Valuation of Four-Quadrant Location Method in Diagnosis and Differential Diagnosis of the Orbital Tumor by Comparison Study Combining CT and MRI with Pathology
Received Date: Nov 24, 2017 / Accepted Date: Nov 28, 2017 / Published Date: Nov 30, 2017
Purpose: To valuate four-quadrant location method in diagnosis and differential diagnosis of the orbital tumor by comparison study combining CT and MRI with pathology.
Materials and methods: Data of 87 patients (44 female and 43 males), aged 1 to 84 years were recruited in this study, including the computed tomography(CT), Magnetic resonance imaging (MRI), and histopathology diagnosis. All orbital tumors were verified radiologically and pathologically in the Hospital of Jinggangshan University from Sep-2008 to April-2016. 49 patients underwent CT scanning (31 Conventional CT and 18 dynamic contrast enhancements CT) and 38 patients underwent MR Imaging (35 dynamic contrast enhancement MRI and 3 conventional MRI). The clinical data were retrieved from the medical record. We classified the orbital region according to four- quadrant and eight-space (FQES) division and traditional muscleconal division with center point of optic nerve.
Results: Among the 87 cases of the orbital tumors, 70 cases (80.45%) were orbital benign tumors and 17 cases (19.54%) were malignant tumors. Regarding the location of the orbit, 41 lesions (47.12%) were in superolateral, 18 lesions (20.68%) were in inferolateral, 16 lesions (18.39%) were in inferomedial, 8 lesions (9.19%) were in superomedial, 3 lesions (3.44%) were in globe, 1 lesion (1.14%) was in optic nerve. The most common tumors are hemangiomas (total 36 cases: 12 in inferolateral, 8 in inferomedial, 9 in superolateral, 7 in superomedial) and 9 cases of pleomorphic adenoma were in superolateral, 9 cases of dermoid cyst ( 7 in superolateral and in 2 inferomedial), 5 cases of inflammatory pseudotumor (4 in superolateral and 1 in inferomedial), 7 cases of lymphoma (3 in superolateral, 2 in inferolateral and 2 in inferomedial ), 3 cases of adenoid cystic carcinoma in superolateral, 3 caese solitary fibrous tumor ( 2 in suprolateral and 1 in inferomedial), 3 cases lipoma (1 in superomedial, 1 in superolateral and 1 in inferolateral), 2 cases choroidal melanoma were in globe, 1 case of metastasis in superolateral, 1 case of meningioma in optic nerve, 1 case of malignant melanoma was in superolateral. The orbital tumors appeared in orbit with mostly regular, oval and rounds shape, well defined margin. The size ranged from 0.8 mm × 4.5 cm to 4.5 cm × 2.0 cm. The CT revealed iso-density in 22, slightly high–density in 15, mixed density in 6, low density in 5 and high density in 1 lesion. Among them, 18 were contrast enhancements. On T1WI image, the MRI revealed low signal intensity in 23 cases, slightly low signal in 4 cases, iso signal intensity in 7 case, high signal intensity in 3 cases, mixed signal intensity in 1 case on T2WI, it revealed high signal intensity in 23 cases, slightly high intensity in 7 cases, low signal intensity in 4 cases, iso signal intensity in 3 cases, mixed signal intensity in 1 case. Among them, 35 contrast enhancement MRI and 3 were non contrast MRI. Benign tumor was diagnosed in 70 patients, of them 34 were male and 36 were female, and the mean age was 45.19 years. Malignant tumor was diagnosed in 17 patients; of them 10 and 7 were male and female respectively, mean age was 57.71 years. There was no significant difference in the age of patients with benign versus malignant tumors (P=0.505). No significant difference was observed in patient’s gender when we compared patients with benign versus malignant tumors (P=0.448). The Right orbit was involved in 36 patients with benign tumor and 11 patients with malignant tumor. Left orbit was involved in 34 patients with benign tumor and 6 patients with malignant tumor. There was no significant difference of side of eye between the benign versus malignant tumors (P=0.324). In comparative study of four quadrant spatial distribution was show significant difference between hemangioma and pleomorphic adenoma (P=0.027) but there was no significant difference seen in other tumors e.g. between lymphoma and inflammatory pseudotumor, between hemangioma and lymphoma, and between pleomorphic adenoma and dermoid cyst. There was also show strongest significant difference between the hemangioma and pleomorphic adenoma (P=0.000) in muscleconal division of the orbit and between hemangioma and lymphoma, (P=0.001) and between hemangioma and dermoid cyst (0.000). A Comparative study of anterior and posterior division of the orbit. There was significant difference between hemangioma and pleomorphic adenoma (P=0.001) and between hemangioma and dermoid cyst (P=0.005). The most significant difference was seen between hemangioma and pleomorphic adenoma in all the comparative studies.
Conclusion: Our study found that the tumor location, margin, shape, radiological findings and pathological results provide important information for diagnosis and differential diagnosis of the orbital tumors. The four-quadrant and eight-space (FQES) division of the orbit in CT and MRI plays an import ant role in determining the location, origin and nature of orbital tumor and lesion, which may have supplementary role to traditional muscleconal division in the assessment of the orbital tumors. The most common neoplasm was orbital cavernous hemangioma and most of orbital tumor s was located in superolateral quadrant region. The role of CT and MRI in detecting the location n and morphology of orbital tumors and to estimate the degree of orbital tumors were well justified by combining the four-quadrant and eight-space (FQES) division with traditional muscleconal division, which is useful for qualitative diagnosis of orbit tumor.
Keywords: Orbital tumors, four quadrant division method, CT, MRI, Pathological diagnosis
The orbit contains globe, extra-ocular muscles, fat, vascular, nerve, connective tissue and lacrimal gland. It is a small part of the skull but variant type of tumors occurs in the orbit that may be primary or secondary tumors and metastatic tumor. The orbital tumors are classified according to their site of origin and involved of the adjustment tissues. The primary tumors arise inside the orbit with unknown causes of the lesions. The most of the primary tumors compress the optic nerve and there is deficit of vision or loss of vision and it protrudes or push forward the globe that is called Proptosis. Proptosis is most common sign of the orbital tumors, masses and inflammatory condition of orbit structures. The secondary orbital tumors arise from the surrounding of the orbit that compresses structures of orbit. As a result, there is difficulty in eye movement and deficit of vision.
The orbital metastasis is spread from others part of body e.g. breast cancer, lung cancer. The four quadrant division of the orbit is a new method of CT and MRI images assessment of the orbital lesions. The orbit is divided into four quadrants and eight spaces. The four quadrants are superomedial, inferomedial, and superolateral, inferolateral and eight spaces are anterior four spaces and posterior four spaces of the orbit. The muscleconal division is traditional method of the evaluation of CT and MRI images of the orbital lesions. It is divided into two parts of the orbit, extraconal and intraconal. The extraconal space extends from the extraocular musle to the periosteum of the orbit and intraconal space is around the optic nerve to extraocular muscles. The orbital tumor is a one of most common cause of blindness of the eye so if we do an early CT and MRI examination of the orbital tumor then we have more chances to prevent blindness and chronic eye diseases. Two third of the benign tumors and one third malignant tumors occur in the orbit . The orbital tumor has low incidence of diagnosis and there are several complications after treatment or operation such as cosmetic problems, severe ophthalmological deficit with loss of vision and eye movement . It is most important to obtain maximum information about the orbital tumor prior to deciding the appropriate treatment strategy in the order to manage post-operative complications [3-5]. For this reason we need to know relationship between pathological profiles of orbital tumors and patients age and tumor location in the orbit. Tumors are classified according to their site of origin with inside and outside of the orbit along with the characteristic of the pathogenic lesions . Previous study observed that the CT and MR images are modalities of choice for assessment of orbital tumors . It is well known that the computed tomography and magnetic resonance imaging have the most important effective on the characterization of the orbital tumors and act vital role in the management of the orbital tumor [8-10]. Therefore, understanding radiological features can facilitate the differentiation of benign from malignant orbital soft tissue masses.
The purpose of this study is to illustrate the diagnosis strategy based on four quadrant location, radiological images features and pathological findings. The study was conducted at the Hospital of Jinggangshan University, China, from sep-2008 to April-2016. We studied the location, patient’s age, sex, tumor origin, type of tumors, CT and MR imaging feature and pathological diagnosis for diagnosis and differential diagnosis in the 87 patients of the orbital tumors. The computed tomography [CT] and Magnetic resonance imaging [MRI] of the orbit were performed on all patients of orbital tumors. The location of the orbital tumor was assigned to four quadrants: superolateral, superomedial, inferolateral, and inferomedial; optic never was considered as centre point. In addition, we mention the muscleconal division: intraconal and extraconal of the orbit and anterior and posterior part of the orbit. The relationship between the CT and MRI with pathological profiles, patient age at diagnosis and tumors location in the orbit was investigated.
Materials and Methods
General information and source of data
The CT and MRI records from the Hospital of Jinggangshan University were retrieved. All patients of orbital tumors and diagnosis at Hospital from September-2008 to April-2016 were retrospectively studied. Eighty seven patients with orbital tumors aged 1 to 84 years were included in the study. All of which were verified on the basics of characteristic finding of CT & MRI and underwent biopsy or tumor resection in hospital and orbital tumors were verified histopathologically for pathological diagnosis.
Clinical symptoms and signs
We studied 87 patients with orbital tumors: Clinical symptoms of eye pain and proptosis were seen in 44 cases, orbital masses with eye pain, decreased visual acuity were seen in 17 cases, eye movement disorder with eye pain conjunctiva swelling were seen in 19 cases, decreased visual acuity and eye movement disorder with eye pain were seen in 9 cases, and there were no obvious symptoms and signs in 3 cases. The right sided lesions were seen in 47 patients and left sided lesions were seen in 40 patients.
CT and MRI examination method
The orbit CT was performed in 39 patients. For scan, we used a 64 slice MDCT scanner [GE light speed VCT, American]. The imaging parameters were classified as follows: Voltage 120 Kvp, tube current 200 mA to 400 mA, helical scan with pitch ratio, 1.375:1, collimation thickness 0.625 × 64 and slice thickness 33 mm, Matrix 512 × 512. All CT images were reconstructed by using both a soft tissue algorithm and a bone algorithm. These images were observed in soft tissue window setting (window width=400 HU and window Level=40 HU) and in a bone window setting (window width=2000 HU and window level=200 HU) respectively. The 13 patients were administered intravenous contrast (omnipaque 300, Amersham health, Princeton, NJ). The iodine contrast agent was injected at a rate of 2.5 ml/sec. The orbit MRI was performed in 26 patients, for scan we used a 3T MRI unit (GE, sigma HDxt, America). The parameters were classified as: T1WI FSE sequence (TR: 720 to 1972 ms, and TE: 12.0 to 21.9 ms) and T2WI FSE sequence (TR: 4480 to 8571 ms, and TE: 95.0 to 119.6 ms). A contrast enhanced imaging obtained with T1WI LAVA (TE: 1.2 to 2.6 ms,) or 3DBRAVO (TR=7.8 ms, TE=3.0 ms), Matrix = 256 × 256, FOV=20 × 20 cm, thickness=3 mm and gap=0.5 cm. The Gd-DTPA was injected at a rate of 2 to 3 mL/sec.
CT and MR images evaluation and orbital division Method
The patients underwent either CT or MRI or both. The orbital tumors were divided into four quadrants of the orbit, superolateral, superomedial, inferolateral, and inferomedial, whereby optic nerve was considered as centre point. On the basis of CT and MRI findings for each tumor, the features namely location, shape, margin, size, density with HU, signal intensity of T1WI and T2WI, enhancement pattern and infiltrative adjustment tissues were analyzed. The pattern of enhancement was graded as gradual, marked, intermediate, mixed, boundary, and slightly homogeneous and heterogeneous enhancement. The pathological profile of the tumors were studied basis on the tumor location, origin, age, sex, shape, margin, size.
In the axial section image of MRI, the orbital septum was divided into anterior and posterior part of the orbit (Figures 1A and 1D).
Figure 1: A) The orbital septum was used for differentiated location of anterior and posterior part of orbit. B) The posterior part of the lesion was positioned with optic nerve in coronal section image. C) The lesion around the globe was positioned with annulus of eye in centre of coronal section image. D) The orbital septum was used for anterior and posterior part of lesion on sagittal section image.
The posterior part of lesion
In the coronal section image of MRI, optic nerve is the centre point of the four quadrants. It is divided into vertical and horizontal axis lines that help to determine and estimate the location of the orbital tumor in posterior part of orbit (Figure 1B).
In the coronal section image, the anterior part of the orbit is divided into four quadrants by vertical and horizontal axis lines; superiolateral, superomedial, inferomedial and inferolatral (Figure 1C).
In the muscleconal method, the orbit is divided by the extraocular muscle into extraconal and intraconal space. The extraconal space lies between extraocular muscle and bony cage of the orbit and the intraconal space lies between extraocular muscle and the surrounding of the optic nerve.
The data analysis was performed using statistical package for social science (SPSS) Version 16.0(SPSS, Chicago, IL) The frequency distribution of individual CT and MR images feature in the benign tumor was compared with malignant tumor by using Chi-square tests. P value of less than 0.05 was considered to represent a significant difference.
The orbital tumors were histopathologically confirmed in all 87 patients (43 male and 44 female mean age 47.63 years range 1-84 years). Benign tumor was diagnosed in 70 patients, of them 34 were male and 36 were female, and the mean age was 45.19 years. Malignant tumor was diagnosed in 17 patients; of them 10 and 7 were male and female respectively, mean age was 57.71 years. There was no significant difference in the age of patients with benign versus malignant tumors (P=0.505) (Table 1). No significant difference was observed in patients’ gender when we compared patients with benign versus malignant tumors (P=0.448) (Table 2). The right orbit was involved in 36 patients with benign tumor and 11 patients with malignant tumor. And left orbit was involved in 34 patients with benign tumor and 6 patients with malignant tumor. There was no significant difference of side of eye between the benign versus malignant tumors (P=0.324) (Table 3). The results presented in Table 4 show that a total 70 (80.45%) patients had benign tumors. Of them, 36 (41.37%) had hemangiomas, 9 (10.34%) had pleomorphic adenomas, 9 (10.34%) had demoid cysts, 5 (5.74%) had inflammatory pseudotumors, 3 (3.44%) had solitary fibrous tumors, 3 (3.44%) had lipomas, 1 (1.14%) had meningioma, and 1 (1.14%) had schwannoma, 1 (1.14%) had granulomatous inflammation, 1 (1.14%) had lymphangiomyoma and 1 (1.14%) had cystadenoma. Among 17 (19.54%) diagnosed with malignant tumors, we found that 7 (8.04%) had lymphomas, 3 (3.44%) had Adenoid cystic carcinomas, 2 (2.29%) had choroidal melanomas, 1 (1.14%) had malignant melanoma, 1 (1.14%) had dedifferentiated chondrosarcoma, 1 (1.14%) had metastasis, 1 (1.14%) had retinoblastoma and 1 (1.14%) had squamous cell carcinoma.
|Age group||Benign tumor (%)||Malignant tumor (%)||P-value|
|0-30||13 (18.6%)||2 (11.8%)||0.505|
|>30||57 (81.5%)||15 (88.2%)|
Table 1: Benign versus malignant tumors of age groups.
|Sex||Benign tumor (%)||Malignant tumor (%)||P-value|
|Male||34 (48.6%)||10 (58.8%)||0.448|
|Female||36 (51.4%)||7 (41.2%)|
Table 2: Benign versus malignant tumor of sex of patients.
|Side of eye||Benign tumor (%)||Malignant tumor (%)||P- value|
|Right||36 (51.4%)||11 (64.7%)||0.324|
|Left||34 (48.6%)||6 (35.3%)|
Table 3: Benign versus malignant tumor of side of eye.
|S/N||Name||Case of number||Percent|
|6||Adenoid cystic carcinoma||3||3.44%|
|7||Solitary fibrous tumor||3||3.44%|
|18||Squamous cell carcinoma||1||1.14%|
|S/N: Serial Number; Infla: Inflammation|
Table 4: Constitutions ratio of orbital tumor.
The orbital tumors’ size ranged from 0.8 mm × 4.5 cm to 4.5 cm × 2.0 cm. Average size was 2.2 cm ×1.8 cm. In 49 cases from CT findings, 23 cases (23/49) had irregular shape, 13 cases (13/49) had oval shape, 8 cases (8/49) had round shape, and 5 cases (5/49) had regular shape (Chart 1). Specifically, we observed 32 cases (32/39) with well-defined margin and 17 cases (17/39) ill-defined margin. According to orbital tumors findings on density, we found 22 cases (22/39) with iso-density, 15 cases (15/39) with slightly high density, 6 cases (6/39) with mixed density, 5 cases (5/39) with low density and one case (1/39) with high density. Non-contrast enhancement CT value ranged from 12 to 122 Hounsfield units, while CT contrast enhancement value ranged from 55 to 82 Hounsfield units. Out 18 cases that received radio-contrast, 7 of them showed slightly homogeneous enhancement, 3 showed slightly heterogeneous enhancement, 3 showed marked homogeneous enhancement, 2 showed marked heterogeneous enhancement, 2 showed mixed heterogeneous enhancements, and one showed focal heterogeneous enhancement (Chart 2). In general, we observed 8 cases with infiltrative adjustment tissues. The tumors size ranged from 0.7 cm × 1.2 cm × 0.6 cm to 4.0 × 3.5 cm × 2.5 cm, in MRI. Among 38 cases from MRI findings, 14 cases (14/38) were irregular shaped, 12 cases (12/38) were round shaped, 8 cases (8/38) were ovals shaped, 4 cases (4/38) were regular, 32 cases (32/38) were well defined margin, and 6 cases (6/38) were ill defined margin. The findings from MRI results show that most of the cases were low signal intensity on T1WI and high signal intensity on T2WI (Chart 1). Among them, 35 cases were contrast enhancement and 3 cases was non-contrast, 14 cases showed gradual homogeneous enhancement and 1 case showed gradual heterogeneous enhancement, 7 cases showed marked homogeneous and 4 showed marked heterogeneous enhancement, 3 cases showed intermediate homogeneous enhancement, 2 cases showed mixed heterogeneous enhancement, 3 cases showed boundary heterogeneous enhancement and 1 case showed slightly homogeneous enhancement. Among them, 5 cases were infiltrative adjustments of tissues (Chart 2).
According to the four quadrant location in the orbit, we found that 41 (47.12%) patients had tumor in superolateral quadrant, 18 (20.68%) in inferolateral quadrant, 16 (18.39%) in inferomedial quadrant, and 8 (9.19%) in superomedial quadrant. In addition, 3 (3.44%) lesions were found in the globe and 1 (1.14%) was found in center of the quadrant (Table 5). We observed that most of tumors were located in superolateral area (Graph 1). 41 lesions (47.12%) included 9 pleomorphic adenomas, 9 hemangiomas, 7 dermoid cysts, 4 inflammatory pseudotumors, 3 Adenoid cystic carcinoma, 3 lymphoma, 2 solitary fibrous tumors 1 lipoma,1 lymphangiomyoma, 1 cytadenoma, and 1 squamous cell carcinoma. In inferolateral area, we found 18 (20.68%) lesions, including 12 hemangioma, 2 lymphomas, 1 inflammatory peudotumor, 1 lipoma, 1 metastasis, 1 dedifferentiated chondrosarcoma. Within inferomedial area, we obseved 16 (18.39%) lesions, including 8 hemangioma, 2 dermoid cyst, 2 lymphoma, 1 solitary fibrous tumor, 1 malignant melanoma, 1 schwannoma 1 granulomatous inflammation. In superomedial area, we found 8 (9.19%) lesions, including 7 hemangiomas, 1 lipoma. In the globe, we obseved 3 (3.44%) lesions, including 2 choroidal melanoma and 1 retinoblastoma and 1 meningioma was observed in centre of quadrant (Tables 4 and 5). There was significant difference in four quadrant locations when compared with benign versus malignant tumor (P=0.023) (Table 6). Most of the orbital tumors were located in the superiolateral quadrant, 32 (45.7%) benign tumor and 6 (35.3%) malignant tumors, 15 (21.4%) benign tumor and 3 (17.6%) malignant tumor in inferolateral quadrant, 13 (18.6%) benign tumor and 3 (17.6%) malignant tumors were located in inferomedial quadrant, 9 (12.9%) benign tumor and 2 (11.8%) malignant tumor located in superomedial quadrant of the orbit. There was also significant difference between the lateral and medial side of the orbit where we found that most of the orbital tumors were located in the lateral side compared to the medial side of the orbit. Still on tumor location, we found that 56 (64.3%) orbital tumors were located in lateral side of the orbit and 27 (31.03%) orbital tumors were located in the medial side of the orbit. Moreover, we observed that most of the malignant tumors were located in lateral side of the orbit. When we studied the muscleconal division of orbit, we found that 54 (62.06%) lesions were in extraconal area, 30 (34.48%) lesions were in intraconal area, 3 (3.44%) lesions were in the globe (Graph 2). Among 54 patients with extraconal tumors, we observed 41 (58.8%) with benign tumors and 13 (76.5%) with malignant tumors (Table 7). Among 30 patients with intraconal tumors, we observed 29 (41.4%) benign tumors, and 1 (5.9%) malignant tumor. Specifically, we found 3 patients with tumors in the globe. There was significant difference in muscleconal division with benign versus malignant (P=0.000) (Table 8). Regarding the anterior and posterior part of the orbit, we observed that 56 (64.36%) lesions were in posterior part, and 31 (35.63%) lesions were in anterior part of the orbit (Graph 3). Of 56 lesions found in posterior part of the orbit, 46 (65.7%) were benign tumors and 10 (58.8%) were malignant tumors. A total of 31 patients were in anterior part of the orbit, of them 24 (34.4%) had benign tumors and 7 (41.2%) had malignant tumors. There was no significant difference in anterior and posterior part of eye with benign versus malignant (P=0.675) (Table 9). In comparative study of four quadrant spatial distribution was show significant difference between hemangioma and pleomorphic adenoma (P=0.027), but there was no significant difference seen in other tumors e.g. between lymphoma and inflammatory pseudotumor, between hemangioma and lymphoma, and between pleomorphic adenoma and dermoid cyst (Table 10). There was also show strongest significant difference between the hemangioma and pleomorphic adenoma (P=0.000) in muscleconal division of the orbit and between hemangioma and lymphoma, (P=0.001) and between hemangioma and dermoid cyst (0.000). A Comparative study of anterior and posterior division of the 7 orbit. There was significant difference between hemangioma and pleomorphic adenoma (P=0.001) and between hemangioma and dermoid cyst (P=0.005). There was no significant were show between hemangioma and lymphoma, between lymphoma and speudotumor. The most significant difference was seen between hemangioma and pleomorphic adenoma in all the comparative studies (Tables 11-21).
|S/N||Name||Number of case||Sup/med||Sup/lat||Infero/med||Infero/lat||Globe||Optic nerve|
|6||Adenoid cystic carcinoma||3||0||3||0||0||0||0|
|7||Solitary fibrosis tumor||3||0||2||1||0||0||0|
|18||Squamous cell carcinoma||1||0||1||0||0||0||0|
|S/N: Serial Number; sup/med: Superomedial; sup/lat: Superolateral; infero/med: Inferomedial; infero/lat: Inferomedial; Dedi: Dedifferentiated|
Table 5: Distribution of orbital tumor.
|Location||Benign tumor (%)||Malignant (%)||Total (%)||P-value|
|Superolateral||32 (45.7%)||6 (35.3%)||43.7%||0.023|
|Superomedial||9 (12.9%)||2 (11.8%)||12.6%|
|inferolateral||15 (21.4%)||3 (17.6%)||20.7%|
|Inferomedial||13 (18.6%)||3 (17.6%)||18.4%|
|In globe||0 (0.0%)||3 (17.6%)||3.4%|
|In optic never||1 (1.4%)||0.0%||1.1%|
Table 6: Significant different of four quadrant location of benign tumor versus malignant Tumor.
|Adenoid cystic carcinoma||3||0||3||0|
|Solitary fibrous tumor||2||1||3||0|
|Squamous cell carcinoma||0||1||1||0|
Table 7: Distribution of anterior posterior and extraconal, intraconal division of the orbit.
|Muscle conal||Benign tumor (%)||Malignant tumor (%)||P-value|
|Extraconal||41 (58.6%)||13 (76.5%)||0.000|
|Intraconal||29 (41.4%)||1 (5.9)|
|In globe||0.0%||3 (17.6%)|
Table 8: Significant different of muscleconal division of benign versus malignant.
|Orbit||Benign tumor (%)||Malignant tumor (%)||P-value|
|Anterior||24 (34.2%)||7 (41.2%)||0.675|
|Posterior||46 (65.7%)||10 (58.8%)|
Table 9: Significant different of Anterior and posterior orbit benign versus malignant tumor.
Table 10: A Comparison of the spatial distribution between cavernous hemangioma and pleomorphic adenoma.
|Location||Lymphoma (%)||Infla.pseudotumor (%)||P-value|
|superiolateral||3 (42.9%)||3 (60.0%)||0.379|
|superomedial||0 (0.0%)||1 (20.0%)|
|inferolateral||2 (28.6%)||1 (20.0%)|
Table 11: A Comparison of the spatial distribution between lymphoma and inflammatory pseudotumor.
|Location||Hemangioma (%)||Lymphoma (%)||P-value|
|superiolateral||9 (25.0%)||3 (42.9%)||0.626|
|superomedial||7 (19.4%)||0 (0.0%)|
|inferolateral||12 (33.3%)||2 (28.6%)|
|Inferomedial||8 (22.2%)||2 (28.6%)|
Table 12: A Comparison of the spatial distribution between hemangioma and lymphoma.
|Location||Pleomorphic adenoma (%)||Dermoid cyst (%)||P-value|
|superiolateral||7 (77.8%)||7 (77.8%)||0.261|
|superomedial||1 (11.1%)||0 (0.0%)|
|Inferomedial||0 (0.0%)||2 (22.2%)|
Table 13: A Comparison of the spatial distribution between pleomorphic adenoma and dermoid cyst.
Table 14: A Comparison of the anterior and posterior division of orbit between cavernous hemangioma and pleomorphic adenoma.
Table 15: A Comparison of the anterior and posterior division of orbit between hemangioma and lymphoma.
|Location||Hemangioma||Dermoid cyst||P- value|
Table 16: A Comparison of the anterior and posterior division of orbit between hemangioma and dermoid cyst.
Table 17: A Comparison of the anterior and posterior division of orbit between lymphoma and speudotumor.
|Location||Pleomorphic adenoma||Dermoid cyst||P- value|
Table 18: A Comparison of the anterior and posterior division of orbit between pleomorphic adenoma and dermoid cyst.
Table 19: A Comparison of the intraconal and extraconal division of orbit between hemangioma and pleomorphic adenoma.
Table 20: A Comparison of the intraconal and extraconal division of orbit between hemangioma and lymphoma.
Table 21: A Comparison of the intraconal and extraconal division of orbit between hemangioma anddermoid cyst.
In the present study, 87 patients were diagnosed with orbital tumors by histopathological diagnosis and radiological diagnosis. There was no significant difference in the age of patients with benign versus malignant tumor. No significant difference was observed in the sex of the patients with benign versus malignant tumor. In line with our findings, a previous study found no significant difference in the age and sex of patients with benign versus malignant tumor. The same study reported no significant difference in the side involvement of tumors between the benign versus malignant tumor but previous study showed significant deference between the benign versus malignant tumor . The age of the patients was divided into two group, group A (0-30 years) and group B (>30 years). Our study showed more orbital tumor affected in group- B compared to group A and also seen most of malignant tumor in group B than group A. The incidence of orbital tumors was relatively low in <30 years older patients. The pathological profile of the patients aged >40 years showed that the patients from this age group were more likely to be diagnosed with both orbital tumor and malignant tumor.
Location of the orbit was divided in four parts, superior, inferior, lateral, medial and optic nerve is central pint of orbit. We further classified location in four quadrants of orbit: superolateral, superomedial, inferolateral and inferomedial with eight spaces in the orbit. We found a significant difference of four quadrant location of the orbit of benign versus malignant orbital tumors. Most of the benign and malignant tumors were located in superolateral quadrant and extraconal space. There are also significant differences between the lateral and medial side of the orbit. Most of the orbital tumors were located in lateral side of the orbit compared to medial side of the orbit. Most of the malignant tumors were located in lateral side compared to the medial side of the orbit. And regarding the muscleconal division of the orbit, intraconal space is between the outside of optic nerve to inside extraocular muscle area. And extraconal space is between the outside of extraocular muscle to inside of orbital bony cage. There was strongest significant difference of the muscleconal division with benign tumor versus malignant tumor. (P=0.000) Almost all malignant tumors were located in extraconal space. 62.6% lesions were in extraconal space and 34.48% lesions were in intracobal space. Most of the benign and malignant tumors were in posterior part as compared to the anterior part of the orbit. Most of the tumors located in superolateral quadrant, were more of benign tumors but malignant tumor were more than other quadrants, among of them many malignant tumors related with lacrimal gland. The cavernous hemangioma was found in all four quadrants, but among them more cavernous hemangiomas were located in inferolateral quadrant and fewer cavernous hemangiomas were located in superomedial quadrant. Previous studies reported similar result to our study [12-13]. Most of the pleomorphic adenoma, dermoid cyst, lymphoma, adenoid cystic carcinoma and inflammatory pseudotumor, solitary fibrous tumor are located in superolateral quadrant. Other tumors were located in different quadrants of the orbit. The retinoblastoma and choroidal melanoma were in the globe and meningioma was in central point of quadrant in orbit.
CT and MRI images feature had high enough sensitivity to distinguish between benign and malignant orbital tumors. However our study showed that most of the malignant tumors had ill-defined margins, irregular shape, infiltrative adjustment of tissues and bone erosion, Isodensity/slightly high density, low signal intensity on T1WI, iso or slightly high signal intensity on T2WI and heterogeneous enhancement. Most of the benign tumors had well defined margin, oval/round shape, isodensity, low intensity on T1WI, high or slightly signal intensity on T2WI and homogeneous enhancement. Similarly, Xian et al. radiological features found that in our results . CT and MRI image study performed for evaluation of the orbital tumor, and certain diagnostic criteria applied in analysis of the orbital tumors, such as patient’s age, sex, size, shape, margin, density, CT value, signal intensity, contrast enhancement pattern and invaded adjustment tissues and bone. It was previously documented that CT and MRI images are important modalities in diagnosis and assessment of the location and extend of a pathological process prior to surgical exploration and others differential diagnosis [14-15].
The cavernous hemangioma is the most common intraorbital tumor found in adults. A previous study reported an incidence of 4.3% among orbital tumors . The most of the common sign and symptoms was pain less proptosis, diplopia, lump and recurrent obstructed vision. Most of the cavernous hemangioma was found between the optic nerve and extraocular muscles with lateral aspect of the intraconal space [13,16]. Our study showed that mostly cavernous hemangioma were with well-defined margin, oval/ round shaped, intraconal space, slightly high density, low signal intensity on T1WI, high signal intensity on T2WI and gradual homogeneous enhancement (Figure 2). The previous result was similar finding with our result [12,17-19]. Schwannoma is a rare orbital tumor that from Schwann cell in the peripheral nervous system [20-22]. The orbital schwannoma commonly origin from sensory branch of the ophthalmic division of the trigeminal nerve. On CT and MRI, schwannoma usually presents as a well-defined margin, regular mass, isodense/slightly high dense, low signal intensity on T1WI, slightly high signal intensity on T2WI and marked homogeneous enhancement.
The orbital cavernous hemangioma and schwannoma presenting with slow progressive enlargement and most of clinically and radiological feature are similar to each other [23-25]. The dynamic contrast enhancement MRI are useful to distinguish between cavernous hemangioma and schwannoma . After Gadolinium administration in both patients: showed enhancement starting from small point or portion and contrast media filling up to tumor, called “progressive enhancement” in cavernous hemangioma and in schwannoma: showed enhancement starting from widely area and heterogeneous enhancement later. So compared with orbital cavernous hemangioma, no progressive enhancement pattern was seen in orbital schwannoma. So progressive enhancement pattern was one of the better findings to differentiate both the tumors [17,27]. On the imaging study, most of the cavernous hemangiomas were separated but compressed the optic nerve and extraocular muscles and schwannoma was usually seen overlapping the optic nerve.
Orbital pleaomorphic adenoma
The pleomorphic adenoma is a benign tumor, painless slowly growing, rare tumor and unilateral mass of the lacrimal gland. The total account 30% of epithelial tumor of the lacrimal gland, lesion while 12% of the pleomorphic adenoma . The pleomorphic adenoma has 75% chances to transform into adenocarcinoma, while the less transform into adenoid cystic carcinoma. The adenoid cystic carcinoma is malignant tumor, usually painful, aggressive growing and unilateral mass of lacrimal gland. It accounts for 30% to 50% of malignant tumor of the lacrimal gland. The radiological features of the adenoid cystic carcinoma are an infiltravive mass on CT, isodensity, often associated with bony destruction. On MRI, hypointense on T1WI, isointense on T2WI and moderate enhancement after contrast Gd- DTPA administration (Figure 3). Our study shows regular/oval shaped well defined, mixed isodensity and mixed heterogeneous enhancement in pleomophic adenoma and irregular shaped, ill defined, isodensity, slightly heterogeneous enhancement and infiltrative adjustment tissues and bone erosion in adenoid cystic carcinoma (Figure 4) [29,30].
Orbital dermoid cyst/epidermoid cyst
Demoid cyst and Epidermoid cyst are benign tumors and belong to choroistomas, which originate from aberrant ectoderm tissue, dermoid and epidermoid cyst are lined by keratinized stratified squamous epithelium. They may displace structure in the orbit causing abnormalities in eye movement, proptosis, diplopia, and may cause optic nerve complication. They were frequently seen in the suprolateral, extraconal space and between the globe and orbital periostem. Differentiation between the dermoid and epidermoid cyst is not usually possible to determine during the clinical and radiological examination. A histopathological result shows the difference between these two cysts. The dermoid cysts contain extra dermalis and produce keratin. Most of the cysts contain blood vessel, hair follicles fat tissues, collagen sebaceous gland and fat tissue [31,32]. The CT and MRI finding is one of the key to define the differential diagnosis of dermoid and epidermoid cyst with others benign and malignant tumors of the orbit. On the CT and MRI, NECT shows a well circumscribed cystic tumor of the low or fat density and calcification may be seen, and (Figures 5 and 6) on MRI typically appear hyperintense on T1WI and hypointense on T2WI [33,34].
Orbital meningioma is a slow growing benign tumor, arising from arachnoid cap cell of the optic nerve sheath. Orbital meningioma accounts for 4-8% of total orbital tumors. It has a common presentation of visual loss, proptosis, painless and progressive mass. Primary orbital meningioma arises from optic nerve sheath and may extant through the optic canal intracranial or sphenoid wing. And secondary orbital meningiomas usually arise from the inner or outer aspects of sphenoid wing. It has a homogeneous enhancement surrounding the optic nerve, intermediate signal intense on the T1WI and T2WI seen (Figure 7) and calcification may seen on CT images. Orbital meningioma is distinguished from orbital lymphoma in a sense that it typically shows less intense enhancement than meningioma, and mould around structures present in lymphoma, and calcification are not seen in lymphoma but in orbital meningioma we can frequently see calcification on CT images. In optic glioma, optic nerve is dilated and enlarged, and in orbital schwannoma it is usually seen overlapping of the optic nerve, while in orbital meningioma it is seen surrounding of the optic never on CT and MRI (Figure 8).
Metastatic tumors are found more in the anterior orbit than the posterior orbit . They most frequently metastatise to the prostate gland, breast, lung, kidney, melanoma carcinoid, neuroblastoma and rhabdomyosarcoma. The most common cause of orbital metastasis in women is breast cancer and in men is lung cancer. Tumor pattern is diffusing infiltrative with obscured anatomical landmark to a focal- well defined mass. CT and MRI features are ill defined margin, irregular shape iso/slightly high density, and hypo intense on T1WI and T2WI and slightly heterogeneous enhancement.
The Choroidal melanoma arises from the blood vessels of choroid of the retina. It is common primary malignant intraocular tumor and second commonest type of primary melanoma in the body. Choroidal melanoma is usually asymptomatic with painless, progressive visual loss and paracentral scotoma in routine examination of the orbit. It is mostly seen as dome or mushroom shaped and as a well circumscribed mass under the retina pigment epithelium. CT and MRI shows well defined margins, hyperdense, high signal intense on T1WI, and low signal intensity on T2WI (Figure 9). Retinoblastoma also arises from the retina. It is most common malignant tumor in children’s (<5 years). Retinoblastoma may be hereditary or in sporadic from; in both cases patients have mutation of retinoblastoma tumor suppressor gene on chromosome 13q14 [33,36]. CT and MRI shows irregular shaped mass, ill-defined margins, hyperdense, hyperintense on T1WI and hypointense on on T2WI and market heterogeneous enhancement. The CT and MRI finding of retinoblastoma are similar to choroidal melanoma but we can distinguish by age of the patients, shape and margin of tumor. Malignant melanoma is the commonest intraocular malignant lesion in adults . It is of melanocytic origin, commonly seen on skin and others sites of mucous membranes. Melanocytes arise from the neural crest cell and produce pigmented melanin then migrate to uvea epidermis and others parts. The commonest orbital malignant melanoma is uveal melanoma, because the uvea is the vascularised portion of the eye, hence a substrate for primary and metastasis neoplasm . The uveal melanoma is sub- classified into anterior uveal melanoma, which arise from the Iris and posterior uveal melanoma arises from the choroid or ciliary body. The choroidal melanoma is commonest malignant tumor in adults. The MRI is the modality of choice for melanoma, T1WI shortness and T2WI is relaxation time so leading to hyperintense on T1WI and hypointense on T2WI. The amelanotic melanoma was seen on MRI similar finding to others tumors with hypointense on T1WI and hyperintense on T2WI and MRI pattern may differentiate between the malignant melanoma and amelanotic melanoma. The similar combinations of pattern, hyperintense on T1WI and hypointense on T2WI have seen in others intraocular lesions like, serous retinal detachment, choroidal melanoma, retinoblastoma, hemorrhagic detachment, retinal capillary hemangioma and inflammatory granuloma due to porteineous contents or blood degradation product .
Orbital dedifferentiated chondrosarcoma
Dedifferentiated chondrosarcoma is a low grade, rare chondrosarcoma and present as a poorly differentiated sarcoma. It is more aggressive highly mitotic and poorly differentiated neoplasm [40,41]. There are a number of histopathologically different type of chondrosarcoma: clear cell chondrosarcoma, myxoid chondrosarcoma, and mesenchymal chondrosarcoma. Our CT and MRI finding, irregular shaped, ill-defined margin, hypointense on T1WI, hyperintense on T2WI and mixed heterogeneous enhancement (Figure 10). Location introlateral quadrant, left side eye, MIRI diagnosis is lymphoma.
Lipoma is well circumscribed slow growing, benign tumor, composed of mature fat cell grouped in lobules by connective tissue septa . These tumors are rare and 1% of all orbital tumors [5,43]. The fibrolipoma is benign tumor that usually found in men in peak incidence is fifth to sixth decade of life and spindle cell lipoma is a welldefined, mobile mass, usually found the superior neck, upperback and shoulder of the male adults in fifth to seventh decade of life. The MRI is usuful for diagnosis of all different variety of lipopma. On MRI usually seen high signal intensity on T1WI and relatively decrease signal intensity on T2WI and fat suppressed MRI is supportive diagnosis for all types of lipoma. On CT shows hypodensity on non-contrast. Differential diagnoses of fibrolipoma are angiolipoma, myxoidlipoma fibrous histocytoma and differential dsiagnosis of spindal cell lipoma are solitary fibrous tumor, hemangiopericytoma and myofibroblastoma.
Orbital solitary fibrous tumor
The solitary fibrous tumor is a rare, benign, Spindle cell tumor that is most commonly found in visceral pleura. The orbital is one of the common extra pleural sites of occurrence. There have been more than 50 cases reported worldwide since first description in the orbit by westra et al. . The solitary fibrous tumor can occur any site of the orbit but more commonly involve in superolateral extraconal . The CT and MRI feature are usually seen the well-defined margin, regular shaped, iso-density, iso-intense on T1WI, and iso-intense/hypointense on T2WI and heterogeneous or homogeneous enhancement (Figure 11). The conforming diagnosis of solitary fibrous tumor is by immunohistochemical methods. The immunohistological studies show the strong and diffuse positive to CD34, vimentin, bcl-2 and negative to desmin, cytokeratin, factor VIII-related antigen, S-100, SMA and muscle specific actins . Distinguish of solitary fibrous tumor from hemangiopericytomas, the result shows in consistent weak positively to CD34 and other hand shows positively to desmin and actins, and negativity to bcvl-2 and CD34 in others tumors. On the CT and MRI differential diagnosis for highly vascular orbital lesions include: cavernous hemangioma, hemangiopericytoma and giant cell angiofibroma. The cavernous hemangioma is distinguished from solitary fibrous tumor by hyper-intense on T2WI and different enhancing characteristic showing the delayed contrast enhancement. The orbital hemagiopericytoma is distinguished on imaging study from solitary fibrous tumor by the market enhancement, bone erosion, infiltrative adjustment tissues.
The orbital lymphoma is mostly primary malignant tumor in adults [46,47]. It is commonly present in fifth to seventh decade of life. The commonest malignant tumor of the orbit is typically B-cell lymphoma of the non-Hodgkin type, arise from mucosa- associated lymphoid tissues of the ocular adnexa . It is usually seen infiltrating structures in superolateral quadrant with frequent involvement of superior and lateral rectus muscles. The orbital malignant lymphoma usually manifests as a diffuse solid, enhancing mass with molding around the globe on images studies, and reflecting the irregular infiltrative of orbital structures [1,4,49-52]. Our result revealed that, on CT and MRI shows, ill-defined margin, irregular shaped, iso-density, iso-intense on T1WI and hyper-intense on T2WI and homogeneous enhancement (7), the earlier studies that showed orbital lymphoma appeared to iso-intense on T1WI and hyper-intense on T2WI . But most of the orbital lymphoma appeared iso-intense on T1WI and T2WI. The orbital inflammatory pseudotumor is idiopathic, benign tumor, noninfective inflammatory tumor in the orbit, with unknown causative factors it has most common sign and symptoms such as painful and unilateral mass which help to distinguish from thyroid associated ophthalmopathy. It is usually diffuse type of inflammatory disease. It is difficult to differentiate from others inflammatory diseases and neoplasms. However, a quick response to a trial steroid therapy may help the diagnosis. Orbital lymphoma can be very difficult to distinguish from orbital pseudotumor, however the lymphoma is usually seen with decreased density on delayed images in dual- phase-spiral CT contrast, and orbital pseudotumor is mostly seen with increased density on delayed images in dual-phase CT contrast . Orbital lymphoma is also typically seen with a brighter DWI signal and lower apparent diffusion coefficient (ADC) than normal orbital structures and orbital pseudotumor is seen with intermediate DWI and ADC signal, similar to normal lacrimal gland . We evaluated the diagnostic relationship between radiological diagnosis and pathological diagnosis. The CT and MRI diagnosis had 56.32% similarity with pathological diagnosis and 43.67% is misdiagnosed in the CT and MRI in our studies. Benign tumors are most often correctly diagnosed as compared to malignant tumors (Figures 12-15).
Our study found that the tumor location, margin, shape, radiological findings and pathological results provide important information for diagnosis and differential diagnosis of the orbital tumors. The fourquadrant and eight-space (FQES) division of the orbit in CT and MRI plays an import ant role in determining the location, origin and nature of orbital tumor and lesion, which may have supplementary role to traditional muscleconal division in the assessment of the orbital tumors. The most common neoplasm was orbital cavernous hemangioma and most of orbital tumors were located in superolateral quadrant region. The role of CT and MRI in detecting the location and morphology of orbital tumors and to estimate the degree of orbital tumors were well justified by combining The four-quadrant and eight-space (FQES) division with traditional muscleconal division, which is useful for qualitative diagnosis of orbit tumor.
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Citation: Akter GS, Hasan MZ, Sana DS, Nayem SI, Islam MS, et al. (2017) Valuation of Four-Quadrant Location Method in Diagnosis and Differential Diagnosis of the Orbital Tumor by Comparison Study Combining CT and MRI with Pathology. J Pain Relief 6: 306. DOI: 10.4172/2167-0846.1000306
Copyright: © 2017 Akter GS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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