Radiological Evaluation of Orbital Masses - Lieberman's...

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

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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

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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