Outcomes of orbital exenteration for craniofacial lesions

Abstract

BACKGROUND Orbital exenteration (OE) is an ablative procedure used in the management of malignancies of the orbit of either primary or secondary origin. Publications evaluating this procedure have suffered from small patient numbers, heterogeneity of pathologies, and poor patient follow‐up. The purpose of this study was to assess patient outcomes in a large cohort of patients undergoing OE at a tertiary cancer center. METHODS A retrospective review was conducted of 180 consecutive patients who underwent OE at the authors' institution. Overall survival (OS) was the primary end point measured in the study. Time to locoregional recurrence (progression‐free survival [PFS]) and disease‐free survival were secondary end points. RESULTS Between the years 1993 and 2011, 180 consecutive patients received OE for craniofacial malignancy at the authors' institution. The median follow‐up for the cohort was 9.7 years (116 months). The median OS was 73 months, and the median PFS was 96 months. The presence of perineural invasion was associated with shorter OS (P = .01) and PFS (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter PFS than negative margins (P < .01) but with no change in OS (P = .15). The overall complication rate was 15%. The major complication rate (Clavien‐Dindo 3b or greater) was 2.8% (n = 5), and there was 1 death observed (0.6%). CONCLUSIONS Used judiciously in the setting of a multidisciplinary management plan, OE for tumor control is a safe therapy. LAY SUMMARY Between the years 1993 and 2011, 180 consecutive patients received orbital exenteration for craniofacial malignancy at the MD Anderson Cancer Center. The median follow‐up for the cohort was 9.7 years. The presence of perineural invasion was associated with shorter overall survival (P = .01) and progression‐free survival (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter progression‐free survival than negative margins (P < .01). The overall complication rate was 15%. The major complication rate (Clavien‐Dindo 3b or greater) was 2.8% (n = 5).

Impact of salvage surgery for recurrent sinonasal cancers with skull base and intracranial involvement

“…In our experience, as shown in the largest series published to date, the complication rate is around 15% in such cases. 25 The complication rate of our cohort was comparable, with about 19% of patients experiencing complications as described in Table 3. As noted in a previous publication from our institution, a large proportion of patients undergo multidisciplinary reconstruction with the frequent use of free flaps; this is consistent with our cohort, of whom 36% underwent free flap placement.…”

“…This may have been due to the use of orbital exenteration in 11 of the 28 patients with orbital involvement. To achieve gross-total resection and negative margins, the indications for orbital exenteration in our practice 25 include invasion of the orbital fat, extraocular muscles, eye, optic nerve, and preseptal structures. 16,26,27 The remaining patients who did not undergo orbital exenteration had orbital involvement limited to the bony boundaries or periorbita.…”

“…As noted in a previous publication from our institution, a large proportion of patients undergo multidisciplinary reconstruction with the frequent use of free flaps; this is consistent with our cohort, of whom 36% underwent free flap placement. 25 Based on the largest series of skull base reconstructions published by our institution, use of free flaps and pedicled flaps is associated with low rates (7.2%) of major complications (flap loss 1.6%, myocardial infarction 0.4%, pulmonary embolus 1.6%, wound dehiscence 3.2%, and short-term skin loss 0.4%). 28 In terms of quality of life, although patients do experience difficulties with anxiety, depression, and social challenges, these are mitigated by the cancer diagnosis and do not change interactions with family members.…”

Orbital Metastases: A Systematic Review of Clinical Characteristics, Management Strategies, and Treatment Outcomes

“…Such a finding substantiates once again that survival is more likely affected by systemic disease control than metastasis-directed local therapy. Orbital exenteration is often considered for treating aggressive craniofacial malignancies with orbital infiltration and perineural invasion, effectively reducing rates of local recurrences and re-operations [ 44 , 45 ]. In orbital metastases, the limited benefit of orbital exenteration is likely due to the underlying systemic spreading of tumor cells and related poor prognoses [ 46 , 47 ].…”

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

“…Traylor et al. studied 180 patients who underwent orbital exenteration for malignancies, 40 of which were for sinonasal primary tumors 2105 . The 30‐day postoperative complication rate was 15%, with surgical site infections, CSF leak, and pneumonia being the most frequent.…”