FDG uptake with SUVmax of 18.7 on F-FDG PET/CT. Primary orbit leiomyosarcoma was diagnosed by surgery-pathology. F-FDG PET/CT has an advantage in excluding secondary or metastatic orbit malignancy.

A rare case of primitive epithelioid leiomyosarcoma of the conjunctiva

PURPOSE

To describe a rare case of conjunctival leiomyosarcoma initially diagnosed as a poorly differentiated squamous cell carcinoma.

METHODS

Clinical, light microscopic, immunohistochemical, and ultrastructural findings are reported.

RESULTS

A 56-year-old Caucasian woman was referred with a history of a progressive, rapidly growing mass in her left eye. Biopsy of the mass and histology yielded a first diagnosis of a poorly differentiated conjunctival squamous cell carcinoma. Orbital exenteration was performed 2 weeks later. Macroscopically, the exenteration specimen showed a soft mass completely involving the conjunctiva and extending to the eyelids and orbital structures. Histological examination revealed a malignant tumour composed of atypical, predominantly epithelioid large cells. Immunohistochemical and ultrastructural studies combined with the light microscopic findings contributed to clarify the diagnosis of epithelioid leiomyosarcoma. The patient was started on chemotherapy and radiotherapy, but died a few months later from widespread metastases.

CONCLUSIONS

primary involvement of the orbit by a leiomyosarcoma is rare, but this eventuality should be considered in the differential diagnosis of rapidly growing orbital and conjunctival masses.

Orbital metastasis of retroperitoneal leiomyosarcoma

Leiomyosarcoma is a relatively rare form of cancer most commonly found in the uterus, stomach, small intestine, retroperitoneum, and vascular tissue. Metastasis is common and surgery with a wide margin of resection is generally considered the most effective management. Leiomyosarcomas, metastatic or primary, of the orbit have rarely been reported. Herein, we report the case of a 51-year-old female with metastatic orbital leiomyosarcoma. The diagnosis was based on her history of leipmyosarcoma, orbital ultrasonography, and computed tomography and confirmed by postoperative histochemistry. She was treated with surgical excision and has remained without recurrence 1 year after surgery.

[Mesenchymal orbital tumors]

Mesenchymal tumors grow from pluripotent mesenchymal cells that form the soft orbital tissue. Primary tumors of the orbital walls are discussed in another section. Tumors from muscle and adipose tissue are rare or exceptional, except rhabdomyosarcoma, described in the section dedicated to pediatric tumors. Most frequent tumors are fibrous histiocytomas and solitary fibrous tumors, which often have a retrobulbar location. Fibrous histiocytoma is benign in only 65 % of cases. Fibrous solitary tumor is now better known (Ag CD34): this tumor is generally benign but frequently recurs.

Primary orbital leiomyosarcoma

A 79-year-old woman was presented with a 6-month history of painless proptosis in the left eye. On examination, there was a palpable superotemporal mass displacing the left eye inferomedially. Orbital CT revealed a heterogeneous, lobulated mass occupying the left orbital space with no bone erosion or destruction. MRI showed an extraconal, heterogenous, lobulated orbital mass in the lacrimal gland region of the left eye. The lesion was excised, and the diagnosis of leiomyosarcoma was made by histopathologic examination and immunohistochemistry. Systemic examinations were negative for a primary or a metastatic tumor. There was no evidence of tumor recurrence after 12 months of follow-up. Primary orbital leiomyosarcoma is a rare tumor that mainly occurs in older women and presents with painless proptosis. It should be considered in the differential diagnosis of superotemporal extraconal lesions.

Sinonasal leiomyosarcoma: review of literature and case report

OBJECTIVES/HYPOTHESIS

To determine prognosis of primary sinonasal leiomyosarcomas after treatment.

STUDY DESIGN

Literature review and case report.

METHODS

Review of English literature from MEDLINE and independent sources with the addition of our case.

RESULTS

Including our case, 63 cases have been reported. Primary treatment includes resection with or without radiation. Chemotherapy has not been reported to be effective. In our case, however, chemotherapy, consisting of etoposide and high-dose ifosfamide, caused the tumor to shrink significantly. On the basis of a review of all reported cases, the overall survival rate at a mean follow-up of 38.24 month is 66%. The minimal overall survival rates at 5 and 10 years are 20% and 6%, respectively.

CONCLUSION

The prognosis for primary sinonasal leiomyosarcomas is poor. However, a 10-year survival has been reported in a few patients. Chemotherapy may be a useful adjunct when managing extensive lesions unamenable to curative resection.

Primary Orbital Leiomyosarcoma

An 84-year-old woman presented with a right upper eyelid nodule, first noted 1 month earlier. Incisional biopsy revealed leiomyosarcoma, which was subsequently treated with wide excision and adjunctive radiotherapy. There has been no evidence of tumor recurrence in 3 years of follow-up.

[Subcutaneous leiomyosarcoma metastatic to the eyelid]

BACKGROUND

Metastatic eyelid lesions are rare. Most metastatic lesions to the eyelid are carcinomas. Leiomyosarcomas are soft tissue sarcomas arising most commonly in the uterus and gastrointestinal tract, whereas dermal leiomyosarcomas are less frequent. Dermal leiomyosarcomas metastatic to the eyelid have not been reported so far.

CASE REPORT

A 28-year-old female patient presented with a rapidly growing tumor of her right lower eyelid. A subcutaneous leiomyosarcoma of the neck had been excised 21 months before with subsequent radiotherapy. Seven months later metastases to the lung, liver, and left upper arm were detected. The patient received chemotherapy. The eyelid tumor was completely excised. Histologically the lesion consisted of spindle cells arranged in fascicles with perinuclear vacuoles and myofilaments. There was a strong immunoreactivity for smooth muscle actin, and negative staining for cytokeratin and S100.

CONCLUSION

Cutaneous and subcutaneous leiomyosarcomas occur at almost any age, but are most common between the 5th and 7th decades. They are more common in men and usually occur at the extremities. The prognosis of cutaneous/subcutaneous leiomyosarcoma correlates with the depth of the tumor. To our knowledge this is the first presentation of a subcutaneous leiomyosarcoma metastatic to the eyelid. Presumably, parenchymatous metastases of this tumor occur before dermal metastases arise.

Partial trisomy of chromosome 10(q22-q24) due to maternal insertional translocation (15;10)

Interchromosomal insertional translocations are rare chromosome rearrangements with an incidence of about 1:80,000 live births. We report on the clinical and cytogenetic findings of a newborn baby with partial trisomy 10q22-10q24 due to a maternal insertional translocation 15;10. Partial trisomy of the long arm of chromosome 10 is a distinctive chromosome aberration characterized by prenatal-onset growth retardation and craniofacial, skeletal, and other somatic anomalies. Most cases are unbalanced products from reciprocal chromosome translocations, and insertional translocations are rarely involved. The proband was initially referred because of severe intrauterine growth retardation, and fluorescence in situ hybridization (FISH) using painting probes confirmed the maternal balanced (15;10) insertion.

Primary orbital leiomyosarcoma: a case report with MRI findings

PURPOSE

To present a case of a primary orbital leiomyosarcoma and the corresponding magnetic resonance imaging (MRI) appearance.

DESIGN

Observational case report.

METHODS

Correlation of MRI with clinicopathologic findings.

RESULTS

A 56-year-old woman presented with a 10-month history of diplopia in left gaze and left exophthalmos. An enhanced MRI of the left orbit revealed an extraconal, peripheral-enhancing mass measuring 2 cm in maximal diameter with displacement of the medial rectus muscle. The mass was excised, and the diagnosis of leiomyosarcoma was made by pathologic examination.

CONCLUSIONS

Although computed tomography scan and ultrasound have been the imaging modalities used previously to evaluate cases of primary orbital leiomyosarcoma, MRI can provide important additional information regarding tumor characterization that is useful in the diagnosis and treatment of this rare malignancy.

Fine needle aspiration (FNA) biopsy of orbital masses: a critical review of 51 cases

FNA biopsy of 51 orbital masses is critically reviewed. Aspiration was performed with a 23 G needle inserted by an ophthalmologist; the smears were prepared by a cytologist. Forty-two cases (83%) were correctly diagnosed as benign or malignant either with (68%) or without (15%) correct specification of the histology. There were two false-negative and seven inadequate cases. Immunocytochemical stains were performed in five cases using the following antibodies: L26 (Pan B), UCHL1 (Pan T), kappa and lambda immunoglobulin light chains (three cases) in order to distinguish inflammatory pseudotumours from low-grade non-Hodgkin's lymphomas. In two cases we used CAM 5.2 (a monoclonal cytokeratin cocktail) and vimentin to ascertain the epithelial origin of two metastatic tumours. In five other cases cytospins were not adequately cellular for immunocytochemistry. Insufficient material and one false-negative sample were obtained from very fibrotic lesions or from posteriorly located lesions. The results are discussed and compared with other series reported in the literature. Orbital FNA biopsy may be considered a useful tool in the diagnostic approach to orbital masses in which the relatively high number of inadequate aspirations is offset by a low cost-benefit ratio.

Leiomyosarcoma metastatic to the orbit: diagnosis of fine-needle aspiration

A 47-yr-old man with history of metastatic low-grade rectal leiomyosarcoma presented with progressive protrusion of his left eye due to an enlarging orbital mass. The differential diagnosis included tumor metastasis or orbital infection due to an unknown infectious agent. Diagnostic fine-needle aspiration (FNA) of the orbit was performed on an urgent basis to institute proper therapy and to save the patient's eyesight. Cytomorphologic examination of the material demonstrated a spindle-cell neoplasm consistent with metastatic leiomyosarcoma. It is a rare event for leiomyosarcoma to occur in the orbit. On our review of the literature, the cytology of primary orbital leiomyosarcoma on FNA has only been reported once. To our knowledge, this is the first report of the FNA cytomorphology of metastatic leiomyosarcoma to the orbit.

Leiomyosarcoma of the orbit: diagnosis of its recurrence by fine-needle aspiration cytology

An 8 1/2-yr-old boy with proptosis was diagnosed to have low-grade leiomyosarcoma of the orbit following lateral orbitotomy and histology of an incompletely excised intraconal mass. He received chemotherapy but had recurrence of proptosis at the age of 12 yr. Ultrasonography revealed a solid mass and its fine-needle aspiration cytology features were consistent with recurrence of leiomyosarcoma. A year later, the cytodiagnosis was confirmed by histology of the excised tumor from a second lateral orbitotomy. Masson's trichrome stain confirmed the smooth muscle nature of the neoplasm and ultrastructural features were in favor of leiomyosarcoma. The patient received intermittent chemotherapy, and is clinically free from disease at the age of 17 yr.

Leiomyosarcoma of the conjunctiva

The clinical, light microscopic, immunohistologic, and ultrastructural findings of a leiomyosarcoma of the conjunctiva are presented. This tumor was diagnosed after a 26-year history and is the first to be adequately documented as having arisen in the conjunctiva.