Clinical and ophthalmological outcome of endoscopic transorbital surgery for cranioorbital tumors

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OBJECTIVE

Cranioorbital tumors are complex lesions that involve the deep orbit, floor of the frontal bone, and lesser and greater wing of the sphenoid bone. The purpose of this study was to describe the clinical and ophthalmological outcomes with an endoscopic transorbital approach (TOA) in the management of cranioorbital tumors involving the deep orbit and intracranial compartment.

METHODS

The authors performed endoscopic TOAs via the superior eyelid crease incision in 18 patients (16 TOA alone and 2 TOA combined with a simultaneous endonasal endoscopic resection) with cranioorbital tumors from September 2016 to November 2017. There were 12 patients with sphenoorbital meningiomas. Other lesions included osteosarcoma, plasmacytoma, sebaceous gland carcinoma, intraconal schwannoma, cystic teratoma, and fibrous dysplasia. Ten patients had primary lesions and 8 patients had recurrent tumors. Thirteen patients had intradural lesions, while 5 had only extradural lesions.

RESULTS

Of 18 patients, 7 patients underwent gross-total resection of the tumor and 7 patients underwent planned near-total resection of the tumor, leaving the cavernous sinus lesion. Subtotal resection was performed in 4 patients with recurrent tumors. There was no postoperative CSF leak requiring reconstruction surgery. Fourteen of 18 patients (77.8%) had preoperative proptosis on the ipsilateral side, and all 14 patients had improvement in exophthalmos; the mean proptosis reduced from 5.7 ± 2.7 mm to 1.5 ± 1.4 mm. However, some residual proptosis was evident in 9 of the 14 (64%). Ten of 18 patients (55.6%) had preoperative optic neuropathy, and 6 of them (60.0%) had improvement; the median best-corrected visual acuity improved from 20/100 to 20/40. Thirteen of 18 patients showed mild ptosis at an immediate postoperative examination, all of whom had a spontaneous and complete recovery of their ptosis during the follow-up period. Three of 7 patients showed improvement in extraocular motility after surgery.

CONCLUSIONS

Endoscopic TOA can be considered as an option in the management of cranioorbital tumors involving complex anatomical areas, with acceptable sequelae and morbidity.

ABBREVIATIONS EOM = extraocular motility; GTR = gross-total resection; NTR = near-total resection; STR = subtotal tumor resection; TOA = transorbital approach.

Article Information

Correspondence Kyung In Woo: Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. eyeminded@skku.edu.

INCLUDE WHEN CITING Published online September 14, 2018; DOI: 10.3171/2018.3.JNS173233.

D.S.K., S.M.Y., and C.K.H. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Case 12: Surgical procedure. A skin marking of the superior eyelid crease (half length) is made at the crease line or supraciliary line for patients without an eyelid crease (A). After infiltration of a local anesthetic, a skin incision is made (B). Dissection between the septum and orbicularis with Wescott scissors (C) is carried in a superolateral direction until the lateral orbital rim is reached (D). The periorbita is dissected to expose the orbital wall (E). The periorbita is then elevated (F) posteriorly up to the deep posterior lateral wall. An endoscope is introduced for visualization within the limited space along the lateral wall of the orbit and a Silastic sheet is used to prevent the periorbita and orbit from iatrogenic injury (G). The lateral orbital wall is drilled to gain exposure to the tumor (H). In this case of an en plaque type of meningioma, the tumor is reduced and debulked using a high-speed diamond drill and Coblator (I and J). The middle cranial fossa is exposed after removal of the tumor (K). The dural defect is reconstructed with the double-button technique using autologous fascia lata (L). Figure is available in color online only.

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    Illustration showing the dural reconstruction method (A and B). Copyright Samsung Medical Center. Published with permission. Figure is available in color online only.

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    Case 9: Surgical procedure. A skin incision on the superior eyelid crease (full length) is made to approach the orbital roof (A). The preseptal approach is carefully carried out in a superolateral direction until the lateral orbital rim is reached (B). The periosteum is incised with a monopolar coagulator along the orbital rim (C). The periosteum is elevated from the lateral orbital rim (D). After removal of the lateral orbital rim (not shown), the periorbita is dissected to expose the tumor margin (E). The lateral orbital wall is drilled to expose the middle fossa dura (F). The foramen rotundum (indicator) can be identified under neuronavigation (G and H). After adequate removal of the sphenoid bone and frontal floor, the tumor margin is fully exposed creating one surgical view (I). After debulking the tumor, the optic nerve can be seen (J). A tumor portion involving the cavernous sinus is left in place (K). A wide dural defect is reconstructed using the double-button technique with allogenic dermis (L). Figure is available in color online only.

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    Cases 1–3 and 7. Case 1: Sphenoorbital meningioma shown on preoperative MR images (A and B) and, after NTR, on postoperative MR images (C and D). Case 2: Sebaceous gland carcinoma involving the frontoorbital bone demonstrated on preoperative MR images (E and F) and, after GTR, on postoperative MR images (G and H). Case 3: Recurrent cystic teratoma located in the orbit shown on preoperative MR images (I and J) and, after NTR, on postoperative MR images (K and L). Case 7: Recurrent metastatic osteosarcoma involving the frontal lobe and orbit demonstrated on preoperative MR images (M and N) and, after GTR, on postoperative MR images (O and P).

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    Case 12: Illustrative case. A 38-year-old woman, with a history of receiving Gamma Knife radiosurgery for a sphenoid wing meningioma involving the lateral orbit, presented with progressive proptosis of 8 mm (A, C, and E). Preoperative MRI showed thickened hyperostosis of the sphenoid bone caused by tumor invasion. She underwent endoscopic transorbital surgery via a superior eyelid crease approach. Postoperative MR image demonstrates GTR of the lesion (B). The patient was discharged 3 days after surgery with very limited edema around the upper eyelid; her proptosis had completely resolved and she had no ophthalmic-related complications (D and F). Figure is available in color online only.

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    Case 9: Illustrative case. A 52-year-old woman showed progressive proptosis of 4 mm, a relative afferent pupillary defect, and compressive optic neuropathy (best-corrected visual acuity [BCVA] 20/32) on the ipsilateral side (D and E). Preoperative MR images showed that the tumor involved the orbital globe, periorbita, the sphenoidal ridge, and the temporal tip (A–C). The tumor widened the superior orbital fissure (SOF), extending the cavernous sinus through the SOF. She had no other cranial nerve deficits. She underwent an extended endoscopic transorbital resection of the tumor. To avoid excessive retraction of the globe, the lateral rim of the orbit was removed to allow removal of the large intraorbital portion of the tumor. NTR of the tumor was performed, leaving the cavernous sinus portion of the lesion (F). Postoperative CT scans showed a large skull defect of the superior and lateral wall of orbit (G and H). Immediately after surgery, she had mild ptosis and periorbital swelling (I); however, the ptosis recovered within 4 weeks. Postoperatively, her decreased visual acuity and field defect were improved (BCVA 20/25 [J]). Figure is available in color online only.

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