Abstract
In this article, the authors are presenting their experience and the results with the surgical treatment of intraorbital intraconal tumors based on a review of 33 constitutive cases. Our data were evaluated in comparison to other major series, and possible factors that might influence surgical outcome and survival are discussed. Thirty-three patients diagnosed with intraorbital intraconal tumors between 1998 and 2009 were treated by transcranial approach. Of these patients, there were 14 males (42.4 %) and 19 females (57.8 %). The age ranged between 2 and 70 years (mean = 36 ± 16.6 years). The follow-up period ranged between 2 and 13 years (mean = 7.3 ± 3.2 years). The most common presenting symptoms were exophthalmus and decreased visual acuity, which was seen in 21 (63.6 %) and 19 patients (57.6 %), respectively. Total resection was achieved in 23 patients (69.7 %) while subtotal resection was done in ten patients (30.3 %). Cavernoma and optic nerve sheath meningioma were the most common histologic variants, which were found in 11 (33.3 %) and 10 (30.3 %) patients, respectively. In the long-term follow-up, 54.5 % of the patients showed total ophthalmologic improvement, 9.1 % showed partial improvement, 21.2 % demonstrated unchanged ophthalmologic status, and 15.2 % showed worse ophthalmologic outcome. Transcranial approach for the treatment of intraorbital intraconal tumors is an effective approach for the management of these pathologies. The effectiveness is clearly demonstrated by the clinical results and outcomes of these patients’ groups.
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Benedicto Colli, Sao Paulo, Brazil
I congratulate the authors for presenting the results of surgical treatment of their series of 33 patients with intraconal orbital tumors. Two transcranial surgical techniques used for approaching orbital tumors are described, a transcranial superior orbitotomy through a frontotemporal craniotomy and a two-piece orbitofrontal craniotomy, removing the superior orbital ring. These approaches are not new, but the access to the medial, lateral, and central compartments of the orbit are described based on detailed surgical anatomy demonstration that helps to understand better this hard topic.
The authors emphasizes that frontotemporal orbitotomy, with opening the optic canal when needed, was sufficient for exposure of smaller apical tumors with minimal anterior globe displacement and that two-piece orbitofrontal craniotomy provided more wide exposure for large tumors, marked anterior globe displacement and exophthalmos, allowing more comfortable and secure dissection of the tumors. Although they attributed the high rate of complete tumor removal (almost 70%), to the use of transcranial approaches, they considered that the exposure technique per se did not influence the extent of the tumor removal during the intraconal approach. This reinforces their opinion that the type of the transcranial approach to be chosen is based on the surgeon experience.
The degree of invasion of the optic nerve was considered the main factor preventing total tumor resection, and this was more common among meningiomas of the optic sheath and gliomas. The results for removal of meningiomas of the optic sheath corroborate the data reported in the major series in the literature where these tumors are considered as very difficult to be removed without visual worsening. Therefore, partial resection for preserving vision can be accepted. The authors have indicated Gamma Knife therapy for patients with residual/recurrent meningiomas of the optic nerve sheath. Although this is a controversial topic, it can be an alternative therapeutic option for patients with preserved vision.
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Abuzayed, B., Kucukyuruk, B., Tanriover, N. et al. Transcranial superior orbitotomy for the treatment of intraorbital intraconal tumors: surgical technique and long-term results in single institute. Neurosurg Rev 35, 573–582 (2012). https://doi.org/10.1007/s10143-012-0393-2
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DOI: https://doi.org/10.1007/s10143-012-0393-2