Juvenile fibromatosis of the orbit: a case report with review of the literature

Solitary orbital myofibroma in a child: A rare case report with literature review

Myofibroma is a rare benign mesenchymal tumor of uncertain histogenesis. A six-year-old boy presented with a unilateral lower eyelid mass of six weeks’ duration. MRI revealed a circumscribed mass in the inferolateral orbit with bony erosion. A systemic examination was unremarkable. Excision with histopathology revealed a partially infiltrative spindle cell tumor with bland nuclear morphology expressing smooth muscle actin and muscle-specific actin, compatible with myofibroma. Solitary myofibroma is a rare childhood orbital tumor and may clinico-radiologically closely mimic a malignancy. Histopathology and immunohistochemistry can help reach a definitive diagnosis. Systemic evaluation and close follow up are crucial in such cases.

A rare erosive orbital mass in a child: Case report of myofibroma

PURPOSE

To present the clinical, histological, and radiographic findings of a case of orbital myofibroma in an unusual location. The literature is reviewed and the clinical relevance discussed.

METHODS

A 5-year-old boy was examined with a 1.5-month history of progressive swelling in the left supraorbital region.

RESULTS

Examination revealed a firm, painless mass in the supralateral region of the left orbit with slight reddish discoloration of the overlying skin. Computerized tomography (CT) scan images showed a well demarcated, homogenous, solid mass with extension to the lacrimal gland region and adjacent to frontal bone erosion. The mass was surgically excised and was confirmed to be myofibroma in diagnostic histological studies. There has been no evidence of recurrence in the first year after surgery.

CONCLUSIONS

Clinical appearance and imaging findings are unspecific for this tumor, and histological examination still remains the definite method of diagnosis. Therefore, it is important to be able to differentiate myofibromas from other malignant tumors with a similar presentation in pediatric patients to avoid mismanagement.

Clinicopathological study of three cases of infantile fibromatosis of the orbit

We report the clinical and pathological findings in three infants with infantile fibromatosis that involved several extraocular muscles which led to disorders of ocular motility. We also describe their clinical features before and after surgery. This was a retrospective interventional case study with clinicopathological correlations. We present three cases of infantile fibromatosis that were diagnosed by clinical features and histopathlogical examination of biopsy specimens. The three patients were all female children aged 1, 3, and 3 years at their initial visit. The orbital tumor was unilateral in all patients. All three patients had disorders of ocular motility because the tumors involved ≥2 extraocular muscles. The margins between the tumor and the involved extraocular muscles were not distinct. We performed partial resection of the tumors to preserve the extraocular muscles. In all cases, the tumors partially remained, but periodic postoperative magnetic resonance imaging showed no enlargement of the tumors during the follow-up period. All three patients had residual limitations of eye movements. We should consider the postoperative binocular function when we treat infantile benign fibrous tumors involving the extraocular muscles.

Submandibular juvenile fibromatosis

This brief clinical study presents a case of a 2-year-old girl with a submandibular mass that caused erosion of the inferior border of the mandible. An incisional biopsy finding revealed juvenile fibromatosis, that is, a group of fibrous proliferations that have biologic behavior and histopathologic pattern intermediate between those of benign fibrous lesions and fibrosarcoma. These lesions should be treated through wide surgical excision, and patients should be kept under regular follow-up because of their high recurrence rate.

Orbital infantile myofibroma: a case report and clinicopathologic review of 24 cases from the literature

Isolated orbital infantile myofibroma are rare tumors in the head and neck. The mass-like clinical presentation and variable histologic features result in frequent misdiagnosis and potentially inappropriate clinical management. There are only a few reported cases in the English literature. Twenty-four patients with orbital infantile myofibroma or myofibromatosis were compiled from the English literature (Medline 1960-2011) and integrated with this case report. The patients included 14 males and 10 females, aged newborn to 10 years (mean, 34.8 months), who presented with a painless mass in the infra- or supraorbital regions, usually increasing in size andassociated with exophthalmos (n = 5). Females were on average older than their male counterparts (38.9 vs. 31.9 months, respectively; P = 0.71). The tumors were twice as frequent on the left (n = 16) than right (n = 8). Patients experienced symptoms for an average of 2.7 months before clinical presentation. The tumors involved the bone (n = 17) or the soft tissues (n = 7) of the orbit, with extension into the nasal or oral cavity (n = 3). The mean size was 3.0 cm, with a statistically significant difference between males and females (mean: 3.9 vs. 1.82; P = 0.0047), but without any differences based on age at presentation (P = 0.25), duration of symptoms (P = 0.66), or bone or soft tissue involvement (P = 0.51). Grossly, all tumors were well-circumscribed, firm to rubbery, homogenous, and white-grey. Histologically, the tumors were biphasic, showing whorled and nodular areas of fusiform cells with extracellular collagen, mixed with a population of small, primitive-appearing, darkly staining cells. Necrosis was not present, but mitoses could be seen. Tumors with immunohistochemistry performed showed strong and diffuse smooth muscle actin and vimentin immunoreactivity, but were negative with muscle specific actin, desmin, MYOD1, myogenin, S100 protein, GFAP, keratin, CD31, 34, Factor VIIIR-Ag, and CD45RB. The principle histologic differential diagnosis includes juvenile hyaline fibromatosis, fibrous hamartoma of infancy, fibromatosis coli, leiomyoma, infantile hemangiopericytoma, infantile fibrosarcoma, Ewing sarcoma/primitive neuroectodermal tumor, and lymphoma. All patients were managed with surgery. Recurrences developed in two patients at 4 and 6 months, respectively. Follow-up data was available on all but two patients (n = 22). These patients were either alive without evidence of disease (n = 18), alive but with disease (n = 3), or had died unrelated to this disease (i.e., neuroblastoma, n = 1). Orbital infantile myofibroma is a rare tumor, presenting in infancy as an enlarging mass of the orbit, with characteristic histomorphologic and immunophenotypic features. Orbital disease is usually isolated rather than part of systemic disease, and shows an excellent long-term prognosis, making appropriate separation from other conditions important.

Solitary myofibroma of the sclera

PURPOSE

To report a novel case of solitary myofibroma involving the sclera.

METHODS

Case report and review of the literature.

RESULTS

A 19-year-old woman had an expanding and painful epibulbar mass clinically diagnosed as nodular scleritis that did not respond to anti-inflammatory therapy. A biopsy showed a proliferation of spindle-shaped cells that reacted strongly positively with immunoperoxidase stains for vimentin and smooth-muscle actin. The diagnosis of solitary myofibroma was made. Six months postoperatively, the patient was well, and the lesion had not recurred.

CONCLUSIONS

Myofibroma should be considered in the differential diagnosis of an epibulbar mass, especially in the setting that would mimic nodular scleritis.

Solitary intraosseous orbital myofibroma in four cases

PURPOSE

To report four pediatric cases of a bone-destructive orbital tumor that proved to be a benign solitary intraosseous myofibroma.

METHODS

Four children, aged 1, 7, 11, and 72 months, developed eyelid fullness or slight proptosis. A solitary intraosseous mass was detected in the inferior (n = 2), superotemporal (n = 1), and supranasal (n = 1) orbital walls. On CT, the mass showed bone destruction. On MRI, the mass appeared circumscribed within a shell of normal surrounding bone and with features of isointensity on T1-weighted images, intense homogeneous gadolinium enhancement, and midrange signal on T2-weighted images. Complete surgical excision of the mass in each case was performed.

RESULTS

On histopathologic examination, the tumors were characterized by whorls and bands of plump myoid cells with eosinophilic cytoplasm consistent with myofibroblasts, sometimes associated with a hemangiopericytoma-like vascular pattern. The diagnosis was also supported by immunohistochemical studies showing positive immunoreactivity for vimentin and smooth muscle actin. None of the patients have shown recurrence in follow-up ranging from 6 months to 3 years.

CONCLUSIONS

Myofibroma is a benign tumor that can occur in the orbital bony wall of children. It can manifest as a bone destructive mass and can simulate a malignant process.

Involvement of the bony orbit in infantile myofibromatosis

Infantile myofibromatosis is a rare disorder of infancy that can provoke osteolytic lesions. A 15-day-old infant presented with three round, firm lesions located on the forehead, shoulder, and back. Excisional biopsy of the forehead lesion revealed that the tumor was composed of spindle cells resembling normal smooth muscle arranged in short fascicles. Immunohistochemical staining was positive for vimentin and actin. Five months later, the child presented with three new lesions, including one in the superolateral aspect of the left orbit. It is important to recognize the multicentric form of infantile myofibromatosis because, despite its aggressive clinical presentation, the disease is benign and usually does not require extensive surgery or chemotherapy.

Orbital and periorbital myofibromas in childhood

PURPOSE

Infantile myofibromatosis is an uncommon tumor that occurs rarely in the periorbit and orbit. This article reports two cases of infantile myofibromatosis of the orbital adnexa and describes the associated clinical, histopathologic, and immunohistochemical findings.

DESIGN

Two retrospective, interventional case reports with clinicopathologic correlation.

INTERVENTION

Treatment consisted of excision of the tumors.

MAIN OUTCOME MEASURES

Histologic and immunohistochemical evaluation and clinical evaluation for tumor recurrence.

RESULTS

The first patient was a newborn male with a large tumor extending from his eyelid that was excised at day 2 of life. Histologic and immunohistochemistry analyses were used to make a diagnosis of infantile myofibromatosis. He remains disease free at age 7 years. The second case was a 6-year-old boy with a 1-month history of proptosis resulting from an orbital mass. Incisional biopsy revealed a tumor consistent with infantile myofibromatosis. He remains tumor free 12 months after complete gross surgical resection.

CONCLUSIONS

Infantile myofibromatosis is an uncommon tumor that is rare in the orbit. Differential diagnosis can be difficult based solely on histologic analysis. Immunohistochemistry evaluation demonstrating cytoplasmic actin filaments within neoplastic spindle cells confirms the diagnosis. As soon as the diagnosis is made, chest and abdominal imaging is of value to define the prognosis and to direct further treatment. After the diagnosis of nonvisceral infantile myofibromatosis, complete gross resection, if possible, is the treatment of choice.

Orbital (desmoid type) fibromatosis

A case of extra-abdominal fibromatosis (EF) of the orbit is described in a 35-year-old man presenting with progressive exophthalmos, right ptosis and diplopia. MRI showed an orbital mass of intermediate signal in T1-weighted images (WI) and low signal in T2WI, which enhanced non-homogeneously after contrast injection. The histological diagnosis of EF was made and the lesion was surgically removed. No recurrence occurred in 40 months of follow-up.

Fibrous histiocytoma and fibrous tissue tumors of the orbit

Fibrous orbital tumors present clinically and radiographically in a broad spectrum ranging from a benign mass, to locally aggressive tumor, to invasive malignancy. Pathologic analysis and diagnosis are often challenging, usually based on a combination of light microscopy, immunohistochemistry, and electron microscopic findings. Some light microscopic and immunohistochemical findings, however, are relatively characteristic. A storiform or cartwheel pattern and vimentin staining are characteristic of fibrous histiocytoma. A herringbone pattern is usually found in fibrosarcoma. A "patternless pattern" and CD34 staining is found most commonly in solitary fibrous tumor. CT and MR imaging findings, as well as clinical presentation, in fibrous orbital lesions are often difficult to distinguish from those of other orbital masses, although there may be useful clues. Benign fibrous lesions are usually well-circumscribed and may chronically remodel bone, whereas more aggressive malignant fibrous tumors tend to have infiltrating margins and may destroy bone on CT or MR imaging. With malignant fibrous masses, enhancement patterns on CT or MR imaging may be more inhomogeneous, with avascular or necrotic nonenhancing regions. At MR imaging, benign lesions tend to be homogeneous on T1, T2, and postgadolinium T1-weighted images, whereas malignant soft tissue lesions may change their pattern from homogeneous on T1-weighted images to heterogeneous with low signal septations on T2-weighted images. Low T2 signal comprising part or all of a fibrous lesion correlates with dense collagen fibers, with a less cellular matrix. Areas of hyperintensity on T2-weighted images correspond with a more cellular matrix of fibroblasts and other cells. Calcification within a tumor, however, may give a similar appearance. Thus, if a lesion has predominantly low signal on T2-weighted images, or less specifically has low signal septations, then a fibrous orbital lesion with high collagen content may be ranked higher in the differential diagnosis (see Figs. 2E and 3B). When T2 signal is intermediate-to-high, then one has a difficult time narrowing the differential diagnosis. Radiographically, distinguishing these lesions from other fibrous orbital lesions, as well as from other varieties of orbital masses, is difficult. Differential diagnosis of fibrous orbital masses includes all the fibrous lesions described in this article, in addition to schwannoma (Fig. 7), neurofibroma (Figs. 4 and 8), hemangiopericytoma (Figs. 9 and 10), rhabdomyosarcoma, meningioma, lymphoma, and metastasis (Figs. 11 and 12). A history of prior orbital irradiation for retinoblastoma or other tumors may raise the possibility of radiation-induced secondary tumors, such as MFH, fibrosarcoma, and osteosarcoma. Determining the extent of orbital involvement remains the primary goal of the radiologist. The final diagnosis still rests with the pathologist.

Fibromatosis of the mandible: case report and review of previous publications

The term 'fibromatosis' is used to denote two main pathological entities: juvenile fibromatosis and adult fibromatosis. It is also possible to distinguish between superficial fibromatosis of the aponeurosis and deep fibromatosis of the muscle-aponeurosis. Histopathological findings have indicated that fibromatosis is an invasive neoformation of fibromatous connective tissue involving adjacent structures. It does not metastasize, though recurrence rates vary. Treatment is based on either excision of the mass, or radiotherapy and chemotherapy if the condition is inoperable. We describe a case of fibromatosis of the mandible in a young girl. The growth was excised completely and she was still disease-free four years later.