ORBITAL TUMORS

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ORBITAL TUMORS
III CONGRESS POLISH SKULL BASE SURGERY
SOCIETY DONALD C. WRIGHT, M.D. Virginia Hospital
Center Arlington, VA
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ACKNOWLEDGEMENT

• MY GENEROUS THANKS TO ALBERT L. RHOTON Jr., MD
  FOR PERMISSION TO UTILIZE SLIDES FOR THIS
  PRESENTATION FROM HIS EXTENSIVE COLLECTION
• PLEASE REFER TO HIS TEXT FOR A COMPLETE REFERENCE
  ON THE ANATOMY OF THE ORBIT
• Rhoton, Albert L., Jr. and Natori, Yoshihiro. The
  Orbit and Sellar Region. Microsurgical Anatomy
  and Operative Approaches. Thieme, New York, 1996.

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CRANIO-ORBITAL SURGERY

• ANATOMY
• DIFFERENTIAL DIAGNOSIS
• SURGICAL APPROACHES

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ORBITAL MASSESDIFFERENTIAL DIAGNOSIS

• MASSES OF OPTIC NERVE/SHEATH
• MENINGIOMA
• OPTIC NERVE GLIOMA
• SCHWANNOMA
• LYMPHOMA
• METASTASIS

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ORBITAL MASSESDIFFERENTIAL DIAGNOSIS

• WELL-CIRCUMSCRIBED MASSES
• CAVERNOUS HEMANGIOMA
• DERMOID CYST
• HEMANGIOPERICYTOMA
• RHABDOMYOSARCOMA
• PLEOMORPHIC ADENOMA
• (LACRIMAL GLAND)

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ORBITAL MASSESDIFFERENTIAL DIAGNOSIS

• INFILTRATIVE MASSES
• PSEUDOTUMOR
• LYMPHOMA
• CAPILLARY HEMANGIOMA
• LYMPHANGIOMA
• METASTASES
• SARCOID

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ORBITAL MASSESDIFFERENTIAL DIAGNOSIS

• MASSES OF THE GLOBE
• RETINOBLASTOMA
• MALIGNANT MELANOMA
• METASTASES

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ORBITAL TUMORSSURGICAL SERIES

• Meningioma (spheno-orbital) 91
• Meningioma (orbital) 70
• Dermoid Cyst 50
• Hemangioma 40
• Lymphangioma 36
• Optic Nerve Glioma 20
• Neurofibroma 12
• Hemangiopericytoma 10
• Rhabdomyosarcoma 8
• Metastatic/other Carcinoma 143
• Orbital Pseudotumor 110
• Maroon JC, Kennerdell, JS 1976-1992

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CRANIO-ORBITAL SURGERYCLINICAL APPROACH

• VISUAL FUNCTION
• LOCALIZATION
• RELATIONSHIP TO OPTIC NERVE

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SURGICAL APPROACHES TO THE ORBIT

• LATERAL APPROACHES (KRÖNLEIN)
• TRANSCRANIAL-SUPRAORBITAL APPROACHES
• MEDIAL APPROACHES (ETHMOIDAL)

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SUPRAORBITAL TRANSCRANIAL ROUTES TO THE OPTIC
NERVE

• (SUPERO) MEDIAL ROUTE APPROACH BETWEEN SUPERIOR
  OBLIQUE AND LEVATOR MUSCLES
• (SUPERO) CENTRAL ROUTE APPROACH BETWEEN LEVATOR
  AND SUPERIOR RECTUS MUSCLES

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ORBITAL PATHOLOGYPERSONAL SERIES N57

• MENINGIOMA 32
• SCHWANNOMA 3
• CHONDROSARCOMA 5
• CHORDOMA 2
• ADENOID CYSTIC CA 4
• OTHER CARCINOMA 4
• CAPILLARY ANGIOMA 3
• OTHER 4

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PERIOPTIC SHEATH MENINGIOMA

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PERIOPTIC SHEATH MENINGIOMA

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VARIATION IN ORIGIN AND GROWTH OF OPTIC SHEATH
MENINGIOMAS

• Maroon Kennerdell

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ORBITAL MENINGIOMASMANAGEMENT STRATEGY

• TUMOR VISUAL
• LOCATION ACUITY TREATMENT
• MID-ANTERIOR STABLE OBSERVATION
• MID-ANTERIOR PROGRESSIVE LOSS SURGERY
• APEX NORMAL OBSERVATION
• APEX PROGRESSIVE LOSS XRT/SURGERY
• APEX NLP SURGERY

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OPTIC SHEATH MENINGIOMASSURGICAL MANAGEMENT

• 7/30 WITH USEFUL VA TREATED SURGICALLY
• 3/7 HAD GOOD POSTOP VISION
• 2/7 WITH SUBDURAL TUMORS IN APEX- BLIND
• 2/7 HAD DECOMPRESSION AND XRT WITH VA

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CRANIO-ORBITAL SURGERYPERIOPTIC SHEATH
MENINGIOMAS

• SURGERY FOR SMALL ANTERIORLY-LOCATED TUMORS
  DETECTED PRIOR TO SEVERE VISUAL COMPROMISE
• MINIMAL SUCCESS IN VISUAL PRESERVATION FOR TUMORS
  THAT INVOLVE ORBITAL APEX

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CHORDOMA 3 YEARS POST SURGERY PROTON XRT

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METASTASIS TO ORBIT (IATROGENIC SPREAD)

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RIGHT ORBITAL METASTASIS POST-OPERATIVE

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ORBITAL INVASION/METASTASISPOST-OPERATIVE

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ORBITAL RECONSTRUCTION

• RARELY INDICATED IN ELECTIVE SURGERY UNLESS
  SIGNIFICANT BONE LOSS OVER INFERIOR FLOOR
• NO INCIDENCE OF ENOPHTHALMUS IF BONE LOSS IS
  MINIMIZED AND INJURY TO ORBITAL FAT/PERIORBITA IS
  AVOIDED

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ORBITAL RECONSTRUCTION

• IF RECONSTRUCTION NECESSARY
• I AVOID USE OF ALLOGRAFT MATERIALS, AND PREFER
  SPLIT CALVARIAL BONE
• RESORPTION IS A PROBLEM WITH AUTOGRAFT IN CASES
  REQUIRING POSTOPERATIVE RADIATION
• TITANIUM MESH USED FOR NON-AUTOGRAFT SITUATIONS

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CRANIO-ORBITAL SURGERYSUMMARY COMMENTS
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