A Novel Surgical Classification of Management of Orbital Tumors

Introduction: The surgical treatment of the orbital tumors sometimes is tricky, with incomplete resection, surgical complications, functional sequel and sometimes the need for orbital reconstruction. The election of the best surgical route will have a less morbidity.

There are many classifications about of the surgical approach of the orbital tumors. These classifications to lack to decide the best surgical approach with the less damage to vital structures.

In this study, we describe a novel surgical classification of management of orbital tumors, emphasizing the importance of each surgical approach according to the surgical goal, nature of lesion, extension, and location of the lesion in relationship with the optic nerve.

Method: We analyzed 50 patients with orbital tumors, who underwent a combination of surgery, radiotherapy and chemotherapy. The patients were treated at National Cancer Institute Mexico.

The surgical management was approached in a selective fashion according to: a) Tumor location in relation to the optic nerve; b) The type of the lesion; c) The size of the tumor; d) The surgical goal (biopsy, debulking and total resection) and e) The extension of the tumor; Afterwards of this knowledge, we made a classification to attack the orbital tumors, always to avoid crossing the optic nerve. We created four zones and analyzed advantages and disadvantages. In neuroanatomy laboratory of Aurora Neuroscience Innovation Institute, we studied each zone with specimens injected, which allowed to understand each surgical corridor.

Results: We analyzed 50 patients, 26 females and 24 males with ages ranging from 18 to 88 years (mean age was 57.6 years. Tumors were benign in 10 patients and malign in 40 patients. We critically reviewed each case to define the most effective and appropriate surgical approach for each patient. We described four zones (a, b, c and d) for approaching the orbit, according to the position of the optic nerve as follows: (a) superolateral, (b) inferior (c) medial and posterior, and (d) invaded orbit.

For zone “a” (n-5) the management was done with a craniotomy, for zone “b” (n-3) the treatment was with a transconjunctival approach and endoscope (endoscopic endonasal and endoscopic sublabial transmaxillary approach), the management in the zone “c” (n-7) was performed with endoscope (endoscopic endonasal transorbital approach) and for zone “d” (n-34) the treatment was with only exenteration, exenteration more maxillectomy and exenteration more craniofacial approach. The zone with more complications was the zone “a” and the zone with less complications was the zone “c.” No patients showed a decline of diplopia or visual function. The best score of ECO was presented in the patients of the zone C and then in patients of the zone A. We analyzed each zone with cadavers injected and we displayed important surgical landmarks.

Conclusion: The amount of the pathology of the orbital tumors is broad, and the potential surgical approaches are many. Dividing the orbit in zones will allow understanding and choosing the best surgical corridor to attack the orbital tumors.