Post on 24-Mar-2018
Jason Comander, PhD, MS4
Gillian Lieberman, MD
Jason Jason ComanderComander, PhD,, PhD,Harvard Medical School Year IVHarvard Medical School Year IV
Gillian Lieberman, MDGillian Lieberman, MDNovember 2005November 2005
Radiological Evaluation of Orbital Masses
Jason Comander, PhD, MS4
Gillian Lieberman, MD
2
Our Patient’s Clinical History• HPI: 78 y/o F with excessive tearing, redness, and
swelling of left eye, worsened on treatment with steroids and then antibiotics. S/p lacrimal sac drainage for presumed dacryocystitis. Now, visual blurriness and light sensitivity.
• PMH: 5 years ago, scleral banding for retinal detachment
• Allergy: Iodinated contrast
Jason Comander, PhD, MS4
Gillian Lieberman, MD
3
Menu of Tests
• Ophthalmologist (generally inside the globe)– Fundus photographs– Angiography- fluorescein, ICG– Ultrasound- usually 1D– Optical Coherence Tomography (OCT)- retinal nerve fiber layer
thickness, imaging of macula• Radiologist (generally outside the globe)
– CT orbit – best for bony detail, foreign bodies,calcifications. Axial and coronal.
– MRI orbit – best for soft tissue, contraindicated if suspect ferromagnetic foreign body. Fat suppression helpful.
– Ultrasound – usually 2D. Best for retinal detachments.– FDG-PET/Gallium scan – as part of cancer workup
Optic disc photograph (JC)
Jason Comander, PhD, MS4
Gillian Lieberman, MD
4
Our Patient - Orbital Anatomy
PACS, BIDMC
Specifications for CT Orbit: Image in the plane of infraorbital-meatal line (not ideal for optic nerve), 3 mm sections. ACR Practice Guidelines - www.acr.org.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
5
Our Patient - Orbital Anatomy
PACS, BIDMC
Anterior chamber
Posterior chamber
Scleral buckle
Medial rectus
Optic nerve
Lacrimal gland
Orbital Fat
Lateral rectus
Axial CT
Jason Comander, PhD, MS4
Gillian Lieberman, MD
6
Our Patient - Orbital Anatomy
Coronal CTPACS, BIDMC
SR SOLR MR
IR
Jason Comander, PhD, MS4
Gillian Lieberman, MD
7
Our Patient - Orbital Anatomy
PACS, BIDMC
T1 axial T1 coronal
SR SOLR MR
IR
Jason Comander, PhD, MS4
Gillian Lieberman, MD
8
Ocular Spaces Companion Patient 1 with orbital mass in three compartments
Akansel G, Hendrix L, Erickson BA, Demirci A, Papke A, Arslan A, Ciftci E. MRI patterns in orbital malignant lymphoma and atypical lymphocytic infiltrates. Eur J Radiol. 2005 Feb;53(2):175-81.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
9
Ocular Spaces Companion Patient 1 with orbital mass in three compartments
Akansel G, Hendrix L, Erickson BA, Demirci A, Papke A, Arslan A, Ciftci E. MRI patterns in orbital malignant lymphoma and atypical lymphocytic infiltrates. Eur J Radiol. 2005 Feb;53(2):175-81.
ExtraconalExtraconalIntraconalIntraconal
PrePre--septalseptal
(Intracranial)(Intracranial)
Jason Comander, PhD, MS4
Gillian Lieberman, MD
10
Our Patient
PACS, BIDMCIn the left orbit, there is soft tissue density mass with ill defined borders, surrounding optic nerve and extending medially into the extraconal and preseptal spaces. Scleral buckle is in place.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
11Axial T1 – lesion isointense to muscle
PACS, BIDMC
Our Patient
Jason Comander, PhD, MS4
Gillian Lieberman, MD
12
Our Patient
PACS, BIDMC
T1
T1 FS post-
contrast
Jason Comander, PhD, MS4
Gillian Lieberman, MD
13
Our Patient
Axial T2PACS, BIDMC
Jason Comander, PhD, MS4
Gillian Lieberman, MD
14
Our patient - FDG-PET
PACS, BIDMC
“low signal intensity in the left orbit– no evidence of FDG-avid disease”
Jason Comander, PhD, MS4
Gillian Lieberman, MD
15
Frequency of Orbital Lesions• 47% Thyroid orbitopathy• 8% Cystic lesions• 8% Inflammatory lesions• 5% Vascular lesions• 4% Lacrimal lesions• 4% Lymphoproliferative lesions• 4% Secondary tumors• 3% Myxomatous and adipose lesions• 2% Mesenchymal lesions• 2% Metastatic tumors• 1%: Optic nerve tumors, fibrous and connective tissue lesions, Osseous
and fibroosseous lesions, histiocytic lesions• 17% Other and unclassified
Dutton J. Orbital Diseases. In: Yanoff M, Duker JS, eds. Ophthalmology. St. Louis: CV Mosby, 1999, 14.1-14.7
Jason Comander, PhD, MS4
Gillian Lieberman, MD
16
Companion Patient 2 Grave’s Ophthalmopathy
http://www.mni.mcgill.ca/neuroimage/nov2001/nov2001_p3.htm
Jason Comander, PhD, MS4
Gillian Lieberman, MD
17
Companion Patient 3 Inflammatory Psuedotumor
© http://rad.usuhs.mil/medpix/
Is not associated with local or systemic disease.
Presents with proptosis, ptosis, conjunctival injection, and pain.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
18
Companion Patient 4 Orbital Cellulitis
http://www.mni.mcgill.ca/neuroimage/nov2001/nov2001_p3.htm
Fat strandingExtension into orbit
Jason Comander, PhD, MS4
Gillian Lieberman, MD
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Companion Patient 5 Cavernous Hemangioma
http://mccoy.lib.siu.edu/projects/mgrey/pathology/headneck/cavernous_hemangioma_orbit/image2.shtml
Smoothly marginated, high density, round contrast enhancing intraconal mass of the left orbit displacing the left globe anteriorly.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
20
Companion Patient 6 Orbital Lymphoma
http://www.mni.mcgill.ca/neuroimage/nov2001/nov2001_p3.htm
Orbital lymphoma displacing the globe laterally and anteriorly.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
21
Companion Patient 7 Meningioma- “Tram-track” sign
http://www.mni.mcgill.ca/neuroimage/nov2001/nov2001_p3.htm
Jason Comander, PhD, MS4
Gillian Lieberman, MD
22
Companion Patient 8 Optic Neuritis
http://www.amershamhealth.com/medcyclopaedia/medical/volume%20VI%201/OPTIC%20NEURITIS.ASP
Jason Comander, PhD, MS4
Gillian Lieberman, MD
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Orbital mass in a 78 y/o: Differential Diagnosis
• Lymphoma• Pseudotumor• Mucocele• Metastatic carcinoma• Leukemia• Melanoma
Jason Comander, PhD, MS4
Gillian Lieberman, MD
24
Orbital mass in a 70 y/o: Radiographic Differential Diagnosis
• Periosteal reaction: pseudotumor• Diffuse radiodensity blending with normal structures:
psuedotumor• Discrete mass: melanoma, lymphoma, leukemia, metastatic
carcinoma, mucocele• Extraocular muscle enlargement: pseudotumor, metastatic
carcinoma, mucocele• Calcific densities: mucocele• Enlargement of superior orbital fissure: metastatic
carcinoma• Erosion of optic canal / sinuses: melanoma, mucocele
Jason Comander, PhD, MS4
Gillian Lieberman, MD
25
Our Patient - Pathological Diagnosis: Atypical Lymphoid Infiltrate, a “low-grade lymphoma”
PACS, BIDMC
Jason Comander, PhD, MS4
Gillian Lieberman, MD
26
Orbital lymphoid neoplasms• Spectrum of disease from benign to malignant
– Inflammatory pseudotumor & reactive lymphoid hyperplasia (benign), atypical lymphocytic infiltrate (can be malignant), lymphoma (malignant)
• Lymphomas are “soft”.– Mold to orbital structures. Rarely invade bone.
Intraocular invasion of lymphoma is rare (case-report: Sarraf D, Jain A, Dubovy S, Kreiger A, Fong D, Paschal J. Mucosa-associated lymphoid tissue lymphoma with intraocular involvement. Retina. 2005 Jan;25(1):94-8)
• Most common orbital lymphoid neoplasm: Non- hodgkin’s lymphoma- MALToma. Arises within orbit (vs. leukemia – spread)
Jason Comander, PhD, MS4
Gillian Lieberman, MD
27
Summary• Menu of tests: inside vs. outside globe
– Inside the eye: fundus photographs, angiography (fluorescein, ICG), OCT
– Outside the eye: Specify “orbit” CT, MRI, U/S. • Most common orbital lesion: Grave’s disease:
muscle thickening sparing lateral rectus• Lymphomas are “soft”: mold around tissue,
invasion rare• In contrast to lymphomas, cellulitis and
pseudotumor present with pain and show radiographic signs of inflammation.
Jason Comander, PhD, MS4
Gillian Lieberman, MD
28
Acknowledgements
• Jonathan Kleefield, M.D.• Barbara Appignani, M.D.• Hugh Curtin, M.D., Mass. Eye & Ear
Infirmary• Gillian Lieberman, M.D.• Pamela Lepkowski• Larry Barbaras our Webmaster
Jason Comander, PhD, MS4
Gillian Lieberman, MD
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References• Akansel G, Hendrix L, Erickson BA, Demirci A, Papke A, Arslan A,
Ciftci E. MRI patterns in orbital malignant lymphoma and atypical lymphocytic infiltrates. Eur J Radiol. 2005 Feb;53(2):175-81.
• Valvassori GE, Sabnis SS, Mafee RF, Brown MS, Putterman A. Imaging of Orbital Lymphoproliferative Disorders. Radiologic Clinics of North America. 1999 37(1):135-150.
• Dutton J. Orbital Diseases. In: Yanoff M, Duker JS, eds. Ophthalmology. St. Louis: CV Mosby, 1999, 14.1-14.7
• ACR Practice Guidelines - www.acr.org. • Image Credits (as labeled)
– http://www.mni.mcgill.ca/neuroimage/nov2001/nov2001_p3.htm– http://rad.usuhs.mil/medpix/– http://www.onjoph.com/– http://mccoy.lib.siu.edu/projects/mgrey/pathology/headneck/cavernous_he
mangioma_orbit/image2.shtml– http://www.amershamhealth.com/medcyclopaedia/medical/volume%20VI
%201/OPTIC%20NEURITIS.ASP