CyberKnife radiotherapy for orbital metastases: A single-center experience on 24 lesions.

OBJECTIVES:: To evaluate the feasibility, in terms of acute toxicity and symptom control, of CyberKnife (Accuray, Sunnyvale, CA)-based stereotactic radiotherapy (CyberKnife-SRT) for metastatic orbital lesions. METHODS:: This retrospective study included patients with symptomatic metastases wholly located within the orbit. Palliative radiation treatment was performed using CyberKnife image-guided technology. Gross tumor volume was defined on a pre-radiotherapy magnetic resonance imaging. Acute and late toxicity was recorded according to Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Scale. RESULTS:: Between April 2012 and July 2016, 21 patients underwent CyberKnife-SRT for 24 orbital metastases from different primary tumors. Median treatment dose was 18 Gy (15-24 Gy) given in a median of 3 fractions (2-3 fractions) with a median dose of 6 Gy/fraction (5-10 Gy/fraction). Acute grade 1 toxicity was observed in eight cases. No local recurrence occurred after median follow-up of 6.2 months (1.1-30.0 months) among 16 lesions that underwent post-stereotactic radiotherapy magnetic resonance imaging. All patients reported decreasing pre-stereotactic radiotherapy symptoms without late toxicity. Follow-up >6 months (median 22.8 months) was available for nine lesions; complete and partial radiological response was registered in four and five of them, respectively. CONCLUSION:: In our experience, CyberKnife-SRT is a well-tolerated treatment that offers high local and symptom control in patients with intraocular and periocular malignant lesions.

Unilateral proptosis as the initial manifestation of malignancy.

Proptosis, a common sign with a broad differential diagnosis, is defined as anterior displacement and protrusion of one or both orbital globes. Patients can present with varying degrees of chronicity, visual loss and associated symptoms. The etiology of acquired unilateral proptosis is diverse, ranging from benign to life-threatening. The causes of unilateral proptosis include traumatic, vascular, endocrine, inflammatory, infective and malignant. Breast carcinoma is the most common metastatic cause of proptosis; however, proptosis has never been reported as the initial manifestation of breast carcinoma. Our patient presented with unilateral proptosis secondary to an intraorbital lesion and histopathology of orbital lesion was suggestive of metastatic breast adenocarcinoma. She was later diagnosed to have primary breast carcinoma. We present this unusual case of a 56-year-old woman who presented with proptosis as the initial manifestation of a metastatic breast malignancy.

Emergency Point-of-Care Ultrasound Detection of Cancer in the Pediatric Emergency Department.

The use of point-of-care ultrasound in the pediatric emergency department is evolving beyond conventional applications as users become more expert with the technology. In this case series, we describe the potential utility of recognizing abnormal anatomy to impact care in the context of possible cancer in pediatric patients. We describe 4 patients with Langerhans histiocytosis, neuroblastoma, Wilms tumor, and rhabdomyosarcoma, in which point-of-care ultrasound was used to facilitate the diagnoses.

Value of MR imaging in the differentiation of benign and malignant orbital tumors in adults.

PURPOSE: To prospectively evaluate magnetic resonance (MR) imaging including dynamic contrast-enhanced MR imaging in the differentiation of benign from malignant orbital masses and to evaluate which MR imaging features are most predictive of malignant tumors. MATERIALS AND METHODS: The study was approved by the institutional review board and signed informed consent was obtained. Nonenhanced, static, and dynamic contrast-enhanced MR imaging was performed in 102 adult patients with an orbital mass. Diagnosis was based on histologic findings. MR imaging features of benign and malignant orbital lesions were evaluated correlated with histological findings. Multivariate logistic regression analysis was employed to identify the best combination of MR imaging features that might be predictive of malignancy. RESULTS: Nonenhanced, static, and dynamic enhancement MR imaging was significantly superior to two other models in prediction of malignancy (p < 0.05). Multivariate logistic regression analysis identified that the most discriminating MR imaging features were isointense mass on T2-weighted imaging and a washout-type time-intensity curve for both observers. CONCLUSION: Nonenhanced, static, and dynamic enhancement MR imaging improved differentiation between benign and malignant orbital masses in adult patients.

Comparison of plan quality provided by intensity-modulated arc therapy and helical tomotherapy.

PURPOSE: Intensity-modulated arc therapy (IMAT) is an arc-based approach to intensity-modulated radiotherapy (IMRT) that can be delivered on a conventional linear accelerator using a conventional multileaf collimator. In a previous work, we demonstrated that our arc-sequencing algorithm can produce highly conformal IMAT plans. Through plan comparisons, we explored the ability of IMAT to serve as an alternative to helical tomotherapy. METHODS AND MATERIALS: The IMAT plans were created for 10 patients previously treated with helical tomotherapy. Treatment plan comparisons, according to the target dose coverage and critical structure sparing, were performed to determine whether similar plan quality could be achieved using IMAT. RESULTS: In 8 of 10 patient cases, IMAT was able to provide plan quality comparable to that of helical tomotherapy. In 2 of these 8 cases, the use of non-axial coplanar or non-coplanar arcs in IMAT planning led to significant improvements in normal tissue sparing. The remaining 2 cases posed particular dosimetric challenges. In 1 case, the target was immediately adjacent to a spinal cord that had received previous irradiation. The second case involved multiple target volumes and multiple prescription levels. Both IMAT and tomotherapy were able to produce clinically acceptable plans. Tomotherapy, however, provided a more uniform target dose and improved critical structure sparing. CONCLUSIONS: For most cases, IMAT can provide plan qualities comparable to that of helical tomotherapy. For some intracranial tumors, IMAT's ability to deliver non-coplanar arcs led to significant dosimetric improvements. Helical tomotherapy, however, can provide improved dosimetric results in the most complex cases.

Avaliação do tratamento dos hemangiomas da região orbitária / Treatment evaluation in orbit vascular anomalies

As anomalias vasculares agrupam os hemangiomas e as más-formações vasculares. Aos primeiros, associa-se a proliferação celular do endotélio como evento principal, as últimas são entendidas como desarranjos da formação vascular, erros na angiogênese. As anomalias vasculares da órbita são os tumores benignos mais freqüentes da região, configuram-se envolvendo diretamente e exclusivamente a região orbitária, ou, por extensão, contínuas com outras regiões da face. São tratadas de forma multidisciplinar e representam riscos para seqüelas e disfunções oculares ou outras estruturas da órbita. Exigem do corpo médico uma grande responsabilidade nas decisões, seja para condução clínica, ou cirúrgica. A órbita detém particularidades em relação às anomalias vasculares quer seja pela complexidade anatômica, quer seja pela dinâmica do desenvolvimento da face. Assim, a opção do tratamento requer cuidadosa análise de diversos fatores interagentes: idade, localização e extensão do comprometimento da órbita, natureza ou classificação da anomalia, fase clínica encontrada, interpretação dos exames de imagem, prejuízo visual e até mesmo puramente estético. Para este estudo, foi a adotada a classificação clínica de Curado de 1992, que divide as anomalias em: Hemangioma Plano, Hemangioma Fragiforme, Hemangioma Tuberoso, Hemangioma Cavernoso, Linfangioma e Síndromes Hemangiomatosas. Foram analisados todos os pacientes portadores de anomalias vasculares da região orbitária, admitidos no Departamento de Cirurgia Plástica Reparadora e de Pediatria do Centro de Tratamento e Pesquisa do Hospital do Câncer, A. C. Camargo, da Fundação Antonio Prudente - São Paulo (SP), no período de janeiro de 1985 a julho de 2001. Em 169 pacientes foram analisadas as variáveis: demográficas, clínicas, específicas das anomalias vasculares da órbita, exames diagnósticos de imagens, complicações decorrentes da evolução natural, tratamentos, complicações dos tratamentos cirúrgicos e resultados. A média do seguimento ambulatorial dos pacientes foi de 58,6 meses (aproximadamente 5 anos), com mediana de 50,0 meses. Dos 169 pacientes estudados, 117 eram do sexo feminino e 52 do sexo masculino, em uma relação de 2,3:1. A maioria, 140 pacientes, era da raça branca. As anomalias vasculares se limitaram à pálpebra superior em 62 pacientes; em 39, à inferior. Em 68 ocupavam tanto a superior quanto a inferior. Quanto à classificação, 23 eram Hemangiomas Planos (más-formações de capilares ou vênulas), pertencentes ou não a síndromes de Sturge-Weber, 108 Hemangiomas Fragiformes ou Tuberosos (hemangiomas), 19 Hemangiomas Cavernosos (más-formações venosa), 11 Linfangiomas (más-formações linfáticas), e 8 síndromes: 4 de PHACE, 2 de DandyWalker, 1 de Kasabach Merritt e 1 de Proteus. O diagnóstico foi mais freqüente nas faixas etárias de 1 a 6 meses -em 77 pacientes. Em 60 pacientes (35,5%), não foram necessários exames de imagem complementar à avaliação clínica. Entre os 109 restantes, encontrou-se a seguinte freqüência dos exames de imagem: radiografia simples - 86 (78,9%), tomografia computadorizada - 75 (68,8%), arteriografia seletiva - 15 (13,8%), cintilografia com hemácias marcadas - 13 (11,9%), ultra-sonografia - 9 (8,3%), e ressonância magnética - 6 (5,5%). As condutas dos 169 pacientes estudados foram divididas em: expectante ­ 59 (34,9%) pacientes; clínica e outras ­ 37 (21,9%); cirúrgica após a clínica e outras ­ 35 (20,7%) e cirúrgica ­ 38 (22,5%) pacientes. Os resultados foram categorizados em: 1 - os designados como recuperação anatômica e funcional total, com simetria das órbitas em 100 (59,2%) pacientes; 2 - os designados como recuperação anatômica e funcional parcial, com assimetria das órbitas em 69 (40,8%) pacientes. Apenas duas anomalias não obtiveram qualquer melhoria após o tratamento e foram incorporados como resultados parciais para análises estatísticas. Os melhores resultados ocorreram: no sexo feminino, na raça branca, nas faixas etárias de 1 a 12 meses, nas classificadas como Hemangiomas Tuberosos ou Fragiformes (hemangiomas), nas localizadas ou nas pálpebras superior ou inferior, mas não concomitantes; e, nas unilaterais não contíguas com outras regiões da face. Tanto as que puderam seguir conduta expectante, como as que seguiram apenas o tratamento clínico apresentaram maioria de resultados com completa restituição anatômica e funcional. Das que necessitaram de tratamento cirúrgico, precedido ou não de tratamento clínico, cerca da metade apresentou resultado de completa restituição anatômica e funcional.

Vascular anomalies comprehend hemangiomas and vascular malformations. Hemangiomas are associated with endotelial cellular divisions lesions, whilst malformations are understood as vascular estructural errors. Orbital vascular anomalies are the most frequent benign tumors of this region and may either involve directly and exclusively the orbit, or affect by extension other contiguous facial regions. They are treated in a multidisciplinar approach and bring potencial risks of ocular sequelae and malfunctions to other orbital structures, demanding an enormous responsibility from medical team in their decisions, either in the clinical or surgical treatment. The orbital vascular anomalies are particularly complex, both because of their anatomic details and the facial development aspects. Thus, treatment options require a careful analysis of several interactive factors: age, nature or classification, extension, localization, image findings, patient clinical conditions, damage to vision and even aesthetic problems. Curado's clinical classification was adopted for this study, dividing vascular anomalies into: Hemangioma Plano (capilar, venular vascular malformation), Hemangiomas Fragiforme e Tuberoso (hemangioma), Hemangioma Cavernoso (venous malformation), Linfangioma (lymphatic malformation) and syndromes. This study analyzes all patients with orbital vascular anomalies admited to Pediatric and Plastic Divisions of Hospital do Câncer, A.C. Camargo, Fundaçao Antônio Prudente ­ São Paulo(SP) between January 1985 to July 2001. Several 169 patients variables were analyzed including: demographical, clinical, specific of vascular orbital anomalies, image exams, complications of the natural evolution, treatment options, surgical complications and results. The mean follow-up was 58,6 months (aproximately 5 years), with a median of 50,0 months. Of the 169 patients studied, 117 were females and 52 males, in a 2,3:1 relation. The majority white - 140 patients. The vascular anomalies were limited to the superior eyelid in 62 patients and to the inferior eyelid in 39. They occupied both the superior and inferior eylids in 68 patients. Regarding classification: 23 were Hemangiomas Planos belonging or not to Sturge-Weber syndromes, 108 Hemangiomas Fragiformes or Tuberosos, 19 Hemangiomas Cavernosos, 11 Linfangiomas and 8 syndromes ­ 4 of PHACE, 2 of Dandy-Walker, 1 of Kasabach Merritt and 1 of Proteus. A total of 77 patients (45,6%) were diagnosed between 1-6 months of age. In 60 (35,5%) patients no exams were need to complement clinical evaluation. In the other 109, frequency of image exams was: simple RX 86 (78,9%), CT 75 (68,8%), angiography 15 (13,8%), mTc99-labeled red cells 13 (11,9%), ultrasonography 9 (8,3%) and MRI 6 (5,5%). Treatment options of 169 patients were divided into: clinical observations ­ 59 (34,9%) patients, pharmacological and other treatment ­ 37 (21,9%) patients, surgical after pharmacological and other treatments ­ 35 (20,7%) patients and surgical ­ 38 (22,5%) patients. Results were categorized as: 1 ­ those described as a complete anatomical and functional recovery, with orbit symmetry 100 (59,2%) patients, and 2 ­ those described as partial anatomical and functional recovery, with orbit asymmetry ­ 69 (40,8%). Only two patients had no improvement after treatment and were assumed as parcial results to statistical analysis. The best results occurred on females, on whites, 1-12 months of age, with Hemangioma Fragiforme and Tuberoso, in superior or inferior eyelid localization and on those affecting only one side, with no extension to other face regions. Patients that could be just clinicaly observed or controlled with drugs had a complete anatomical and functional restoration in the majority of the patients. Those that needed surgical treatment, following or not pharmacological treatment, had a complete anatomical and functional restoration in approximately half of the patients.

Cancer metastatic to the orbit: the 2000 Robert M. Curts Lecture.

PURPOSE: To report the demographics and clinical features of a large series of patients with orbital metastasis. METHODS: Retrospective chart review on 100 consecutive patients and a literature review on orbital metastasis. RESULTS: Of 100 patients, the primary tumor site was breast in 53 (53%), prostate gland in 12 (12%), lung in 8 (8%), skin (melanoma) in 6 (6%), kidney in 5 (5%), gastrointestinal tract in 5 (5%), choroid (melanoma) in 2 (2%), parotid gland in 1 (1%), and adrenal gland (neuroblastoma) in 1 (1%). Of patients in whom a detailed history was available, there was no history of cancer at the time of presentation in 19%. In 10%, the primary tumor remained undetected despite systemic evaluation. There were 36 male patients and 64 female patients whose mean age at diagnosis was 62 years (median 60 years, range 5 to 91 years). Both the right and left orbits were affected equally, and 4 cases (4%) were bilateral. The most frequent clinical findings were limited ocular motility (54%), proptosis (50%), and palpable mass (43%). The diagnoses were established by history, systemic survey, imaging studies, and biopsy. Treatment included chemotherapy, hormone therapy, irradiation, surgical excision, or observation, depending on clinical circumstances. Among patients with sufficient follow-up, 95% died of metastasis, with overall mean survival of 15 months (median 15 months; range 3 to 96 months) after orbital diagnosis. CONCLUSIONS: The most common primary cancers that metastasize to the orbit are breast, prostate gland, and lung cancer. In 19%, there is no history of cancer when the patient presents with ophthalmic symptoms and in 10% the primary site remains obscure despite systemic evaluation. The systemic prognosis is generally poor.

Magnetic resonance scanning in orbital tumor diagnosis.

We have compared the accuracy of magnetic resonance scanning (MRI) versus computed tomography (CT) in the differentiation of lateral orbital masses. The MRI results did not improve our ability to accurately diagnose malignant epithelial and lymphoid tumors.

[Computerized tomography potentials in the diagnosis of malignant neoplasms]. / Vozmozhnosti komp'iuternoi tomografii v diagnostike zlokachestvennykh novoobrazovanii.

The results of examinations of 3,500 cancer patients carried out at the Center since 1979 are discussed. Evidence on the role of computed tomography in the diagnosis of tumors of the head, neck, lung, peritoneal cavity and retroperitoneal space is presented. The specific mode of identification of cancer and benign tumors of different sites by means of computed tomography as well as the resolving power of the method in detecting tumor are described. Particular attention is focused on differential diagnosis between malignant, benign tumors and inflammatory processes.

Tumor imaging in children.

Twnty-six children suspected of having malignant diseases were examined by Gallium-67 scintigraphy. The scintigrams were pathologic in the 20 children with final diagnoses of malignancy. The lesions visualized by scintigraphy were 12 primary tumors and eight cases of local recurrence or dissemination of cancer. Gallium-67 did not accumulate in a hematoma of the liver, and scintigraphy was normal in five children with no clinical evidence of tumor recurrence. Several cases are reported and the clinical value of 67Ca scintigraphy for detection and control of childhood neoplasms is emphasized.