Clinico-pathological Characteristic of Orbito-naso-cranial Communicating Lesions

doi:10.21203/rs.3.rs-3347772/v1

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Clinico-pathological Characteristic of Orbito-naso-cranial Communicating Lesions

https://doi.org/10.21203/rs.3.rs-3347772/v1

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Objective: This study aims to comprehensively analyze of orbito-naso-cranial communicating lesions to elucidate clinical manifestations, pathological classification, and specific lesion sites. The findings will enhance the diagnosis and preoperative evaluation of orbito-naso-cranial communicating lesions.

Methods: The 74 patients were classified into three groups based on the involved locations: Group A (orbito-nasal), group B (orbitocranial), and group C (orbito-naso-cranial). The clinical characteristics, pathological classification, and variations in the involved sites among these three groups were subjected to statistical analysis.

Results: Among the enrolled patients, 49 and 25 had benign and malignant lesions, respectively. Among benign lesions, neurogenic tumors (17 cases) constituted the largest proportion. Among malignant lesions, hematogenous (seven cases) and glandular (seven cases) tumors constituted the largest proportion. In the three groups, the malignant ratio in group C (55.6%, 10/18) was significantly higher than that in groups A (7.2%, 5/29) and B (37.0%, 10/27). The ethmoid sinus (35 cases) was the most prevalent site, including 24 benign and 11 malignant cases. Furthermore, there was greater invasion in the nasal cavity (28.0% vs. 0.0%, P=0.000) and anterior cranial fossa (40.0% vs. 8.2%, P=0.003) in malignant lesions than in benign lesions.

Conclusions: There is a higher incidence of orbito-nasal communication and infiltration of the nose and anterior cranial fossa in malignant tumors compared to benign lesions.

Level of Evidence: Level 4

pathology

orbito-naso-cranial

malignant

benign

tumor

The human orbit presents unique characteristics, including the complexity of the surrounding structures, such as the facial sinuses and the brain. It lies below the anterior cranial fossa, above the maxillary sinus, lateral to the ethmoid sinus and the nasal cavity, and anterior to the middle cranial fossa (medial) and the temporal fossa (lateral) (Weisman, Kikkawa 2001, Sanchez-Diaz 2018, Regoli and Bertelli 2017). The orbital bone wall has several natural openings including the optic nerve foramen, supraorbital fissure, and infraorbital fissure. Hence, tumor compression and erosion of the bone wall results in bone defects (Guibert-Tranier, Piton 1979). Consequently, pathological alterations in the orbit, paranasal sinuses, and craniocerebral structures can connect and impact each other clinically, resulting in communicative lesions.

Because of the invasion of multiple sites, the clinical symptoms of orbito-naso-cranial communicating lesions are more complex and more urgent than those of simple orbital lesions. In addition to exophthalmos, diplopia, and decreased vision, complications such as nasal stuffiness and epistaxis are encountered in tumors involving the paranasal sinuses and nasal cavity(Aftahy, Barz 2020, Ferrari, Migliorati 2021). Prognosis varies greatly with the site of involvement, and surgical resection is often difficult(Waldman, Shimonov 2022).

Orbitocranial communicating lesions are often reported as rare and complex cases. He et al. (He, Lu 2021) presented 13 patients with orbitocranial communicating tumors and orbito-naso-cranial communicating tumors. In the study, the classification of IC/EC tumors in the anterior cranial fossa was based on the use of CT and MRI modalities and involved six patients with cranionasal communicating tumors, four patients with cranio-orbital communicating tumors, and three patients with cranial-nasal-orbital communicating tumors. All patients underwent a modified Derome or transfrontal basal approach, and all tumor resections were satisfactory. Safi et al. (Safi, Behn 2017) analyzed the prognosis of orbito-nasal communicating lesions and found that for patients with invasion of the structures beyond the orbital periosteum, exenteration yields better survival results than preservation of the orbital structures in combination with radiotherapy. However, most studies contain a small number of cases, and no study has conducted a comparative analysis of the communicative mass of the orbit, sinuses, and brain. The orbit and its adjoining communicative placeholders have no uniform name as yet. This study is the first to summarize and analyze orbital, paranasal, and cranial lesions, with the aim of providing a reference for the diagnosis and treatment of orbital complex lesions.

The communication sites of the orbital communicating space differ due to different pathological types(Shin, Kondo 2015); This study analyzed 74 cases of orbital communicating space-occupying lesions to investigate the clinical manifestation and pathological classification of orbito-naso-cranial communicating lesions. The study also examined the frequency distribution of specific sites involved and their correlation with clinical pathological factors. The ultimate aim of the study was to contribute to the diagnosis and preoperative evaluation of such communicative masses.

Patients

The design of this study is a retrospective study reported accoording to the Preferred Reporting of Case Series in Surgery (PROCESS) 2020 criteria(Agha, Sohrabi 2020). The patient demographics and clinical data were obtained from the electronic medical record system of Union Hospital, which is affiliated with Tongji Medical College of Huazhong University of Science and Technology. The search was conducted on March 10, 2021 using the keywords "Orbital tumor/paranasal sinus tumor/brain tumor". To ensure the availability of complete data, we limited our analysis to cases from the period of 2010 to 2020, as the number of surgical procedures for orbital communicating tumors performed in our hospital was limited a decade ago, resulting in incomplete data.

A total of 1909 cases were initially retrieved through the electronic medical record system, out of which 109 cases met the inclusion criteria. However, 35 cases were excluded due to insufficient pathological diagnosis or incomplete information. Ultimately, a total of 74 cases were included in the analysis.

In our investigation, clinical patient files were analysed for sex, age, ocular laterality, symptoms, treatment measures and postoperative complications.

The inclusion criteria are as follows: (1) Patients diagnosed with orbito-naso-cranial communicating lesions. (2) Patients with complete medical records and data available for analysis. (3) Patients who had undergone diagnostic imaging to confirm the lesion. (4) Patients who had undergone surgical treatment for the lesion.

The Exclusion criteria are as follows: (1) Patients with non-orbito-naso-cranial communicating lesions. (2) Patients with incomplete medical records or missing data. (3) Patients who did not have complete medical records. (4) Patients who had underlying medical conditions that could confound the results (e.g., other brain tumors, neurological disorders).

Imaging data

The imaging data were evaluated in a blinded manner by a team of five experts, consisting of two radiologists and three clinical specialists, including an ophthalmologist, an otolaryngologist, and a neurosurgeon. The evaluation involved the determination of various parameters such as the size, extent, invasion site, and classification of communication of the lesion.

To ensure the accuracy of the evaluation, the experts worked independently of one another, and their findings were compared and cross-validated. The diagnostic consistency of the evaluations was deemed reasonable based on the level of agreement between the assessments.

Classification

The study utilized existing imaging data and anatomical structures of the orbit to evaluate the invasion of the orbital and surrounding tissues caused by communicating lesions. An expert panel classified the cases into three groups based on the extent of the lesion invasion. Group A consisted of lesions invading the orbit and any of the following parts: ethmoid sinus, frontal sinus, maxillary sinus, sphenoid sinus, and nasal cavity. Group B consisted of lesions invading the orbit and any of the following parts: frontal lobe, anterior cranial fossa base, sphenoid Ala, temporal lobe, middle cranial fossa base, cavernous sinus, great wing of sphenoid bone, and internal cranial segment of nerve canal. Group C consisted of lesions invading the orbit and any of the following parts: ethmoid sinus, frontal sinus, maxillary sinus, sphenoid sinus, nose, frontal lobe, base of anterior cranial fossa, wing of sphenoid bone, temporal lobe, base of middle cranial fossa, cavernous sinus, great wing of sphenoid bone, and intracranial segment of the nerve canal.

Pathological data

In our study, a total of 72 individuals who underwent surgery were included. The intraoperative pathological materials were collected and sent to the pathology department of our hospital for analysis. The tissue samples were fixed with 10% formaldehyde and processed into paraffin-embedded sections, which were subsequently stained with routine hematoxylin-eosin for microscopic examination. To ensure the accuracy and reliability of the pathological diagnosis, all cases were reviewed and reclassified by two senior pathologists according to the criteria of the WHO classification(Thompson and Bishop 2022). In addition, two patients included in the study underwent surgery at another hospital, and their pathological sections were transferred to our institution for review. The diagnosis was found to be consistent with the previous hospital's diagnosis and was included in our pathological data analysis.

Data synthesis and analysis

SPSS Statistics version 17.0 (IBM Corp., Armonk, USA) was used for analysis and statistical significance was set at P < 0.05. The comparison of benign and malignant lesions between groups with different communication sites was analyzed using independent sample chi-square test, and then pairwise comparison was conducted if the difference between groups was statistically significant. The chi-square test was performed on the invasive sites of benign and malignant tumors. When the sample size was insufficient, Fisher’s exact test was selected. In descriptive data analysis, non-normally distributed data are shown as median and interquartile range (IR),

and normally distributed variables are shown as mean and standard deviation.

Ethics approval

Ethical approval

was obtained from the Ethics Committee of Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology. We conducted it in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments.

The requirement for written informed consent was waived by the ethics committee (the Ethics Commit-tee of Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology).

Demographic data

Overall, 47 men and 27 women were included and 40 and 34 cases involved the right and left eye, respectively, with an average age of 45 years (range, 2–85 years). The course of disease ranged from 3 days to 20 years. The main symptoms include exophthalmos, eyelid swelling, vision loss, eye pain, tearing, diplopia, niffles, epistaxis, headache, abnormal facial sensation and and other symptoms. Table 1 provides further detailed demographic and clinical information.

Table 1

Demograpgic baseline clinical features
	Overall sample n = 74	O-N n = 29	O-C n = 27	O-N-C n = 18
Male sex, n(%)	47(63.5%)	18(62.1%)	18(66.7%)	7(38.9%)
Age(y)	47(31–61)	59(45–63)	43(12–58)	48(39–60)
OD, n(%)	40(54.1%)	15(51.7%)	17(63.0%)	8(44.4%)
Course	3 days-20 years	6 days-20 years	3 days-16 years	9 days-20 years
Anamnesis, n(%)
Head and face trauma	10(13.5%)	5(17.2%)	3(11.1%)	2(11.1%)
Head and face surgery	27(36.5%)	12(41.4%)	6(22.2%)	9(50%)
Main symptoms, n
Exophthalmos	32	11	15	6
Eyelid swelling	28	10	8	10
Vision loss	22	12	4	6
Eye pain	25	10	6	9
Tearfulness	11	5	4	2
Diplopia	8	3	3	2
Sniffles	6	4	0	2
Epistaxis	4	3	0	1
Headache	14	8	5	1
Abnormal facial sensation	5	2	1	2

The history of head and facial trauma and surgery accounted for a large proportion of our study cases: in the orbital-nasal group, 5 (17.2%) had a history of head and facial trauma, while 12 (41.4%) had a history of head and facial surgery. In the orbital-cranial group, 3 (11.1%) had a history of head and facial trauma, and 6 (22.2%) had a history of head and facial surgery. in the orbital-nasal-cranial group, 2 (11.1%) had a history of head and facial trauma, and 9 (50%) had a history of head and facial surgery.

Treatment measures and surgical complications

In our study, the treatment modalities used for the cases were as follows (Table 2): 49 cases (66.2%) underwent ophthalmic surgery, five cases (6.8%) received ENT (ear, nose, and throat) surgery, four cases (5.4%) underwent brain surgery, nine cases (12.2%) received combined surgery involving multiple specialties, six cases (8.1%) were treated with medication, and one case (1.4%) opted for no treatment for personal reasons. Additionally, nasal endoscopy-assisted resection was utilized in 10 cases (13.5%) of the surgeries performed.

Table 2

Treatment and complications
	Total
Treatment, n(%)
Ophthalmic surgery	49(66.2%)
ENT surgery	5(6.8%)
Brain surgery	4(5.4%)
Combined surgery	9(12.2%)
Medication	6(8.1%)
No treatment	1(1.4%)
Nasal endoscopy-assisted	10 (13.5%)
Complications (n)
Ocular complications (15)	Vision loss (6) Ptosis (5) Ocular motility disorders (3) Tearfulness (2)
Cerebral complications (6)	Cerebrospinal fluid leakage (3) Facial numbness (2) Intracranial hematoma (1)
Nasal complications (5)	Rhinorrhea (4) Oral nasal fistula (1)
Systemic complications (5)	Infection (3) Abnormal body temperature (2)

Among the patients who underwent surgical treatment, 28 individuals developed postoperative complications (Table 2). Ocular complications were observed in 15 cases, vision loss in six cases, ptosis in five cases, ocular motility disorders in three cases, and tearfulness in two cases. Cerebral complications were noted in six cases, consisting of cerebrospinal fluid leakage in three cases, facial numbness in two cases, and intracranial hematoma in one case. Additionally, five cases of nasal complications were identified, with rhinorrhea occurring in four cases and oral nasal fistula in one case. Systemic complications were also present in five cases, with three cases of infection and two cases of abnormal body temperature.

Benign and malignant

There were 49 benign space-occupying lesions (66.2%) and 25 malignant tumors (33.8%). The number of benign communicating tumors was ranked from highest to lowest (Table 3, Fig. 1): neurogenic tumors in 17 cases (34.7%), epithelial tumors in 10 cases (20.4%), inflammatory pseudotumors in eight cases (16.3%), angiogenic tumors in five cases (10.2%), proliferative lesions in three cases (6.1%), hematoma in two cases (4.1%), osteogenic tumor in one case (2.0%), myogenic tumor in one case (2.0%), lacrimal gland tumor in one case (2.0%), and germ cell tumor in one case (2.0%). The number of malignant tumors was ranked from highest to lowest (Table 4, Fig. 2): hematogenous tumors in seven cases (28%), glandular tumors in seven cases (28%), and epithelial tumors in three cases (12.0%). There were three cases of mesenchymal tissue tumors (12.0%), two cases of metastatic carcinoma (8.0%), one case of osteogenic tumor (4.0%), one case of retinal tumor (4.0%), and one case of undifferentiated carcinoma (4.0%).

Table 3

Histopathology of benign communicative occupying lesions
Histopathology	Total n = 49	O-N n = 24	O-C n = 18	O-N-C n = 7
Neurogenic
Meningoma	9	1	4	4
Schwannoma	4	0	4	0
Neurofibroma	4	0	4	0
Epithelial
Mucous cyst	4	4	0	0
Dermoid cyst	2	1	0	1
Benign cyst	2	2	0	0
Epithelial cyst	1	0	0	1
Inverted papilloma	1	1	0	0
Vascular
Vascular tumors	4	3	1	0
Hemangiopericytoma	1	0	0	1
Osteogenetic
Osteoma	1	1	0	0
Muscle derived
Myocutaneous cell tumor	1	1	0	0
Lacrimal gland derived
Pleomorphic adenoma	1	1	0	0
Germ cell derived
Teratoma	1	0	1	0
Non-neoplastic lesions
Inflammatory pseudotumor	8	5	3	0
Cell proliferation	3	2	1	0
Haematoma	2	2	0	0

Table 4

Histopathology of malignant communicative occupying lesions
Histopathology	Total n = 25	O-N n = 5	O-C n = 9	O-N-C n = 11
Blood system derived
Lymphoma	4	2	2	0
Plasmacytoma	1	0	0	1
Myeloid sarcoma	1	0	1	0
Leukemia	1	1	0	0
Glandular derived
Adenoid cystic carcinoma	3	0	1	2
Sebaceous carcinoma	2	1	1	0
Adenocarcinoma	2	0	0	2
Epithelial
Squamous cell carcinoma	2	1	0	1
Tricholemmal carcinoma	1	0	1	0
Mesenchymal tissue derived
Spindle cell sarcoma	3	0	1	2
Metastatic
Metastatic carcinoma	2	0	1	1
Osteogenetic
Osteosarcoma	1	0	0	1
Retinal derived
Retinoblastoma	1	0	0	1
Unknown
Undifferentiated carcinoma	1	0	1	0

In the orbito-nasal space-occupying group (group A), there were 24 cases (82.8%) of benign tumors and five cases (17.2%) of malignant tumors. In the orbitocranial space-occupying group (group B), there were 17 (63.0%) benign tumors and 10 (37.0%) malignant tumors. In the orbito-naso-cranial space-occupying group (group C), there were eight cases (44.4%) of benign tumors and 10 cases (55.6%) of malignant tumors. There was a significant difference in the constituent ratio of benign and malignant tumors between groups B and C (P = 0.006 < 0.05). Statistical analyses (Table 5) showed that the proportion of malignant tumors in patients with orbito-nasal communication was higher than that in patients with orbito-nasal communication.

Table 5

Analysis of the properties of different communication space occupying
	Total n = 74	O-N n = 29	O-C n = 27	O-N-C n = 18
Benign, n	49	24	17	8
Malignant, n	25	5	10	10
P₁	0.024
P₂	0.095
P₃	0.221
P₄	0.006
P₁: Chi-square test among three groups, P₂: Chi-square test group O-N vs group O-C, P₃: Chi-square test group O-C vs group O-N-C, P₄: Chi-square test group O-N vs group O-N-C

Involved Sites

The specific sites involved were statistically analyzed, and the ethmoid sinus was the most frequently involved site in all cases (N = 35). We analyzed the differences between benign and malignant tumors and the occupation of different invasive sites. Statistically significant differences were found in the proportions of nasal invasion (P = 0.000 < 0.05) and anterior cranial fossa invasion (P = 0.003 < 0.05) between the benign and malignant groups. According to the statistical results in Table 6, there was a higher likelihood of malignant occupying lesions invading the nasal and anterior cranial fossa compared to benign occupying lesions.

Table 6

Analysis of occupying properties of different invasive sites
	Benign, n	Malignant, n	Total, n	P
Ethmoid sinus	24	11	35	0.685*
Frontal sinus	16	5	21	0.253*
Maxillary sinus	12	7	19	0.744*
Sphenoid sinus	5	0	5	0.160⁺
Nasal cavity	0	7	7	0.000⁺
Anterior cranial fossa	4	10	14	0.003⁺
Middle cranial fossa	16	6	22	0.441*
* : Pearson's chi-square test + : Fisher's exact test

Representative Cases

Case 1

A 62-year-old female patient was admitted with a chief complaint of redness and inability to open the right eye for more than 3 months. The patient had no significant medical history. On examination, the right eyelid was swollen with complete ptosis. Additionally, the conjunctiva showed mixed congestion, and there was tenderness upon palpation of the sclera (+). Limited extraocular movements were observed in all directions except for medial rotation of the right eye. The degree of proptosis was measured as 10mm in the right eye and 9mm in the left eye, with an interorbital distance of 87mm. MRI imaging (Fig. 3A-C) revealed an irregular soft tissue mass adjacent to and within the right orbit, extending from the inferior posterior region towards the temporal fossa via an enlarged inferior orbital fissure, and possibly showing slight extension along the superior orbital fissure. CT scan of the orbit (Fig. 3D-F) showed a heterogeneous density mass in the posterior inferior part of the right orbit, with partial erosion of the outer wall of the orbit and extension into the temporal fossa. The patient underwent surgical resection, and the histopathological examination (Fig. 3G, H) confirmed extranodal marginal zone lymphoma. Follow-up visits showed no tumor recurrence.

Case 2

A 47-year-old female patient presented with a complaint of redness and swelling of the right eye for 2 years, accompanied by protrusion for 2 months. The patient had a history of palpitations and a head injury 18 years ago. On examination, the visual acuity was 1.0 and the intraocular pressure was 17mmHg in both eyes. The right eyelid showed redness and swelling, and a soft, indistinct mass protruded from the upper outer quadrant of the conjunctiva. Limited upward and outward gaze was observed in the right eye. The degree of proptosis was measured as 20mm in the right eye and 14mm in the left eye, with an interorbital distance of 98mm. MRI imaging (Fig. 4A-C) revealed localized thickening and expansion of the right lateral and superior walls of the orbit, along with involvement of portions of the frontal bone, temporal bone, greater and lesser wings of the sphenoid bone, and posterior wall of the ethmoid sinus. The affected bones showed increased periosteal reaction with unclear borders. Soft tissue thickening was observed in the extraconal space, eyelids, temporal muscle, and diffuse thickening of the dura mater in the right frontal-temporal region. CT scan of the orbit (Fig. 4D-F) showed extensive thickening and expansion of the right lateral and superior walls of the orbit, as well as the frontal bone, greater and lesser wings of the sphenoid bone, temporal bone, and bilateral posterior ethmoidal sinus walls. The affected bones exhibited uneven density and rough cortical surfaces, with significant periosteal reaction characterized by layered and radial needle-like projections. The patient underwent combined surgical treatment by the ophthalmology and neurosurgery departments, and the histopathological examination (Fig. 4G, H) confirmed a meningioma of the fibroblastic subtype (WHO grade I). Postoperative follow-up visits showed no complications such as cerebrospinal fluid leakage, and there was no tumor recurrence.

Orbital-associated communicative tumors are a very complex disease, and our study is the first to examine this disease by site, analyzing their similarities and differences. Studies have found that these disorders have symptoms related to the eyes, nose, and brain, but it is usually proptosis or decreased vision as the first symptom of the disease. Other symptoms, such as nasal congestion and dizziness, are not recognized until the doctor collects the history after the patient is admitted to the hospital. Previous studies(Aftahy, Barz 2020, Liang, Deng 2011, Miman, Bayindir 2009) on series of orbital communication tumors have also reported symptoms such as proptosis, nasal congestion, and dizziness. Occasionally, these symptoms are present in the same patient, which highlights the need for clinicians to consider the possibility of orbitocranial or orbital-nasal communication involvement in patients presenting with multiple site symptoms, as this may be indicative of a more extensive tumor invasion.

Our investigation revealed that a significant proportion of patients with communicative tumors had a medical history of head and face surgery or trauma, indicating a potential link between tumor invasion and these particular medical antecedents. Head and face trauma or surgery may create a conduit for communication between the orbit and cranial cavity, thereby facilitating the further development of tumors. The relationship between traumatic brain injury and brain tumor development has been previously delineated in several care reports and epidemiological studies(Shah, Sanan 2022, Dehghani, Azadi 2014, Chen, Keller 2012). However, no causal relationship between the two can currently be established. Consequently, heightened vigilance should be exercised when managing patients with a history of head and face surgery or trauma, as they may be at increased risk for developing orbital-nasal and orbitocranial communication tumors.

In our investigation, we found that surgical intervention for such tumors required the involvement of multiple departments, including ophthalmology, otolaryngology, and neurosurgery, with frequent use of endoscopy-assisted resections. The incidence of postoperative complications, such as vision loss and cerebrospinal fluid leakage, was 35.1%. many authors have described their techniques and style of approach, including the transbasal approach, where complication rates have ranged from 30 to 50%, but they have also described rates over 70%. (Feiz-Erfan, Spetzler 2008, Feiz-Erfan, Han 2005)This is due to the fact that communicative tumors tend to invade multiple sites, and a preoperative multidisciplinary assessment and combined surgical approach are essential to minimize postoperative complications after achieving complete surgical resection.

In our study, benign tumors accounted for 66.2% and malignant tumors accounted for 33.8%. Among benign communication tumors, 17 cases (34.7%) were neurogenic tumors, mainly meningiomas, which is consistent with previous reports. Meningiomas can either be primary in the orbit or intracranial meningioma mutual spread. Most of the former originate from arachnoid cells outside the optic nerve and ectopic meningeal cells inside the orbit. The latter are mostly spread from intracranial sphenoid ridge meningioma(FY 2014). Among malignant communication tumors, seven cases (28%) were hematogenesis tumors, mainly lymphoma, which is a common ocular adnexal malignant tumor, accounting for 5–15% of all extranodal lymphomas(M 2020).

In 29 cases of orbito-nasal space-occupying tumors, benign tumors accounted for 82.8% and malignant tumors accounted for 17.2%, which differed from the 58.7% reported by Wu et al., (SE 2014) potentially due to the different inclusion and classification criteria. In the orbitocranial space-occupying group, benign tumors accounted for 63.0% and malignant tumors accounted for 37.0%, which was consistent with the proportion of benign tumors reported by Wang et al.(Wang Y 2005) in 2005. In the orbito-naso-cranial space-occupying group, benign tumors accounted for 44.4% and malignant tumors accounted for 55.6%. The results showed that the proportion of malignant tumors in orbito-nasal space-occupying cases was higher than that in orbito-nasal space-occupying cases, suggesting that malignant tumors may be associated with extensive invasive communication. Therefore, in cases with imaging examinations showing the tumor communicating with the orbit, paranasal sinuses, or brain, it is advised to consider having a preoperative multidisciplinary team while making the surgical plan. Simultaneously, it is recommended that intraoperative frozen section pathological investigations be performed as much as possible in cases where there is a possibility of a malignant communication space, as they help in rapid diagnosis, distinguishing between benign and malignant nature of the tumor during surgery, and aid in determining the scope of intraoperative resection(Chevez-Barrios 2005). Wang et al.(Wang Y 2005) proposed that if the tumor was proven to be a malignant communicating tumor using frozen biopsy, the scope of resection should be expanded, and the tumor should be completely resected as far as possible. If the periorbital and eyeball have been seriously invaded and eyesight has been lost, enucleation of the orbital contents should be performed. Radiotherapy and chemotherapy were performed early after surgery to improve the curative effect.

Our study found that tumors communicating with the orbit and the anterior cranial fossa or the nasal cavity had a higher proportion of malignancy compared to benign tumors. However, in our statistical analysis of the invasion of other parts, we did not find a statistically significant difference between benign and malignant tumors.

Malignant tumors have a strong invasiveness that can easily cause bone destruction and spread widely. The anterior cranial fossa, which is composed of the orbital plate of the frontal bone, the anterior part of the sphenoid body, the winglet of the sphenoid bone, and the ethmoid plate of the ethmoid bone, and the middle cranial fossa, which is composed of the sphenoid bone body, the great wing of the sphenoid bone, and the petrous part of the temporal bone, are vulnerable to invasion by tumors. The supraorbital fissure, infraorbital fissure, and optic foramen are all distributed in these areas (Morani, Ramani 2011), making the middle cranial fossa the most vulnerable site when the tumor invades the orbit. Tumors invading the anterior cranial fossa can erode the bone wall or spread from the middle cranial fossa or paranasal sinuses. Therefore, the proportion of malignant tumors that can invade and communicate with the anterior cranial fossa is higher than that of benign lesions. The same is true for orbital space-occupying communication with the nasal cavity(Castelnuovo, Lambertoni 2021).

Therefore, if preoperative imaging data of patients show a high possibility of a malignant tumor in the orbit communicating with the nasal cavity, turbinate, or anterior cranial fossa, the final diagnosis of space-occupying requires postoperative pathological examination and immunohistochemistry. The location of imaging communication can assist clinicians in judging the lesions before surgery. Surgery alone or combined with postoperative radiation therapy and sometimes chemotherapy is the mainstay of treatment. The choice of therapy depends on the histology and aggressiveness of the tumor(Jorgensen and Heegaard 2018).

As it is a retrospective case series, it is not possible to draw causalities with respect to clinical outcome. However, we performed a detailed analysis of the patient's preoperative clinical data and imaging data. As our study involved three departments, each of which performed a variety of surgical methods, we did not explore the specific surgical modalities and prognosis of patients in more detail.

This study shows that there is a higher incidence of orbito-nasal communication and infiltration of the nose and anterior cranial fossa in malignant tumors compared to benign lesions.

Funding

This work was supported by the National Natural Science Foundation of China (81900912).

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Data availability

The data for this manuscript can be obtained from the author upon reasonable request.

Ethics approval

Ethical approval was obtained from the Ethics Committee of Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology.

Consent to publish

The authors affirm that human research participants provided informed consent for publication of the images in Figures 3 and 4.

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Clinico-pathological Characteristic of Orbito-naso-cranial Communicating Lesions

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Abstract

Figures

Introduction

Materials and methods

Patients

Imaging data

Classification

Pathological data

Data synthesis and analysis

Ethics approval

Results

Demographic data

Treatment measures and surgical complications

Benign and malignant

Involved Sites

Representative Cases

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

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