Fibro-osseous, osseous, and cartilaginous lesions of the orbit and paraorbital region. Correlative clinicopathologic and radiographic features, including the diagnostic role of CT and MR imaging

Craniofacial Fibrous Dysplasia in Fronto-Orbital Region: A Single-Center Retrospective Study of 38 Cases

OBJECTIVE

This study presents the clinical characteristics, imaging manifestations, and surgical experience in 38 patients diagnosed with craniofacial fibrous dysplasia in fronto-orbital region (foFD).

METHODS

We retrospectively analyzed the clinical data from 38 patients who had surgery for foFD. The surgical procedure typically involved extensive tumor removal, followed by immediate reconstruction of the frontal bone and orbit using synthetic materials. Additionally, 9 patients underwent simultaneous microscopic decompression of the optic canal.

RESULTS

Common clinical manifestations included progressive fronto-orbital bone deformity (35), proptosis (28), orbital dystopia (21), and visual impairment (9). The disease primarily affecting the frontal bone (38), the sphenoid bone (28), and the ethmoid bone (24). The optic canal was involved in 9 patients with functional impairment. Computed tomography scans in all 38 cases revealed satisfactory repair material positioning and complete resolution of frontal deformities. Among the 9 patients who underwent optic canal decompression, 7 experienced partial recovery of visual acuity after surgery.

CONCLUSIONS

In the surgical treatment of foFD, it is crucial to achieve maximal bone resection and repair skull defects, while decompressing the optic canal can provide significant benefits for patients with decreased visual function preoperatively. The use of preformed artificial materials offers advantages in aesthetic restoration after lesion excision.

Clinical correlation recommended: accuracy of clinician versus radiologic interpretation of the imaging of orbital lesions

Purpose: To assess the accuracy of radiographic interpretation between the clinician and radiologist when compared to histopathology of orbital lesions. Methods: A retrospective chart review of patients at the University of California Davis Eye Center who underwent orbitotomy from 1/1/2000 to 5/22/2019 was performed. Charts with a preoperative imaging report, preoperative clinical assessment including the clinician's interpretation of imaging, and histopathologic diagnosis were included. The specific diagnoses were grouped into related classes of pathology for the analysis. The clinical and radiologic assessments were compared against the final histopathologic diagnosis for concordance. A concordance analysis was performed. Results: 242 patients (mean age 49 years, 53.5% female) were reviewed. Of these records 185 documented the clinician's clinical impression, the radiology report, as well as the histopathology report. The clinician's preoperative assessment had substantial agreement [kappa = 0.72 (0.65,0.79)] with the final histopathologic result and was correct in 75.7% (140/185) of cases whereas the radiology report was correct in 52.4% (97/185) with a moderate level of agreement [kappa = 0.47 (0.39, 0.55)]. In 49.2% (91/185) of cases the final histopathology correlated with both the clinical impression and radiology report [kappa = 0.58 (0.55, 0.61)]. Conclusions: The accurate interpretation of orbital imaging is a challenge and histopathologic examination remains the gold standard for diagnosis. While orbital imaging is a valuable diagnostic tool the interpretation of these studies is most accurate when conducted in the context of the patient's medical history, clinical exam, and with the physician most familiar with various orbital lesions.

Radiologic Features of Sinonasal Tumors

Imaging evaluation of sinonasal tumors is most often conducted with computed tomography, which excels at identifying the effects of these masses on adjacent osseous structures, and magnetic resonance imaging that is ideal for distinguishing pathologic masses from mucosal thickening and fluid that are common in the sinonasal spaces and depicting extension into the surrounding soft tissues, orbits, and intracranial compartment. Accordingly, the two studies are complementary exams and both are commonly utilized in the assessment of these masses. Less commonly, positron emission tomography can provide additional metabolic evaluation of potential metastatic disease in patients with malignant disease. While these imaging modalities are excellent for the portrayal of an abnormality, there is considerable overlap in the imaging appearance of these tumors and specific imaging manifestations linked to a particular tumor are frequently lacking. Therefore, while the mass may be readily identified, narrowing the differential diagnosis to a single specific entity is rare. Nevertheless, cross-sectional imaging plays an essential role in patient management and valuable guidance for successful biopsy or surgical resection in virtually all cases. This review emphasizes essential imaging manifestations that correlate with sinonasal tumors in general and highlight certain features that may implicate a specific disease process.

Management of Ossifying Fibroma in a Suspicious Case of Hyperparathyroid-Jaw Tumor Syndrome

The purpose of this article is to report a case of ossifying fibroma in the mandible associated with hyperparathyroid-jaw tumor syndrome, in a 46-year-old Caucasian female, surgically resected and reconstructed with iliac crest bone, followed by implant placement. This is a rare syndrome with an autosomal dominant pattern, with the development of primary hyperparathyroidism mainly due to parathyroid adenomas. Fibro-osseous lesions in the jaws can be present and can also precede the development of the endocrine disorder. As renal abnormalities and uterine tumors can develop, an interdisciplinary approach is imperative for its diagnosis and management, due to the possibility of recurrence and potential for malignancy.

Paranasal sinus and skull base fibro-osseous lesions: when is biopsy indicated for diagnosis?

BACKGROUND

Paranasal sinus fibro-osseous (FO) lesions represent a heterogeneous group, often sharing overlapping radiographic and pathologic features posing a dilemma in accurate diagnosis. The objective of this study was to correlate preoperative radiologic and postoperative histologic diagnosis to help guide a diagnostic algorithm.

METHODS

Retrospective analysis of 60 FO lesions between 1994 and 2010.

RESULTS

The mean age was 42.3 years with average follow-up of 12.5 months. The preliminary radiologic diagnosis was osteoma in 22 (36.7%), fibrous dysplasia (FD) in 9 (15%), ossifying fibroma (OF) vs FD in 5 (8.3%), and OF in 3 (5%) cases. The diagnosis was indeterminate in 21 (35%) cases. Management consisted of excision in 29 (48.3%), observation in 17 (28.3%), and biopsy in 14 (23.3%) patients. For patients undergoing resection or biopsy, positive predictive value of preoperative radiology was 100% (10/10) for osteoma, 85.7% (6/7) for FD, and 33.3% (1/3) for OF cases. For the indeterminate lesions, most common pathologic diagnoses for 21 patients included osteoma in 4 (17.4%), arrested pneumatization in 3 (14.3%), OF in 3 (14.3%), and FD in 2 (9.5%). For FD vs OF cases, 3 underwent surgery, revealing osteoma, FD, and OF in 1 patient each.

CONCLUSION

In this series, radiologic-histopathologic correlation was high for osteoma and FD and low for OF and OF vs FD. This data suggests that patients with classic radiologic characteristics of osteoma and FD may be observed, unless resection is warranted based on clinical symptomatology. Preoperative diagnosis of OF, OF vs FD, or indeterminate lesions may warrant a biopsy to establish firm diagnosis to guide definitive management, especially if preoperative computed tomography (CT) imaging is concerning for an aggressive FO neoplasm.

Imaging appearance of bone tumors of the maxillofacial region

This paper reviews the imaging appearance of benign and malignant bone tumors of the maxillofacial region. A benign bone tumor commonly appears as a well circumscribed lesion. The matrix of the tumor may be calcified or sclerotic. Malignancies often display aggressive characteristics such as cortical breakthrough, bone destruction, a permeative pattern and associated soft-tissue masses. Computed tomography scan is an excellent imaging modality for accurate localization of the lesion, characterization of the tumor matrix and detection of associated osseous changes such as bone remodeling, destruction or periosteal reaction. Magnetic resonance imaging is of limited value in the evaluation of maxillofacial bone tumors.

A rare case of psammomatoid ossifying fibroma in the sphenoid bone reconstructed using autologous particulate exchange cranioplasty

Psammomatoid ossifying fibroma (POF), a variant of ossifying fibroma, is a benign fibroosseous lesion typically arising within the nasal cavity, paranasal sinuses, and orbit. Cranial vault involvement is exceedingly rare, with very few cases reported in the literature. The authors report a case of POF in the neurocranium of an 11-year-old child, 4 years after chemotherapy and radiation therapy for acute lymphoblastic leukemia. This case is reported in view of its rarity, novelty of presentation, and the difficulty in diagnosis due to its radiological resemblance to aneurysmal bone cyst or monostotic cystic fibrous dysplasia, further aggravated by the clinical scenario. A novel technique of cranial reconstruction called autologous particulate exchange cranioplasty was used following tumor excision.

Value of MR imaging in the differentiation of benign and malignant orbital tumors in adults

Purpose

To prospectively evaluate magnetic resonance (MR) imaging including dynamic contrast-enhanced MR imaging in the differentiation of benign from malignant orbital masses and to evaluate which MR imaging features are most predictive of malignant tumors.

Materials and methods

The study was approved by the institutional review board and signed informed consent was obtained. Nonenhanced, static, and dynamic contrast-enhanced MR imaging was performed in 102 adult patients with an orbital mass. Diagnosis was based on histologic findings. MR imaging features of benign and malignant orbital lesions were evaluated correlated with histological findings. Multivariate logistic regression analysis was employed to identify the best combination of MR imaging features that might be predictive of malignancy.

Results

Nonenhanced, static, and dynamic enhancement MR imaging was significantly superior to two other models in prediction of malignancy (p < 0.05). Multivariate logistic regression analysis identified that the most discriminating MR imaging features were isointense mass on T2-weighted imaging and a washout-type time–intensity curve for both observers.

Conclusion

Nonenhanced, static, and dynamic enhancement MR imaging improved differentiation between benign and malignant orbital masses in adult patients.

Imaging of craniofacial fibrous dysplasia

Fibrous dysplasia is a relatively common disorder of bone. It may affect the bones of the face and skull and, in so doing, produce a wide variety of clinical presentations. Plain film assessment of craniofacial fibrous dysplasia may be difficult because of varying appearances and complex, overlapping structures. The MRI appearances of fibrous dysplasia are often non-specific and may be confusing. Findings on CT are also variable, but more commonly lead to a specific diagnosis. This is because of the characteristic ground-glass appearance of woven bone, seen on CT in most if not all cases of craniofacial fibrous dysplasia.

Cemento-ossifying Fibroma Of Paranasal Sinus Presenting Acutely As Orbital Cellulitis

Fibro-osseous lesions of the face and paranasal sinuses are relatively uncommon. These lesions have overlapping clinical, radiologic and pathologic features causing difficulty in diagnosis. Neoplastic fibro-osseous paranasal sinus lesions can be benign or malignant. The benign fibro-osseous lesions described are: ossifying fibroma (and its histologic variants) and fibrous dysplasia. The variants of ossifying fibroma differ in the nature of calcified material (i.e. cementum versus bone), in the location of the lesion (oral versus paranasal sinus or orbital), other morphologic variations (presence of psammomatoid concretions) and biologic behavior (aggressive versus stable). Presence of cementum or bone classifies the lesion as cementifying fibroma or ossifying fibroma respectively while lesions with mixture of both cementum and bone are called cemento-ossifying fibroma. We describe a case of a young adult male with cemento-ossifying fibroma of paranasal sinus presenting acutely as left orbital cellulitis with proptosis.

Maxillofacial fibrous dysplasia: personal experience with gadoliniumenhanced magnetic resonance imaging

PURPOSE

The authors sought to identify radiological criteria assisting in the diagnosis of craniofacial fibrous dysplasia and differential diagnosis of fibro-osseous lesions by comparing computed tomography (CT) and magnetic resonance imaging (MRI) findings and histological results in 23 patients with presumed fibrous dysplasia.

MATERIALS AND METHODS

From February 2000 to March 2005, 23 patients (17 women and six men, aged 9-66 years) with facial bone disease underwent CT and MRI studies. Imaging findings were compared with the results of histological examination performed within 1 month of the radiological diagnosis.

RESULTS

The combination of CT and MRI led to a presumptive diagnosis of fibrous dysplasia in all cases, but histology confirmed the diagnosis in 18 cases only. In two cases that had initially been considered cyst-like variants of fibrous dysplasia and were associated with irregular enhancement at MRI, histology characterised the lesions as single locations of multiple myeloma. In one case, targeted biopsy of areas showing intense enhancement led to a diagnosis of low-grade fibrosarcoma; in the remaining two cases, the definitive diagnoses were ossifying fibroma and myeloproliferative disease.

CONCLUSIONS

MRI proved useful in differentiating fibrous dysplasia from other bone diseases, defining clinical behaviour, identifying neoplastic foci within dysplastic tissue and distinguishing benign from malignant bone lesions. The authors suggest a broader use of contrast-enhanced MRI for the diagnosis and follow-up of dysplastic lesions of the facial bones and for planning appropriate surgical treatment.

Benign Fibro-Osseous Lesions of the Jaws: A Study of 127 Chinese Patients and Review of the Literature

The aim of this study is to analyze all the cases of benign fibro-osseous lesions treated at School and Hospital of Stomatology, Wuhan University, to compare the results obtained in this study with those previously documented by other authors. The 127 cases diagnosed as a fibro-osseous lesion were retrieved, and information about these lesions was documented. In all, 127 cases of benign fibro-osseous lesions were surgically treated. Of these, 55 were cemento-ossifying fibroma, 43 ossifying fibroma, and 29 fibrous dysplasia. Cemento-ossifying fibromas mostly occur in men of the second decades, mostly in the mandible. Ossifying fibromas had almost equal sex predilection and age distribution peaked in the second decades, mostly in the mandible. Fibrous dysplasia also had equal sex predilection, and age distribution peaked in the second and third decades, with equal occurrence in both jaws. The tumors needed to have a regular follow-up after the surgery.

Craniofacial polyostotic fibrous dysplasia: a case report and review of the literature

Craniofacial fibrous dysplasia is 1 of 3 types of fibrous dysplasia that can affect the bones of the craniofacial complex, including the mandible and maxilla. A 49-year-old white male presented with an extensive previous medical history. Initial radiographic assessment comprised panoramic and PA cephalometric radiographs and provided a working diagnosis of fibrous dysplasia. Advanced imaging included conventional CT, cone beam CT, and MRI. Three areas in the craniofacial complex were diagnosed as FD. The patient also presented with severe degenerative joint disease of the left TMJ. In this case, all FD lesions were radiopaque and presented with ground glass appearance. The relative importance of each imaging modality in the diagnosis and assessment of FD is discussed.

Rethinking orbital imaging establishing guidelines for interpreting orbital imaging studies and evaluating their predictive value in patients with orbital tumors

PURPOSE

To establish guidelines for interpretation of orbital imaging by magnetic resonance imaging (MRI) and/or computed tomography (CT), and to apply these guidelines and examine their predictive value in 131 patients with biopsy-proven orbital tumors.

DESIGN

Prospective evaluation of imaging studies.

PARTICIPANTS

Imaging studies (CT and/or MRI) from 131 cases with biopsy-proven orbital tumors.

METHODS

Guidelines for reviewing orbital imaging studies (MRI and/or CT) were established based on 5 major characteristics: (1) anatomic location, (2) bone and paranasal sinuses involvement, (3) content, (4) shape, and (5) associated features. In total, 84 features were established by an experienced orbital surgeon and a neuroradiologist. Applying these 84 features, imaging studies of 131 biopsy-proven orbital tumors were evaluated by 3 physicians.

MAIN OUTCOME MEASURES

Imaging features: characteristics, sensitivity, specificity, and positive and negative predictive values in various groups of orbital tumors and kappa values.

RESULTS

One hundred thirty-one cases of biopsy-proven orbital tumors were evaluated. Benign lesions were more likely to be smaller in size, round or oval in shape (29% of all benign tumors, 0% in malignant and inflammatory, P<0.001), and associated with hyperostosis (22% of all benign lesions, P<0.001). They were also more likely to be hyperdense or hypodense on CT imaging (15% and 11%, respectively; P<0.05 in comparison with inflammatory and malignant tumors). Inflammatory processes showed panorbital involvement (23% vs. 3%, and 0% in benign and malignant tumors, respectively; P<0.001). Orbital fat involvement and fat stranding were noticed only in inflammatory lesions (19% and 16%, respectively; P<0.001). None of the features occurred only in malignant tumors, but they tend to involve the anterior orbit more commonly (54% vs. 20%, and 29% in benign and malignant; P = 0.002), and were more likely to show bone erosion (31% vs. 6%, and 16% in benign and inflammatory tumors, respectively; P = 0.004) and molding around orbital structures (29% vs. 3% in benign, and 0% in inflammatory tumors, respectively; P<0.001). Features such as panorbital involvement, orbital fat, frontal sinus opacity, molding around orbital structures, perineural involvement, and fat stranding had specificity of 97% to 100%, but low sensitivity.

CONCLUSIONS

Guidelines for analysis of orbital imaging studies (CT or MRI) are suggested. Based on these guidelines several imaging features showed significantly different occurrences in benign, malignant, and inflammatory processes; although this can help in differential diagnosis, tissue diagnosis may still be required.

Fibro-osseous lesions of the face and jaws

Maxillofacial fibro-osseous lesions (FOL) consists of lesions that differ, with the exception of fibrous dysplasia, to those found in the rest of the skeleton. FOLs of the face and jaws are cemento-osseous [corrected] dysplasia, fibrous dysplasia and cemento-ossifying fibroma. Radiology is central to their diagnosis because the pathology for all FOLs is similar, although they range widely in behaviour, from dysplasia, hamartoma to benign neoplasia with occasional recurrence. Furthermore, once diagnosed the management of each is different. For cemento-ossifying dysplasia, this may mean doing nothing, simply because no treatment is generally appropriate. Almost all cemento-osseous [corrected] fibromas should be treated surgically, whereas cases of fibrous dysplasia are treated according to their clinical presentation, ranging from review and follow-up to surgery necessary to save the patient's sight or reduce deformity. The most important and frequent features of the FOLs differential diagnosis is discussed with assistance of a flow-chart.

Imaging of orbital disorders in pediatric patients

The spectrum of orbital lesions occurring in childhood is wide, including a variety of both benign and malignant disorders. Although physical examination and fundoscopy may aid in establishing the diagnosis of retro-ocular lesions, imaging remains a critical step in the evaluation of the pediatric orbit. Ultrasonography, CT, and MR imaging are the primary modalities for the evaluation of the diseased orbit, and careful observation of the characteristic radiological features usually leads to correct diagnosis; however, some of the lesions look very similar and are difficult to differentiate from each other. The purpose of this article is to review the common and unusual entities that may involve the pediatric orbit, to describe the radiological features, and to evaluate the efficacy of US, CT, and MRI in the diagnosis and management of these conditions.

Fibro-osseous and giant cell lesions, including brown tumor of the mandible, maxilla, and other craniofacial bones

Fibro-osseous, osseous, cartilaginous, and giant cell lesions of the mandible, maxilla, and other craniofacial bones share overlapping clinical, radiologic, and pathologic features that may lead to diagnostic confusion and possible misdiagnosis. The value of combined clinical-radiologic-pathologic correlation in the diagnosis of these lesions is paramount to achieving the correct diagnosis with subsequent implementation of appropriate therapeutic intervention.

Radiological appearances of sinonasal abnormalities

The aim of this pictorial review is to present a variety of abnormalities of the sinonasal cavities to emphasize the diversity of lesions occurring in this region. These include congenital, neoplastic and granulomatous disorders and some allergic and inflammatory lesions with uncommon radiological appearances, as well as expanding lesions of the facial bones or of dental origin with secondary involvement of the related sinus(es).

3D-CT vascular setting protocol using computer graphics for the evaluation of maxillofacial lesions

In this paper we present the aspect of a mandibular giant cell granuloma in spiral computed tomography-based three-dimensional (3D-CT) reconstructed images using computer graphics, and demonstrate the importance of the vascular protocol in permitting better diagnosis, visualization and determination of the dimensions of the lesion. We analyzed 21 patients with maxillofacial lesions of neoplastic and proliferative origins. Two oral and maxillofacial radiologists analyzed the images. The usefulness of interactive 3D images reconstructed by means of computer graphics, especially using a vascular setting protocol for qualitative and quantitative analyses for the diagnosis, determination of the extent of lesions, treatment planning and follow-up, was demonstrated. The technique is an important adjunct to the evaluation of lesions in relation to axial CT slices and 3D-CT bone images.