Orbital Exenteration Research Articles

Rhino-orbital mucormycosis due to Apophysomyces ossiformis in a patient with diabetes mellitus: a case report

BackgroundThe most common aetiological agents of mucormycosis are Rhizopus, Mucor, Apophysomyces and Lichtheimia. Apophysomyces is comparatively rare, as it has been reported in less than 3% of mucormycosis cases. The genus Apophysomyces includes six species, and only A. elegans, A. mexicanus, A. variabilis and A. ossiformis have been reported to cause infections in both immunocompetent and immunocompromised patients.Case presentationWe present a case of a 46-year-old male patient with bilateral blepharoedema, corneal opacity in the left eye and poorly controlled diabetes mellitus. The patient was subjected to total maxillectomy, exenteration of the left orbit and treatment with liposomal amphotericin B. Direct mycological analysis with KOH 10% revealed hyaline, coenocytic, long and wide hyphae. Apophysomyces ossiformis was identified from maxillary biopsy using 18S-ITS1–5.8S-ITS2-28S rRNA gene amplification and sequencing. The patient requested to be transferred to another hospital to continue treatment, where he died on the ninth day after admittance.ConclusionTo the best of our knowledge, this is the first case of rhino-orbital mucormycosis due to A. ossiformis with a fatal outcome. This case reveals the need to identify the fungus causing mucormycosis with molecular methods to identify adequate treatment therapies for patients with this infection.

Prognostic Factors for Orbital Exenteration, Local Recurrence, Metastasis, and Death From Disease in Conjunctival Squamous Cell Carcinoma.

Information regarding risk of metastasis and disease-related death (DD) from conjunctival squamous cell carcinoma (SCC) is relatively scarce. We explored prognostic factors for orbital exenteration, local recurrence, nodal metastasis, and DD in patients with conjunctival SCC. Retrospective cross-sectional study. All consecutive patients with conjunctival SCC treated by the senior author at MD Anderson Cancer Center during1999-2018 were included. Survival curves were estimated using the Kaplan-Meier method, and survival differences were assessed using 2-sided log-rank tests. The study included 44 patients (24 men, 20 women); median age was 64 years (range, 40-90). T categories at presentation were as follows: Tis, 20 patients; T2, 8; T3, 9; and T4, 7. Eighteen patients (41%) had tumors exclusively in the bulbar conjunctiva; 26(59%) had nonbulbar conjunctival involvement. The median follow-up time was 29.2 months (95% CI: 21.8-44.3). Orbital exenteration was performed in 10 cases (23%) and was associated with T3 or more advanced disease at presentation (p < 0.001). Seven patients developed local recurrence during follow up. History of organ transplant correlated with local recurrence and orbital exenteration (p < 0.01). Nodal metastasis was present in 1 patient at presentation and occurred in 3 patients during follow up, for an overall nodal metastasis rate of 9% (4/44). By end of follow up, 2 patients had died of disease, 4 had died of other causes, and 38 were alive with no evidence of disease. The results suggest that both orbital exenteration and nodal metastasis are independent variables associated with DD. In patients with conjunctival SCC, orbital exenteration and nodal metastasis are associated with DD and organ transplantation is associated with orbital exenteration.

Conjunctival Carcinomas Arising in the Anophthalmic Socket.

The aim of this study was to report management and outcomes of patients in which conjunctival carcinomas arose in the anophthalmic socket. The authors retrospectively analyzed the data of patients which presented the anophthalmic socket after surgery. The clinical records of 4 patients with histological diagnosis of conjunctival carcinoma in the anophthalmic socket, referred to our Department, between January 2014 and December 2019 was collected. The study included 4 men (median age 58 years). A previous enucleation surgery had been performed in all patients due to previous ocular trauma for three patients (Case 1, 3, and 4) and due to a retinoblastoma for 1 patient (Case 2). All patients underwent surgical excision of the lesion and only 1 patient (case 3) underwent orbital exenteration due to the high-grade of the cancer. The most common tumor was the squamous cell carcinoma (2 cases) followed by 1 case of high-grade mucoepidermoid carcinoma and 1 case of carcinoma in situ. Systemic work-up was performed for all the patients. Conjunctival TNM, according to the American Joint Committee on Cancer TNM staging system was used to stage the lesions. The median follow-up time was 15 months. Considering the severity and rarity of these tumors, a careful ophthalmological examination of the cavity and a correct revision of the prosthesis should be mandatory in order to ensure the elimination of any macro and microscopic irregularities that can then in the long-term cause chronic inflammation of the tissues and consequently promote the growth of carcinomas.

Temporal Muscle Bipartition and Tripartition Transposition for Reconstructing the Orbital and Oral Empty Space in Mucormycosis of the Middle Third of the Face.

Temporal muscle has great versatility to cover defects, caused by resections or large soft tissue losses of the middle facial third, has been used for more than 100 years. In the skin, the temporal muscle is transformed by the phenomenon called skin dermalization and mucolization in the oral cavity. This article shows how the temporal muscle is divided into two segments (bipartition) or three segments (tripartition) achieving a transposition of the muscle to cover large empty spaces caused by orbital exenteration or in maxilectomy. In coronal slice tomography, we demonstrate the perfect adaptation of the temporal muscle to the periorbital soft tissues in 360 degrees of the orbital region. In the defect produced by the maxilectomy, a perfect seal is obtained to achieve the separation of the nasal cavity from the oral cavity. The treatment was carried out in 3 immunocompromised adult patients, who presented mucormycosis of the middle third of the face and could not swallow or feed. The result we have in the survival of rhinocerebral mucormycosis is very high, due to extensive resections. Achieving that the patient has an adequate swallowing. We consider that the treatment is excellent due to the proximity of the temporal muscle to the surgical defect, achieving the objective of reconstruction without rejection.

Automated Noncontact Facial Topography Mapping, 3-Dimensional Printing, and Silicone Casting of Orbital Prosthesis

A proof-of-concept workflow study for the fabrication of custom orbital exenteration prostheses via automated noncontact scanning, 3D printing, and silicone casting. Noncomparative, interventional case series. Setting: Single-center institutional study. StudyPopulation: Three patients who have discontinued wearing of the ocularist-made exenteration prosthesis due to altered fit, discoloration, or material degradation. InterventionProcedure: A digital representation of the exenteration socket and contralateral periocular region was captured through noncontact facial topography mapping. Digital construction of the anterior prosthesis surface was based on the mirrored image of the contralateral side, and the posterior surface contour was based on orbital cavity geometry. The anterior and posterior surface details were digitally merged. A 2-piece mold was designed and produced in a 3D printer. Colorimetry was used to create a custom blend of pigments for incorporation into the Shore 40 silicone elastomer to generate a prosthesis that approximates the patient's skin tone. MainOutcomeMeasures: Prosthesis symmetry, skin tone match, comfort of wear, and appearance. The first copy of every 3D-printed orbital prosthesis using this fabrication workflow produced good symmetry, color match, and prosthesis fit. In one case, the recontoured second copy with improved prosthesis edge-to-skin interface was made without the patient present. A noncontact 3D scanning, computer-aided design, 3D printing, and silicone casting for fabrication of orbital prosthesis was developed and validated. This production workflow has the potential to provide an efficient, standardized, reproducible exenteration prosthesis and to overcome the principal barriers to an affordable custom prosthesis worldwide: access and cost.

Incidence of Orbital Exenteration: A Nationwide Study in France over the 2006-2017 Period

ABSTRACT Purpose Orbital exenteration is a radical and disfiguring surgery mainly performed for treating orbital malignancies. Recently, several studies found favorable results in terms of overall survival with eye-sparing surgeries combined with targeted therapies and/or radiotherapy. The aim of this study was to assess the incidence of orbital exenteration and its evolution in France between 2006 and 2017. Methods A national observational cohort study was conducted in France between January 2006 and December 2017. Data were collected from the national PMSI (Programme de Médicalisation des Systèmes d’Information) database provided by the CNAM (Caisse Nationale de l’Assurance Maladie). All patients undergoing orbital exenteration over the study period in France were included. Results One thousand and fifty-seven patients were included. The mean annual number of orbital exenterations was 88.1 (63–117), corresponding to a mean incidence of 0.1/100,000 inhabitants/year. A male predominance was noted (n = 626, 59.2%). Exenteration was mainly performed between 75 and 79 years. The underlying etiology was available for 821 patients (77.7%): malignancies were the most common (n = 755; 92.0%) followed by infectious diseases (n = 16; 1.9%). Over the study period, no statistical difference in the mean incidence of orbital exenteration was found (p = .132). Conclusion The mean annual incidence of orbital exenteration was 0.1/100,000 inhabitants in France and was not significantly modified during the study period.

Prognostic factors for local recurrence and survival and impact of local treatments on survival in lacrimal gland carcinoma

Background/aimsTo identify prognostic factors for local recurrence, distant metastasis and disease-specific survival (DSS) for lacrimal gland carcinoma.MethodsAll consecutive patients with lacrimal gland carcinoma treated from January 1998 through December 2018...

Clinical features and prognosis of sebaceous carcinoma arising in the eyelid or conjunctiva.

The aim of this study was to clarify the demographics, clinical features, and outcomes of Japanese patients with sebaceous carcinoma of the eyelid or conjunctiva. Retrospective study. One hundred twenty-five patients with sebaceous carcinoma of the eyelid or conjunctiva diagnosed at Tokyo Medical University Hospital between 1994 and 2017 were reviewed. The outcomes of the 116 patients who were treated and followed for at least 24months at our hospital were investigated. The patients reviewed comprised 52 men and 74 women. The average age at diagnosis was 70.6 ± 13.8 (range 31-96) years. The main lesion was located in the upper eyelid in 51% of the patients; in the lower eyelid in 38% of the patients; and in other regions in 11% of the patients. Treatments included surgical resection with or without eyelid reconstruction in 108 cases (93%), orbital exenteration in 5 cases (4%), and radiation therapy in 3 cases (3%). Local recurrence was detected in 11 cases (9%). Metastasis to the regional lymph nodes was confirmed in 10 cases (9%). Four patients (3%) died because of direct intracranial invasion of the tumor. Risk of local recurrence and metastasis was significantly related to larger tumor size. Proper diagnosis and treatment at the optimal timing is critical to improve the outcome of sebaceous carcinoma of the eyelid or conjunctiva. Long-term follow-up is required because local recurrence and metastasis may occur several years after treatment.

Periorbital, conjunctival and primary intraorbital carcinomas: Survival and risk factors after orbital exenteration.

This study aimed to analyse the disease-free survival (DFS), overall survival (OS) and risk factors after orbital exenteration in patients with periorbital, conjunctival and primary intraorbital carcinomas. Patients undergoing orbital exenteration due to a primary carcinoma between March 2000 and March 2018 were included in this retrospective study. Risk factors in all the patients were evaluated using univariate and multivariate analyses. In total, 97 patients were enroled in this study. The most common tumours were conjunctival carcinoma (35 cases), squamous cell carcinoma of the skin (27 cases) and basal cell carcinoma (20 cases). The median follow-up period was 36 months. The average age of the patients was 67.3 years (range, 29-93 years). In all the patients, OS was 85% after 1 year and 69% after 5 years, while DFS was 71% after 1 year and 55% after 5 years. Univariate analysis of OS revealed that the following parameters were predictive of a poor prognosis: localisation, neck dissection, lymph node metastases, lymphatic invasion, perineural invasion, resection margins and immunosuppression. Multivariate analysis revealed resection margins as the only independent risk factor. Orbital exenteration is rarely necessary in patients with periorbital, conjunctival and primary intraorbital carcinomas; however, it can be performed as an ultima ratio treatment with a curative intent. Clear margins can be achieved in most cases. OS and DFS are not significantly different in the subgroups. In most cases, recurrence occurs within the first 2 years.

Modified types of orbital exenteration, survival, and reconstruction.

This study aims to analyse the various modifications of orbital exenteration. Patients undergoing orbital exenteration from March 1978 to October 2019 were included in this retrospective study. The patients were evaluated on the basis of the indication, type of exenteration, reconstruction technique, overall survival (OS), and disease-free survival (DFS). In total, 300 patients were enrolled in this study. As many as 24 patients had lid and conjunctiva sparing anterior exenteration, 16 had lid sparing anterior exenteration, 83 had anterior exenteration, 14 had lid and conjunctiva sparing total exenteration, seven had lid sparing total exenteration, 44 had total exenteration, one had lid and conjunctiva sparing extended exenteration, 23 had lid sparing extended exenteration, and 88 had extended exenteration. As many as 39 patients had a primary wound closure. Six patients underwent reconstruction with a split-thickness skin graft, 177 patients with a local or regional flap, and 40 patients with a microvascular flap. A total of 38 patients did not undergo reconstruction. The mean follow-up was 40months (range 6-216months). The OS rate was 82.2% after 1year, 58.5% after 5years, and 49% after 10years for all patients with malignant tumours. The DFS rate was 67.7% after 1year, 45.6% after 5years, and 31.7% after 10years. Individual types of orbital exenteration allow patient-adapted therapies. The preservation of uninvolved orbital tissue facilitates orbital reconstruction. The type of exenteration did not have any influence on overall survival.

Immune Checkpoint Inhibitor Therapy as an Eye-Preserving Treatment for Locally Advanced Conjunctival Melanoma.

The authors present 2 patients with locally advanced conjunctival melanoma for whom definitive surgery would mean an orbital exenteration with its associated inherent total visual loss and major facial disfigurement. Instead both patients were treated with immune checkpoint inhibitor therapy. In 1 patient neoadjuvant pembrolizumab was used for approximately 12 months and the patient experienced near-total clinical resolution of the conjunctival melanoma. Multiple surgical biopsies of very small residual pigmentation showed pigmented macrophages and a complete pathologic response. In the second patient who presented with a locally advanced and metastatic conjunctival melanoma, significant shrinkage of conjunctival mass was observed after treatment with a combination of ipilimumab and nivolumab for 5 months, and this allowed preservation of the eye and ocular function.

Orbital exenteration and reconstruction in a tertiary UK institution: a 5-year experience

ABSTRACT Purpose Orbital exenteration is a radical oncological surgery that is usually indicated for advanced primary orbital tumors or invasion from local malignancy. We report a 5-year series from a tertiary head and neck center with particular focus on our ablative and reconstructive approach. Methods We performed a clinicopathological review of patients referred to Guy’s and St Thomas’ NHS Foundation Trust Head and Neck multidisciplinary team for management input of an orbital malignancy during the period of 2013 to 2018. Cases involving local invasion from sinonasal malignancy were excluded. The reconstructive approach, perioperative complications, disease-free and overall survival were analyzed. Results 27 patients were identified and of those treated surgically, a radical extended orbital exenteration was required in almost half (44.4%), with squamous cell carcinoma being the most common pathology (55.6%). A concurrent neck dissection and parotidectomy were commonly performed with confirmed or suspected regional disease, or in the presence of high-risk pathological features. This approach resulted in favourable 2-year overall survival in these advanced stage cases of 84.6% and disease-free survival of 73.2%, with 92% achieving a negative surgical margin. The majority of treated patients required a free flap reconstruction, especially when an extended exenteration defect or adjuvant treatment was anticipated. The anterolateral thigh flap was the most commonly used donor site, and we present our algorithm for reconstruction of these defects. Conclusions A multidisciplinary approach to advanced orbital malignancy with a comprehensive approach to surgical resection and reconstruction results in favorable oncological outcomes and addresses functional and cosmetic patient rehabilitation.

Orbital exenteration: Symptoms, indications, tumour localizations, pathologies, reconstruction, complications and survival

ObjectiveThis study aims to evaluate malignant and benign diseases that lead to orbital exenteration. PatientsFrom December 1999 to September 2017, patients undergoing orbital exenteration were included in this retrospective study. All of them were evaluated on clinical symptoms, indications, tumour localizations, pathologies, reconstruction techniques, complications, recurrences, and survival. ResultsOf the 205 patients enrolled in this study, 94 had a carcinoma, 73 melanoma, 9 a sarcoma, 14 some other malignant disease, and 15 a benign medical condition. Sixteen patients underwent reconstruction using a local eyelid skin flap (7.8%), 6 with a split-thickness graft (2.9%), 144 with a local flap (70.2%), and 25 with a microvascular graft (12.2%), whereas 14 patients did not undergo reconstruction (6.8%). The most common complications were wound dehiscences (25 cases), pain (17 cases), and partial flap necroses (13 cases). Moreover, 62% of the patients were treated with different facial prostheses or artificial eyes. Given these results, it appears that lymph nodes and distant metastases, as well as lymphatic invasion into vessels, perineural invasion, and non-cleared resection margins, seem to affect overall survival after orbital exenteration. ConclusionDifferent reconstruction techniques can be used to provide the patient with maximum functionality and aesthetics after orbital exenteration. Individual concepts should be discussed at the beginning of the treatment. Using primary reconstruction and providing osseointegrated implant-retained prostheses remain the gold standard.

Low-dose cisplatin administration through the superficial temporal artery combined with definitive radiotherapy for maxillary sinus squamous cell carcinoma.

e18562 Background: Although patients with locoregional advanced maxillary sinus squamous cell carcinoma (MSSCC) are often treated with surgery followed by postoperative radiotherapy (RT), the cosmetic and functional outcomes are unsatisfactory. Moreover, the efficacy and safety of intra-arterial chemoradiotherapy are controversial. Methods: In this study, we investigated the efficacy and safety of low-dose cisplatin administration through the superficial temporal artery (STA) combined with definitive RT in patients with MSSCC. Between January 2009 and December 2018, 57 patients were administered weekly intra-arterial infusions of cisplatin (30–50 mg/m2/5h) through the STA with simultaneous intravenous infusions of sodium thiosulfate. Overall response rate (ORR), local progression-free survival (LFS), maxillectomy-free survival (MFS), progression-free survival (PFS), overall survival (OS), and safety were evaluated retrospectively. The impact of clinical factors on survival was investigated using the Cox proportional hazard models. Results: The median follow-up time was 44 months (range, 10–80 months). There were 4, 26, 23, and 4 patients with cT2, cT3, cT4a, and cT4b, respectively. All patients completed the planned treatment except for one patient who discontinued owing to facial palsy. The ORR was 98% with 51 and 5 patients having complete and partial responses, respectively. The 3-year LFS, PFS, and OS were 74%, 63%, and 81%, respectively for all patients and 100%, 81%, and 94%, respectively for 22 patients received 70 Gy irradiation. Notably, the 3-year MFS was 95% for all patients and 100% in patients received 70 Gy RT. The most common grade 3 or more toxic event was oral mucositis (22.8%). Additionally, 4 (7.0%) patients had catheter-related infections. Late grade 3 or more adverse events included optic nerve disorder (8.8%), osteonecrosis (7.0%), encephalopathy (1.8%), and increased creatinine levels (1.8%). Salvage surgery including hard palate resection and orbital exenteration were performed in 2 and 1 patients, respectively. No clinical factor was correlated with survival outcomes in our study cohort. Conclusions: Low-dose cisplatin through STA combined with RT, especially 70 Gy RT, was associated with promising tumor response, high organ preservation rate, and tolerable adverse events in MSSCC patients. Further prospective studies are warranted to compare these outcomes with primary surgery.

Current trends in the management of lacrimal gland tumors: A National Cancer Database study.

e18573 Background: Lacrimal Gland (LG) tumors are rare with data limited to very few comparative trials. The original treatment is Orbital Exenteration followed by Radiotherapy (RT). Contemporary strategies like orbit sparing surgeries and Neoadjuvant Intra-arterial Chemotherapy (CT) are gaining popularity but remains controversial given the paucity of data. Our aim was to determine the pathological distribution and compare the treatment modalities used in LG tumors with the help of a large national database. Methods: From the 2004-2016 National Cancer Database (NCDB), we included Epithelial LG tumors. We excluded Lymphomas, Melanomas, Sarcomas and other metastatic lesions. Descriptive statistics, Hazard Ratio (HR) estimates and Kaplan Meier (KM) survival analysis were used. Results: A total of 669 LG tumors were identified. The distribution based on Pathology and treatment strategies used is represented in the table. The point survival estimate comparison between the surgical types and the various treatment groups showed no significance. Conclusions: SCC was the most common histological type. There was no difference in the overall outcome between radical and orbit sparing procedures. Adjuvant RT and adjuvant chemoradiation did not confer any additional survival benefit over surgery alone. Mallen-St Clair et. using the SEER database (321 LG patients) showed that RT improves Disease Specific Survival in SCC. Moving forward, larger population-based studies and prospective trials are needed to determine the most ideal management option. The NCDB is a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society. The data used in the study are derived from a de-identified NCDB file. The American College of Surgeons and the Commission on Cancer have not verified and are not responsible for the analytic or statistical methodology employed, or the conclusions drawn from these data by the investigator. [Table: see text]

Rapid Rehabilitation With Skin-Muscle Sparing Orbital Exenteration: A Single-Center Series

To examine the features and clinical management of patients who underwent skin-muscle sparing orbital exenteration in a tertiary referral center. Retrospective case-note review for patients undergoing skin-muscle sparing orbital exenteration at Moorfields Eye Hospital between 1997 and 2012. Patient demographics, clinical features, histopathology, clearance, surgery, adjuvant therapy, and outcomes were analyzed. Seventy-four patients (33 male; 45%) had skin-muscle sparing orbital exenteration at a median age of 63.8 years (median 65.5, range 13-96 years) for malignancies primarily arising in the eyelids (34 cases; 46%), orbit (25 cases; 34%) or conjunctiva (15 cases; 20%). The commonest pathologies were sebaceous carcinoma (20 cases; 27%), melanoma (19 cases; 26%), squamous cell carcinoma (12 cases; 16%), and basal cell carcinoma (9 cases; 12%). The patients had very rapid rehabilitation with primary closure of skin-muscle flaps over the cavity, either directly (63/74 patients; 85%), or with addition of local flaps. Local radiotherapy had been given before exenteration to 18 (24%) patients, was administered after exenteration in 19 (26%) patients, and both before and after surgery in 5 (7%); those having postoperative radiotherapy were referred at 2-3 weeks after exenteration, and the initial prosthetics fitting was started at 3-6 weeks after surgery. Thirty-eight (51%) patients died during a follow-up of 1-164 months (mean 55, median 47 months); 20/38 (53%) died from metastases-although 9/20 had known metastatic disease prior to palliative exenteration. Three patients were alive with apparently inactive metastases at 30, 39, and 140 months after surgery. Direct closure of skin-and-muscle flaps is achievable in almost all undergoing orbital exenteration. In contrast to skin-grafting, free myocutaneous flaps or secondary intention healing, this allows early referral if adjunctive orbital radiotherapy is needed, and the initial fitting of prosthetics can be within weeks of surgery. The technique also avoids the much greater donor-site morbidity of other reconstructive techniques, such as local or free myocutaneous flaps.

CD73 Is Enriched in Cutaneous Carcinomas That Invade the Orbit.

To compare the expression of CD73 in indolent nodular basal cell carcinomas and cutaneous lesions that invade the orbit. Immunohistochemical staining for CD73 was performed on nodular basal cell carcinomas and invasive basal cell carcinomas. The numbers of positively staining cells were counted across 5 consecutive ×40 microscopic fields, and a statistical comparison was performed via a dedicated computerized software package. Ten control specimens and 11 invasive tumors were analyzed. In nodular basal cell carcinomas, the mean number of positively staining cells was 0.72/×40 field (standard deviation = 0.80 cells/×40 field), whereas invasive tumors demonstrated a mean of 6.53 positive staining cells/×40 field (standard deviation = 3.33 cells/×40 field). This difference was statistically significant (p = 0.0002). CD73 is enriched in orbital invasion of cutaneous carcinomas. This checkpoint may represent an important target for therapeutic management of these lesions. Immunotherapeutic agents that have been designed to treat other neoplasms may decrease the requirement for orbital exenteration in this clinical scenario.

A Rare Case of Sino-Orbital Invasive Aspergillosis in a Kidney Transplant Recipient

Invasive sino-orbital aspergillosis is an uncommon but potentially life-threating complication of kidney transplantation. Here we report a case of a patient with invasive aspergillus fumigatus sinusitis extending into the orbit in a kidney transplant recipient who was successfully treated with voriconazole and surgical debridement without requiring orbital exenteration. This case illustrates a rare but life-threatening complication of immunosuppression that highlights the importance of suspecting and promptly recognizing fungal infection of the sinuses in vulnerable organ transplant recipients in order to avoid significant morbidity and mortality.

Malignant Mixed Tumor (Carcinoma Ex Pleomorphic Adenoma) of the Lacrimal Gland.

To review the clinical presentation, treatment, and prognosis of patients with malignant mixed tumor (carcinoma ex pleomorphic adenoma) of the lacrimal gland. Clinical records and radiographic images were reviewed for patients with malignant mixed tumor of the lacrimal gland treated at the center during 2008-2019. The study included 9 patients (6 men, 3 women) aged 17-66 years (median age, 56 years). Six had primary malignant mixed tumor with no history of orbital lesions, and 3 had previously been diagnosed with pleomorphic adenoma. Tumor, Node, Metastasis classification per the eighth edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual were T1aN0M0 in 2 patients, T2aN0M0 in 3 patients, T4bN0M0 in 2 patients, and T4cN0M0 in 2 patients. Two patients underwent orbital exenteration, 6 patients underwent eye-sparing surgery, and 1 patient had an unresectable tumor because of cavernous sinus extension. All patients received radiotherapy (intensity-modulated radiotherapy in 3 and proton therapy in 6). All patients received chemotherapy, 8 concurrently with radiotherapy and 1 after radiotherapy. The median follow-up time was 70 months. At last contact, 6 patients were alive without evidence of disease; 2 had died of disease, 1 of distant metastasis, and the other of cavernous sinus invasion. The findings suggest that de novo malignant mixed tumor of the lacrimal gland is more common than disease that results from transformation after incomplete resection of lacrimal gland pleomorphic adenoma. Most cases can be treated with eye-sparing surgery and radiation unless skull base extension is present.

Complex reconstruction of the orbitofrontal regions using three regional flaps after orbital exenteration for the treatment of basal cell carcinoma

Objective. The current paper presents an interesting case of facial reconstruction after the excision of a giant basal cell carcinoma located in the orbitofrontal region. Methods. Performing the excision while securing the appropriate oncologic safety margin has determined the appearance of a soft tissue defect that required a complex reconstruction using three regional flaps: frontal, temporal fascial and temporal muscle flaps. Results. After the excision and reconstruction in a single surgical stage, the postoperative result was favorable, the 12 months assessment showing that the patient was satisfied with the aesthetic aspect. Conclusion. Including the orbital exenterations in the excisional treatment of giant neoplasms located in the facial region requires a complex reconstructive plan. The surgical team has to consider the relief of the anatomical structures that are targeted, as well as the necessity of achieving satisfactory aesthetic results while ensuring oncological radicality.