Ординатура / Офтальмология / Английские материалы / Tumors of the Eye and Ocular Adnexa_Char_2001

Figure 24–2. Axial MRI scan demonstrates a number of neurofibromas both inside and lateral to the orbit in a young man with NF1.

Amyloid tumors can produce orbital fibrosis. Approximately 20 cases of orbital amyloid have been reported. Most often, these are hard, irregular, nontender masses in the superior extraconal space.16 Figure 24–4 demonstrates amyloidosis in the lacrimal fossa on axial CT. This case is interesting, in that it points out that although calcification in the lacrimal fossa has been felt by some to be almost diagnostic of malignancy, it is not necessarily so. Most patients have been between 25 and 80 years of age; 4 cases have been bilateral. Most patients with amyloid tumors of the orbit do not have systemic amyloidosis.17 In a minority of cases, there is systemic involvement with hematologic abnormalities, including hypergammaglobulinemia, and BenceJones proteins in the urine.

Less commonly, other processes can produce orbital fibrosis. Congenital orbital fibrosis can occur as an idiopathic, isolated orbital disease (Figure 24–5). Fibrous dysplasia of the orbit is a bony lesion usually seen in young people; it is discussed in Chapter 23. Lesions arising from the sinuses produce fibrosis; they are discussed in Chapter 22. Many other reactive processes with widely varied etiologies can produce orbital fibrosis. In three cases, we have even observed localized orbital fibrosis from migrated contact lenses.18

A

B

C

Figure 24–3. A, Nodular fasciitis with the globe displaced superiorly. B, CT with computer reformation of the case shown in Figure 24–3A with nodular fasciitis.

Figure 24–4. Orbital amyloid localized in the lacrimal fossa. This patient was initially referred as a probable malignant lacrimal gland tumor because of the calcification noted.

wall was detected by us and resected because of a history of malignancy (Figure 24–6).

The confusion regarding the pathology of fibrous tumors has led to an evolution in the nomenclature. Approximately 10 cases of solitary fibrous tumors of the orbit have been reported.22–24 In the differential diagnosis with solitary fibrous tumor or giant cell fibroblastoma and giant cell angiofibromas, approximately 15 such cases involving the orbit have been described.25–27 Usually, these lesions behave in a benign manner, although recurrences can develop.25 Psammonatoid ossified fibromas of the orbit should be completely excised, which is a curative proce-

Figure 24–5. Congenital orbital fibrosis in a neonate with no history of family or in utero problems.

Figure 24–6. Ossifying fibroma of the orbital wall.

dure.28 Rarely, an orbital leiomyosarcoma can ossify and be somewhat confusing histologically.29

The use of cosmetic silicone injections and of paraffin products in some dressings used for sinus surgery have resulted in a small number of reports of localized or diffuse orbital fibrosis. In patients with orbital fibrosis who have had cosmetic silicone injections or sinus surgery, history is crucial because it points out the necessity for specialized histologic stains to establish the diagnosis.30,31

REFERENCES

1.Char DH. Thyroid eye disease, 2nd ed. New York, NY: Churchill Livingstone Inc.; 1989.

2.Dalley RW. Fibrous histiocytoma and fibrous tissue tumor of the orbit. Radiol Clin North Am 1999;37: 185–94.

3.Wenig BM, Mafee MF, Ghosh L. 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. Radiol Clin North Am 1998;36:1241–51.

4.Font RL, Hidayat AA. Fibrous histiocytoma of the orbit. Hum Pathol 1982;13:199–209.

5.Verity MA, Ebert JT, Hepler RS. Atypical fibrous histiocytoma of the orbit: an electromicroscopic study. Ophthalmologica 1977;175:73–9.

6.Jakobiec FA, Howard JM, Jones IS, Tannenbaum M. Fibrous histiocytomas of the orbit. Am J Ophthalmol 1974;77:333–45.

412 TUMORS OF THE EYE AND OCULAR ADNEXA

7.Rodrigues MM, Furgiuele FP, Weinreb S. Malignant fibrous histiocytoma of the orbit. Arch Ophthalmol 1977;95:2025–8.

8.Weiss SW, Enzinger FM. Malignant fibrous histiocytoma: an analysis of 200 cases. Cancer 1978;41: 2250–66.

9.Mairal A, Terrier P, Chibon F, et al. Loss of chromosome 13 is the most frequent genomic imbalance in malignant fibrosis histiocytoma. Cancer Genet Cytogenet 1999;111:134–8.

10.Myer DR, Wobig JL. Bilateral localized orbital neurofibromas. Ophthalmology 1992;99:1313–7.

11.Tricoulis D, Davaris P, Sarafianos K, Economou N. Fibroma of the orbital wall after dacryocystectomy: a case report. Ann Ophthalmol 1981;13:1167–8.

12.Allen PW. Nodular fasciitis. Pathology 1972;4:920–6.

13.Font RL, Zimmerman LE. Nodular fasciitis of the eye and adnexa. Arch Ophthalmol 1966;75:475–81.

14.Kaw YT, Ruesta RA. Nodular fasciitis of the orbit diagnosed by fine needle aspiration cytology. Acta Cytologica 1993;37:957–60.

15.Meacham CT. Pseudosarcomatous fasciitis. Am J Ophthalmol 1974;77:747–9.

16.Nehen JH. Primary localized orbital amyloidosis. Acta Ophthalmolgica 1979;57:287–95.

17.Cohen MN, Lessell S. Amyloid tumor of the orbit. Neuroradiol 1979;18:157–9.

18.Nocolitz E, Flanagan JC. Orbital mass as a complication of contact lens wear. Arch Ophthalmol 1978; 96:2238–9.

19.Levine MR, Chu A, Abdul-Karim FW. Brown tumor and secondary hyperparathyroidism. Arch Ophthalmol 1991;109:847–9.

20.Johnson LN, Sexton M, Goldberg SH. Poorly differentiated primary orbital sarcoma (presumed malignant

rhabdoid tumor). Arch Ophthalmol 1991;109:1275–8.

21.White VA, Heathcote JG, Hurwitz JJ, et al. Epithelioid sarcoma of the orbit. Ophthalmology 1994;101: 1680–7.

22.Char DH, Caputo G, Miller T. Orbital fibrous histiocytomas. Orbit 2000 [in press].

23.Ing EG, Kennerdell JS, Olson PR, et al. Solitary fibrous tumor of the orbit. Ophthal Plast Reconstr Surg 1998;14:57–61.

24.Heathcote JG. Pathology update: solitary fibrous tumour of the orbit. Can J Ophthalmol 1997;32: 432–5.

25.Dei Tos AP, Seregard S, Calonje E, et al. Giant cell angiofibroma. A distinctive orbital tumor in adults. Am J Surg Pathol 1995;19:1286–93.

26.Wiebe BM, Gottlieb JO, Holch S. Extraorbital giant cell angiofibroma. APMIS 1999;107:695–8.

27.Hayashi N, Borodic G, Karesh JW, et al. Giant cell angiofibroma of the orbit and eyelid. Ophthalmology 1999;106:1223–9.

28.Hartstein ME, Grove AS Jr, Woog JJ, et al. The multidisciplinary management of psammomatoid ossifying fibroma of the orbit. Ophthalmology 1998;105: 591–5.

29.Wiechens B, Werner JA, Luttges J, et al. Primary orbital leiomyoma and leiomyosarcoma. Ophthalmogica 1999;213:159–64.

30.Raszewski R, Guyuron B, Lash RH, et al. A severe fibrotic reaction after cosmetic liquid silicone injection: a case report. J Cranio-Maxillo-Facial Surg 1990;18:225–8.

31.Hintschich GR, Beyer-Machule CK, Stefani FH. Paraffinoma of the periorbit: a challenge for the oculoplastic surgeon. Ophthalmic Plast Reconstr Surg 1995;11:39–43.

Metastases to the orbit are uncommon but can simulate primary orbital tumors, thyroid orbitopathy, or idiopathic orbital inflammation. There is little data on the molecular biology of orbital metastases. Heartstein and co-workers queried whether different integrin subunits might be important for the tendency of tumors to metastasize to the orbit, but data in support of this concept is tenuous.1

Metastases can involve single or multiple orbital areas. In two large surgical series, the incidence of orbital metastases was 3 percent and 7 percent.2 Metastatic tumors can involve extraocular muscles, the intraconal space, the globe and contiguous orbit (see Figure 17–18), the orbital bones, and the orbit and adjacent brain and sinuses.3–8 Atypical orbital metastatic presentations include cystic tumors, diffuse extraocular muscle enlargement, bone production, enophthalmos, and pulsatile tumors.9–12

The orbit is a much less common site of metastases than the eye. Two series have noted that between 11 and 14 percent of ophthalmic metastases involve the orbit; one series reported a 32 percent incidence.1,7,12–14 Similar to patients with ocular metastases, approximately 50 percent of those with orbital metastases present to the ophthalmologist prior to the discovery of the primary neoplasm.7

In adult men and children, ophthalmic involvement is often the first sign of malignancy.15–19 In contrast, metastases to the orbit in adult women are most often from breast carcinoma; these patients have usually had treatment for the primary breast malignancy prior to the discovery of the orbital metastases.7 A number of rarer causes of orbital metastases include pancreatic carcinoma, hepatocellular carcinoma, pheochromocytoma, testicular carcinoma, prostate cancer, bladder

carcinoma, seminoma, cardiac myxoma, bile duct carcinoma, cervical carcinoma, male breast cancer carcinoid, mycosis fungoides, gastrinoma (Zollinger-Ellison syndrome), pleural mesothelioma, liposarcoma, thymus carcinoma, Ewing’s sarcoma, and squamous cell

carcinoma.7,8,14,20–47

A complete history is the most important component of the clinical evaluation of patients with possible orbital metastases. In over 60 percent of cases, a known history of primary malignancy can be obtained, especially in breast cancer cases.48 I surveyed our orbital tumor files and noted that onethird of the patients were referred without a history of known malignancy and eventually were diagnosed as having orbital metastases. In most of these patients, a thorough history did not reveal the true nature of the orbital process.

In some metastatic tumors, there can be a very long latency between the primary neoplasm and the discovery of metastatic disease. In breast carcinoma, melanoma, and renal cell carcinoma, this interval has been as long as 30 years.49

The clinical and computed tomography (CT) or magnetic resonance imaging (MRI) patterns of orbital metastases in adults are varied. Often, the superior, extraconal orbit is involved with contiguous bone lesions. Frequently, the eye is proptotic and displaced inferiorly (Figure 25–1). In orbital lesions that are neither in the lacrimal fossa nor adjacent to the sinuses, bony destruction is most commonly due to a metastatic tumor (Figure 25–2). Other causes of bone destruction include mucocele, infection, Wegener’s granuloma, midline lethal granuloma, a type of angiocentral T-cell lymphoma, Langerhans’ histocytosis syndromes, sarcomas, hematic cysts

Figure 25–2. Direct coronal scan demonstrating metastatic renal carcinoma causing destruction of the orbital roof.

C

Figure 25–3. A, Patient who presented with axial proptosis and ophthalmoplegia. History and laboratory evaluation were negative for malignancy; diagnosis was established by FNAB. B, Axial CT scan demonstrates intraconal diffuse metastasis. C, FNAB shows the presence of an adenocarcinoma of unknown origin.

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B

Figure 25–4. A and B, Metastatic cutaneous melanomas simulating a unifocal medial rectus enlargement. Diagnosis in both cases was confirmed with FNAB.

or thyroid orbitopathy (see Figure 19–5). Unlike thyroid orbitopathy, which usually involves only the muscle belly, metastatic deposits in the extraocular muscles are usually less regular and often involve both the muscle belly and its tendon.

Most orbital metastases are unilateral; endophthalmos is an uncommon presentation (mainly with scirrhous breast or gastric carcinoma) (Figure 25–5).52 Restriction of extraocular motility is frequent, and in our experience with outpatients, 50 percent presented with this symptom. The location of orbital metastases on the basis of imaging studies demonstrates that over 50 percent are extraconal, 20 percent are intraconal, and 20 percent involve both locations.50,53 Approximately 50 percent of metasta-

Figure 25–5. Clinical photograph of a patient with metastatic scirrhous breast carcinoma to the orbit.

tic orbital foci involve bone; this finding is more common in patients who present with the orbital lesion prior to the discovery of the primary malignancy.7 Figure 25–6 shows a carcinoma metastatic to the orbital bone producing an osteoblastic pattern. CT and MRI are more useful than ultrasonography in the evaluation and management of patients with suspected orbital metastases.54,55 Often, in older patients with unsuspected orbital metastases, the differential diagnosis is between a pseudotumor and a metastasis; ultrasonography cannot differentiate these two entities.56 The diagnostic category used by some ultrasonographers that lumps pseudotumor and metastases together is of questionable utility, since it includes the two most common diagnostic entities. We retrospectively observed that CT and MRI were more accurate than ultrasonography for diagnosing orbital metastases, and the delineation of bone, sinus, or brain involvement on MRI or CT were also superior. In some cases the T1 and T2 patterns of inflammation and metastases are different, but this is not

Figure 25–6. Prostate carcinoma metastatic to orbital bone. A PSA was markedly elevated.

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reliable (see Table 15–2).54 In addition, if radiation is going to be used for treatment, it is imperative to be certain that there are no occult frontal lobe metastases. The imaging techniques should be used to assess areas contiguous to the orbit.

FNAB is an excellent ancillary diagnostic modality in patients suspected of having ocular metastasis.52,57 Figure 25–7 shows two metastatic orbital tumors diagnosed using FNAB. Figure 25–8A shows a case of scirrhous carcinoma metastatic to the orbit. The author performed multiple fine-needle biopsies under CT control, but only obtained fibrous material. An open biopsy established the correct diagnosis (Figure 25–8B). Fibrous scirrhous metastases often cannot be correctly diagnosed with this technique.58

In some cases, imaging studies demonstrate an indiscrete or focal lesion, and subjective findings are negative for malignancy. Figures 25–9 to 25–12

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Figure 25–8. Scirrhous carcinoma metastasis into the orbit. This lesion could not be diagnosed with FNAB despite numerous attempts.

Figure 25–7. A and B, In both these patients, a diagnosis of metastases could be established with FNAB, under CT control. This biopsy technique has much lower morbidity than open surgical procedure.

Figure 25–9. Solitary discrete orbital metastasis in a patient with no history of systemic malignancy.

Figure 25–10. Solitary orbital lesion in a patient with a history of breast carcinoma, but no other evidence of metastatic disease.

show atypical metastatic lesions that we thought were primary orbital tumors prior to biopsy.

Palliative therapy is indicated for most orbital metastases. In one study of breast metastases to ocular structures, those to the orbit were associated with

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Figure 25–11. A, Patient with discrete lateral extraconal tumor on axial T1-weighted MRI scan. B, While this tumor, like many metastases, enhanced with gadolinium, a number of other benign and malignant tumors also have this imaging pattern.

Metastases 417

a worse prognosis than those to the choroid (2 versus 6 months survival), although data on this point are sparse.59 In our experience with approximately 30 cases, the mean survival was < 1.3 years and < 30 percent of patients survived beyond 2 years.1

Orbital metastases are treated in four general ways. If a focal symptomatic lesion is found, it is removed (see Figure 17–12). As an example, we and others have removed uveal melanomas that have metastasized to the other orbit when they have impinged upon the remaining optic nerve, causing visual loss.60,61 Figure 25–13 shows such a lesion compressing the optic nerve. After its removal, vision returned to 20/20. More commonly, visual loss is due to a nonresectable metastatic lesion, as this breast metastasis that compressed the optic nerve at the orbital apex (Figure 25–14). Usually, patients

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Figure 25–12. A, Axial CT scan shows discrete intraconal mass with a negative medical history. Biopsy showed it to be metastatic. B,

Coronal T1-weighted MRI scan of case shown in Figure 25–12A.

418 TUMORS OF THE EYE AND OCULAR ADNEXA

Figure 25–13. Metastatic uveal melanoma compresses the contralateral optic nerve, producing visual loss. Resection of tumor produced return of vision.

have either diffuse orbital involvement or a lesion that can only be partially debulked, due to either its location or its association with vital structures. Some of these patients respond to chemotherapy; if a new lesion is present and other systemic disease is noted, this is an excellent therapeutic option. As others have noted, many metastatic orbital foci will respond to radiation therapy.4,13,59–67 Often, we use a total of 40 gray of external beam photon irradiation for diffuse orbital metastases, for lesions that cannot be removed in toto without damage to vision, and for lesions not responsive to chemotherapy. Most patients with orbital metastases whom we have

Figure 25–14. T1-weighted axial MRI scan shows optic nerve compression by a breast metastasis to the orbital apex. This responded nicely to irradiation.

treated with radiation and chemotherapy had a good orbital response. Some authors have noted that patients with orbital carcinoid, which produces 5- hydroxyindoleacetic acid (5-HIAA), appear not to respond well to this treatment; but that was not our experience in 4 patients. Patients with cutaneous melanoma metastatic to the orbit were not responsive to either photon or charged particle radiation.47,48

As others have observed, patients with orbital metastases have a limited life expectancy. In our experience, the mean survival is 1.3 years, which is similar to that reported in some other series.

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