Management of Neglected Periorbital Squamous Cell Carcinoma Requiring Orbital Exenteration

Abstract

With its perineural invasion capacity, periorbital squamous cell carcinoma (SCC) may easily invade orbital structures. When SCC invades the orbital musculature or the orbit itself, orbital exenteration, one of the most disfiguring operations on the face, is required. We reviewed elderly patients with periorbitally localized SCC requiring orbital exenteration to evaluate reconstructive options and survival. A chart review of patients' records was conducted to identify all patients older than 65 years with periorbital malignancy requiring orbital exenteration from 2006 to 2011. A total of 9 patients who met the criteria were included in the study. The mean age at surgery was 77 ± 6.7 years, and the mean defect size was 74.2 cm2. All patients had a similar history of late presentation to a doctor because of hesitation to undergo surgery. The temporoparietal fascia flap, galeal flap, free gracilis flap, and free vastus lateralis musculocutaneous flap were the treatment options for reconstruction of the defects. All patients died during follow-up, and the mean survival was 15.7 months (range, 6-36 months). Only 2 of them had relapse before the death. Our small series suggest that elderly patients with periorbital SCC requiring orbital exenteration may not have enough survival to relapse because of the death from different causes without relapse or any sign of spreading cancer. Also, prolonged surgery with free flap reconstruction may increase the risk of postoperative intensive care unit requirement. Because local flaps may work very well for reconstructing the orbital exenteration defects, free flap option should be kept for selected cases.

Reconstruction after orbital exenteration using gracilis muscle free flap

“…The gracilis muscle flap is preferred by many authors for functional restoration to treat facial paralysis, brachial plexus injury as a free functioning muscle transfer, extremity reconstruction, and chest wall reconstruction . Karabekmez et al described their experience in reconstruction after OE in patients with neglected periorbital squamous cell carcinoma. In their limited series of nine patients, different flaps were used such as temporal fascia, galea, free vastus lateralis myocutaneous flap, and free gracilis flap.…”

“…In their limited series of nine patients, different flaps were used such as temporal fascia, galea, free vastus lateralis myocutaneous flap, and free gracilis flap. However, free gracilis flap was used in only one patient in this report, as well as other limitations of the article were age of patients above 65 years and death of all patients in follow‐up period (mean survival was 15.7 months) . There was no prosthetic rehabilitation for orbit.…”

Perineural Spread of Head and Neck Cancer: Ophthalmic Considerations

“…31 So-called stage 1 tumors that have not extended beyond the orbit can be excised (potentially endoscopically 32 ), but as these tumors often involve small nerves, this may not always be successful. Exenteration has been advocated for treatment in the past, 33,34 although there is fairly good evidence that this does not prevent systemic spread in adenoid cystic carcinoma. Even with exenteration, evidence of perineural involvement has a worse prognosis.…”

Survival following orbital exenteration at a tertiary brazilian hospital

“…Many patients are referred to psychological services after the operation or even refuse to undergo the surgical procedure. Constant vigilance, good doctor-patient relationship, early diagnosis and prompt treatment would provide better prognosis, especially in emerging countries 6,7 .…”