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MORPHOLOGICAL SPECTRUM OF ORBITAL LESIONS AT TERTIARY CARE HOSPITAL IN LAHORE.

Byline: SARFRAZ S., JAFRI A., ZAHID R. and AKHLAQ M.

Key words: Orbital lesions, Benign, Malignant, Inflammatory.

INTRODUCTION

The orbit is an anatomically complex structure in bony socket of skull having globe, includes eye lids, eye ball, extra ocular muscles, cranial nerves, blood vessels, fat, lacrimal glands, ducts, ciliary ganglions, supported by ligaments and different supportive muscles of the face.1,2 Inflammation or neoplastic lesions of orbit, all affect quality of life greatly.3

Orbital tumors are the abnormal growths of the structures that are part of orbit, which can be benign, malignant or metastatic.4 Different kinds of orbital tumors can occur involving any structure of eye e.g. optic nerve glioma, orbital meningioma, hemangioma, lymphangioma,5 neurofibroma, sarcoma.6,7 Thyroid dysfunction may cause tumor like condition and lateral protrusion of eye balls (Graves' Disease).8,9 Extraconal lesions are dermoid tumor21 (dermoid cyst) and pleomorphic adenoma of the lacrimal gland.10

Tumors of the eye lids are more common than other tumors of the orbital regions described above; 5-10% of all skin cancers occurs in the eyelids. Basal cell carcinoma (BCC) is the most frequent malignant eyelid tumor followed by squamous cell carcinoma (SCC), sebaceous gland carcinoma and malignant melanoma.11

A survey was conducted in United States of American to evaluate the orbital tumors in 2011. Primary tumors were more common as compared to secondary (metastatic). Of the tumors, 171 (64%) were primary orbital, 69 (26%) were secondary orbital, and 28 (10%) were metastatic tumors, 27 (10%); inflammatory conditions, 21 (8%); vascular lesions, 20 (7%); mesenchymal tumors, 18 (7%), optic nerve and nerve sheath tumors, 7 (3%); peripheral nerve tumors, 3 (1%), histiocytic lesions, 3 (1%); cystic lesions, 3 (1%), and other lesions, 1 (< 1%). The rate of malignant tumors was higher than benign, e.g. 169 (63%) had malignant tumors and 99 (37%) had benign tumors. The most common malignancy was lymphoma.12

In a Nigerian study, the most common ophthalmic malignancies were SCC of the conjunctiva and eyelids.13 In institutes of Western Nepal, the common most malignancy was SCC then BCC, malignant melanoma and lacrimal gland adenocarcinoma.14

A comparative study in Karachi Pakistan showed that 115 (31.9%) cases were benign and 245(68%) were malignant out of 360 cases. The most common malignant tumor was SCC, 67 (34.5%); followed by rhabdomyosarcoma, 10 (5.15%); sebaceous cell carcinoma and malignant lymphoma, 6 (3.09%); malignant melanoma, 4 (2.06%); cystic lesions, 54 (46.9%), inflammatory lesion, 44 (38.2%); angiomatous lesions, 22(8.8%) and pleomorphic adenoma was 7 (2.8%).15

In another study in North-West Pakistan revealed that BCC was the most common tumor (59%), followed by SCC (31.5%), sebaceous gland carcinoma (6.8%) and malignant melanoma (1.3%).16

MATERIAL AND METHODS

This study was carried out in Pathology Department King Edward Medical University, Mayo Hospital Lahore from June 2013 to June 2014 after approval of synopsis. It was Descriptivestudy. Approval of the study was taken by statistical committee of CPSP. A total of 280 cases were taken by non-probability purposive sampling technique. Patients undergoing histopathology of biopsy were enrolled in this study. Their demographic features i.e. age, sex, case number and medical records were noted. The biopsies received in the Pathology Department were fixed in the formalin, processed and then slides were stained with haematoxylin and eosin stain. Histological examination was carried out by a consultant histopathologist under light microscope. Orbital lesions from eyelid, lacrimal gland, globe, conjunctiva and intraconal tissues were included in this study.

They were further sub classified into inflammatory, benign, malignant or metastatic. All these information was recorded on proforma. The final results of study were compiled on the basis of histopathology as inflammatory, benign, malignant and metastatic lesions.

Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics (%age) was used to describe the data. Mean and standard deviation was calculated for quantitative variables i.e. age. Frequency was presented for qualitative variables i.e. inflammatory, benign, malignant and metastatic in both age groups and in both genders. Data was stratified for the age ([greater than or equal to]18 to 40 years and above 40 years of age) to address the effect modifiers.

RESULTS

A total of 280 surgical biopsies were studied at Pathology Department, King Edward Medical University Lahore. Specimens from all patients underwent surgical examination and biopsy procedure, with orbital lesions included in the study. Their ages ranged from 18-85 years. Both genders, male and female were included in the study. The mean age of patients presenting with orbital lesionsand undergoing surgical biopsy came out to be 42.15 +- 18.17 years. Most of the patients ranged between 20-26 years and 60-62 years of age. In males and females lesions were found more in 20 and 60 years of age. Thefemale to male ratio was 1:1.2.

This showed that males experienced orbital complaints and orbital lesions more than females however there was no significant statistical difference among their lesions.

Of 280 lesions; there were 66 (23%) inflammatory lesions, 111 (40%) benign and 103 (37%) malignant lesions. There were 153 (54.6%) males and 127 (45.4%) females. Out of 153 orbital lesions seen in males, 47 (31%) were inflammatory, 50 (33%) benign and 55 (36%) malignant lesions. Out of 127 orbital lesions detected in females, 18 (14%) were inflammatory, 61 (48%) were benign and 48 (38%) were malignant lesions. Male showed greater numbers of orbital lesions as compared to females but inflammatory lesions were more observed in males as compared to females. While there was no significant difference seen in other lesions.

Among inflammatory lesions, fungal infections were 23 (8.2% of total number of cases i.e. 280), granulomatous tuberculous lesions were 9 (3.2%), inflamed granulation tissues were 7 (2.5%), and Inflamed Pseudotumor were also 7 (2.5%). Chronic Sclerosing Dacryocystitis was seen in 3 (1%) cases, Bacterial Keratitis in 3 (1%) cases, Graves Disease in 3 (1%) patients and Pyogenic granulomas in patients 3 (1%). Dacroadenitis was diagnosed in 2 (0.7%) cases while chronic Osteomyelitis, Abscess, inflamed lacrimal duct cyst, canaliculitis, Pemphigus Vulgaris and Actinomycosis were seen in 1 (0.4%) cases each.

Among benign lesions, Dermoid cyst,Capillary Hemangioma, Epidermoid Inclusion cyst, Squamous cell Papilloma , Pterygium Sebaceous Cyst, Simple cyst were most common lesions comprising of 28 (10%), 11 (4%), 8 (3%), 8 (3%), 7 (2.5%), 5 (2%), 5 (2%) respectively. Other lesions were rare like Lipoma in 4 (1.4%), Pleomorphic adenoma in 4 (1.4%), Benign nevus in 3 (1%), cavernous hemangioma in 3 (1%), AV malformations in 3 (1%) cases, Coloboma in 3 (1%) Meningioma Grade I in 2 (0.7%). Schwannoma, Chronic Osteomyelitis, Benign Fibrous Histiocytoma, Eccrine Poroma, lobular hemangioma, Veruucus hyperplasia, Xan-thelasma, Mucocele, Phthisis bulbi, Osteoma and Optic nerve glioma were seen in 1 (0.4%) cases in each.

Table 1: Squamous cell carcinoma is more frequent followed by Basal cell carcinoma

No. of###Morphological Spectrum of

###Frequency###Percentage

Lesions###Malignant Orbital Lesions

###1.###SCC###38###13.6

###2.###BCC###24###8.6

###3.###Malignant Melanoma###9###3.2

###4.###Sebaceous Gland Carcinoma###8###3.00

###5.###Basosquamous carcinoma###6###2

###6.###Rhabdomyosarcoma###5###1.8

###7.###Non Hodgkin Lymphoma###4###1.4

###8.###Adenoid Cystic Carcinoma###3###1.00

###9.###Osteogenic Sarcoma###2###0.7

###10.###Dysplasia Grade III###2###0.7

###11.###Round Blue cell tumor###1###0.4

###12.###Metastatic Papillary Thyroid###1###0.4

###Carcinoma

###Total###103###36

Among Malignant orbital lesions, SCC was most common lesions, seen in 38 (13.6% cases) followed by BCC 24 (8.6%) cases, Malignant Melanoma 9 (3.2%) cases and Sebaceous Carcinoma in 8 (3%) patients. Basosquamous Cell carcinomas were seen in 6 (2%) cases, Adenoid cystic carcinomas in 3 (1%) and dysplasia grade III in 2 (0.7%) cases. Among non-epithelial malignant neoplasms, 5 (1.8%) cases of Rhabdomyosarcoma and 4 cases of NHL were also seen. Each 1 (0.7%) case of round blue cell tumor and metastatic papillary thyroid carcinoma were also seen in this study.

Out of 54 malignant cases in males, SCCs were 24 (44.4%) and the most common lesions followed by BCCs 13 (24%), Malignant Melanomas 4 (7.4%), adenoid cystic carcinomas 3 (5.5%), Rhabdomyosarcomas 3 (5.5%), Basosquamous Carcinomas 2 (3.7%), Sebaceous Glands Carcinomas 2 (3.7%), NHLs 2 (3.7%) and Osteogenic sarcoma 1 (1.8%).

Out of 49 malignant cases in females, SCC were 14 (27.5%) and the most common lesions followed by BCC 11 (22.5%), Sebaceous Glands Carcinomas 6 (12%), Malignant Melanomas 5 (10%), Basosquamous Carcinomas (8%), Rhabdomyosarcomas (4%), NHLs (4%), dysplasia grade III 2 (4%), round blue cell tumor 1 (2%), Osteogenic sarcoma 1 (2%) and metastatic papillary thyroid carcinoma 1 (2%).

DISCUSSION

Tumors of orbital region are main reason of proptosis, which can result in loss of eyesight. Present study revealed type of lesions and different diseases in different ages.15 Lesions are divided into three major groups like, inflammatory lesions, benign tumors and tumor like lesions, premalignant and malignant neoplasms. The classification is necessary not only for treatment purpose but also is important for cosmetic purpose, cicatricial retraction, post-traumatic loss of tissue, congenital colobomas. The final diagnoses of these lesions are also important to consider reconstruction techniques with grafts and flap in orbital regions.11

Eye surgeons, are focusing the non-surgical approach for benign and inflammatory lesions, while excisions are preferred for malignant group, basal cell carcinoma and complete surgical excision with frozensection control of the margins offers the lowest tumorrecurrence rate. An important acquisition has been made on SCC for which the sentinel node biopsy has revealed early metastatic cancer. For other epithelial tumors like sebaceous gland carcinoma that seem to indicate an increased risk for orbital invasion.17

In our study, the malignant lesions, showed two peaks of 20 years and 60 years in both males and females. The mean age of patients presenting with orbital lesions (OLs) and undergoing surgical biopsy came out to be 42.14 +- 18.18 years. Most of the patients ranged between 20-26 years and 60-62 years of age. The findings are consistent with Ud-Din et al.18

There were 280 patients in this study and there were 153 (54.6%) males and 127 (45.4%) females. The female to male ratio was 1:1.2. This showed that males experienced orbital complaints and orbital lesions a bit more than females. In this study, the incidence of neoplastic lesions exceeded that of non-neoplastic lesions (inflammatory) and our findings are consistent with other studies done in Pakistan.12 There were 153 orbital lesions seen in males, 47 (31%) were inflammatory, 50 (33%) benign and 55 (36%) malignant lesions. There were 127 orbital lesions detected in females, 18 (14%) were inflammatory, 61 (48%) benign and 48 (38%) malignant lesions.There was a significant difference in inflammatory lesions in both sexes. Males showed greater numbers of orbital lesions as compared to females.

Orbital inflammatory disease (OID) are 6% of orbital diseases, affects all age, a frequent cause for orbital biopsy Differential diagnosis of OID ranges from idiopathic inflammatory disease to systemic or local inflammatory conditions to other associated conditions such as neoplasm, infection, congenital malformation, or trauma. There is lot of difference in the morphological spectrum of inflammatory lesions, mentioned in the literature and found in our study. By far the most common forms are the various idiopathic inflammations (53%), including inflammatory pseudotumor and myositis. While in our study, among inflammatory lesions, fungal infections were 8.2% and were more common followed by granulomatous tuberculous lesions 3.2%, inflamed granulation tissues were 2.5%, InflammatoryPseudo tumors 2.5%.

In present study, fungal infection and tuberculosis were more prevalent diseases in same descending orders in males and females followed by other diseases with little difference.

Orbital cysts (Dermoid, epidermoid, simple cyst) were also seen in present study sample. Other benign lesions were also observed in our study like Capillary Hemangioma, Squamous Papilloma (Viral Wart), Pterygium, were most common lesions were comprising of 3.9%, 2.9%, 2.5%, respectively. These findings are consistent with other studies done in Pakistan.12

In literature, most common was hemangioma, accounting for 16.66%. Cavernous hemangiomas are the most frequent among vascular tumors accounting for 50% of all vascular tumors and 13.5 % of all orbital lesions.19

In present study Hemangioma was the second most common lesion (Capillary Hemangioma 4%, Cavernous hemangioma 1% and Lobular hemangioma 0.4%) after Cystic diseases. Among vascular tumors, Capillary Hemangiomas were the most frequent 4% of all other lesions. Our findings are consistent with Chinda et al.19 In our study, Dermoid cystic lesions were most frequent benign tumors, comprising of 10% followed by epidermoid cysts (3%), simple cysts (1.8%) and sebaceous cysts (1.8%).

Among the neuroepithelial tumors, one case of optic meningioma grade 1 constituting 2% of benign optic tumors in males and one case of low grade optic glioma was found to be closer to the other study in Pakistan.15

The climate of Pakistan is dry and dusty with high sun exposure; similar factors may be operative in the causation of squamous cell carcinoma. Among the epithelial tumors, SCC was the most common malignant ophthalmic tumors; the frequency was closer to some studies.15,18 In our study, among malignant orbital lesions, the SCC was most common lesions, seen in 13.6% cases followed by BCC in 8.6% cases, Malignant Melanoma in 3.2% cases. Basosquamous Cell carcinomas were seen in 2.1% cases.

The most common malignant eyelid tumor in the United States and the United Kingdom is reported to be the BCC which occurs most frequently on the lower eyelid and medial canthus in elderly patients6. In present study the second most common eyelid tumor was BCC (8.6% cases).

Our findings are not consistent with other international studies where BCC was the most frequent malignant eyelid tumor, followed by SCC, sebaceous gland carcinoma and malignant melanoma.11 This could be due to geographical distribution of these malignancies, where SCC is more common in Pakistan and other Asian Countries. Malignant melanoma of the uvea is common malignant melanomas in the United States. Melanoma is most common in the western ocular malignancy.

Among mesenchymal tumors, Rhabdomyosarcoma was observed in 5 cases with different age group (range 20-70 years), which is less in frequency than other comparative studies of Pakistan. The reason for lower number of cases can be due to the fact that, study is limited to one medical institute.

It is concluded that benignorbital lesions were more frequent than malignant and inflammatory lesions. Fungal infections were more frequent inflammatory lesions followed by Tuberculosis. Dermoid cysts were commonest benign OLs followed by hemangiomas. SCC was the most common malignancy found followed by BCC, MM, Sebaceous gland carcinoma, Rhabdomyosarcomas and lymphomas.

Authors' Contributions

SS: Main author who put all her efforts to write, collect and compile all data. AJ: She helped to collect diagnostic reports from pathology department. RZ: She guided how to add data in SPSS. MA: She guided how to write article.

ACKNOWLEDGEMENT

In the name of Almighty Allah whose special blessings and mercy gave me courage, strength and power to start this research work and enabled me to accomplish it successfully. It gives me a great pleasure to acknowledge my cordial gratitude to my respected and honorable supervisor, Professor Dr. Mulazim Hussain Bukhari and my fellows doctors who helped me out. Dr. Anum helped me to collect data, Dr. Remisha who helped me enter data in SSP and to make tables and graphs and Dr. Maham who helped me write article for publication.

Conflict of Interest

Author declare no conflict of interest.

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Publication:Biomedica
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Date:Sep 30, 2018
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