Intraorbital solitary fibrous tumor requiring preoperative embolization of feeding artery

Abstract

Solitary fibrous tumors (SFTs) are derived from mesenchymal cells and commonly develop in thoracoabdominal organs; however, their occurrence in orbit is rare. The first-choice treatment is to surgically remove as much of the SFT as possible; however, if total removal is not achieved, the recurrence rate is high, resulting in poor prognosis. A 42-year-old man presented with painless right-sided proptosis and diplopia 4 years ago. Orbital computed tomography revealed a right extraconal mass medial to the optic nerve, measuring 25 mm. Magnetic resonance imaging demonstrated iso-signal intensity on T1- and T2-weighted imaging, including flow-void signals. During biopsy of the intraorbital mass, which was performed by ophthalmologists 3 years earlier, difficulty with hemostasis occurred due to massive hemorrhage from the mass. The mass grew to reach a maximal diameter of 33 mm, resulting in referral to the authors’ department. Diagnostic cerebral angiography revealed a hypervascular orbital tumor with multiple feeding arteries. To control intraoperative bleeding, the patient underwent preoperative endovascular embolization. Subsequently, the tumor was completely removed using a combination of microsurgical craniotomy and endoscopic endonasal approach, without the occurrence of massive intraoperative hemorrhage from the tumor. Postoperatively, his clinical course was uneventful except for the remaining preoperative diplopia. The tumor was diagnosed histologically as SFT and has not recurred for 8 months since surgery. Preoperative intravascular embolization of branches of the ophthalmic artery can be performed safely, resulting in excellent control of intraoperative bleeding and facilitating complete removal of SFT without additional complications.

Preoperative transarterial embolization of a recurrent orbital solitary fibrous tumor with significant hypervascularity: a case report

“…The endovascular approach is more effective for tumors in the orbit. Compared with previous reposts [ 1 , 4 – 6 ], we demonstrated a large intraconal mass with multiple feeder vessels arising from 4 points of origin (Table 1 ), including main feeder vessels with numerous tangled branches arising from the ophthalmic artery and the IMA. Because the points of entry of the vessels from ophthalmic artery were too thin for the microcatheter to pass through, liquid Onyx was an effective means of embolizing these tangled feeder vessels due to its slow precipitation properties [ 1 ].…”

“…Since then, researchers have found these tumors in extrapleural locations such as the lungs, liver, kidneys, thyroid gland, parotid gland, pericardium, peritoneum, mediastinum, nasal cavities, and orbit [ 9 ]. Clinically confirmed orbital SFTs are very rare, with approximately only 90 cases reported up to date [ 4 ]. These tumors are generally considered benign but recurrent and malignant variations have recently been noted.…”

“…Since recurrent or malignant SFTs can be highly vascular with multiple large feeder vessels, the attempts to biopsy and resection them might fail because of massive hemorrhage without taking preoperative measures [ 4 , 7 ]. Preoperative embolization is recommended to reduce the risk of hemorrhage.…”

“…It was determined that it would be difficult to completely resect the tumor using conventional orbitotomy or craniectomy and preserve the patient’s existing vision at the same time. There was also concern that traditional orbitotomy surgery would cause massive blood loss, which might result in incomplete resection of the tumor, with the possibility of future recurrence or even malignant metastasis [ 4 , 7 ]. In addition, we were faced with the dilemma of whether to enucleate the eyeball.…”

“…Embolization is an alternative approach to minimize intraoperative hemorrhage and improve the gross total removal (GTR) rate. There are few reports of transarterial embolization of orbital SFTs; only 4 have been published in English [ 1 , 4 – 6 ]. In this study, we successfully resected a large, recurrent orbital SFT with multiple feeder vessels after transarterial embolization.…”