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Preoperative Imaging to Predict Orbital Invasion by Tumor

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Preoperative Imaging to Predict Orbital Invasion by Tumor PREOPERATIVEIMAGING TO PREDICT ORBITAT INVASION BY TUMOR Marc D. Eisen, BA,1 David M. Yousem, MD,t'' Laurie A. Loevner,MD,t'' Erica R. Thaler, MD,1 Warren B. Bilker, PhD,3 Andrew N. Goldberg, MD1 1 Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 2 Department of Radiology, University of Pennsylvania Medical Center, 3400 Spruce Street, Philadelphia, Pennsylvania 19104 3 Department of Biostatistics and Epidemiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania Accepted 4 October 1999 Keywords: sinonasal;orbital invasion; imaging; tumor; nasolac- Abstract: Background. Our purposewas to examinethe ac- rimalfossa curacy of preoperativeimaging in assessingtumor invasionol the orbit and nasolacrimalsystem. Methods. Nineteenpreoperative CT and 17 preoperativeMR imagesfrom patientsat risk for orbitalinvasion were retrospec- T.r*orr of the paranasal sinuses present late in reviewed.Invasion was corroboratedby pathologicand in- tively often with extensive disease. Exten- traoperativeassessment. their course, Resu/ts. Tumor adlacentto the periorbitawas the most sen- sion to the orbit and nasolacrimal system has an sitive predictorof orbital invasion(90%) for both CT and MRl. impact on patient prognosis and the surgical ap- Extraocularmuscle involvementon MRI (100%) and orbitalfat proach to these tumors. If orbital invasion is sus- (80% the highestpositive predic- obliteration MRl, 86% CT) had pected, the surgeon and the patient are con- tive valuesol the criteriaevaluated. Extraocular muscle displace- ment and enhancementwere less accurate(<65%) predictors. fronted with the difficult decision of exenteration. No one criterionwas>79o/o accurate in predictingorbital invasion. Orbital exenteration can be emotionally trau- Six or more positivecriteria predicted invasion with 67% sensi- matic for patients, yet it may be required for com- tivityand 80% specificity(accuracy, 72o/"). CT was moreaccurate plete oncologicresection. The difficult decision re- than MRI in seven of nine criteria.Invasion of the nasolacrimal systemwas predictedaccurately (89%). garding the eye cannot be made on the basis of Conclusions. Althoughpreoperative imaging can aid in sur- ophthalmic symptoms alone. In cases in which gicalplanning, it shouldnot replaceintraoperative assessment in the clinical examination and imaging are unclear, ambiguouscases of orbitalinvasion. @ 2000 John Wiley & Sons, preoperative patient counseling regarding the eye lnc. Head Neck 22: 456-462, 2OOO. is complex. A more accurate assessment of tumor invasion of the orbit and nasolacrimal system pre- Correspondenceloj L. A. Loevner,Department of Radiology,University of PennsylvaniaMedical Center,3400 Spruce Street,Philadelphia, PA operatively would benefit both the surgeon and '1 9104. the patient. Patients may be better informed with @ 2000John Wiley & Sons,Inc. regard to their prognosis becausetumors that in- 456 lmaging to Assess Orbital Invasion HEAD& NECK August2000 vade the orbit carry a worse prognosis than those pendently and randomly, and thus a total of 36 that do not.1 In addition, accurate preoperative (17 MRI, 19 CT) imaging studies were evaluated. assessmentmay help the surgeonplan the extent MRI was performed on a 1..5T system (Signa; of resectionin those casesirt which invasion was General Electric Medical Systems, Milwaukee, previously unclear. Most surgeons use the rela- WI). The MRI protocol consistedof conventional tionship between the tumor and the periorbita to spin-echo sagittal Tl-weighted images and axial determine whether exenteration is necessary;tu- and coronal T1' and T2-weighted images. Con- mor invasion through the periorbita may warrant trast-enhanced (0.1 mmol/kg of gadopentetate exenteration, whereas an intact periorbita typi- dimeglumine lMagnevist; Schering, Berlin, Ger- cally warrants preservation.2 When tumor abuts manyl) axial Tl-weighted images with frequency- the periorbita, however,assessing periorbital con- selectivefat suppressiontechniques were also ac- tinuity may be diffrcult. quired. Other imaging parameters included The nasolacrimal system is also susceptibleto section thickness of 5 mm, 2 excitations, and a invasion by paranasal sinus tumors. Tumor may 256 x 192 matrix. track along the nasolacrimal duct and thereby re- CT scans were performed with 3- to 5-mm sec- quire more extensive resection than would have tion thickness in axial and coronal planes. Images been anticipated by the bulk diseaseevident pre- were photographed for soft tissue and bone detail. patients operatively. Three received iodinated contrast before patients'studies were The purpose of this study was to determine CT scanning.The other un- whether preoperative imaging could offer an ac- enhanced. Eleven criteia involving the tumor, orbit, and curate assessmentof tumor extensionto the orbit nasolacrimal fossa were used to assess each and nasolacrimal system. Involvement of the or- study: three criteria for the tumor's relationship bital fat manifest as soft tissue stranding in the to the periorbita (abutting, displacing, or bowing fat is the current imaging criterion suggestive of the periorbita laterally); one for the interface be- neoplastic invasion. However, the accuracy with tween the tumor and periorbita ("nodular" if the which imaging predicts invasion into these struc- margin had focal irregularity or "smooth" if it did tures is poorly studied. In this study we evaluate not); one for orbital fat invasion (soft tissue the accuracy of various imaging criteria in pre- stranding or infiltration within the extraconal fat dicting tumor invasion of the orbit and nasolacri- contiguous with the primary tumor); three for the mal system. We also sought to compare the efii- extraocular muscles (displaced,enlarged, or ab- cacy between magnetic resonanceimaging (MRI) normal signal intensity/density); one for orbital and CT imaging with regard to assessingorbital bone integrity; and one for nasolacrimal system invasion. invasion (tumor extensiorr into the nasolacrimal sac or duct). For studies in which contrast was MATERIALSAND METHODS administered (n : 20; 17 MRI, 3 CT), extraocular (19 Twerrty-frvepatients merr and 6 women) with muscle enhancement was also evaluated. Two tumors of the paranasal sinuses,anterior cranial neuroradiologists unaware of the surgical find- fossa, or skin surrounding the orbit seen over a ings carried out retrospective image analysis in- (1988-1998) 10-yearperiod were chosenfrom the dependently and blindly. Each reader was re- records of the University of Pennsylvania Cancer quired to choosewhether each criterion was met. Center database.Six patients had tumors origi- The strength of interobserver consensus for all nating in the maxillary sinusl six in the ethmoid the criteria was determined by kappa analysis.s sinus; six in the nasal cavity; and one each in the sphenoid sinus, cavernoussinus, maxilla, frontal sinus, forehead, eyelid, and anterior cranial fossa. Table 1. Definitionsol crileriaevaluation Tumor histologic frndings included 12 carcino- Term Definition mas; 6 inverted papillomas; 3 melanomas;and 1 each fibroma, sarcoma, odontogenic keratocyst, Sensitivity TP/(TP+ FN) and meningioma. Patients selected from Specificity TN/(TN+ FP) the da- Positivepredictive value IP/(TP + FP) tabase had preoperative imaging, surgery, and Negativepredictive value IN/(TN + FN) pathologic correlation. Preoperative imaging Accuracy TP+TN/(TP+FN+TN+FP) (n : (n : studies included MRI 6), CT 8), or both Abbreviations: FN,false negative;FP, falsepositive; TN, true negative: TP, (ru : 11). Individual studies were reviewed inde- true posrtive. lmagingto AssessOrbital Invasion HEAD& NECK August2000 457 Table 2. Radiologic-pathologiccorrelation for evaluatingtumor invasion of orbitwith MRl. Periorbita Adlacentto Periorbita bowed Extraconalfat EOM Periorbita displaced laterally involved displaced Nln nf dicanroomontq UCTVVUUII IUdUUI> 1 2 0 1 2 Truepositives 9 B 7 4 7 Truenegatives 2 3 3 6 4 .1 Falsepositives 5 4 4 3 Falsenegatives 1 2 3 6 3 Sensitivity(%) 90 BO 70 40 70 Specificity(o/.) 29 43 43 B6 57 Positivepredictive value (9"7 64 67 64 BO 70 Negativepredictive value (%) 67 60 50 50 57 Accuracy(%) 65 65 59 59 A1 Differencesbetween the two readers' evaluations less than 70Vo.Orbital fat invasion was radiologi- were resolvedby consensus. cally suspectedin only one MRI and one CT scan The operative and/or pathologic reports were in which orbital invasion was absent pathologi- used as the "gold standard" for orbital and naso- cally (false positives),and thus this criterion had lacrimal invasion. Positive invasion was defined both a high specifi city (>857o)and positive predic- as tumor extension through the periorbita and tive value (80% MRI, 867oCT) (Fig. 1 and 2). Yet into orbital fat. If the periorbita remained uncom- orbital fat involvement was a less than 607osen- promised,the orbit was consideredto be free from sitive imaging criteria for orbital invasion. neoplastic invasion. Fourteen of the 25 patients Extraocular muscle (EOM) involvement had confirmed orbital invasion. The sensitivity, tended to be a specific,yet insensitive,finding. All specifrcity,positive and negative predictive value, MRI images showing enlargement,enhancement, and accuracywere used to evaluate eachcriterion or abnormal EOM signal had pathologically con- (Table 1). firmed orbital invasion (PPV : I00Va)and a bet- ter result than CT, although a considerablenum- RESULTS ber of confirmed
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