Primary Malignant Orbital Tumors

Prostate Cancer With Orbital Metastasis

Prostate cancer (PCa) is one of the most commonly diagnosed cancers in men worldwide, with an increasing incidence due to advancements in detection methods. The majority of PCa cases are sporadic, though a small percentage is hereditary. PCa primarily metastasizes to the bones, followed by lymph nodes, liver, and thorax. However, metastasis to atypical sites, including the orbit, remains exceedingly rare. Orbital metastasis from PCa is associated with a poor prognosis and can lead to significant visual impairment. This case report describes a 71-year-old male patient with a history of hypertension, atrial fibrillation, and obstructive uropathy, who presented with diplopia and left-sided ptosis. Imaging revealed a left intraconal orbital mass with intracranial extension, leading to the diagnosis of metastatic prostate adenocarcinoma. Further evaluation revealed extensive bone metastases and retroperitoneal lymphadenopathy. The patient was diagnosed with high tumor burden and castration-naïve metastatic PCa and treated with a combination regimen of androgen deprivation therapy, docetaxel, and darolutamide, resulting in significant reduction in prostate-specific antigen levels. Despite initial success in lowering tumor burden, the patient experienced side effects, including a rash, leading to discontinuation of chemotherapy. This case underscores the importance of considering PCa in the differential diagnosis of orbital tumors, despite its rarity. Surgical resection and palliative radiation were employed to manage the orbital mass, and ongoing treatment with denosumab was initiated to address the extensive bone metastases. This case highlights the clinical challenges and treatment considerations in patients with atypical metastatic spread of PCa and emphasizes the need for a multidisciplinary approach in managing such complex presentations.

En Bloc Orbitectomy in the Management of Advanced Orbital Cancer: A Retrospective Study of Seven Different Carcinomas

AIM

An en bloc orbitectomy is one of the most invasive surgical procedures in the orbit, primarily used to remove advanced malignancies, ensure negative resection margins, and local cancer control. This study examines the indications, clinical features, outcomes, and survival rates of patients who underwent this surgery for periocular and orbital malignancies.

PATIENTS AND METHODS

A retrospective consecutive case series of seven patients with various orbital carcinomas managed with en bloc orbitectomy from 2018-2023 at the University Hospital in Pilsen, Czech Republic, was conducted. Minor surgeries and other diagnoses were excluded.

RESULTS

The study included seven patients, with an average age of 68.7 years (range 50-83, median 74). Orbitectomy was part of salvage surgery in two patients and debulking in one. R0 resection was achieved in only 50% of cases; defects were reconstructed with a free anterolateral thigh (ALT) flap in one case and local flaps in others. Therapeutic neck dissection was performed in three patients directly after surgery, in one case 15 months after orbitectomy.

CONCLUSION

A thorough examination of indications, patient and tumor features, and reconstructive possibilities should precede an en bloc orbitectomy. Despite being highly invasive, it should be adequately indicated to avoid less invasive surgeries that could complicate radical surgery and impair disease control.

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.

A novel case of recurrent cylindroma of the orbit

Cylindroma is a rare benign tumour of eccrine origin that has not been previously reported within the orbit. We report a case of a recurrent orbital cylindroma following incomplete excision. A 75-year-old female presented with a recurrent left inferomedial orbital mass. Seven years prior a mass of the same location was excised and on histology at the time resembled a cylindroma. The patient had a history of lung adenocarcinoma. Magnetic resonance imaging (MRI) found the recurrent mass to be a well-circumscribed lesion anterior to the inferior oblique. The mass was subsequently excised. Histological analysis found a well-circumscribed neoplasm with a characteristic jigsaw pattern of nested cells, consistent with cylindroma. This case demonstrates the possibility for cylindromas to occur within the orbit and their ability to reoccur if incompletely excised.

Imaging characteristics of orbital tumors: A case series analysis

Orbital tumors are a diagnostic and therapeutic challenge due to their varied etiologies and potential for severe complications, either of vision and systemic status. This case series particularly highlights the clinical presentation, imaging features and outcomes of management of three patients with different types of orbital masse. This includes lacrimal gland neoplasm, choroidal melanoma with metastasis and intra-conal mass suspicious of intra-orbital melanoma.

Orbital Lesions: A bird's eye view of series of 2068 cases in 27 years in a tertiary care hospital in Pakistan

Objective

To determine the relative frequency of orbital lesions based on the site of origin and histopathology at a Tertiary care hospital (Mayo Hospital, Lahore Pakistan) from 1996 till 2022 (27 years).

Methods

This descriptive case series included 2651 patients of all age groups presenting with orbital lesions who initially got enrolled at Institute of Ophthalmology Mayo Hospital, Lahore from 1996 till 2022. Of these, 583 patients left against medical advice. So, clinical data of 2068 patients were completely analyzed. Lesions were managed medically and/ or surgically. Final clinical diagnosis, with the help of histopathology, was used to classify the lesions.

Results

There were 1258 (60.9%) adults and 810 (39.1%) children, 1358 (65.66%) were neoplastic while 710 (34.33%) non-neoplastic lesions. Amongst the neoplastic lesions, 405 (29.8 %) were benign and 953 (70.2%) malignant. Primary orbital lesions were 1676 (81.04%), Secondary orbital lesions were 300 (14.51%), Endocrine/ hematopoietic reticulo-endothelial system lesions were 84 (4.06%) and Metastatic lesions from distant organs were 08 (0.39%).

Conclusion

Retinoblastoma, rhabdomyosarcoma, optic nerve gliomata were common in children. Pleomorphic adenoma & adenocystic carcinoma of lacrimal gland, cavernous hemangioma, optic nerve meningioma, neurofibroma, schwannoma, squamous cell carcinoma of eyelid, carcinoma of maxillary antrum and lymphomas were more common in adults.

Pearls & Oy-sters: A Challenging Optic Neuropathy-What Not to Miss in Optic Nerve Sheath Enhancement

Optic neuropathies include a wide range of disorders from ischemic, toxic, demyelinating, or inflammatory processes with acute/subacute onset to more gradual compressive or genetic etiologies. Accurate clinical history and multimodality optic nerve imaging including MRI and optical coherence tomography have greatly improved the diagnosis of patients with optic neuropathies. We report a case of a woman with severe monocular visual acuity deficit. Optic nerve sheath enhancement seen on MRI led to a broad differential diagnosis including demyelinating causes, optic nerve sheath meningioma (ONSM), tuberculosis, and sarcoid optic neuropathy. Lack of response to treatment with steroids or plasmapheresis led to biopsy, which confirmed the diagnosis of ONSM.

Spindle Cell/Sclerosing Rhabdomyosarcoma of the Orbit

A 3-year-old boy developed proptosis over 3 weeks. CT and MRI disclosed a 3.2 × 1.9 cm soft-tissue mass of the right extraconal and intraconal orbit with sphenoid bone erosion. After debulking through an upper eyelid crease incision, the tumor was diagnosed as a spindle cell/sclerosing rhabdomyosarcoma. DNA sequencing was negative for an L122R mutation in MyoD1 . Spindle cell/sclerosing rhabdomyosarcoma is an uncommon variant of this neoplasm, and only 2 patients with orbital tumors have been reported in 2 case series. Spindle cell/sclerosing rhabdomyosarcomas confined to the orbit are considered to have an excellent prognosis when treated with chemotherapy and radiation therapy. Diagnosis and treatment planning rely on histology, immunohistochemistry, and molecular analysis.

Orbital Metastases: A Systematic Review of Clinical Characteristics, Management Strategies, and Treatment Outcomes

BACKGROUND

Orbital metastases often lead to severe functional impairment. The role of resection, orbital exenteration, and complementary treatments is still debated. We systematically reviewed the literature on orbital metastases.

METHODS

PubMed, Scopus, Web-of-Science, and Cochrane were searched upon PRISMA guidelines to identify studies on orbital metastases. Clinical characteristics, management strategies, and survival were analyzed.

RESULTS

We included 262 studies comprising 873 patients. Median age was 59 years. The most frequent primary tumors were breast (36.3%), melanoma (10.1%), and prostate (8.5%) cancers, with median time interval of 12 months (range, 0-420). The most common symptoms were proptosis (52.3%) and relative-afferent-pupillary-defect (38.7%). Most metastases showed a diffuse location within the orbit (19%), with preferential infiltration of orbital soft tissues (40.2%). In 47 cases (5.4%), tumors extended intracranially. Incisional biopsy (63.7%) was preferred over fine-needle aspiration (10.2%), with partial resection (16.6%) preferred over complete (9.5%). Orbital exenteration was pursued in 26 patients (3%). A total of 305 patients (39.4%) received chemotherapy, and 506 (58%) received orbital radiotherapy. Post-treatment symptom improvement was significantly superior after resection (p = 0.005) and orbital radiotherapy (p = 0.032). Mean follow-up was 14.3 months, and median overall survival was 6 months. Fifteen cases (1.7%) demonstrated recurrence with median local control of six months. Overall survival was statistically increased in patients with breast cancer (p < 0.001) and in patients undergoing resection (p = 0.024) but was not correlated with orbital location (p = 0.174), intracranial extension (p = 0.073), biopsy approach (p = 0.344), extent-of-resection (p = 0.429), or orbital exenteration (p = 0.153).

CONCLUSIONS

Orbital metastases severely impair patient quality of life. Surgical resection safely provides symptom and survival benefit compared to biopsy, while orbital radiotherapy significantly improves symptoms compared to not receiving radiotherapy.