Orbital Tumors Workup

  • Author: Michael Mercandetti, MD, MBA, FACS; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Aug 4, 2011
 

Laboratory Studies

  • Laboratory testing should be directed by the clinician's suspicion level of the presumed etiology of the lesion. For example, lymphatic tumors require blood cell counts, imaging studies, and bone marrow evaluation. Often, the diagnosis is made following orbital biopsy or after removal of the lesion. In these scenarios, laboratory studies are predicated by the histopathologic findings.
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Imaging Studies

  • The structural complexities of the orbit and its content present an imaging challenge. Strides in radiologic modalities have allowed the clinician to obtain detailed and logistic information about orbital tumors.
  • Before the advent of computerized tomography (CT) scans, roentgenography was the imaging modality most commonly used to evaluate suspected orbital masses. Since roentgenography allows for only a 1-dimensional view and poorly defines soft tissue structures, CT scan has become the mainstay of orbital imaging.
  • CT scan, first used in the 1970s, is the product of tissue density calculations. X-rays with different vectors are emitted, penetrating through target tissues with resulting radioabsorbencies. These differences in radioabsorbencies are assigned value-specific gray shades to create the 2-dimensional image. CT scan can produce detailed axial and coronal views of soft tissue and bony structures. Image windows from 1.0-3.0 mm in thickness allow for detailed evaluation of orbital masses. Contrast-enhanced images may be obtained and can help identify inflammatory processes, vascular tumors, and engorged vessels. Calcified lesions are discernible without the addition of contrast. Axial CT scan revealing lateral orbital neoplasm. Axial CT scan revealing lateral orbital neoplasm.
  • Magnetic resonance imaging (MRI) excites protons by applying a radio frequency with a strong magnetic field. Hydrogen nuclei emit signal intensities that are assigned specific gray tones to create an anatomical reproduction. Three-dimensional views can be gained, directly, in any anatomical plane offering excellent spatial resolution of orbital masses and soft-tissue enhancement. MRI may provide excellent soft-tissue resolution, but CT scan is superior for gleaning details about orbital bony structures.
  • Ocular ultrasonography can be used to visualize anterior and middle orbital lesions. Sound waves of 5-15 MHz breech orbital tissues that reflect echogenic energy captured by an oscilloscope. A-scan ultrasonography allows for a 1-dimensional description of echoes, while B-scan ultrasonography provides a 2-dimensional image. C-scan ultrasonography affords coronal views, and D-scan ultrasonography creates 3-dimensional orbital views. With the advent of CT scan, C and D ultrasonography remain unpopular. Doppler ultrasonography may be used to evaluate orbital vasculature and blood flow.
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Diagnostic Procedures

  • Fine needle aspiration biopsy (FNAB) is a technique used for diagnosing orbital lesions. This outpatient procedure allows for retrieval of a cytological specimen through a well-controlled and minimally invasive surgical technique. In experienced surgical hands, FNAB can differentiate benign from malignant lesions with an accuracy of 95%. FNAB coupled with clinical and radiological finding can lead to a proper diagnosis in 80% of cases. Disadvantages include poor cellular yield, cytopathologic and not a histological diagnosis, difficulty in interpreting the specimen, and inadequate cellular yields requiring another biopsy procedure. Potential complications include retrobulbar hemorrhage, globe perforation, ptosis, extraocular motility dysfunction, and inadvertent entry intracranially. Patients with cystic lesions should not undergo FNAB.
  • Open biopsy of an orbital tumor is the common method of obtaining tissue from the orbital lesion. It also may be necessary if FNAB is not able to obtain adequate tissue for pathological assessment. An advantage of the open biopsy is the establishment of a histological diagnosis because enough of a specimen usually is obtained. Disadvantages include the associated morbidity and costs associated with this procedure.
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Contributor Information and Disclosures
Author

Michael Mercandetti, MD, MBA, FACS  Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota

Michael Mercandetti, MD, MBA, FACS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Ophthalmology, American College of Surgeons, American Society for Laser Medicine and Surgery, American Society of Ophthalmic Plastic and Reconstructive Surgery, Association of Military Surgeons of the US, and Sarasota County Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Cohen, MD  Eyelid and Facial Aesthetic and Reconstructive Surgery, Diseases and Surgery of the Orbit and Lacrimal System, Cosmetic Laser Surgery

Adam J Cohen, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Jorge G Camara, MD  Professor of Ophthalmology, Department of Surgery and Director of Fellowship Training Program in Ophthalmic Plastic and Reconstructive Surgery for Countries Served by the Aloha Medical Mission, University of Hawaii John A Burns School of Medicine

Jorge G Camara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and American Society of Ophthalmic Plastic and Reconstructive Surgery

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark T Duffy, MD, PhD  Consulting Staff, Division of Oculoplastic, Orbito-facial, Lacrimal and Reconstructive Surgery, Green Bay Eye Clinic, BayCare Clinic; Medical Director, Advanced Cosmetic Solutions, A BayCare Clinic

Mark T Duffy, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Ophthalmic Plastic and Reconstructive Surgery, Sigma Xi, and Society for Neuroscience

Disclosure: Allergan - Botox Cosmetic Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

  1. Lin LK, Andreoli CM, Hatton MP, Rubin PA. Recognizing the protruding eye. Orbit. 2008;27(5):350-5. [Medline].

  2. Kennerdell JS, Maroon JC, Malton ML. Surgical approaches to orbital tumors. Clin Plast Surg. Apr 1988;15(2):273-82. [Medline].

  3. Goldberg RA, Lessner AM, Shorr N, Baylis HI. The transconjunctival approach to the orbital floor and orbital fat. A prospective study. Ophthal Plast Reconstr Surg. 1990;6(4):241-6. [Medline].

  4. Rootman J, Stewart B, Goldberg RA. General indications for orbital surgery. In: Orbital Surgery: A Conceptual Approach. Lippincott-Raven; 1995:12.

  5. Lane KA, Bilyk JR. Preliminary study of positron emission tomography in the detection and management of orbital malignancy. Ophthal Plast Reconstr Surg. Sep-Oct 2006;22(5):361-5. [Medline].

  6. Ahn JY, Shim JY, Yang WI, Kim TS. Meningeal solitary fibrous tumor as an unusual cause of expohthalmos: case report and review of the literature. Neurosurgery. Jun 2001;48(6):1362-6. [Medline].

  7. Borden JA. Treatment of tumors involving the optic nerves and chiasm. Semin Ophthalmol. Mar 2002;17(1):22-8. [Medline].

  8. Bouvier D, Raghuveer CV. Aspiration cytology of metastatic chordoma to the orbit. Am J Ophthalmol. Feb 2001;131(2):279-80. [Medline].

  9. Chiarelli AG, De Min V, Saetti R, Fusetti S, Al Barbir H. Surgical management of thyroid orbitopathy. J Plast Reconstr Aesthet Surg. Feb 2010;63(2):240-6. [Medline].

  10. Cohen AJ, Mercandetti M, Weinberg DA. Cavernous hemangioma. eMedicine Journal [serial online]. May 13, 2009;Available at http://emedicine.medscape.com/article/1218120-overview.

  11. De Riu G, Meloni SM, Gobbi R, Soma D, Baj A, Tullio A. Subciliary versus swinging eyelid approach to the orbital floor. J Craniomaxillofac Surg. Dec 2008;36(8):439-42. [Medline].

  12. Dutton JJ. Clinical and surgical orbital anatomy. Ophthalmol Clin North Am. 1996;9(4):527-39.

  13. Eagle RC. Eye Pathology. In: An Atlas and Basic Text. WB Saunders; 1999:247-83.

  14. Glasgow B, Goldberg R, Gordon L. Fine-needle aspiration of orbital masses. Ophthalmol Clin North Am. 1995;8:73-82.

  15. Goldberg SH, Cantore WA. Tumors of the orbit. Curr Opin Ophthalmol. Oct 1997;8(5):51-6. [Medline].

  16. Henderson JW. Orbital Tumors. 2nd ed. Lippincott-Raven; 1980.

  17. Holmes S, Hutchison I. Reconstruction of the orbital floor after its removal for malignancy. Br J Oral Maxillofac Surg. Apr 2001;39(2):158-9. [Medline].

  18. Huh WW, Beverly Raney R. Orbital metastasis in patients with rhabdomyosarcoma: case series and review of the literature. J Pediatr Hematol Oncol. Oct 2006;28(10):684-7. [Medline].

  19. Karaki M, Kobayashi R, Mori N. Removal of an orbital apex hemangioma using an endoscopic transethmoidal approach: technical note. Neurosurgery. Jul 2006;59(1 Suppl 1):ONSE159-60; discussion ONSE159-60. [Medline].

  20. Kennerdell J, Ing E, Wang S. Orbital fine-aspiration aspiration biopsy. Ophthalmol Clin North Am. 1996;9:573-580.

  21. Levine MR. Manual of Oculoplastic Surgery. Butterworth-Heinemann; 1996:281-291.

  22. Mathai AM, Naik R, Pai MR, Kini JR, Kumar S, Ballal CK. Orbital melanocytoma. Orbit. 2008;27(5):383-7. [Medline].

  23. Mercandetti M, Cohen AJ. Exophthalmos. eMedicine Journal [serial online]. February 25, 2010;Available at http://emedicine.medscape.com/article/1218575-overview.

  24. Ohtsuka K, Hashimoto M, Suzuki Y. High incidence of orbital malignant lymphoma in Japanese patients. Am J Ophthalmol. Nov 2004;138(5):881-2. [Medline].

  25. Pfeffer MR, Rabin T, Tsvang L, Goffman J, Rosen N, Symon Z. Orbital lymphoma: is it necessary to treat the entire orbit?. Int J Radiat Oncol Biol Phys. Oct 1 2004;60(2):527-30. [Medline].

  26. Sato K, Kubota T, Kodera T, Kitai R, Takeuchi H, Yoshida K. Melanocytoma in the orbital apex. J Neurooncol. Mar 2009;92(1):107-10. [Medline].

  27. Shields JA. Diagnosis and Management of Orbital Tumors. WB Saunders; 1989.

  28. Shikishima K, Miyake A, Ikemoto I, Kawakami M. Metastasis to the orbit from transitional cell carcinoma of the bladder. Jpn J Ophthalmol. Sep-Oct 2006;50(5):469-73. [Medline].

  29. Tanaka A, Mihara F, Yoshiura T, et al. Differentiation of cavernous hemangioma from schwannoma of the orbit: a dynamic MRI study. AJR Am J Roentgenol. Dec 2004;183(6):1799-804. [Medline].

  30. Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Arch Otolaryngol Head Neck Surg. Jul 2008;134(7):764-7. [Medline].

  31. Tenzel RR, Miller GR. Orbital blow-out fracture repair, conjunctival approach. Am J Ophthalmol. May 1971;71(5):1141-2. [Medline].

  32. Tsirbas A, Kazim M, Close L. Endoscopic approach to orbital apex lesions. Ophthal Plast Reconstr Surg. Jul 2005;21(4):271-5. [Medline].

  33. Turbin RE, Pokorny K. Diagnosis and treatment of orbital optic nerve sheath meningioma. Cancer Control. Sep-Oct 2004;11(5):334-41. [Medline].

  34. Wojno TH. Surgical approaches to orbital disease. Ophthalmol Clin North Am. 1996;9(4):581-591.

  35. Yan J, Wu Z. Cavernous hemangioma of the orbit: analysis of 214 cases. Orbit. Mar 2004;23(1):33-40. [Medline].

 
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Patient with orbital tumor on the right. Note chemosis, ptosis, and proptosis. Patient is also lifting the right brow in an effort to elevate the ptotic lid.
Axial CT scan revealing lateral orbital neoplasm.
 
 
 
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