Thabit Odat, Mohammad Al-Aqarbeh, Ameen Al-Khateeb, Monsif Anaqreh, Ahmad Al-Dhoun

(作者單位：約旦，安曼 11855，約旦皇家醫(yī)療服務醫(yī)院，眼科)

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突發(fā)惡性眼周腫瘤調(diào)查研究

Thabit Odat, Mohammad Al-Aqarbeh, Ameen Al-Khateeb, Monsif Anaqreh, Ahmad Al-Dhoun

(作者單位：約旦，安曼 11855，約旦皇家醫(yī)療服務醫(yī)院，眼科)

摘要

關鍵詞：惡性的；眼周腫瘤；基底細胞癌

Abstract

?AIM: To study the incidence, epidemiology, and clinical characteristics of incidental malignant periocular tumors at the royal medical services hospitals of Jordan.

?METHODS: Retrospective medical charts of 327 patients with malignant periocular tumor diagnosis at Jordan military hospitals between 2004 and 2015 were reviewed. Study variables included age, gender, city where patient lived, the presenting complaint (not caused by or related to tumor), clinical and histological diagnosis, size of the tumor, location, and surgical procedure.

?RESULTS:A total of 327 charts reviewed, 46 (14.1%) patients were found to have incidental malignant periocular tumor. Males where affected more than females with a ratio of 2:1. The average age was 66.39±10.59 (22-83y). The most common presenting symptom or disease was blurring of vision secondary to cataract (44%), followed by combined cataract and other associated complaints such as epiphora in 21.7%.

Preliminary clinical diagnosis corresponded with histological diagnosis in 95.7% of skin cancer. The average size of the lesions was 1.04×0.85 mm2(0.2×0.2-3.0×3.0 mm2). There was no significant relationship between the maximum diameter of the tumor and age of the patient, (P=0.105). The most frequent location of tumors was the lower eyelid (30.4%) followed by the medial canthus (26.1%). The follow up period ranged between 6mo and 3y (average 9.3mo).

?CONCLUSION: Incidental malignant periocular malignant tumors were relatively common in this study, which urges excision of any suspicious lesion particularly young patients. A prospective study is needed to investigate the reasons why some patients neglect these lesions.

KEYWORDS:?malignant; periocular tumors; basal cell carcinoma

Citation:Odat T, Al-Aqarbeh M, Al-Khateeb A, Anaqreh M, Al-Dhoun A. Incidental malignant periocular tumors.GuojiYankeZazhi(IntEyeSci) 2016;16(4):610-613

INTRODUCTION

Malignant periocular tumors can arise primarily from any structures that surround the eyes such as the skin and its appendages, conjunctiva, and lacrimal gland, secondarily from distant organs by distant metastasis, or by invasion from the near structures such as the nasal cavity and sinuses[1]. The most common periocular tumors arise from the skin and usually related to direct sun exposure[2]. The risk of developing skin cancer is related to time and duration of sun exposure before the second decade of life[3-6]. The ultra-violet radiation exposure affects stratum basale; the only living layer of the epidermis, more than other layers and may lead toFigure 1Anatomic locations, clinical characteristics, and the presenting complaint or disease in patients with incidental malignant periocular tumorsA: Galbellar pigmented nodulo-ulcerative BCC in patient with bilateral brunescent cataract, bilateral blepharoptosis, and right corneal opacity; B: Right lower eyelid amelanotic nodulo-ulcerative BCC in patient with bilateral corneal dystrophy; C: Left lateral nasal wall pigmented nodulo-ulcerative BCC in patient with bilateral brunescent cataract, dermatochalasis, and upper lid retraction. D: Amelanotic nodular BCC in patient with left lower eyelid trichiasis and corneal opacity; E: Nodulo-ulcerative BCC in patient with diabetic retinopathy; F: Left lower eyelid pigmented BCC in patient with cataract; G: Right ala nasi pigmented nodulo-ulcerative BCC in patient with mild ectropion and epiphora; H: Pigmented nodular BCC in young patient.

malignant transformation[5-6]. Unless affecting vital structures and causing secondary symptoms such as epiphora when the tumor compresses the upper lacrimal drainage system small periocular lesions are usually neglected by elderly people and consider them as part of the aging process. Even asymptomatic big tumor may be unnoticed by blind patients. In young patients, primary skin cancer is rare and usually related to skin disease such as basal cell nevus syndrome (Gorlin-Goltz syndrome)[7]. With global radiation of 2080 kWh/m2and more than 300 sunny days a year, the risk of ultra-violet-related skin cancer may be relatively high in Jordan[8].

As there are no studies in the literature about the incidence of incidental malignant periocular tumors we retrospectively studied the incidence, epidemiology, and clinical characteristics of these tumors at the royal medical services hospitals of Jordan.

SUBJECTS AND METHODS

Retrospective medical charts of 327 patients with malignant periocular tumor diagnosis at Jordan military hospitals between 2004 and 2015 were reviewed. The Directorate of the Royal Medical services Institutional Review Board (IRB) prospectively granted ethical approval. Informed consent was not obtained because the data were collected retrospectively from the medical charts. Each patient was assigned a case number, so no personal identifiers were used in the data for statistical analysis. The data were then transferred to electronic excel spreadsheet for statistical analysis. Study variables included age, gender, city where patient lived, the presenting complaint (not caused by or related to tumor), clinical and histological diagnosis, size of the tumor, location, and surgical procedure.

Exclusion criteria included patients who had inadequate information, patients with a complaint related to or caused by the lesion, patients with a previously excised malignant periocular tumor, patients with a skin disorder that predisposes to cancer.

Figure 2The presenting complaint or disease of malignant periocular tumors.

Statistical analysis simple statistical analysis and parameters were used such as average, range, and standard deviation, andP.

RESULTS

Of the 327 charts reviewed, 46 (14.1%) patients were found to have incidental malignant periocular tumor. Males (30) outnumbered females (16) with a ratio of 2∶1. The average age was 66.39±10.59 (22-83y). The most common presenting symptom or disease was blurring of vision secondary to cataract 20 (44%), followed by combined cataract and other associated complaints such as epiphora in 10 (21.7%) (Figure 1). One patient, who was 22-year-old male and works as an anesthesia technician, had basal cell carcinoma (BCC) noticed by the surgeon incidentally (Figure 2).

Most of the patients lived in Irbid city in the north of Jordan 41.3%, followed by Amman city in the middle of Jordan 30.4%, Karak city south of Jordan 23.9%, Mafraq city east of Jordan 2.2%, and Aqaba city south of Jordan 2.2%. Preliminary clinical diagnosis corresponded with histological diagnosis in 95.7% of skin cancer while in 2 cases the preliminary clinical diagnoses were molluscum contagiosum and sebaceous cyst and the histological diagnoses were basal cell carcinoma(Figure 3). One patient was complaining of dermatochalasis and during follow up visits she was noticed to have proptosis secondary to lacrimal gland lymphoma.

The average size of the lesions was 1.04×0.85 mm (0.2×0.2-3.0×3.0 mm). Both the smallest and largest lesions were on the lateral side of the nose close to the medial canthus. There was no significant relationship between the maximum diameter of the tumor and age of the patient, (P=0.105). The most frequent location of tumors was the lower eyelid (30.4%) followed by the medial canthus (26.1%) (Figure 4).

Incisional biopsy is usually done to prove the diagnosis if the lesion is big or if excision may need major reconstruction, while excisional biopsy is done if the tumor is small and highly suspicious of malignancy. Most of small lesions in elderly patients can be excised and repaired by direct closure as they usually had skin laxity. Excisional biopsy and direct closure was done in about one fifth of patients (Table 1).The follow up period ranged between 6mo and 3y (average 9.3mo).

DISCUSSION

Malignant periocular tumors are usually painless and the presenting complaint is either related to the size, bleeding, or recurrent infection of the tumor or related to their effects on near structures such as upper lacrimal drainage system that lead to epiphora. Incidental periocular tumor was relatively common 14.1% in this study, which reflects the ignorance of these tumors by elderly patients, especially small ones, or because of visual impairment. Review of literature revealed that the most common incidental periocular tumor is the benign orbital cavernous hemangioma, which is usually found incidentally when imaging for other indication but there are no reports on the frequency of incidental malignant periocular tumors[9-10]. In our study the most common malignant tumor was basal cell carcinoma (97.8%) with its different clinical subtypes and this is due to the high ultraviolet radiation and frequent sunny days in Jordan[8]. Other reasons are the clinical nature of small BCC, which are usually subtle, and the high incidence of BCC (95%) in the general population in comparison with other skin cancer. Review of literature revealed that basal cell carcinoma is more common than all other human malignancies combined[11].

Basal cell carcinoma has characteristic clinical signs that aid in diagnosis but it can masquerade any benign lesions such ascutaneous leishmaniasis[12], BCC masqueraded contagious molluscum and sebaceous cyst in 2 cases in our study.

Although the BCCs is usually associated with advancing age but its incidence was increasing progressively among young adults (20-40y) over the last 2 decades[13]. This increase could be related to changes in sun exposure habits, environmental changes, migration patterns, and to a lesser extent, increased prevalence of immunosuppressant use[14].

Figure 3Clinical diagnosis of malignant periocular tumors.

Figure 4Anatomic locations of malignant periocular tumors.

Table 1Surgical procedures used for malignant periocular tumors

SurgeryNumber(%)Incisionalbiopsy19(41.3%)Directclosurewithorwithoutcantholy-sis10(21.7%)Rhomboidflap6(13.0%)Slidingflaps3(6.5%)Rotationalflap3(6.5%)Tenzelsemicircularflap2(4.3%)Hughesflap1(2.2%)Glabellarflap1(2.2%)Lateralorbitotomy1(2.2%)Total46(100%)

Although there are more than 300 practicing ophthalmologists in Jordan, most of them do cataract surgery but the incidence of cataract is still high, which explain why most of the patients with incidental malignant periocular tumors, especially small size, presented for cataract (44%) treatment[14].

Because there were 2 oculoplastic clinics, one in Amman (Al Hussein hospital) and one in Irbid (Prince Rashid Bin Al Hassan hospital), the biggest military hospitals, this may explain the high incidence of malignant periocular tumors in these 2 cities. Most of the people in Irbid city live in rural areas, where many of them had outdoor activities; this may explain the high frequency of affected patients in this city.

While big tumors arising from the orbit are usually symptomatic, small tumors are usually discovered incidentally by radio-imaging studies for other indications[10]. In this study one patient had bilateral upper eyelids dermatochalasis and the subtle proptosis was noticed during follow up visit. Radio-imaging studies showed lacrimal gland mass and excisional biopsy revealed malignant non-Hodgkin lymphoma. Clinical examination and radiological investigations including PET scan showed no systemic involvement. Adjunctive radiotherapy and chemotherapy were given and the patient is under follow up over the last 3y.

The location of the tumors was similar to symptomatic periocular malignant tumors with regard to lower eyelids and medial canthus, (30.4% and 26.1% respectively)[15], but different with regard to other locations. The dorsum of the nose (15.2%) was more frequently affected than the forehead (10.7%) and upper eyelids (2.2%).

Slightly more than one fifth of the tumors were small enough to be completely excised and closed directly without any other adjuvant surgical procedure and one tumor was big that required upper eyelid sharing procedure.

Overall,the incidence of incidental periocular malignant tumor is significant and any patients, particularly young adults, with a suspicious lesion should have a biopsy to rule out malignancy as early diagnosis decreases patient morbidity and mortality. A prospective study is needed to investigate the reasons why some patients neglect these lesions.

REFERENCES

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DOI:10.3980/j.issn.1672-5123.2016.4.05

通訊作者：Thabit Odat. thabitodat@hotmail.com

目的：研究約旦皇家醫(yī)療服務醫(yī)院中突發(fā)惡性眼周腫瘤的發(fā)病率、流行病學及臨床特征。

方法：回顧性研究?；仡櫡治鑫以涸?004～2015年收治的327例診斷為惡性眼周腫瘤患者的病歷資料。研究參數(shù)包括年齡、性別、患者所在城市、現(xiàn)病史(非腫瘤引起或與腫瘤相關的)、臨床與病理診斷、腫瘤大小、位置及手術方式等。

結果：在327例患者中，46例(14.1%)患者診斷出患有突發(fā)惡性眼周腫瘤。男性與女性的患病比例為2:1。平均年齡為66.39±10.59(22-83)歲。最常見的臨床疾病或癥狀為白內(nèi)障致視覺模糊(44%)，其次為白內(nèi)障合并其他相關癥狀類似淚溢癥等(21.7%)。初步臨床診斷聯(lián)合病理診斷95.7%為皮膚癌。平均病變大小為1.04×0.85(0.2×0.2～3.0×3.0)mm2。腫瘤的最大直徑和患者年齡無明顯關系(P=0.105)。最常見的腫瘤位于下眼瞼(30.4%)，其次為內(nèi)眥處(26.1%)。隨訪時間6mo至3a(平均9.3mo)。

結論：突發(fā)惡性眼周腫瘤在本研究中較為常見，任何可疑病灶須盡快切除。一些患者忽視這些病變的原因需要進一步的前瞻性研究分析。

引用：Odat T, Al-Aqarbeh M, Al-Khateeb A, Anaqreh M, Al-Dhoun A. 突發(fā)惡性眼周腫瘤調(diào)查研究.國際眼科雜志2016;16(4):610-613