Fibrous histiocytomas of the orbit

Solitary Fibrous Tumor of the Orbit

We report three cases of solitary fibrous tumor (SFT) arising in the orbit. All patients presented with nontender swelling of the affected eye, and one patient presented with nasolacrimal duct obstruction. All three patients had well-circumscribed tumors that had histologic features identical to those of SFT of the pleura (fibrous mesothelioma). The neoplastic cells were purely fibrogenic. They were reactive with antivimentin and CD-34 and demonstrated no smooth muscle or neural differentiation (nonreactive with antibodies to actin, desmin, and S 100 protein). KP-1 (CD-68) immunoreactivity was present focally within the neoplastic cells in all three tumors; however, it was strongly positive within tumor infiltrating macrophages. Electron microscopy per formed on one tumor showed fine fibroblastic differentiation with phagocytic activity confined to infiltrating macrophages. SFT of the orbit is a distinct pathologic entity that merits distinction within the broad group of orbital fibrous tumors. Int J Surg Pathol 2(3):193-198, 1995

[Rationale for a diagnostic approach in non-Graves' orbital inflammation--Report of 61 patients]

INTRODUCTION

Orbital inflammatory syndromes include a wide variety of inflammatory intraorbital processes which are very different in terms of clinical presentation and prognosis. We currently prefer to differentiate so-called "specific" inflammations, for which an etiology is able to be identified, from idiopathic orbital inflammatory syndromes (IOIS), for which the etiology remains unknown and the histology is nonspecific.

PURPOSE

To propose an efficient diagnostic approach for clinicians managing patients with non-Graves' orbital inflammations.

MATERIALS AND METHODS

This is a retrospective and prospective study concerning 61 patients managed by the medical team for non-Graves' orbital inflammations between May, 1999 and May, 2013 in the ophthalmology departments of Nice and Limoges university hospitals in France. Seventeen specific inflammations, 19 orbital lymphomas and 25 idiopathic orbital inflammatory syndromes were included. Patients were divided into two groups. Thirty-six patients (group 1) underwent primary biopsy, while for the other 25 (group 2), therapy was begun empirically without biopsy. We could therefore compare both approaches in terms of diagnostic efficiency and time until identification of a specific etiology.

RESULTS

Our statistical results show that an approach without primary biopsy leads to a number of specific diagnoses statistically much lower than that obtained by the approach with primary biopsy. Also, the risk of missing a specific inflammation (with as a consequence an inappropriate treatment and a risk of functional sequelae as well as a fatal risk of missing a lymphoproliferative pathology) is very clearly higher in the case of not performing primary biopsy. Finally, the average time elapsed between the initial consultation with the ophthalmologist and a specific diagnosis was one month in the case of the first approach, while this delay was almost three times higher with the second approach, with a mean of 2.91 months (P<0.01).

DISCUSSION

Our study shows that biopsy should be the mainstay of diagnostic management. A trial of empiric treatment is only performed first in myositis or in locations where biopsy could jeopardize functional prognosis. It should only be done after biopsy in all other cases. Of course, in all cases of relapse or recurrence after treatment, biopsy should be performed or repeated.

CONCLUSION

The diagnostic work-up of a patient with an orbital inflammatory process must of course include blood testing and orbital imaging, but also a systematic primary biopsy for histological examination in the vast majority of cases. It must be repeated at least in the case of any doubt about the diagnosis or in the case of any recurrence or resistance to treatment.

Orbital fibrous histiocytomas

Orbital fibrous histiocytomas can be difficult to diagnose and manage. These tumors, especially those with intermediate histologic features, often recur. Historically, non-invasive tests to differentiate scars from recurrent disease have a high error rate. We present a case of recurrent orbital fibrous histiocytoma in which the diagnosis was established with poitron emission tomography (PET) scans. This technique may be helpful in difficult cases to differentiate scars from a recurrent mesenchymal tumor.

Orbital giant cell fibroblastoma

BACKGROUND: This report describes the clinical and morphologic (light and electron microscopic and immunohistochemical) features of orbital giant cell fibroblastoma which, to the best of our knowledge, has not been reported before in the ophthalmological literature. METHODS: Clinical symptoms, computed tomography (CT), and magnetic resonance (MR) features, light and electron microscopic and immunohistochemical findings were reviewed in a 65-year-old woman who developed an orbital giant cell fibroblastoma. RESULTS: The patient presented with a large, infiltrating, intra- and periorbital mass, causing severe proptosis, ocular displacement, and visual loss on the left side. CT and MR imaging demonstrated a large, irregular tissue density in the orbit leading to displacement of the globe anteriorly and inferolaterally. With T(1)-weighted MR images, the lesion was isointense to the gray matter of the brain and revealed marked enhancement with Gd-DTPA. Histopathologically, the tumor consisted of a mixture of spindle and multinucleated giant cells scattered within a myxomatous stroma. CONCLUSION: Giant cell fibroblastoma, a benign mesenchymal tumor of infancy, is rarely encountered within the orbital region. This lesion is considered to be a distinct, non-metastasizing tumor, but its clinical management may be very difficult, as in our case, because of its invasive nature and potential for recurrence.

Fibrous histiocytoma of the lacrimal sac

BACKGROUND

Fibrous histiocytoma is a slow-growing tumor that most commonly occurs in the superficial and deep soft tissue, with an occasional occurrence in the orbit. However, fibrous histiocytoma of the lacrimal sac is very rare.

METHODS

A case report of a 33-year-old man with a palpable mass in the right lacrimal sac and epiphora is presented, with a review of the literature pertaining to this unusual case.

RESULTS

The patient was found to have a 3 x 2-cm-sized mass in the right lacrimal sac. Under the impression of benign tumor, the tumor was excised. Histopathological diagnosis of fibrous histiocytoma was made on the surgical specimen. Following surgical treatment, the patient has remained free of symptoms.

CONCLUSIONS

Fibrous histiocytoma of the lacrimal sac is a rare disease. This case report and a review of the literature demonstrated that surgical excision appears to control the tumor.

Orbital fibrous histiocytoma: computed tomography in 10 cases and a review of radiological findings

The computed tomographic features of 10 primary and secondary fibrous histiocytomas arising in the orbit are reviewed. Positive factors indicating the diagnosis were absent; orbital enlargement was more common in malignant tumours, but other indications of the degree of malignancy or invasiveness were present in only one case.

Benign fibrous histiocytoma of the kidney

A case of benign fibrous histiocytoma of the kidney in a 48-year-old man is reported. A 7-year followup has revealed no recurrence. To our knowledge there have been no previous reports of benign fibrous histiocytoma of the kidney.

Orbital fibrous histiocytoma in an infant

A rare case of fibrous histiocytoma in an infant is described. The tumour appeared to arise in the medial orbit, invading the ethmoid and maxillary sinuses. Surgical and medical management, and the subsequent clinical course in a 11 year follow-up period are described. Histogenesis of this primary mesenchymal tumour is discussed.

Infantile subconjunctival and anterior orbital fibrous histiocytoma. Ultrastructural and immunohistochemical studies

A fleshy, polypoidal and partially lobulated lesion that protruded between the eyelids from the medial caruncular region and that infiltrated the contiguous anterior orbital tissues developed over 1 month in a 9-month-old infant. The microscopic features of the tumor included a plump spindle cell population, more polygonal cells, early xanthoma cell transformation, infiltrating lymphocytes and eosinophils, and multinucleated giant cells, the last not exhibiting classic Touton characteristics. The histopathologic differential diagnosis ranged among fibrous histiocytoma, juvenile xanthogranuloma, and eosinophilic granuloma (histiocytosis-X). Results of electron microscopy disclosed abundant rough-surfaced endoplasmic reticulum, a paucity of lysosomes, and no Langerhans' (Birbeck) granules. Immunohistochemistry corroborated the fibrohistiocytic nature of the tumor, because histochemical stains for the enzymes alpha-1-antichymotrypsin and lysozyme, and monoclonal or polyclonal antibodies against common leukocytic antigen and S-100 protein, were negative--whereas they would have been expected to be positive in various combinations in the different histiocytic proliferations. Vimentin was identified in the tumor cells; this is an intermediate cytoplasmic filament almost always present in mesenchymal proliferations. The distinctions between fibrous histiocytomas of stromal cell origin and true histiocytic proliferations of bone marrow cell provenance are explored.

Fibrous histiocytoma of the lacrimal sac

Fibrous histiocytoma is a rare tumor whose ocular manifestations usually involve the orbit or, less commonly, the conjunctiva and ciliary body. We have treated two patients with fibrous histiocytoma of the lacrimal sac. One, a 62-year-old woman who had had hordeolum and trachoma, had a visual acuity of counting fingers at 1 m in the affected eye. The fellow eye had been enucleated ten years previously. The entire lacrimal sac was surgically removed and a brown cystic tumor measuring 28 x 12 x 10 mm was found. The second patient, a 32-year-old man, had undergone an unsuccessful dacryocystectomy for epiphora. When he underwent a dacryocystorhinostomy some months later, a mass measuring 20 x 15 x 12 mm was found in the wall of the lacrimal sac. Microscopic examination of the two excised lacrimal sacs showed that the walls were thickened by cells resembling fibroblasts and by cells resembling histiocytes. The fibroblasts were characterized by collagen production, were fusiform or oval in shape, and were arranged in bundles. The histiocytes were larger and had abundant (and sometimes vacuolated) cytoplasm. All the cells appeared to be mature.

Fibrous histiocytoma of the orbit. A clinicopathologic study of 150 cases

This is a clinicopathologic study of 150 cases of fibrous histiocytoma of the orbit. The tumors occurred in adults (median age, 43 years). The upper and nasal portions of the orbit were the most common sites of involvement. The most common signs and symptoms were proptosis (60 per cent), mass (46 per cent), and decreased vision (25 per cent). Based on the histopathologic features, the tumors were classified in three groups: benign (94 cases), locally aggressive (39 cases), and malignant (17 cases). The biological behavior correlated well with the duration of symptoms, the size and margins of the mass, and the histologic classification. The rate of recurrence was 31 per cent for the benign tumors, 57 per cent for the locally aggressive tumors, and 64 per cent for the malignant tumors. Follow-up data were obtained for 123 patients, with a mean duration of seven years. The ten-year survival of patients with benign, locally aggressive, and malignant fibrous histiocytoma was 100 per cent, 92 per cent, and 23 per cent, respectively. Nine patients died as a result of the tumor, six from local invasion of adjacent structures and three from metastatic disease. Fibrous histiocytoma is the most common primary mesenchymal orbital tumor of adults. The origin of the neoplasm is probably a primitive mesenchymal cell. Complete surgical excision appears to be the treatment of choice.

Fibrous histiocytoma of the corneoscleral limbus: The ultrastructure of a distinctive inclusion

A case of epibulbar fibrous histiocytoma is presented, with emphasis on the electron microscopic aspects due to the paucity of ultrastructural descriptions of this rare tumor. A tan-yellow conjunctival tumor developed at the corneoscleral limbus in a 31-year-old male. The clinical diagnosis was confirmed by routine histopathologic evaluation, which demonstrated a typical matted or storiform cellular pattern. Electron microscopy revealed a mixed cell population, composed primarily of histiocytic and fibroblastic cells. The histiocytic cells contained lysosomes and phagosomes and had interdigitating cell processes. The fibroblastic cells were characterized by prominent rough-surfaced endoplasmic reticulum and variable amounts of lipid within vacuoles, but did not possess lysosomes or phagosomes. Both cells occasionally contained an unusual curvilinear structure, suggesting a shared histogenesis. This distinctive inclusion appeared to be a modification of the rough-surfaced endoplasmic reticulum. The nature and origin of the tumor cells are discussed on the basis of their ultrastructure.

Fibrous histiocytomas of the oral mucosa

The oral lesions reported in this article fall into the first category of benign fibrous histiocytomas analogous to those which occur on sun-exposed skin surfaces of young objects. The ages of the patients, the histologic features and the history of traumatic episodes, as well as their biologic behaviors on follow-up, are all features compatible with those benign lesions which occur in the skin. According to the information presented in these cases, there is stronger evidence that the lesions of the oral mucosa, like their dermatologic counterparts, are representative of reactive inflammatory processes rather than neoplastic processes. It is of considerable interest that in both cases reported here the patients were children whose lesions developed following significantly severe traumatic episodes. Also of interest is the finding that the lesions healed with no recurrences or complications, even though in one of the cases it was not completely removed. These findings are in agreement with other reports of such lesions which have occurred in the head and neck regions of children and young adults. From the over-all information obtained in the literature review regarding the biologic behavior of benign fibro-histiocytic lesions, the collected data seem to indicate that lesions of the skin and superfacial mucosal surfaces which occur in children and young adults are proliferative, reactive lesions and infection, or irradiation. Systemic, visceral, or deep-seated lesions in the lower extremities appear to be true neoplasms and their prognoses must be considered as guarded.

Fibrous histiocytoma

A 13-year-old boy underwent excision of a fibrous histiocytoma, which was initially thought to be a leiomyoma. When the tumor recurred, it was resected using wide tissue margins and frozen section control. Visual acuity remained normal although there has been some postoperative diplopia. There has been no recurrence over the past year. A local aggressive surgical approach is advocated when this tumor appears in the pediatric age group.

Orbital fibrous histiocytoma in an infant

A case of fibrous histiocytoma of the orbit occurred in a 1-year-old infant. The tumor was excised, and no recurrence has been evident.

Fibrous histiocytoma of the tarsus

A 21-year-old white man had an asymptomatic eyelid mass that had slowly enlarged for one year. On clinical examination the lesion was well circumscribed; it appeared subconjunctivally but provoked no conjunctival inflammation, and had a consistency suggestive of cartilage. Microscopic examination showed it was matted and composed of elongated fibro-histiocytes and an evenly distributed population of xanthoma cells and Touton giant cells. The lesion was easily removed by local excision because of a pseudocapsule formed by remnants of the tarsus; there has been no recurrence during a 12-month follow-up.

Ophthalmic striated muscle neoplasms

Rhabdomyosarcoma, the most common primary malignant childhood orbital tumor, is composed of neoplastic striated muscle cells (rhabdomyoblasts) in various stages of differentiation and in patterns suggestive of neoplastic analogs of normal muscle embryogenesis. Orbital rhabdomyosarcoma is most commonly seen in children and adolescents, the average age of onset of symptoms being 7.8 years. The tumor usually presents as a rapidly evolving exophthalmos, often associated with drooping of the upper eyelid. A mass is palapable in only 25% of cases, loss of central vision at the time of presentation is uncommon, and laboratory studies are often of little help in diagnosis. The best diagnostic aid is a high index of suspicion whenever one sees a rapidly progressive exophthalamos in a child. Orbital rhabdomyosarcoma is almost always of the embryonal type, believed to originate in the orbital soft tissues from undifferentiated pluripotential embryonic mesenchyme. In the past, orbital exenteration has been the primary therapy. Review of 162 literature cases of orbital rhabdomyosarcoma, generally treated by unassisted surgery, revealed that only 25% of the patients survived 3 or more years. Recently, it has been shown that radiation therapy, alone or combined with chemotherapy, can be successful. A multidisciplinary approach, utilizing surgery, radiation therapy and chemotherapy has also been advocated. Both approaches appear to offer greater survival than unassisted orbital exenteration. The possibility of primary radiation therapy is extremely promising; if it becomes increasingly effective, a mutilating surgical procedure may become obsolete.

Leiomyoma and leiomyosarcoma of the orbit

Comparison of the clinical and pathologic features of two orbital leiomyomas, two leiomysarcomas, and one embryonal rhabdomyosarcoma showed the leiomyomas occurred in young individuals and the leiomyosarcomas in older patients. The histopathologic diagnosis rested on the intense cytoplasmic eosinophilia and nostriated longitudinal cytoplasmic filaments demonstrated by means of the trichrome stain. The leiomyosarcomas disseminated 15 months and seven years after their orbital presentations. The treatment of both leiomyoma and leiomyosarcoma is surgical. Leiomyomas are encapsulated growths that may have small satellite nodules projecting from the main tumor mass; thus, a margin of normal tissue should also be excised, lest a small lobulation be left behind to serve as the seed for a late recurrence. Once the diagnosis of leiomyosarcoma has been made, and no evidence of metastasis has been found after a thorough systemic evaluation, the orbit should be exenterated, because the tumor is unencapsulated and liable to widespread dissemination. Rhabdomyosarcoma has a much more fulminant course than leiomyosarcoma, and especially more so than that of leiomyoma of childhood. The histopathologic diagnosis of a malignant smooth muscle tumor in a child should always be questioned, since embryonal rhabdomyosarcoma is a much more likely diagnosis.