Sections

Workup

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.

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.^[13]

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 1-3 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. See the image below.

Axial CT scan revealing lateral orbital neoplasm.

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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.

Coronal MRI showing left orbital cavernous hemangioma.

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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.

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.

Other Tests

Genetic analysis of tumors has aided in tumor identification.^[14]

Staging

The TNM guideline advocated by the American Joint Committee on Cancer (AJCC)^[15]is used to stage cancers of the orbit. The "T" relates to tumor characteristics and size, "N" denotes status of the lymph nodes in the regional area, and "M" stands for metastases. These components result in an overall "stage" that ranges from 0 to IV.^{[16, 17]}

The two most employed stages are a clinic stage and a pathologic stage, the latter being based on the tissue itself.

Treatment & Management

Lin LK, Andreoli CM, Hatton MP, Rubin PA. Recognizing the protruding eye. Orbit. 2008. 27(5):350-5. [Medline].
Kennerdell JS, Maroon JC, Malton ML. Surgical approaches to orbital tumors. Clin Plast Surg. 1988 Apr. 15(2):273-82. [Medline].
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].
Castelnuovo P, Turri-Zanoni M, Battaglia P, Locatelli D, Dallan I. Endoscopic Endonasal Management of Orbital Pathologies. Neurosurg Clin N Am. 2015 Jul. 26 (3):463-72. [Medline].
Kent JS, Allen LH, Rotenberg BW. Image-guided transnasal endoscopic techniques in the management of orbital disease. Orbit. 2010 Dec. 29 (6):328-33. [Medline].
Lee KY, Ang BT, Ng I, Looi A. Stereotaxy for surgical navigation in orbital surgery. Ophthal Plast Reconstr Surg. 2009 Jul-Aug. 25 (4):300-2. [Medline].
Kent JS, Allen LH, Rotenberg BW. Image-guided transnasal endoscopic techniques in the management of orbital disease. Orbit. 2010 Dec. 29 (6):328-33. [Medline].
Rootman J, Stewart B, Goldberg RA. General indications for orbital surgery. Orbital Surgery: A Conceptual Approach. Lippincott-Raven; 1995. 12.
Urken ML, Mehra S. Orbital Tumors: Determining the Type of Orbital Tumor. Head and Neck Cancer Guide. Available at http://headandneckcancerguide.org/adults/introduction-to-head-and-neck-cancer/orbital-tumors/type-cancer/. Accessed: August 15,2017.
Jaafar M, Madigan W. Pediatric Orbital and Ocular Tumors. Children's National Health System. Available at https://childrensnational.org/choose-childrens/conditions-and-treatments/eye-conditions/orbital-and-ocular-tumors. Accessed: August 15, 2017.
Shahinian H. Orbital Tumors. http://www.skullbaseinstitute.com. Available at http://www.skullbaseinstitute.com/head-and-neck-tumors/orbital-tumors-endoscopy.html. Accessed: August 15, 2017.
Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital Neoplasms in Adults: Clinical, Radiologic, and Pathologic Review. Radiographics. 2013 Oct. 33(6):1739-1758. [Medline].
Rao AA, Naheedy JH, Chen JY, Robbins SL, Ramkumar HL. A clinical update and radiologic review of pediatric orbital and ocular tumors. J Oncol. 2013. 2013:975908. [Medline]. [Full Text].
Jakobiec FA, Stagner AM, Eagle RC Jr, Lally SE, Krane JF. Unusual pleomorphic adenoma of the lacrimal Gland: Immunohistochemical demonstration of PLAG1 and HMGA2 oncoproteins. Surv Ophthalmol. 2017 Mar - Apr. 62 (2):219-226. [Medline].
AJCC 8th Edition Staging. American Joint Committee on Cancer https://cancerstaging.org/CSE/general/Pages/articles.aspx. Available at https://cancerstaging.org/CSE/general/Documents/AJCC%20Staging%20Rules%208th%20Ed.pdf. Accessed: August 15, 2017.
Urken ML, Mehra S. Orbital Tumors: Determining the Stage of the Cancer. Head and Neck Cancer Guide. Available at http://headandneckcancerguide.org/adults/introduction-to-head-and-neck-cancer/orbital-tumors/stage-cancer/. Accessed: August 15, 2017.
Cancer.Net Editorial Board,. Lacrimal Gland Tumor: Stages and Grades. Cancer.Net. Available at http://www.cancer.net/cancer-types/lacrimal-gland-tumor/stages-and-grades. August 2015; Accessed: August 15, 2017.
Udhay P, Bhattacharjee K, Ananthnarayanan P, Sundar G. Computer-assisted navigation in orbitofacial surgery. Indian J Ophthalmol. 2019 Jul. 67 (7):995-1003. [Medline].
Unadkat SN, Rennie CE, Grant WE. Endoscopic transnasal image-guided approach to diagnosis in orbital apex and optic canal lesions. J Laryngol Otol. 2019 Jun. 133 (6):501-507. [Medline].
Wang EW, Zanation AM, Gardner PA, Schwartz TH, et.al. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol. 2019 Jul. 9 (S3):S145-S365. [Medline].
Golbin DA, Lasunin NV, Cherekaev VA, Grigorieva NN, Serova NK, Mindlin SN, et al. [Biopsy and resection of skull base tumors using transorbital endoscopic approaches: primary results]. Zh Vopr Neirokhir Im N N Burdenko. 2019. 83 (3):42-56. [Medline].
Paluzzi A, Gardner PA, Fernandez-Miranda JC, Tormenti MJ, Stefko ST, Snyderman CH, et al. "Round-the-Clock" Surgical Access to the Orbit. J Neurol Surg B Skull Base. 2015 Feb. 76(1):12-24. [Medline]. [Full Text].
Orlandi D, Sconfienza LM, Lacelli F, Bertolotto M, Sola S, Mauri G, et al. Ultrasound-guided core-needle biopsy of extra-ocular orbital lesions. Eur Radiol. 2013 Jul. 23(7):1919-24. [Medline].
Jeng Tyng C, Matushita JP Jr, Bitencourt AG, Neves FB, Amoedo MK, Barbosa PN, et al. Uncommon primary tumors of the orbit diagnosed by computed tomography-guided core needle biopsy: report of two cases. Radiol Bras. 2014 Nov-Dec. 47(6):380-3. [Medline]. [Full Text].
Mascott RC, Karcioglu ZA. 3D Computer Image Analysis and Guidance for Surgical and Radiosurgical Treatment. Karcioglu ZA. Orbital Tumors: Diagnosis and Treatment. 2nd. New York: Springer Science +Business Media; 2015. Chapter 32: 435-446.
Lane KA, Bilyk JR. Preliminary study of positron emission tomography in the detection and management of orbital malignancy. Ophthal Plast Reconstr Surg. 2006 Sep-Oct. 22(5):361-5. [Medline].
Fawcett , N. Expanding Targeted Therapies to Rare Eye, Orbit Cancer. Michigan Health Lab. Available at http://labblog.uofmhealth.org/lab-report/expanding-targeted-therapies-to-rare-eye-orbit-cancer. June 10, 2016; Accessed: August 15, 2017.
Jian T, Sun F, Tang D, Wang S, Wu T, Zhao L. Clinical Analysis of Transcranial Orbitotomy Approach on Cranio-orbital Tumors. J Craniofac Surg. 2015 Mar. 26(2):441-6. [Medline].
Yarovoy AA, Bulgakova ES, Shatskikh AV, Uzunyan DG, Kleyankina SS, Golubeva OV. CORE needle biopsy of orbital tumors. Graefes Arch Clin Exp Ophthalmol. 2013 Aug. 251(8):2057-61. [Medline].
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. 2001 Jun. 48(6):1362-6. [Medline].
Borden JA. Treatment of tumors involving the optic nerves and chiasm. Semin Ophthalmol. 2002 Mar. 17(1):22-8. [Medline].
Bouvier D, Raghuveer CV. Aspiration cytology of metastatic chordoma to the orbit. Am J Ophthalmol. 2001 Feb. 131(2):279-80. [Medline].
Chhabra N, Wu AW, Fay A, Metson R. Endoscopic resection of orbital hemangiomas. Int Forum Allergy Rhinol. 2014 Mar. 4(3):251-5. [Medline].
Chiarelli AG, De Min V, Saetti R, Fusetti S, Al Barbir H. Surgical management of thyroid orbitopathy. J Plast Reconstr Aesthet Surg. 2010 Feb. 63(2):240-6. [Medline].
Cohen AJ, Mercandetti M, Weinberg DA. Cavernous hemangioma. Medscape Reference Journal [serial online]. May 13, 2009. [Full Text].
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. 2008 Dec. 36(8):439-42. [Medline].
Dutton JJ. Clinical and surgical orbital anatomy. Ophthalmol Clin North Am. 1996. 9(4):527-39.
Eagle RC. Eye Pathology. An Atlas and Basic Text. WB Saunders; 1999. 247-83.
Glasgow B, Goldberg R, Gordon L. Fine-needle aspiration of orbital masses. Ophthalmol Clin North Am. 1995. 8:73-82.
Goldberg SH, Cantore WA. Tumors of the orbit. Curr Opin Ophthalmol. 1997 Oct. 8(5):51-6. [Medline].
Henderson JW. Orbital Tumors. 2nd ed. Lippincott-Raven; 1980.
Holmes S, Hutchison I. Reconstruction of the orbital floor after its removal for malignancy. Br J Oral Maxillofac Surg. 2001 Apr. 39(2):158-9. [Medline].
Huh WW, Beverly Raney R. Orbital metastasis in patients with rhabdomyosarcoma: case series and review of the literature. J Pediatr Hematol Oncol. 2006 Oct. 28(10):684-7. [Medline].
Karaki M, Kobayashi R, Mori N. Removal of an orbital apex hemangioma using an endoscopic transethmoidal approach: technical note. Neurosurgery. 2006 Jul. 59(1 Suppl 1):ONSE159-60; discussion ONSE159-60. [Medline].
Kennerdell J, Ing E, Wang S. Orbital fine-aspiration aspiration biopsy. Ophthalmol Clin North Am. 1996. 9:573-580.
Levine MR. Manual of Oculoplastic Surgery. Butterworth-Heinemann; 1996. 281-291.
Mathai AM, Naik R, Pai MR, Kini JR, Kumar S, Ballal CK. Orbital melanocytoma. Orbit. 2008. 27(5):383-7. [Medline].
Mercandetti M, Cohen AJ. Exophthalmos. Medscape Reference Journal [serial online]. February 25, 2010. [Full Text].
Ohtsuka K, Hashimoto M, Suzuki Y. High incidence of orbital malignant lymphoma in Japanese patients. Am J Ophthalmol. 2004 Nov. 138(5):881-2. [Medline].
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. 2004 Oct 1. 60(2):527-30. [Medline].
Sato K, Kubota T, Kodera T, Kitai R, Takeuchi H, Yoshida K. Melanocytoma in the orbital apex. J Neurooncol. 2009 Mar. 92(1):107-10. [Medline].
Shields JA. Diagnosis and Management of Orbital Tumors. WB Saunders; 1989.
Shikishima K, Miyake A, Ikemoto I, Kawakami M. Metastasis to the orbit from transitional cell carcinoma of the bladder. Jpn J Ophthalmol. 2006 Sep-Oct. 50(5):469-73. [Medline].
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. 2004 Dec. 183(6):1799-804. [Medline].
Tanna N, Preciado DA, Clary MS, Choi SS. Surgical treatment of subperiosteal orbital abscess. Arch Otolaryngol Head Neck Surg. 2008 Jul. 134(7):764-7. [Medline].
Tenzel RR, Miller GR. Orbital blow-out fracture repair, conjunctival approach. Am J Ophthalmol. 1971 May. 71(5):1141-2. [Medline].
Tsirbas A, Kazim M, Close L. Endoscopic approach to orbital apex lesions. Ophthal Plast Reconstr Surg. 2005 Jul. 21(4):271-5. [Medline].
Turbin RE, Pokorny K. Diagnosis and treatment of orbital optic nerve sheath meningioma. Cancer Control. 2004 Sep-Oct. 11(5):334-41. [Medline].
Wojno TH. Surgical approaches to orbital disease. Ophthalmol Clin North Am. 1996. 9(4):581-591.
Wu W, Selva D, Jiang F, Jing W, Tu Y, Chen B, et al. Endoscopic transethmoidal approach with or without medial rectus detachment for orbital apical cavernous hemangiomas. Am J Ophthalmol. 2013 Sep. 156(3):593-9. [Medline].
Yan J, Wu Z. Cavernous hemangioma of the orbit: analysis of 214 cases. Orbit. 2004 Mar. 23(1):33-40. [Medline].
Zhang N, Huang Q, Zhou B, Shi JT, Wang CS, Zhang SZ. [Transnasal endoscopic removal of orbital apex cavernous hemangioma]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2013 Mar. 48(3):204-8. [Medline].
Gündüz K,Yanık Ö. Myths in the Diagnosis and Management of Orbital Tumors. Middle East Afr J Ophthalmol. 2015 Oct-Dec. 22(4):415-20. [Medline]. [Full Text].
von Holstein SL, Fehr A, Persson M, Nickelsen M, Therkildsen MH, Prause JU, et al. Lacrimal gland pleomorphic adenoma and carcinoma ex pleomorphic adenoma: genomic profiles, gene fusions, and clinical characteristics. Ophthalmology. 2014 May. 121 (5):1125-33. [Medline].

Media Gallery

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.
Coronal MRI showing left orbital cavernous hemangioma.
Left lateral lid crease incision to access the superolateral orbit.

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Orbital Tumors Workup

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