Orbital Invasion Research Articles

Orbital Invasion by Periocular Infiltrating Basal Cell Carcinoma

Orbital Invasion by Periocular Infiltrating Basal Cell Carcinoma

Epigenetic inactivation of the E-cadherin gene in eyelid sebaceous gland carcinoma

E-cadherin and β-catenin are crucial components of the cell-cell adhesion complex. Their loss has often been associated with tumour metastasis and poor clinical outcome. Both loss of E-cadherin at the cell membrane and a stabilizing mutation in CTNNB1 (β-catenin gene) have been associated with ovarian, colorectal, hepatocellular and nonmelanoma skin cancer, such as squamous and basal cell carcinomas. Absence of E-cadherin may be caused by promoter hypermethylation of the E-cadherin gene (CDH1). To determine the role of E-cadherin promoter hypermethylation and CTNNB1 gene mutation in the aggressive behaviour of sebaceous gland carcinoma of the eyelid. Thirty-six cases of sebaceous gland carcinoma were subjected to E-cadherin methylation-specific polymerase chain reaction and mutational analysis for the CTNNB1 gene. E-cadherin and β-catenin staining was evaluated by immunohistochemistry. Results were correlated with the clinicopathological features of sebaceous gland carcinoma. nMethylation of the E-cadherin promoter region was detected in 72% of eyelid sebaceous gland carcinoma cases and loss of E-cadherin immunostaining in 83%. E-cadherin promoter hypermethylation showed a significant association with the loss of membranous E-cadherin (P = 0·038) and it was of borderline significance with reduced disease-free survival (P = 0·05). It was also found to be associated with advanced age (73%), tumour size ≥ 2 cm (77%), orbital invasion (83%), lymph node metastasis (60%), tumour recurrence (60%) and poor histological differentiation (90%). DNA sequencing revealed no stabilizing β-catenin gene mutation in sebaceous gland carcinoma. Loss of membranous β-catenin was observed in 61% cases, which associated significantly with both E-cadherin promoter methylation (P = 0·0262) and loss of E-cadherin membranous localization (P=0·0015). Epigenetic inactivation of the E-cadherin gene causes loss of membrane-bound E-cadherin and could contribute to the reduced disease-free survival in eyelid sebaceous gland carcinoma. Mutations in the β-catenin gene do not seem to be involved in the pathogenesis of eyelid sebaceous gland carcinoma.

Multidisciplinary therapy consisting of minimally invasive resection, irradiation, and intra‐arterial infusion of 5‐fluorouracil for maxillary sinus carcinomas

Current goals for the treatment of maxillary sinus carcinoma include the preservation of vision, eating, communication, and appearance, as well as the achievement of a cure. Japanese patients (n = 121) with maxillary sinus carcinoma were analyzed retrospectively. All patients underwent multidisciplinary therapy including minimally invasive resection, 20 Gy irradiation, and intra-arterial infusion of 5-fluorouracil. The 5- and 10-year overall survival rates were 73% and 68%, respectively. In 97 patients with squamous cell carcinoma (SCC), the 5- and 10-year overall survival rates were 76% and 70%, respectively. All 29 patients with orbital invasion retained the orbital contents, and 21 of these patients demonstrated adequate visual acuity. There were 16 complications, including trismus (5 patients), double vision (5 patients), fistula formation (3 patients), and cataract (3 patients). A multidisciplinary therapy, consisting of minimally invasive resection, irradiation, and regional chemotherapy, can yield good patient prognosis and quality of life after treatment.

Pathology Quiz Case 2

A 71-YEAR-OLD WOMAN PRESENTED WITH A 3-month history of nasal obstruction and epistaxis in June 2003. Eleven years earlier, she had undergone 8 weeks of radiotherapy to the nasopharynx and neck (dosage, 72 Gy; 2 Gy per fraction) for nasopharyngeal carcinoma. Physical examination revealed a fungating, gray-tan tumor mass occupying the entire nasal chamber. Laboratory tests demonstrated a lactate dehydrogenase level of 140 IU/L and an alkaline phosphatase level of 67 IU/L. Magnetic resonance imaging with intravenous gadolinium injection showed an extensive heterogeneous soft tissue mass in the ethmoidal sinuses, the sphenoidal sinus, and the nasal chamber, with invasion of the right orbit and skull base (Figure 1). The patient then underwent a craniofacial resection with orbital preservation. The surgical specimen demonstrated malignant spindleto polygonal-shaped stromal cells with pleomorphic nuclei and occasional mitoses. Nests of chondroid tissue and woven bone as well as osteoid material were also seen around the tumor cells (Figure 2 and Figure 3). Adjuvant chemotherapy with cisplatin (80 mg) and epirubicin hydrochloride (35 mg) was administered in August 2003. However, neutropenic fever, pneumonia, and acute pancreatitis developed after chemotherapy, and the patient died of septic shock with multiple organ failure. What is your diagnosis?

A Case of Paranasal Diffuse Large B-Cell Lymphoma with the Orbital Invasion Masquerading as Chronic Sinusitis

A Case of Paranasal Diffuse Large B-Cell Lymphoma with the Orbital Invasion Masquerading as Chronic Sinusitis

Squamous Carcinoma and Dysplasia of the Conjunctiva and Cornea: An Analysis of 101 Cases

Objective To evaluate clinical and histopathologic factors of squamous conjunctival neoplasia associated with recurrence. Design Retrospective, clinical case series. Participants One hundred one eyes of 99 patients with squamous conjunctival dysplasia, carcinoma in situ, or squamous cell carcinoma. Methods Review of the medical records, pathology reports, and color photographs. Main Outcome Measures Demographic information, laterality, tumor size, extension, pathologic diagnosis, seventh edition of the American Joint Committee on Cancer Classification (AJCC) staging system stage, treatment methods, recurrence, and duration of follow-up. Results Malignant squamous conjunctival neoplasia was seen most commonly in males at a median age of 71 years. Recurrences were seen in 12.9% (n = 13/101), with 92.3% occurring 6 to 12 months after primary treatment. Recurrence was not correlated significantly to age, gender, laterality, clinical appearance or focality of the tumor at presentation. However, tumors larger than 5 mm in diameter, tumors extending more than 2 mm onto the cornea, and tumors with local invasion (corneal, scleral, intraocular or orbital invasion) were associated with a higher risk of recurrence. Increasing AJCC T-stage was correlated strongly to the incidence of recurrence (P = 0.0006). Rates were 1.7% for Tis-staged tumors, 0% for T1- and T2-staged tumors, 34.3% for T3-staged tumors, and 50% for T4-staged tumors. Histopathologic diagnosis was correlated to recurrence (P = 0.037). None of the tumors defined histologically as dysplasia showed recurrence, whereas 12.8% of carcinoma in situ tumors and 22.2% of squamous cell carcinoma tumors recurred. Although the overall recurrence rate was 12.9%, the rate for tumors treated primarily at the authors' center was 4%, significantly less than the recurrence rate in previously operated tumors (P = 0.0003). Lymph nodes demonstrated positive results in 1%, and in no patient did distant metastasis develop. Conclusions Advanced AJCC T-stage, locally invasive tumors, and more pathologically aggressive tumors were at higher risk for recurrence. Inadequate initial therapy also was an important risk factor for recurrence. Treatment strategies should be affected by tumor staging at presentation. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article. To evaluate clinical and histopathologic factors of squamous conjunctival neoplasia associated with recurrence. Retrospective, clinical case series. One hundred one eyes of 99 patients with squamous conjunctival dysplasia, carcinoma in situ, or squamous cell carcinoma. Review of the medical records, pathology reports, and color photographs. Demographic information, laterality, tumor size, extension, pathologic diagnosis, seventh edition of the American Joint Committee on Cancer Classification (AJCC) staging system stage, treatment methods, recurrence, and duration of follow-up. Malignant squamous conjunctival neoplasia was seen most commonly in males at a median age of 71 years. Recurrences were seen in 12.9% (n = 13/101), with 92.3% occurring 6 to 12 months after primary treatment. Recurrence was not correlated significantly to age, gender, laterality, clinical appearance or focality of the tumor at presentation. However, tumors larger than 5 mm in diameter, tumors extending more than 2 mm onto the cornea, and tumors with local invasion (corneal, scleral, intraocular or orbital invasion) were associated with a higher risk of recurrence. Increasing AJCC T-stage was correlated strongly to the incidence of recurrence (P = 0.0006). Rates were 1.7% for Tis-staged tumors, 0% for T1- and T2-staged tumors, 34.3% for T3-staged tumors, and 50% for T4-staged tumors. Histopathologic diagnosis was correlated to recurrence (P = 0.037). None of the tumors defined histologically as dysplasia showed recurrence, whereas 12.8% of carcinoma in situ tumors and 22.2% of squamous cell carcinoma tumors recurred. Although the overall recurrence rate was 12.9%, the rate for tumors treated primarily at the authors' center was 4%, significantly less than the recurrence rate in previously operated tumors (P = 0.0003). Lymph nodes demonstrated positive results in 1%, and in no patient did distant metastasis develop. Advanced AJCC T-stage, locally invasive tumors, and more pathologically aggressive tumors were at higher risk for recurrence. Inadequate initial therapy also was an important risk factor for recurrence. Treatment strategies should be affected by tumor staging at presentation.

IMRT for Sinonasal Tumors Minimizes Severe Late Ocular Toxicity and Preserves Disease Control and Survival

To report late ocular (primary endpoint) and other toxicity, disease control, and survival (secondary endpoints) after intensity-modulated radiotherapy (IMRT) for sinonasal tumors. Between 1998 and 2009, 130 patients with nonmetastatic sinonasal tumors were treated with IMRT at Ghent University Hospital. Prescription doses were 70 Gy (n= 117) and 60-66 Gy (n = 13) at 2 Gy per fraction over 6-7 weeks. Most patients had adenocarcinoma (n = 82) and squamous cell carcinoma (n = 23). One hundred and one (101) patients were treated postoperatively. Of 17 patients with recurrent tumors, 9 were reirradiated. T-stages were T1-2 (n = 39), T3 (n = 21), T4a (n = 38), and T4b (n = 22). Esthesioneuroblastoma was staged as Kadish A, B, and C in 1, 3, and 6 cases, respectively. Median follow-up was 52, range 15-121 months. There was no radiation-induced blindness in 86 patients available for late toxicity assessment (≥6 month follow-up). We observed late Grade 3 tearing in 10 patients, which reduced to Grade 1-2 in 5 patients and Grade 3 visual impairment because of radiation-induced ipsilateral retinopathy and neovascular glaucoma in 1 patient. There was no severe dry eye syndrome. The worst grade of late ocular toxicity was Grade 3 (n = 11), Grade 2 (n = 31), Grade 1 (n = 33), and Grade 0 (n = 11). Brain necrosis and osteoradionecrosis occurred in 6 and 1 patients, respectively. Actuarial 5-year local control and overall survival were 59% and 52%, respectively. On multivariate analysis local control was negatively affected by cribriform plate and brain invasion (p = 0.044 and 0.029, respectively) and absence of surgery (p = 0.009); overall survival was negatively affected by cribriform plate and orbit invasion (p = 0.04 and <0.001, respectively) and absence of surgery (p = 0.001). IMRT for sinonasal tumors allowed delivering high doses to targets at minimized ocular toxicity, while maintaining disease control and survival. Avoidance of severe dry eye syndrome and radiation-induced blindness suggests IMRT as a standard treatment for sinonasal tumors.

Olfactory groove meningioma: Discussion of clinical presentation and surgical outcomes following excision via the subcranial approach

To describe surgical outcomes and radiographic features of olfactory groove meningiomas treated by excision through the subcranial approach. Special emphasis is placed on paranasal sinus and orbit involvement. Retrospective review of a series of patients. Nineteen patients underwent excision of olfactory groove meningioma (OGM) via the transglabellar/subcranial approach between December 1995 and November 2009. Nine patients had previously undergone prior resection at outside institutions, and four had prior radiotherapy in addition to a prior excision. Transglabellar/subcranial surgical approach to the anterior skull base was performed. Tumor histology included three World Health Organization (WHO) grade III lesions, one WHO grade II lesion, and 15 WHO grade I lesions. Fourteen patients had evidence of extension into the paranasal sinuses, with the ethmoid sinus being most commonly involved. Kaplan-Meier estimates of mean overall and disease-free survival were 121.45 months and 93.03 months, respectively. The mean follow-up interval was 41.0 months, and at the time of data analysis three patients had recurrent tumors. Seven (36.8%) patients experienced a major complication in the perioperative period; there were no perioperative mortalities. Orbit invasion was observed in four patients, with optic nerve impingement in 11 patients. Of these, three patients had long-term diplopia. No patients experienced worsening of preoperative visual acuity. Olfactory groove meningiomas demonstrate a propensity to spread into the paranasal sinuses, particularly in recurrent cases. Given a tendency for infiltrative recurrence along the skull base, this disease represents an important area of collaboration between neurosurgery and otolaryngology. The subcranial approach offers excellent surgical access for excision, particularly for recurrences that involve the paranasal sinuses and optic apparatus.

Inflammatory pseudotumors of the head and neck in pathology-proven cases

The purpose of this case series is to characterize the CT and MRI features of pathology-proven inflammatory pseudotumors in the head and neck. Our search identified three orbital, one maxillary sinus, and one skull base inflammatory pseudotumor. All of the lesions demonstrated some degree of infiltrative features on imaging. On CT, all of the orbital inflammatory pseudotumors were of homogeneous soft tissue density. One of the orbital inflammatory pseudotumors demonstrated bone erosion and two others demonstrated stranding of the orbital fat. The maxillary sinus lesion initially appeared aggressive with bone erosion and orbital invasion. Calcifications were identified in the dural inflammatory pseudotumor. Among the lesions that were given contrast during CT or MRI. All exhibited some degree of enhancement. The two pseudotumors that underwent MRI were isointense on T1 and T2, with scattered areas of low signal. The orbital inflammatory pseudotumors underwent orbitotomy. However, the maxillary sinus and skull base lesions regressed with steroid therapy. Inflammatory pseudotumors of the head and neck regions typically manifest as enhancing soft tissue masses associated with infiltrative changes. Despite their sometimes-aggressive appearance, these lesions may respond well to steroid treatment. Imaging plays an important role in diagnosing and following inflammatory pseudotumors.

PARANASAL SINUSES AND NASAL CAVITY

Objectives: To describe the clinical and neuro-radiological patterns of orbital invasion by the sino-nasal diseases. Study Design: Descriptive, Retrospective study. Period: 2004 to 2009. Subjects and Methods: We retrospectively reviewed fifty four cases of nasal and paranasal sinus diseases invading the orbit. The medical charts were analyzed. The data considered for the study was age, sex, ocular presentation and associated systemic problems of the patients. The neuro-radiological results were correlated with the clinical picture. Results: The age range was from 6 to 85 years (mean 45.5). Male to female ratio was 3.5: 1. The initial clinical presentation was Proptosis (66.66%), disturbance of vision (25.9%), ophthalmoplegia (11.11%), diplopia (9.26%) and ptosis (9.26%). 79.63% patients had inflammatory etiology and 20.4% had neoplastic lesions in the nasal and paranasal sinuses extending into the orbit.

Evaluation on the influence of the histopathological invasion for the prognosis of patients with retinoblastoma

Objective To evaluate the influence of histopathological invasion on the survival prognosis of patients with unilateral retinoblastoma. Methods Seventy-seven patients with unilateral retinoblastoma who were treated by primary enucleation were followed up after treatment. The patients were followed up for a median period of 49 months (range from 1 week to 89 months). The survival data were collected by follow-up appointment, telephone or letter. The Kaplan-Meier method was used to calculate the cumulative survival rate and curve comparison was done with the log-rank test including the degree of the optic nerve invasion, choroidal invasion, choroidal invasion with or without optic nerve invasion, as well as the anterior segment involvement or not. Results The two years survival rate was 88.31%. The survival rate of the group with tumor involvement in the cut end of optic nerve was 16.67%, and significantly lower than other groups with optic nerve involvement (χ2 = 19.51, 18. 42, 18. 42, 14.39;P=0. 000 0). The survival rate of the group with massive choroidal invasion and scleral involvement was 60.00% and significantly lower than the group without choroidal involvement (χ2 = 7.69, P= 0. 005 5). The survival rate of the group with optic nerve involvement and massive choroidal invasion was 75.00%, and the survival rate of the group with optic nerve involvement and scleral or orbital invasion was 60.00%. The survival rate of those two groups were significantly lower respectively than the group only with optic nerve invasion (χ2= 4.25, P=0. 039 3;χ2 =7. 59, P=0. 005 9). There was no significant difference of survival rate between groups with or without anterior segments involvement (χ2 =0.05,P=0.823 5). Conclusions The risk factors for RB death include the surgical marginal involvement of optic nerve, massive choroidal invasion combined with optic nerve and scleral involvement. The anterior segment involvement has no effect on prognosis of patients with unilateral retinoblastoma. Key words: Retinoblastoma/pathology; Prognosis; Survival rate

Orbital nocardiosis

Dear Editor, We read with interest the rare case of disseminated orbital actinomycetoma reported by Shanbagh et al.[1] The authors have crafted a good report highlighting the clinical features, radiological findings, and management of orbital actinomycetoma caused by Nocardia brasiliensisbrazilienses / Nocardia asteroides.[1] We would, however, like to bring to the fore a few issues not addressed by the authors. The authors’ claim to be the first in reporting orbital invasion of actinomycetoma is misplaced. A quick literature search revealed a report by Patil et al., which described a 26-year-old male who was found to have multiple discharging sinuses on the scalp, with orbital and intracranial invasion.[2] Interestingly the presentation, clinical features, imaging, and histopathological details of the two patients have an uncanny resemblance and the ‘patients’ and authors are from the same hospital.[12] Figure 3 in the article is wrongly labelled as computed tomography (CT) scan of orbit while it shows pictures of magnetic resonance imaging (MRI). The authors have described the osteolytic changes seen in longstanding undiagnosed cases of actinomycosis.[1] However, in the interest of the readers, this needs further emphasis and documentation. Patil et al. have described the characteristic moth-eaten appearance of the frontal bone along with orbital and intracranial invasion, in the case reported by them.[2] It may be of interest to note that orbital actinomycosis has been also reported by Pagliani and Sullivan et al.[34] Pagliani et al. described a case of orbital actinomycosis in a patient with a history of carcinomas of the breast and kidney.[3] A CT scan of brain and orbit in this patient showed multiple orbital lesions and widening of the ipsilateral cavernous sinus.[3] Sullivan et al. described a case of orbital actinomycosis with a small ill-defined lesion in the posterolateral orbit.[4] The significant difference was that the periocular skin was uninvolved in both the above-mentioned cases.

A Case of Paranasal Diffuse Large B-Cell Lymphoma with the Orbital Invasion Masquerading as Chronic Sinusitis

A Case of Paranasal Diffuse Large B-Cell Lymphoma with the Orbital Invasion Masquerading as Chronic Sinusitis

Orbital exenterations: an 18-year experience from a single head and neck unit

To review the outcomes of the patients who undergo orbital exenteration for malignancy. A retrospective review of patients who underwent orbital exenteration performed at Royal Prince Alfred and Concord Hospitals between 1990 and 2008. A total of 38 patients were identified. The most common malignancies were squamous cell carcinoma (14 cutaneous and five mucosal origin), basal cell carcinoma (12 cutaneous) and melanoma (five patients). Orbital invasion was the main indication for orbital exenteration. Additional procedures were performed in 29 (76%) patients at the time of exenteration, including craniotomies in eight patients and maxillectomy in 15 patients. Flap reconstructions were required in 35 (92%) patients, including 33 free flap repairs and two local flap repairs. Post-operative complications included cerebrospinal fluid leak (16%) and wound-related complications (13%). The disease-specific survival rate was 97% at 1 year and 92% at 5 years. The local control rate was 83% at 1 year and 55% at 5 years. Fifty per cent of patient mortality and 63% of local recurrence occurred within the first post-operative year. In this series, locoregional control and survival were high, suggesting that aggressive surgical measures such as orbital exenteration are not unreasonable in well-selected patients. Free flap reconstruction is a reliable reconstructive technique which may reduce major complications. The first post-operative year is the most important period when monitoring for recurrence.

Clinico-pathological correlations of fatty acid synthase expression in retinoblastoma: An Indian cohort study

Retinoblastoma (RB), the most common intra-ocular malignancy in children under 5 years of age, has an estimated incidence of about 2000 a year in India, where most cases are in advanced stage at the time of diagnosis. Newer therapeutic approaches would reduce the morbidity of chemotherapy in children with RB. Fatty Acid Synthase (FASN), a lipogenic multi-enzyme complex, is minimally expressed in normal human tissues and over expressed in many cancers, making it an attractive target for cancer therapy. We analyzed RB tissues for FASN protein expression by immunohistochemistry, western blot, and ELISA, and FASN mRNA expression by RT-PCR. FASN expression was correlated with the clinico-pathological characteristics of the tumors. FASN immunostaining was positive in all the 44 RB tissues analyzed (100%). However, FASN expression was heterogeneous within the tumor samples. Tumors with invasion of choroid, optic nerve, orbit and/or retinal pigment epithelium showed significantly higher FASN immunoreactivity than the tumors without invasion ( P < 0.05), supported by western analysis ( P < 0.05). FASN expression was significantly high in poorly differentiated retinoblastomas ( P < 0.05). FASN protein and FASN mRNA estimated by ELISA and RT-PCR respectively showed multi-fold expression over the non-neoplastic muller glial cells that varied quantitatively between tumor tissues. FASN mRNA over-expression was substantially lower than the corresponding FASN protein expression values. The present study reports (i) markedly high expression of FASN protein in poorly differentiated and in invasive retinoblastomas, and (ii) multi-fold over-expression of FASN mRNA and protein in RB tissues, although at varying levels, indicating FASN to be a potential therapeutic target in retinoblastoma management.

HTLV Associated T‐cell Lymphoma Presenting as a Sinus Mass with Proptosis: A Case Report

Results: A 48 year old woman from Guyana presented with bilateral eye swelling and unilateral vision loss progressing over 4 weeks. On examination there was severe bilateral proptosis and chemosis. Imaging studies showed a large mass centered in the ethmoid sinuses with bilateral orbital invasion but no intracranial extension. An orbital biopsy revealed a large Tcell lymphoma. Serologic tests for HTLV were positive. She was treated with chemotherapy and responded well with improvement of vision in both eyes.

Does β-catenin have a role in pathogenesis of sebaceous cell carcinoma of the eyelid?

AimExpression of β-catenin in sebaceous cell carcinoma (SbCC) of the eyelid and its correlation with histopathological features.Method48 cases of SbCC were analysed immunohistochemically using monoclonal β-catenin antibody and the results...

Neoadjuvant Chemotherapy in Recurrent Sebaceous Carcinoma of Eyelid With Orbital Invasion and Regional Lymphadenopathy

A 35-year-old man presented with a recurrent temporal conjunctival mass (25 × 12 mm) involving about six-clock hours of the limbus in the left eye. The mass encroached onto the temporal half of cornea and showed surface keratin, large intrinsic and feeder vessels. It infiltrated the deep corneal stroma. There were no cells in the anterior chamber. Ultrasound biomicroscopy confirmed infiltration of deep corneal stroma without intraocular invasion. Surgery involved excision of the conjunctival component with 4-mm margin, lamellar sclerectomy and a penetrating sclerokeratoplasty with 3 mm of healthy corneal margin. Cryotherapy (double-freeze-thaw) was done to the conjunctival margins. Histopathology showed it to be invasive sebaceous cell carcinoma. A thin layer of deep corneal stroma and all conjunctival margins were uninvolved. At thirty-six weeks after treatment the left eye recorded a visual acuity of finger counting at 1 meter distance and no recurrence.

Conjunctival Melanoma: Outcomes Based on Tumor Origin in 382 Consecutive Cases

To evaluate prognostic factors based on origin of conjunctival melanoma. Interventional case series. Three hundred eighty-two consecutive patients. Retrospective chart review. Melanoma-related metastasis and death. The melanoma arose from primary acquired melanosis (PAM; n = 284; 74%), from pre-existing nevus (n = 26; 7%), and de novo (n = 72; 19%). The mean tumor base was 11 mm for melanoma arising from PAM, 6 mm for melanoma arising from nevus, and 10 mm for those arising de novo. At 5 years (10 years), melanoma metastasis occurred in 19% (25%) in melanoma arising from PAM (P = 0.003), 10% (26%) in melanoma from nevus (P = 0.193), and 35% (49%) in those de novo. Factors predictive of metastasis by multivariable analysis included tumor origin de novo (P = 0.001), palpebral location (P<0.001), nodular tumor (P = 0.005), and orbital invasion (P = 0.022). At 5 years (10 years), melanoma-related death occurred in 5% (9%) in melanoma arising from PAM (P<0.001), 0% (9%) in melanoma arising from nevus (P<0.057), and 17% (35%) in those arising de novo. Factors predictive of death by multivariable analysis included tumor origin de novo (P<0.001), fornix location (P = 0.04), and nodular tumor (P = 0.001). Melanoma arising de novo carries a higher risk of melanoma-related metastasis and death compared with those cases arising from PAM or nevus.

Globe-Sparing Surgery for Medial Canthal Basal Cell Carcinoma with Anterior Orbital Invasion

To describe a case series of patients with anterior orbital invasion by medial canthal basal cell carcinoma (BCC) managed with non-exenterating surgery. International, multicenter, retrospective, noncomparative, consecutive case series. Twenty patients identified from the individual institutions' databases with histologically confirmed orbital invasion by periocular BCC. Examination of charts, relevant imaging, and histopathologic data. Demographics; clinical characteristics and radiologic features; histopathologic features; surgical techniques for excision, reconstruction, and subsequent procedures; complications; visual acuity; and recurrence. Twenty patients were identified. Twelve of 20 patients (60%) had recurrent BCCs, with 1 patient having had prior radiotherapy for previously incomplete excision. Eighteen of 20 patients (90%) had a palpable mass, 16 of 20 patients (80%) had clinical involvement of the nasolacrimal system, and 1 of 20 patients (5%) had limited extraocular movements. Preoperative radiologic evidence of orbital invasion was found in 10 of 20 patients (50%). Histologic evidence of orbital invasion was present in every patient, the subtypes being infiltrative (9/20, 45%), nodular (4/20, 20%), micronodular (2/20, 10%), multifocal (1/20, 5%), and mixed (4/20, 20%); extratumoral perineural invasion was present in 1 patient (5%). Final margins were clear in 18 of 20 patients (90%), positive in 1 of 20 patients (5%), and unclear in 1 of 20 patients (5%). Reconstruction was by direct closure in 1 patient and by a variety of standard oculoplastic flaps and grafts in 19 of 20 patients (95%). Twelve of 20 patients (60%) had postoperative extraocular muscle movement restriction, and 15 of 20 patients (75%) had epiphora. Subsequent revision procedures were needed in 12 of 20 patients (60%), including insertion of a lacrimal bypass tube and revision of medial canthal position. At a mean follow-up of 38 months, 18 of 20 patients (90%) were still alive (2 deaths due to other causes) with 1 recurrence (exenterated). Postoperative visual acuity was within 2 Snellen lines of preoperative visual acuity in 17 of 20 patients (85%). With careful planning and margin control, conservative surgery in this highly selected group proved possible with a low rate of disease recurrence, albeit with a relatively short follow-up. Postoperative complications, such as epiphora and ophthalmoplegia, were largely expected; most patients underwent subsequent revision procedures to address these and other complications. The author(s) have no proprietary or commercial interest in any materials discussed in this article.