Orbital rhabdomyosarcomas: A review

Epidemiology, trends, and survival of ocular and orbital rhabdomyosarcoma: a nationwide study in the USA (1996-2018) : Ocular and orbital rhabdomyosarcoma in the USA

BACKGROUND

Rhabdomyosarcoma (RMS) is a rare malignancy that affects both children and young adults. Therefore, the current incidence and mortality rates of ocular and orbital rhabdomyosarcoma (ORMS) need to be clarified. We aimed to explore the epidemiology, trends, and survival outcomes of ORMS in the United States population spanning over two decades, from 1996 to 2018.

METHODS

We retrospectively reviewed 92,633 patients with ocular and adnexal malignancies and identified 640 ORMS cases from the North American Association of National Cancer Registries. Demographics, tumor characteristics, treatment modalities, and survival outcomes were analyzed.

RESULTS

Most ORMS cases (71.7%) were reported in children aged-0-9 years. The age-adjusted incidence of ORMS was 0.1 per million population (ppm), with males demonstrating a higher incidence (0.12 ppm) than females (0.09 ppm). Whites had the highest incidence rate (0.11 ppm). Embryonal ORMS is the most common histological subtype. The incidence trend over the 22-year study period revealed a decline in ORMS from 0.124 to 0.076, in contrast with the incidence of whole-body RMS, which showed an insignificant increase. The 5-year relative survival rates of patients with ORMS were 89.7%, whereas the 10-year relative survival rate was 87.2%. The 5-year relative survival trend for ORMS increased but was insignificant.

CONCLUSIONS

ORMS primarily affects young children and males, with the embryonal subtype being the most common. Despite the declining incidence, survival rates have remained stable, underscoring the need for further research on the risk factors, diagnostics, and management strategies to improve patient outcomes.

KEY MESSAGES

What is known Ocular and Orbital Rhabdomyosarcoma (ORMS) predominantly affects children, especially males, and is the most frequent primary tumor in the  orbit during childhood. The embryonal subtype is the most common histological subtype of ORMS. What is new A significant decline in the incidence of ORMS was observed over the 22-year study period, in contrast to the overall incidence of whole-body  rhabdomyosarcoma. It has a characteristic bigeminal distribution with a peak at 3-4 and another at 6  years. Patients receiving combined treatment modalities showed improved survival  rates, while those undergoing surgery alone had poorer outcomes. Despite advancements in treatment, there has been no significant increase in  the 5-year relative survival trends for ORMS.

Multidisciplinary Management of Aggressive Orbital Rhabdomyosarcoma in an Adult Patient: A Case Report and Literature Review

Embryonic rhabdomyosarcoma (RMS) is a common tumor in children. In adults, it is an extremely rare tumor. There are three histological subtypes: embryonic, alveolar, and pleomorphic RMS. Pleomorphic RMS is most common in adults. Orbital site is a common primary site in children. In adults, it is an unusual presentation site. Management of RMS is based on a multimodal approach, including surgery, radiotherapy, and chemotherapy. In the pediatric population, a multidisciplinary approach has been validated in prospective trials in Europe and the USA. In adults, there is no consensus on the management of these tumors in the absence of dedicated clinical trials. Management of adult RMS is based on pediatric guidelines and data from retrospective series of adults. The prognosis of RMS differs according to age. Adult RMS has worse survival than in children. We report a case of a 37-year-old female patient presenting with an orbital embryonic RMS. Treatment involved enucleation, but rapid local progression was observed. Chemotherapy was initiated, but evaluation after three cycles demonstrated significant tumor progression. Surgical intervention combined with radiotherapy was performed, followed by adjuvant chemotherapy. This case highlights the aggressive biology of embryonal RMS in adults and the role of a multimodal treatment approach.

Fibromatosis Colli on Point of Care Ultrasound (POCUS): A Case Report

Fibromatosis colli is a rare benign fibrosis of the sternocleidomastoid (SCM) muscle which manifests clinically as congenital muscular torticollis, or an ipsilateral head tilt with contralateral turning of the neck. Though benign, care must be taken not to miss other etiologies with similar clinical presentations, such as malignancies or abscesses. Point of care ultrasound (POCUS) offers a rapid, low-cost, and accessible option for adjunct imaging. In this case report, a 26-day-old boy presented to the pediatric emergency department for evaluation of a nontender, firm left-sided neck mass with preferential turning of his head to the right. POCUS showed a noncompressible, homogenous, well-defined mass in the left SCM without increased vascularity consistent with fibromatosis colli. The patient was discharged from the emergency department with outpatient follow-up. His follow-up course required no further imaging or testing, and the patient's symptoms resolved with physical therapy.

Primary ocular, adnexal, and orbital rhabdomyosarcoma: A review

We review the primary orbital, ocular, and adnexal rhabdomyosarcoma (RMS) spectrum of tumors and describe its clinicoradiological and histopathological features, molecular updates, management protocols, outcomes, and challenges. Despite being a favorable site, the prognosis remains dismal for cases of relapsing, refractory, and metastatic orbital RMS. A wide heterogeneity of data exists in terms of survival rates and treatment regimens spread across various geographic locations and age groups. Molecular cytogenetics is a crucial factor in both the diagnosis and effective management of RMS. Novel targeted therapy may play an integral role in avoiding treatment-related morbidity and mortality. Large-scale studies are warranted to formulate standardized regimens and uniformity, especially for advanced and metastatic cases.

Long-Term Outcomes After Multidisciplinary Treatment for Pediatric Orbital Rhabdomyosarcoma

(1) Background: Orbital rhabdomyosarcoma is a rare and aggressive soft tissue tumor that primarily occurs in the eye socket (orbit) of children. Treatment usually involves a combination of surgery, chemotherapy, and radiation therapy, aiming to remove the tumor and prevent metastasis. (2) Methods: An institutional retrospective study was conducted with data from 39 patients with primary orbital RMS treated between 1995 and 2016 at the Amsterdam University Medical Centers/Emma Children Hospital. (3) Results: The median age at presentation was 7 years (range, 9 months to 16 years). The median follow-up period was 9.4 years (range, 3 to 25 years). Ten underwent chemotherapy and excision without additional radiotherapy. A total of 29 patients received additional local treatment: Ablative surgery MOld technique with after loading brachytherapy and surgical REconstruction (AMORE) (N = 21), proton (N = 4) or external beam radiation treatment (EBRT; N = 4). We found 14 cases with recurrences, 9 of which underwent exenteration and two of which died. The 10-year overall survival rate was 95% and the EFS was 63%. (4) Conclusions: long-term follow-up with 10-year survival rate of orbital RMS in this series was 95% achieved by local tumor control and eye preservation in 77% of our study population.

Adult and pediatric orbital rhabdomyosarcoma: comparison of characteristics and outcomes

INTRODUCTION

Rhabdomyosarcoma (RMS) is a common pediatric orbital malignancy but is extremely rare in adults. This study assesses clinical and radiographic features, management, and outcomes in adult orbital RMS patients with comparison to pediatric patients.

METHODS

A retrospective chart review from 2000-2023 at Bascom Palmer Eye Institute was conducted evaluating patients aged 0 to 100-years-old with biopsy-confirmed orbital RMS. Medical records were reviewed for demographics, clinical features, imaging, histopathology, management, and outcomes. Statistical analysis was conducted with Mann-U Whitney and chi-squared testing.

RESULTS

Twenty-four patients were included, 15 children (mean age 6.4 ± 4.4 years) and 9 adults (35.7 ± 12.4 years). Patients in both groups presented with eyelid edema followed by proptosis with similar symptom duration (p = 0.31). Lesions were frequently located medially and inferiorly in both groups. At presentation, adults had significantly more metastatic disease in addition to bone, extraocular muscle, intracranial, and parameningeal involvement. The most common pediatric RMS subtype was embryonal (80%), whereas most adults were alveolar (77.8%, p = 0.001). Treatment in both groups frequently included chemoradiation. Both groups demonstrated similar local recurrence (p = 0.72), overall survival (p = 0.86), and ophthalmologic sequelae (p = 0.45), although pediatric follow-up duration was notably longer.

CONCLUSIONS

To our knowledge, this study is the largest report of adult orbital RMS from a single institution, highlights key comparisons in features and outcomes between adult and pediatric orbital RMS, and provides an updated literature review. While pediatric and adult orbital RMS clinical presentations are similar, adult disease more often demonstrates aggressive features, including alveolar subtype, local structure involvement, and lower disease-free survival.

Orbital embryonal rhabdomyosarcoma: a case-based update

BACKGROUND

Rhabdomyosarcoma (RMS) is the most prevalent soft tissue sarcoma in children, with approximately 30% of head and neck RMS occurring in the orbit. The management of orbital RMS is complex, requiring a multidisciplinary approach and careful surgical planning. The objective of the present paper is to provide the neurosurgeon with an update on this challenging tumor.

CASE DESCRIPTION

A 12-year-old boy was admitted to our department after the onset of diplopia in his right eye, associated with quickly worsening ipsilateral eyelid edema and mild proptosis. MRI revealed an anterior superomedial, extraconal, and intraorbital expansive lesion. Complete tumor removal was performed through a trans-orbital approach. Histological diagnosis of embryonal RMS was done. The patient underwent radio-chemotherapy in accordance with the EpSSG RMS2005 subgroup C protocol. The patient is alive and disease-free.

DISCUSSION AND CONCLUSION

The intricacies of treating orbital tumors necessitate meticulous planning to safeguard vital structures while guaranteeing comprehensive oncological treatment. A multidisciplinary approach with a specific protocol depending on the location and characteristics of the tumor is required. The available treatment options include surgical intervention or combination therapies, such as chemotherapy and radiotherapy. The successful management of these diseases depends on the careful coordination and application of the available techniques.

Primary orbital and adnexal rhabdomyosarcoma: a study of 54 Asian Indian patients

PURPOSE

To describe the clinical presentation, management, and outcomes of orbital and adnexal rhabdomyosarcoma (RMS) in an Asian-Indian cohort and analyze the factors predictive of outcomes.

METHODS

Retrospective interventional case series of 54 patients of histopathology-proven RMS.

RESULTS

The mean age of presentation with RMS was 10 years (median, 7 years; range, <1-54 years). The most common tumor location was the superonasal quadrant (n = 21, 39%). Extensions beyond the orbit into the sinuses, temporal fossa, and brain were seen in 15 (28%), 3 (6%), and 8 (15%), respectively. First-line treatment modalities included a combination of surgical debulking, chemotherapy, and external beam radiotherapy in 20 (37%) patients; chemotherapy and radiation in 20 (37%); complete surgical excision and chemotherapy in 3 (6%); orbital exenteration, chemotherapy, and external beam radiotherapy in 1 (2%); chemotherapy alone in 1 (2%) patient, and 9 (17%) patients were lost to follow up. By Intergroup Rhabdomyosarcoma Study Group (IRSG) grouping, tumors belonged to groups I (n = 2,4%), II (n = 13, 29%), and III (n = 30, 67%). Kaplan-Meier survival estimates for tumor recurrence, lymph node metastasis, systemic metastasis, and death (n = 45) were 84%, 82%, 95%, and 95% at 1 year, 69%, 76%, 81%, and 77% at 5 years, 69%, 76%, 81%, and 77% at 10 years, respectively. On multivariate regression, age >18 years was found to have a significantly increased risk of locoregional LN metastasis (p = 0.005).

CONCLUSION

Despite aggressive treatment modalities, the 5-year disease-specific survival rate was 77% in Asian-Indian cohort. Age > 18 years at presentation was associated with a poorer prognosis.

Ocular manifestations and long-term complications of rhabdomyosarcoma in children

BACKGROUND/OBJECTIVES

The purpose of the study was to describe the ocular manifestations of rhabdomyosarcoma in a large cohort of children.

SUBJECT/METHODS

This was a retrospective observational cohort study. The medical records of all pediatric patients with head and neck rhabdomyosarcoma diagnosed between 1997 and 2021 at a tertiary-care pediatric hospital were analyzed. The main outcome measures were the incidence and prognostic role of ocular findings at presentation and long-term ocular complications.

RESULTS

There were 77 children with head and neck rhabdomyosarcoma in the study cohort with 38 patients showing ocular manifestations at presentation. Median age at diagnosis was 6.0 years, the median follow-up was 5.7 years and 54.5% were male. At last follow-up, 70.1% had no evidence of progression, 26.0% were deceased, and 2.6% were on palliative treatment. Orbital signs were common (44.2%). The most common ocular findings were proptosis (18.2%), restriction of extraocular motility (28.6%), strabismus/diplopia (22.1%) and ptosis (16.9%). The most common long-term complications were bony hypoplasia/facial asymmetry (40.3%) and keratopathy/dry eye (31.2%). Poor visual acuity (≤20/200) was noted in 13 (16.9%) patients with 5 (6.5%) patients requiring an exenteration. Survival was 100% in primary orbital RMS (p = 0.02), whereas any or a combination of cranial nerve palsies carried a poor prognosis (42% survival, p = 0.008).

CONCLUSIONS

In our cohort, half of children with rhabdomyosarcoma had ocular manifestations at presentation with about one-third showing orbital tumor involvement. Cranial nerve involvement carried a significantly worse prognosis for survival.

Late dental and bone alterations in patients after orbital rhabdomyosarcoma treatment

PURPOSE

Orbital rhabdomyosarcoma is a rare soft tissue sarcoma in childhood but with a good prognosis. Treatment usually includes surgery, chemotherapy, and radiotherapy. This study aimed to evaluate long-term alterations in teeth and cranial bones in children, adolescents, and young adults after oncologic treatment for childhood orbital rhabdomyosarcoma.

METHOD

This was a cross-sectional study that evaluated patients treated for orbital rhabdomyosarcoma between 1988 and 2011. Demographic, clinical, and treatment data were collected during the study period; also, panoramic radiographs, cephalometric study, and photographs of the face were taken.

RESULTS

Eight long-term survivors were studied. Of those, 50% were male, 75% had less than 5 years of treatment, and 88% had only one of the orbits affected by the tumor. Regarding treatment, 50% received 50.4 Gy of radiotherapy in the orbit; the chemotherapy included vincristine, actinomycin D, and cyclophosphamide in 75% of the cases and also ifosfamide and etoposide in 25%. The children presented craniofacial alterations, mainly when radiotherapy occurred between 0 and 5 years old (p = 0.01). The mandibles also showed dental alterations, probably due to chemotherapy.

CONCLUSION

In conclusion, orbital RMS patients treated with chemoradiotherapy, important dental, and facial bone alterations were found. The most significant were in the maxilla and close to the irradiation field. Dental and mandibular bone alterations were also found, indicating the probable chemotherapy action, as this region was not included in the irradiation field.

P. AS. An Unusual Case of Metastasis to Bilateral Breasts Masquerading as Disseminated Tuberculosis in a 17-Year-Old Girl with Quadriplegia-Where Is the Primary? An Unsolved Mystery

Invasive breast cancer, no special type, is the most frequent subtype of breast malignancy encountered as compared to secondary breast cancer. The most common tumors metastasizing to the breast include lymphoma and melanoma. Rhabdomyosarcoma (RMS) is a common soft-tissue neoplasm in the paediatric population, often seen in regions such as the head and neck, genitourinary system, trunk, and extremities. While metastatic RMS to the breast is uncommon, it tends to occur primarily in adolescent girls, with the alveolar variant being the most frequently encountered. In this case presentation, we describe the unique instance of a 17-year-old girl admitted to the hospital with quadriplegia which on initial clinical evaluation was diagnosed as disseminated tuberculosis involving the spine (Pott's spine), but on further cytologic and histopathologic assessment revealed the unexpected diagnosis of rhabdomyosarcoma. This case draws attention to the unusual occurrence of rhabdomyosarcoma metastasis to bilateral breasts, that to with an embryonal morphology, and underscores the challenge of identifying the primary site of this rare manifestation.

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

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

A retrospective study of conjunctival lesions in the Paediatric Eye Clinic over 12 years

BACKGROUND

Paediatric conjunctival lesions are rare and diverse. Though often indolent and asymptomatic, they can in some cases be sight or life-threatening. Awareness of concerning features of conjunctival lesions is key to optimal management. We aim to provide insight into management of paediatric conjunctival lesions though a review of cases in our service in last 12 years.

METHODS

We present a retrospective analysis of our population-based cohort of children with conjunctival lesions presenting to our regional service in Belfast between 2011 and 2022 inclusive. We detail three rare cases of paediatric conjunctival lesions; a congenital intrascleral cyst leading to astigmatic amblyopia, a rapidly changing salmon-pink lesion confirmed as an embryonal rhabdomyosarcoma and an unusual presentation of a chronic granuloma arising from the caruncle.

RESULTS

85 conjunctival lesions were identified in <16 year olds giving a cumulative incidence of 27 cases per 100,000 population over 12 years. Mean age at presentation was 7 years old. Most common lesions were naevi (40%), limbal dermoids (21%), conjunctival melanosis (14%), conjunctival cysts (7%) and phlycten (6%). When seen at presentation 8% of cases were immediately listed for surgery, 28% were discharged and 64% entered a phase of observation.

CONCLUSION

Paediatric conjunctival lesions have potential to cause visual manifestations, whilst some may undergo malignant transformation. Anterior segment photography is crucial in monitoring change and facilitating early discharge in the absence of sinister features. Malignant transformation must be considered in changing lesions which ought to have histological diagnosis obtained to prevent potentially sight and life-threatening conditions.

Primary orbital rhabdoid tumour masquerading as atypical persistent foetal vasculature

We present a case of primary rhabdoid tumour of the orbit. Presenting features at birth included congenital ptosis, conjunctival injection, hyphaema and microphthalmia. The unique presentation caused a late diagnosis following the development of rapid proptosis 6 months later. We suggest that orbital rhabdoid tumour be considered in the differential diagnoses of patients presenting with atypical persistent foetal vasculature features.

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

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

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

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

Total external ophthalmoplegia and orbital apex syndrome as first presenting feature of Rhabdomyosarcoma involving petrous part of the temporal bone: A case report

INTRODUCTION AND IMPORTANCE

Rhabdomyosarcoma (RMS) can have various unusual presentations. We report an unusual presentation of RMS as orbital apex syndrome in a six-year-old boy involving the petrous part of the temporal bone.

CASE PRESENTATION

A six-year-old boy presented with drooping of the left eyelid for seven days associated with headache, left-sided hearing loss, and nasal blockage. Contrast-enhanced magnetic resonance imaging (CE-MRI) brain and orbit revealed an ill-defined expansile vascular lesion centered at the petrous part of the left temporal bone with extension to the cavernous sinus, which was confirmed as RMS on histopathology and immunohistochemistry. The patient was managed by chemotherapy and radiotherapy.

CLINICAL DISCUSSION

RMS is the most common aggressive malignant soft tissue tumor in the pediatric population. It accounts for 4-8 % of all malignancies in children below 15 years of age, with strong male preponderance. The most common site for RMS is head and neck (45 %), having maximum incidence during the first decade of life.

CONCLUSION

Total external ophthalmoplegia in a child is an acute emergency; it should be properly worked up, and neuroimaging should always be advised. Prompt diagnosis and management by a multidisciplinary team can be both life and sight-saving.

A rare case of pediatric orbital rhabdomyosarcoma in Nepal: a case report

Orbital rhabdomyosarcoma (RMS) is a highly malignant, mesenchymal orbital tumor of childhood with a predilection in children less than 20 years of age. It presents as a space-occupying lesion in the orbit, most commonly over the superior nasal quadrant of the orbit. The patient usually presents with rapid onset unilateral proptosis and eyelid edema.

Case Ppresentation

In this article, a 14-year-old male presented with rapidly progressive swelling of the right orbit. On ocular examination, there was nonaxial inferolateral proptosis of the right eye. Computed tomography revealed a large soft tissue density tissue lesion in the right nasal cavity and meati measuring at least 3.2×2.7×5.4 cm in size with the erosion of the right orbit along with extension of the lesion in the extraconal compartment of the orbit. An MRI of the brain with contrast showed a heterogeneously enhancing altered signal intensity lesion. Debulking was planned, and a biopsy of the mass was sent that gave an impression of alveolar RMS. He also received radiotherapy and chemotherapy at one of the cancer hospitals in Nepal. Postsurgical follow-up showed gradual improvement in the visual acuity of the right eye. No evidence of metastasis and recurrence was found upon subsequent follow-up.

Conclusion

Thus, early diagnosis and prompt treatment is most for a favorable prognosis in the case of RMS. The main aim of this article was to briefly overview a rare case of RMS, its clinical presentation, diagnosis, treatment modalities, and its prognosis.

Congenital alveolar rhabdomyosarcoma - case report

Rhabdomyosarcoma is the most common soft tissue sarcoma of childhood and is very rare in the neonatal period. At this age, the alveolar type is a remarkably uncommon variety. We report a 56 days old female with alveolar RMS of the right eye noted since the age of 7 days with fast progression and unfavorable prognosis. Congenital alveolar RMS is an important cause of neonatal onset rapidly progressive proptosis. Early onset, alveolar type, and late diagnosis were poor prognostic factor.

Point-of-Care Ultrasound Assessment of Orbital Rhabdomyosarcoma in a Pediatric Patient

ABSTRACT

Rhabdomyosarcoma is the most common soft tissue tumor in children and orbital lesions account for 10% of these diagnoses. This case describes a young boy who presented with eyelid swelling that was initially concerning for an expanding hematoma given a history of recent trauma to the eye. Point-of-care ultrasound identified 2 distinct lesions surrounding the globe, which prompted further investigation, including ophthalmology consult and computed tomography. The case presented highlights the initial misdiagnosis on both point-of-care ultrasound and computed tomography and the importance of using color Doppler on ultrasound to distinguish an orbital rhabdomyosarcoma from a posttraumatic hematoma.

Primary orbital monophasic synovial sarcoma with calcification: A case report

BACKGROUND

Synovial sarcoma is a malignant mesenchymal neoplasm with variable epithelial differentiation. Most synovial sarcoma cases are reported in young adults and can arise in any body site. Notably, primary orbital synovial sarcoma is rare.

CASE SUMMARY

An 8-year-old east Asian girl with 1-month history of gradual painless proptosis and lacrimation of the right eye was admitted. The patient presented with painless proptosis, downward eyeball displacement, and upward movement disorders. According to clinical manifestations, imaging examinations and postoperative immunohistochemical examinations, the diagnosis was monophasic synovial sarcoma with calcification. The patient underwent anterior orbitotomy procedure for removal of the right orbital mass under general anesthesia. The diagnosis of monophasic synovial sarcoma with calcification was confirmed finally through histological and immunohistochemical exam. The follow-up period was 6 mo, and no recurrence was observed during this period.

CONCLUSION

Primary orbital monophasic synovial sarcoma with calcification is a rare sarcoma, and clinical manifestations and imaging results are not specific. The tumor may present similar features as a benign tumor. Comprehensive analysis of clinical, radiological, and pathological findings is critically important for making the right diagnosis. Conventional treatment approach for synovial sarcoma is surgical resection with adjuvant or neoadjuvant radiotherapy, which is highly effective for localized tumors.

Primary orbital monophasic synovial sarcoma with calcification: A case report

BACKGROUND

Synovial sarcoma is a malignant mesenchymal neoplasm with variable epithelial differentiation. Most synovial sarcoma cases are reported in young adults and can arise in any body site. Notably, primary orbital synovial sarcoma is rare.

CASE SUMMARY

An 8-year-old east Asian girl with 1-month history of gradual painless proptosis and lacrimation of the right eye was admitted. The patient presented with painless proptosis, downward eyeball displacement, and upward movement disorders. According to clinical manifestations, imaging examinations and postoperative immunohistochemical examinations, the diagnosis was monophasic synovial sarcoma with calcification. The patient underwent anterior orbitotomy procedure for removal of the right orbital mass under general anesthesia. The diagnosis of monophasic synovial sarcoma with calcification was confirmed finally through histological and immunohistochemical exam. The follow-up period was 6 mo, and no recurrence was observed during this period.

CONCLUSION

Primary orbital monophasic synovial sarcoma with calcification is a rare sarcoma, and clinical manifestations and imaging results are not specific. The tumor may present similar features as a benign tumor. Comprehensive analysis of clinical, radiological, and pathological findings is critically important for making the right diagnosis. Conventional treatment approach for synovial sarcoma is surgical resection with adjuvant or neoadjuvant radiotherapy, which is highly effective for localized tumors.

Acute myeloid leukaemia presenting as proptosis in an infant

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

Multidisciplinary approach to orbital embryonic rhabdomyosarcoma: About a case

Of the head and neck tumoral lesions in children and adolescents, 5%-10% are primary malignant tumors. Among these tumors, orbital rhabdomyosarcoma stands out, which is the most common primary soft tissue sarcoma in children. Its diagnosis requires a high degree of clinical suspicion, and it can be corroborated with a series of examinations, in order to stage it and carry out the appropriate treatment. Currently, surgery and chemotherapy are the primary treatments, and the use of conventional radiotherapy is limited to cases where previous treatments fail or there is a risk of recurrence. The following case report aims to expose the clinical picture, diagnosis, staging and integral treatment of orbital rhabdomyosarcoma, as well as the interdisciplinary management that was performed to improve the patient's prognosis.

Deep learning models for benign and malign ocular tumor growth estimation

Relatively abundant availability of medical imaging data has provided significant support in the development and testing of Neural Network based image processing methods. Clinicians often face issues in selecting suitable image processing algorithm for medical imaging data. A strategy for the selection of a proper model is presented here. The training data set comprises optical coherence tomography (OCT) and angiography (OCT-A) images of 50 mice eyes with more than 100 days follow-up. The data contains images from treated and untreated mouse eyes. Four deep learning variants are tested for automatic (a) differentiation of tumor region with healthy retinal layer and (b) segmentation of 3D ocular tumor volumes. Exhaustive sensitivity analysis of deep learning models is performed with respect to the number of training and testing images using eight performance indices to study accuracy, reliability/reproducibility, and speed. U-net with UVgg16 is best for malign tumor data set with treatment (having considerable variation) and U-net with Inception backbone for benign tumor data (with minor variation). Loss value and root mean square error (R.M.S.E.) are found most and least sensitive performance indices, respectively. The performance (via indices) is found to be exponentially improving regarding a number of training images. The segmented OCT-Angiography data shows that neovascularization drives the tumor volume. Image analysis shows that photodynamic imaging-assisted tumor treatment protocol is transforming an aggressively growing tumor into a cyst. An empirical expression is obtained to help medical professionals choose a particular model given the number of images and types of characteristics. We recommend that the presented exercise should be taken as standard practice before employing a particular deep learning model for biomedical image analysis.

[Treatment and management of orbital tumors]

BACKGROUND

There are various options for the conservative treatment of the most frequent orbital tumors. These can delay, complement or be superior to the surgical approach, which is often prone to complications.

OBJECTIVE

This article gives a summary of the possible treatment options for the most common orbital tumors in childhood and adulthood.

METHODS

A literature search was carried out and the possible treatment pathways are presented.

RESULTS

1. Frequent orbital tumors in childhood: a systemic treatment with noncardioselective beta blockers is the primary treatment for capillary orbital hemangiomas. In cases of no response, steroids, interferon alpha or cyclophosphamide are treatment options. Observation is a possible option for smaller dermoid cysts, in cases of progression excision can become necessary. Symptomatic optic nerve gliomas can also be observed and in cases of progression treated with chemotherapy, mTOR/MEK inhibitors or radiotherapy (children > 5 years). Rhabdomyosarcomas are biopsied and subsequently treated by radiotherapy and chemotherapy. 2. Frequent orbital tumors in adulthood: asymptomatic cases of cavernous hemangiomas of the orbit can just be observed. Symptomatic hemangiomas can be surgically excised or treated with radiotherapy. For meningiomas of the optic nerve sheath radiotherapy is a very effective treatment. Surgical excision should be reserved for cases with no prognosis of visual acuity. There is also the option to treat with antiprogesterone. Orbital lymphomas with purely orbital involvement can be treated with radiotherapy, chemotherapy or the application of rituximab.

CONCLUSION

There are now very effective conservative treatment options for many orbital tumors. In some cases a surgical procedure can be avoided and a good visual function can be retained.

Germline ATM mutation and somatic PIK3CA and BCOR mutations found in an infant with aggressive orbital embryonal rhabdomyosarcoma

Purpose

To report a case of aggressive infantile orbital embryonal rhabdomyosarcoma harboring germline ATM mutation and 2 somatic mutations as revealed by next-generation sequencing and the potential application for personalized therapy.

Observations

A 7-month-old male developed a rapidly progressive left proptosis over 6 weeks due to a large medial orbital mass. Biopsy revealed embryonal rhabdomyosarcoma. After the first cycle of chemotherapy, re-imaging showed interval tumor enlargement with intracranial extension. Craniotomy, combined with orbital exenteration, was performed. Tumor specimens and blood samples were sent for 596 gene DNA sequencing panels with RNA-sequencing focused on actionable mutations as well as gene fusion detection. Sequencing revealed 3 clinically relevant mutations: a germline ATM loss-of-function (LOF) mutation, a somatic PIK3CA gain-of-function mutation, and a somatic BCOR LOF mutation. No chromosomal translocation was detected. Workup for metastasis was positive for bone marrow involvement. Despite standard high-dose adjuvant chemotherapy in combination with radiation therapy, the patient died 10 months later with metastatic diseases.

Conclusions and importance

This case highlights an aggressive form of embryonal rhabdomyosarcoma in an infantile orbit. The presence of germline mutation may explain the increased chemo-resistance and adverse prognosis, and may be used as the target for genomic-directed therapy.

Alveolar rhabdomyosarcoma metastatic to the brain

Alveolar rhabdomyosarcoma (ARMS) has a predilection for the peripheral extremities, and brain metastases are rare, with only a few cases reported after the initial diagnosis. We present a 22-year-old male patient with a right orbital-ethmoidal ARMS who presented with a recurrence to the brain 1 year after the initial diagnosis. He was referred to our institution due to acute neurological deterioration. A brain MRI was performed, showing an enhancing bilateral parafalcine lesion centred about the bilateral cingulate gyri with extension into the corpus callosum. The patient was taken to the operating room for a stereotactic biopsy under general anaesthesia, which was compatible with metastatic ARMS. Our case is exceedingly rare, considering the initial diagnosis of an orbital/ethmoidal ARMS, its subsequent metastasis to the brain and its clinical sequelae after a biopsy. Prognosis after cerebral metastatic ARMS is dismal, with most patients expiring due to central nervous system metastatic disease.

Experience with Orbital Tumors from a Tertiary Cancer Centre of North East India: A Pathology Perspective

Background  The orbit is an anatomically complex structure comprising the globe, extraocular muscles, fat, vascular, nervous, glandular, and connective tissues. A wide variety of neoplasms can arise from different orbital structures, which can create a diagnostic challenge to the pathologists. No formal study has been conducted in this regard in North East India. Aim and Objectives  This article aims to document the pattern and prevalence of orbital tumors in our institute and assess the utility of histopathological examination (HPE) and immunohistochemistry (IHC) in the precise diagnosis of these neoplasms. Materials and Methods  A retrospective analysis of orbital tumors was performed over a period of 5 years from 2013 to 2018 in the department of pathology at a tertiary cancer center of North East India following all the guidelines of the institutional ethics committee. Results  A total of 35 cases of orbital neoplasms, evaluated by HPE and IHC, were found, all of them being malignant tumors. The age range was 4 months to 85 years. Male to female ratio was 1.5:1. The most common tumor found was lymphoma, accounting for 10 cases (28.6%), all of which were non-Hodgkin lymphoma (NHL). All these cases except one occurred in adults, thus making it the most common tumor in adults in this study. Diffuse large B cell lymphoma, not otherwise specified, was the most common NHL, followed by follicular lymphoma, mature T cell NHL, extranodal marginal zone lymphoma, and B cell lymphoblastic lymphoma. Rhabdomyosarcoma and poorly differentiated/undifferentiated carcinoma jointly were the second most common tumors, totaling seven cases (21.21%) each. This was followed by melanoma (three cases), myeloid sarcoma (three cases), Ewing sarcoma/peripheral neuroectodermal tumor (PNET) (three cases), neuroblastoma (one case), and angiosarcoma (one case). Among these, rhabdomyosarcoma, granulocytic sarcoma, Ewing sarcoma/PNET, and neuroblastoma exclusively troubled the children. IHC markers including the lymphoma panel, and soft tissue ones were crucial in the precise diagnosis of the neoplasms encountered. Conclusion  A variety of malignant orbital tumors may be seen in clinical practice. Management of these tumors requires a multidisciplinary approach. HPE in conjunction with IHC evaluation is of utmost importance in the veracious recognition of orbital tumors for their proper management.

Multidisciplinary approach to orbital embryonic rhabdomyosarcoma: about a case

Of the head and neck tumoral lesions in children and adolescents, 5 to 10% are primary malignant tumors. Among these tumors, orbital rhabdomyosarcoma stands out, which is the most common primary soft tissue sarcoma in children. Its diagnosis requires a high degree of clinical suspicion, and it can be corroborated with a series of examinations, in order to stage it and carry out the appropriate treatment. Currently, surgery and chemotherapy are the primary treatments, and the use of conventional radiotherapy is limited to cases where previous treatments fail or there is a risk of recurrence. The following case report aims to expose the clinical picture, diagnosis, staging and integral treatment of orbital rhabdomyosarcoma, as well as the interdisciplinary management that was performed to improve the patient's prognosis.

PET/CT and PET/MRI in ophthalmic oncology (Review)

Orbital and ocular anatomy is quite complex, consisting of several tissues, which can give rise to both benign and malignant tumors, while several primary neoplasms can metastasize to the orbital and ocular space. Early detection, accurate staging and re-staging, efficient monitoring of treatment response, non-invasive differentiation between benign and malignant lesions, and accurate planning of external radiation treatment, are of utmost importance for the optimal and individualized management of ophthalmic oncology patients. Addressing these challenges requires the employment of several diagnostic imaging techniques, such as high-definition digital fundus photography, ultrasound imaging, optical coherence tomography, optical coherence tomography (OCT)-angiography, computed tomography (CT) and magnetic resonance imaging (MRI). In recent years, technological advances have enabled the development of hybrid positron emission tomography (PET)/CT and PET/MRI systems, setting new standards in cancer diagnosis and treatment. The capability of simultaneously targeting several cancer-related biochemical procedures using positron emitting-radiopharmaceuticals, while morphologically characterizing lesions by CT or MRI, together with the intrinsic quantitative capabilities of PET-imaging, provide incremental diagnostic information, enabling accurate, highly efficient and personalized treatment strategies. Aim of the current review is to discuss the current applications of hybrid PET/CT and PET/MRI imaging in the management of patients presenting with the most commonly encountered orbital and ocular tumors.

Differential effect of adenosine on rhabdomyosarcoma migration and proliferation

INTRODUCTION

Adenosine and its receptors are involved deeply in the regulation of tumour biology. Purine nucleotides are released from stressed cells in states of hypoxia or radiochemotherapy-induced cell damage. Adenosine exerts its effect through the P1 family of selective receptors. The purpose of the study was to evaluate the exact role of extracellular role on biology of Rhabdomyosarcoma (RMS) cells.

MATERIAL AND METHODS

Series of in vitro studies accompanied by immunohistochemical, RQ-PCR and shRNA methods have characterised adenosine receptor expression on Rhabdomyosarcoma cell lines, normal skeletal muscle and effect of adenosine on Rhabdomyosarcoma growth and migration.

RESULTS

Extracellular adenosine (highest at 50 μM, p < 0.05) and AMP (highest at 300 μM, p < 0.05) markedly enhanced chemotaxis in the Boyden chamber assay The reaction is mostly governed by the A1 receptor, which is greatly overexpressed in Rhabdomyosarcoma as compared with normal skeletal muscle. Cell migration induced by adenosine and AMP is blocked by pertussis toxin, phospholipase C and MAP kinase inhibitor, which demonstrates the importance of these signalling pathways. High doses of adenosine have a detrimental effect on cellular proliferation, in a receptor-independent manner (≥ 500 μM; p < 0.05). The blockage of adenosine transporter by dipyridamole abolishes this effect, indicating involvement of an intrinsic pathway. Further increase of adenosine concentration, induced by deaminase inhibitors, augment the effect.

CONCLUSIONS

Our results suggest that adenosine and AMP trigger cell migration by binding to P1 receptors and directing cancer cells to the sites of hypoxia or cellular damage. Specifically by A1 receptor which is overexpressed in RMS.

Primary Conjunctival Rhabdomyosarcoma in a Pediatric Patient

Rhabdomyosarcomas are neoplasms with a high degree of malignancy and arise from the embryonic mesenchyme. They represent approximately 5% of all pediatric tumors and their main locations are the head and neck (45%), trunk (40%), and extremities (15%). Twenty-five percent to 30% of the head and neck rhabdomyosarcomas appear in the orbit; however, its origin from the conjunctiva is rare, with few case reports published in the literature.

We present the case of a five-year-old girl with a diagnosis of primary embryonic rhabdomyosarcoma of the conjunctiva, treated with surgery and chemotherapy. After completing the treatment, it was followed up with controls for oncological ophthalmology, pediatric hematology-oncology, and radiotherapy oncology every six months with magnetic resonance of the orbits. Two years after the end of treatment, the patient is disease-free.

Conjunctiva rhabdomyosarcoma is a rare lesion, with few previously reported cases. In the reported case, the histopathological findings and positivity of the different immunohistochemical markers allowed a definitive diagnosis of rhabdomyosarcoma. The excellent prognosis of this pathology is probably linked to the early diagnosis of the disease and the timely administration of radical treatment.

It is essential to be able to identify conjunctival rhabdomyosarcoma from its clinical and histopathological characteristics in order to achieve early diagnosis and provide adequate treatment to patients.

An overview of radiological manifestations of acquired dental developmental disturbances in paediatric head and neck cancer survivors

OBJECTIVES

In paediatric cancer survivors treated with chemotherapy and radiotherapy therapy, late effects on dental development are quite common. Oral radiologists are not familiar with the radiographic images of these specific dental consequences of chemotherapy and radiotherapy. With the goal of educating colleagues, to raise awareness of the needs of survivors, and to identify directions for future research, we present dental radiographs of survivors treated for head and neck rhabdomyosarcoma with chemotherapy and radiotherapy. Also, based on the survivors reviewed, a radiographic inventory of commonly found late dental developmental effects seen in conjunction with treatment is presented.

METHODS

Panoramic radiographic findings of five illustrative cases are presented, from a group of 42 survivors of head and neck rhabdomyosarcoma treated at the Academic Medical Center Amsterdam, The Netherlands over the past 25 years.

RESULTS

Five cases showing dental developmental disorders are presented. These cases show an association of the location of the radiation field and the developmental stage of the teeth with the severity of the effect on dental development. We also report an inventory of severe and moderate effects of chemotherapy and radiotherapy on the development of molars and anterior teeth.

CONCLUSIONS

This paper presents five cases and a radiographic inventory to illustrate disturbances of dental development associated with chemotherapy and radiotherapy in children. Medical and dental professionals involved in the treatment of cancer survivors are relatively unaware of the dental consequences of radiation therapy and the age dependency of specific regional effects. These effects can be severe, with great impact on quality of life. Further research in this area could help improve planning of radiation therapy for children, potentially preventing or limiting dental or maxillofacial sequelae.

Orbital cellulitis clinically mimicking rhabdomyosarcoma

Introduction

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

Purpose

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

Case presentation

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

Conclusions

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

Craniofacial Approaches to Pediatric Orbital Tumors

Primary pediatric orbital tumors requiring surgery are uncommon and often require multidisciplinary management. Commonly used surgical approaches to the orbit include transconjunctival, transcutaneous (eyelid), transcranial, or extracranial osteotomies. This paper reviews a 10-year experience of cases that required a transcranial or extracranial surgical approach at the Birmingham Children's Hospital. A total of 9 patients were identified between the years 2008 to 2017. Pathologies included rhabdomyosarcoma, juvenile ossifying fibroma, optic nerve glioma, and retinoblastoma. Surgical approaches to the orbit included supraorbital bar osteotomy (transcranial) or lateral orbitotomy (extracranial). Surgical team members included neurosurgery, craniofacial surgery, and ophthalmology. This study aims to review the role of surgery in management as well as the specific indications for performing transcranial or extracranial osteotomies. It also highlights the excellent access achieved with the use of these osteotomies in certain cases, especially when compared with transconjunctival or transcutaneous approaches.

Genetic profiling of rhabdomyosarcoma with clinicopathological and radiological correlation

OBJECTIVE

Orbital Rhabdomyosarcoma is a highly malignant tumor predominantly affecting children. Our study adds more understanding of this tumor to ophthalmologists from the clinicopathological, radiological and genetic aspects.

DESIGN

A retrospective clinicopathological and radiological study of ocular rhabdomyosarcoma with genetic profiling.

PARTICIPANTS

All the cases with confirmed tissue diagnosis of orbital rhabdomyosarcoma presenting at a tertiary eye hospital in Riyadh, Saudi Arabia during the period 1985-2015.

METHODS

Charts and histological slides of 26 patients were reviewed. DNA was extracted from paraffin-embedded biopsies and genotyping was performed to detect chromosomal abnormalities and Copy-number variations regions.

RESULTS

18 males and 8 females were included with a mean age at presentation of 6.9 years (SD of 4.4). Proptosis and globe displacement were the commonest clinical presentations. Embryonal histopathological type was the commonest (73.1%) with superior orbital involvement (p = 0.024). Using magnetic resonance imaging, the embryonal type showed higher Apparent diffusion coefficient (ADC) value compared to the alveolar type (p = 0.98). Genetic profiling showed Copy-number gain in regions spanning PAX3, DDIT3, Gli, Wnt6 genes. DICER1 gene implication was found in 9 sporadic cases.

CONCLUSION

Rhabdomyosarcoma is rare and occurs with a mean age of 7 years, predominantly among males. The commonest embryonal type is significantly correlated with superior orbital involvement. Radiologically, it shows an ADC of 0.67-0.09 × 10^-3mm²/s. (p = 0.98). The gain in PAX3, DDIT3, Gli1, Wnt6 genes is a new finding while the DICER1 gene implication in the absence of familial hereditary carcinoma is another interesting finding.

Botryoid Rhabdomyosarcoma of the Conjunctiva in a Young Boy

Primary conjunctival rhabdomyosarcoma (RMS) is a rare entity that can present with or without papillomatous features. A 5-year-old Asian boy was referred for a rapidly growing conjunctival tumor in the superior fornix of the left eye. Surgical excision yielded a 28 mm multilobulated papillomatous specimen that exhibited histopathologic and immunohistochemical features consistent with embryonal (botryoid) RMS. Molecular analysis revealed the absence of the PAX3/FOXO1 fusion gene, indicating favorable prognosis. After surgery, he was promptly treated with systemic chemotherapy and proton beam radiotherapy.

Aggressive orbital rhabdomyosarcoma in adulthood: A case report in a public hospital in Damascus, Syria

Orbital rhabdomyosarcoma (RMS) is a highly malignant tumor that originates mainly from mesenchymal tissue. It is considered a rare childhood malignancy; therefore, presentation in adulthood is scarce. In this case report, a 36-year-old male patient presented with a rapidly progressive RMS of the left orbit. The patient was treated in a different institution with radiochemotherapy with good response. However, relapse occurred after 2 months of completing the course, as rapid growing proptosis. Computed tomography scan revealed a lesion in the left orbit with invasion of the left ethmoid cells and the left maxillary sinus. Exenteration of the left orbit with the left partial maxillectomy and ethmoidectomy was performed. RMS is a highly aggressive malignancy that should be considered in any orbital mass that progresses rapidly. Surgery should be the first line in treatment. Delay in diagnosis and inappropriate treatment negatively affects the outcome.

Orbital and nasal meningoencephaloceles secondary to chronic hydrocephalus: A rare cause of bilateral proptosis

Introduction Orbital meningoencephalocele formation is primarily a result of congenital defects in the pediatric population and trauma of the anterior cranial fossa in adults. We present a unique case of nontraumatic nasal and orbital meningoencephaloceles presenting as bilateral proptosis with exotropia secondary to chronic hydrocephalus. Clinical presentation A 20-year-old male with a history of tuberous sclerosis, X-linked intellectual disability, and epilepsy presented to the emergency department with two days of nausea, emesis, seizures, and two months of progressive proptosis. Initial radiographs of the skull showed a "copper beaten" appearance, indicating chronically elevated intracranial pressure. Computed tomography imaging of the head demonstrated bilateral defects in the cribriform plate and anterior cranial fossa. Magnetic resonance imaging of the brain revealed triventricular hydrocephalus with meningoencephalocele extension into the nasal cavity and frontal horn herniation into the extraconal space of the orbits. The hydrocephalus was managed with ventriculoperitoneal shunt placement with rapid and complete resolution of the proptosis. Conclusion No reports have described bilateral proptosis as the presenting finding of orbital and nasal meningoencephaloceles in the absence of trauma or congenital defect. This case study demonstrates the management of meningoencephalocele formation secondary to chronic hydrocephalus.