New Targeted Therapies and Immunotherapies for Locally Advanced Periocular Malignant Tumours: Towards a New ‘Eye-Sparing’ Paradigm?

The management of periocular skin malignant tumours is challenging. Surgery remains the mainstay of treatment for localised eyelid cancers. For more locally advanced cancers, especially those invading the orbit, orbital exenteration has long been considered the gold standard; however, it is a highly disfiguring and traumatic surgery. The last two decades have been marked by the emergence of a new paradigm shift towards the use of ‘eye-sparing’ strategies. In the early 2000s, the first step consisted of performing wide conservative eyelid and orbital excisions. Multiple flaps and grafts were needed, as well as adjuvant radiotherapy in selected cases. Although being incredibly attractive, several limitations such as the inability to treat the more posteriorly located orbital lesions, as well as unbearable diplopia, eye pain and even secondary eye loss were identified. Therefore, surgeons should distinguish ‘eye-sparing’ from ‘sight-sparing’ strategies. The second step emerged over the last decade and was based on the development of targeted therapies and immunotherapies. Their advantages include their potential ability to treat almost all tumours, regardless of their locations, without performing complex surgeries. However, several limitations have been reported, including their side effects, the appearance of primary or secondary resistances, their price and the lack of consensus on treatment regimen and exact duration. The aim of this article was to review the evolution of the management of locally advanced periocular malignant tumours over the last three decades and highlight the new paradigm shift towards the use of ‘eye-sparing’ strategies.

Role of Quantitative Diffusion-Weighted Imaging in Differentiating Benign and Malignant Orbital Masses

Aim To determine the role of diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) values in differentiating benign and malignant orbital masses. Materials and Methods After obtaining institutional ethical board approval and informed consent from all patients, an observational study was done for a period of 24 months in the radiology department of a tertiary care hospital in South India. Conventional magnetic resonance imaging and DWI using a 3T scanner was done for all patients with suspected orbital mass lesion. ADC value and clinicohistopathological correlation were studied for every patient. Chi-square test was used to compare the signal characteristics of DWI and ADC maps between benign and malignant lesions. A comparison of mean ADC values for benign and malignant masses was performed using Student’s t-test for independent samples. The cut-off value for ADC was obtained using the receiver operating characteristic (ROC) curve. Results Of 44 patients with orbital lesions, 70% were benign and 30% were malignant. There was a significant difference in the mean ADC values of benign and malignant orbital masses. Using ROC curve analysis, an optimal ADC threshold of 1.26 × 10−3 mm2/s was calculated for the prediction of malignancy with 100% sensitivity, 80.65% specificity, and 86.36% accuracy (95% confidence interval: 0.872, 1.00, p < 0.0001). Two ADC thresholds were used to characterize the orbital masses with more than 90% confidence. Conclusion Quantitative assessment of ADC is a useful noninvasive diagnostic tool for differentiating benign and malignant orbital masses. Malignant orbital lesions demonstrate significantly lower ADC values as compared with benign lesions.

Endoscopic Two-Port Technique for Orbital Tumors, A Combined Transnasal and Sublabial Approach: A Retrospective Case Study

Background: We investigated the indications for a combined endoscopic transnasal and sublabial transantral approach for the surgical treatment of orbital lesions. Methods: This case study enrolled 10 patients scheduled for endoscopic transnasal surgery for treating orbital lesions from 2009 to 2020. When the tumor was localized to the medial part of the orbit, patients underwent endoscopy with a transnasal mononostril approach. Alternatively, when the tumor was localized to the mediocaudal part of the orbit, and when instrument maneuverability was limited, the transnasal approach was combined with a sublabial transantral approach. This two-port surgery approach was preferred over a trans-septal approach (binostril approach), because the two-port approach could expand the operating field in the medial part of the orbit. Here, we evaluated the indications, complications, and advantages of monoportal and combined two-portal approaches. Results: Among the 10 patients enrolled, 8 (80.0%) underwent surgery with the transnasal mononostril approach, and 2 (20.0%) underwent surgery with the combined transnasal mononostril and sublabial transantral approach. In the two latter cases, visualization of the operation field was excellent, and there was adequate room for manipulating instruments. No dysesthesia in the region of infraorbital nerve was observed postoperatively.Conclusion: The combination mononostril-transantral approach provided the space necessary to maneuver instruments and to visualize the surgical field in treating mediocaudal orbital lesions. This two-portal approach enabled extensive resections of intraconal lesions; thus, it could be considered a suitable alternative to the binostril approach.