FP1870 : Is Adjuvant Radiotherapy Indicated after Orbital Exenteration for Conjunctival Tumors?
Dr.RAKSHA RAO, R17558, Dr.Santosh G Honavar
Purpose: To study the need for adjuvant radiotherapy in patients undergoing orbital exenteration for orbital extension of conjunctival tumors.
Methods: Retrospective chart review of patients undergoing orbital exenteration for orbital extension of the conjunctival tumors.
Results: Of 46 patients, 42 (91%) had orbital extension of ocular surface squamous neoplasia (OSSN), and 4 (7%) had orbital extension of conjunctival melanoma. The mean age at presentation was 51 years (median, 49 years; range: 7-79 years). There were 35 (76%) males and 11 females (24%). 5 (11%) patients had xeroderma pigmentosa and 1 (2%) had HIV infection. The mean duration of symptoms was 9 months (median, 5 months; range, 2-20 months). The most common symptom was orbital mass (n=40, 87%). The most common morphology of the conjunctival tumor was nodular (n=40, 87%), followed by diffuse (n=6, 13%). The tumor in the orbit extended upto the anterior orbit in 21 (46%) patients, mid-orbit in 22 (48%), and posterior orbit in 3 (7%). All patients underwent eyelid-sparing orbital exenteration. Histopathology showed negative surgical margins in all 46 patients. 1 (2%) patient with preauricular lymph node metastasis underwent lymph node dissection and radiation to the same region, excluding the orbit. No patient received adjuvant chemotherapy or orbital radiation in this series. At a mean duration of follow-up of 39 months (median, 24 months; range, 13-63 months), none of the patients developed orbital recurrence or metastasis.
Conclusion: Adjuvant orbital radiotherapy may not be indicated in patients undergoing orbital exenteration for orbital extension of conjunctival tumors when the surgical margins are negative.
Various publications in the literature have reported the clinicopathological profile and outcomes of orbital exenteration in ocular adnexal malignancies, however none of them clearly define the role of adjuvant radiotherapy in exenterated orbits for orbital extension of conjunctival tumors. The purpose of this study is to define the need for adjuvant radiotherapy in patients undergoing orbital exenteration for orbital extension of conjunctival tumors.
This is a retrospective interventional case series consisting of all patients who underwent orbital exenteration. Of the 86 orbital exenteration, ocular surface tumor with orbital extension comprised more than half of cases, and these patients were our study group.
The mean age of patients in this study was 51 years, with male predominance. All patients underwent unilateral exenteration. 11% of the patients had Xeroderma Pigmentosa, while only 1 patient had HIV infection. Visual acuity at presentation was better than 20/200 in one half of the patients. 91% of the ocular surface tumors were SCC, while the rest 9% were conjunctival melanoma. On imaging, the tumor invasion was confined to the anterior orbit in 46% of the patients, mid orbit in 48%, and posterior orbit in 7% patients. All exenterations were performed by the eyelid sparing technique. Conventional total exenteration were used in three-fourths of the patients, and the rest underwent sub-total exenteration. Surgical marginal positivity was seen in none of the patients. Post exenteration, adjuvant therapy was necessary in 1% cases, and this was lymph node dissection with radiation to the pre-auricular area. None of the patients received radiation to the orbit. At a mean duration of follow-up of 39 months, and there was no single case of local recurrence, systemic metastasis or death. Of the many studies on the invasiveness of conjunctival SCC the one by Miller et al is notable, in which they concluded that the SCC of the conjunctiva has a low incidence of invasiveness, and the recurrence of conjunctival epithelial malignancies depends on the status of surgical margins. In a yet another publication by the Shields group from Wills eye hospital, the authors performed 24 orbital exenterations for invasive conjunctival tumors. Post exenteration, none of the orbits received adjuvant radiotherapy and only 1 patient with conjunctival melanoma recurred, however, the surgical margins of this patient could not assessed. In the study, they concluded that orbital exenteration for conjunctival tumors generally achieves good tumor control. Rathbum and Beard in their series had 3 patients who underwent exenteration for invasive conjunctival SCC, and none of them received adjuvant chemo or radiotherapy, and there was no long-term local recurrence or systemic metastasis. In a study from the Goldberg group, the authors mention that when the involved tissue and the bone is removed completely, the incidence of recurrence and tumor-related death in conjunctival tumors is low. In conclusion, adjuvant orbital radiotherapy may not be indicated in patients undergoing orbital exenteration for orbital extension of conjunctival tumors when the surgical margins are negative.
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