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Orbital Tumors

Diagnosing Orbital Tumors

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and definitely if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like most cancers in the head and neck, this will include some combination of biopsy and imaging tests, which is the term that doctors use to refer to X-rays, MRIs, CT scans, etc.

If you came to a head and neck cancer specialist after having something small removed from your nasal cavity and found it was cancer only afterwards, your doctor might skip some of the tests and jump to close follow-up or additional treatment. Be sure to bring all the reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumors that are easily evaluated on physical examination, imaging might not be necessary. For larger tumors, or tumors in locations that are difficult to examine (including those in the orbit), your doctor will probably order some sort of imaging to get more information about the tumor location and possible spread to regional lymph nodes. An important reason to get a scan for orbital tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment your doctor recommends for you.

For most head and neck cancers, if imaging is required, your doctor will most likely start with a computed tomography (CT) scan with contrast. Other tests might include magnetic resonance imaging (MRI) and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your orbit (or a mass in your neck).

Orbital biopsy

An orbital biopsy can be done in a few different ways by either an eye surgeon or a head and neck surgeon.

  • Open biopsy: In some cases, particularly if the diagnosis can be surmised based on imaging and history, your surgeon might recommend you go to the operating room and be put to sleep. Then, he or she can expose the orbital tumor and either take a small piece to get a frozen section diagnosis immediately from the pathologist, remove a small piece and send it off to the pathologist for additional detailed analysis or simply remove the entire tumor (the last one is called an excisional biopsy). Some studies have shown that performing a biopsy without removing the entire tumor may lead to a worse outcome.1 Riedel KG, Markl A, Hasenfratz G, Kampik A, Stefani FH, Lund OE. Epithelial tumors of the lacrimal gland: clinico-pathologic correlation and management. Neurosurg Rev. 1990;13(4):289-98. The exact approach taken to perform the biopsy will depend on the location of the tumor.
  • Fine needle aspiration biopsy: Just as in neck masses and other sites of disease, a very thin needle can be inserted through the skin and into the lesion to extract cells. Numbing medicine is usually not necessary. However, the area should be thoroughly cleaned.2 Tijl JW, Koornneef L. Fine needle aspiration biopsy in orbital tumours. Br J Ophthalmol.1991 August;75(8):491-492.
  • Transnasal biopsies: For tumors that are growing into the nose, or tumors that are on the inner part of the orbit, your doctor might be able to perform a biopsy through the nose using special cameras. You will have your nose decongested and numbed. Then, using a camera and a long forcep, your surgeon can take a piece of the tumor. If the surgeon needs to take down some of the orbital wall to get access to the tumor, he or she will probably prefer to do the procedure in the operating room with you asleep.

Neck biopsy

If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck:

  • Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumor and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. A number of “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

DIFFERENT TYPES OF FINE NEEDLE ASPIRATION BIOPSIES

By Feel” FNAB Ultrasound Guided FNAB CT-Guided FNAB
When Your Doctor Might Use This Technique If the lump can be easily felt by your doctor If your doctor thinks it will be difficult to get the needle directly into the lump with certainty If your doctor doesn’t think he or she will be able to get into the tumor by feel or with ultrasound guidance
What to Expect Your doctor will feel the lump and place a tiny needle directly into it to extract some cells. Your doctor will use a gentle probe on your face or neck, identify the tumor with the ultrasound and then watch the needle go directly into the tumor on the ultrasound machine. You will be placed into a CT scanner, and a few low-dose CT scans will be performed—first to localize the tumor and then to make sure the needle that is placed is actually within the tumor.There is new technology known as fluoroscopic CT scanning in which the radiologist can quickly take a few scans without leaving the room, moving the needle around to get it into the right place.
  • Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumor rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.3 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.
  • Open neck biopsy: An open biopsy involves making an incision over the tumor and removing a piece or all of the tumor to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumor is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.
References

1 Riedel KG, Markl A, Hasenfratz G, Kampik A, Stefani FH, Lund OE. Epithelial tumors of the lacrimal gland: clinico-pathologic correlation and management. Neurosurg Rev. 1990;13(4):289-98.

2 Tijl JW, Koornneef L. Fine needle aspiration biopsy in orbital tumours. Br J Ophthalmol.1991 August;75(8):491-492.

3 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.

4 Smitt, MC, Donaldson SS. Radiotherapy is successful treatment for orbital lymphoma. International Journal of Radiation Oncology*Biology*Physics. 1993;26(1):59-66.

5 Bolek TW, Moyses HM, Marcus Jr RB, Gorden III L, Maiese RL, Almasri NM, Mendenhall NP. Radiotherapy in the management of orbital lymphoma. International Journal of Radiation Oncology*Biology*Physics. Volume 44, Issue 1, 1 April 1999;31-36.

6 Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology. 1990 May;97(5):620-4.

7 Skinner HD, Garden AS, Rosenthal DI, Ang KK, Morrison WH, Esmaeli B, Pinnix CC, Frank SJ. Outcomes of Malignant Tumors of the Lacrimal Apparatus: The University of Texas MD Anderson Cancer Center Experience. Cancer. 2011;117(12):2801-2810.

8 Wright J, Rose G, Garner A. Primary malignant neoplasms of the lacrimal gland. Br J Ophthalmology. 1992;76:401-407.

9 Kim M, Park K, Kim JH, Kim Y, Lee J. Gamma knife radiosurgery for orbital tumors. Clin Neurol Neurosurg. 2008;110:1003-1007.

10 Douglas JG, Laramore GE, Austin-Seymour M, et al. Treatment of locally advanced adenoid cystic carcinoma of the head and neck with neutron radiotherapy. Int J Radiat Oncol Biol Phys. 2000;46:551-557.

11 Finger PT. Radiation Therapy for Orbital Tumors: Concepts, Current Use, and Ophthalmic Radiation Side Effects, Survey of Ophthalmology. Volume 54, Issue 5, September–October 2009;545-568.

12 Meel R, Pushker N, Bakhshi S. Adjuvant chemotherapy in lacrimal gland adenoid cystic carcinoma. Pediatr Blood Cancer. 2009;53:1163-1164.

13 Meldrum ML, Tse DT, Benedetto P. Neoadjuvant intracarotid chemotherapy for treatment of advanced adenocystic carcinoma of the lacrimal gland. Arch Ophthalmol. 1998;116:315-321.

14 Oberlin O, Rey A, Anderson J, Carli M, Raney RB, Treuner J, Stevens, MC. Treatment of orbital rhabdomyosarcoma: survival and late effects of treatment—results of an international workshop. Journal of clinical oncology. 2001;19(1),197-204.