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   Table of Contents      
CASE REPORT
Year : 2019  |  Volume : 67  |  Issue : 12  |  Page : 2110-2113

Primary chondromyxoid fibroma of the orbit: An orbital mass with calcification


1 Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission11-Jul-2019
Date of Acceptance30-Oct-2019
Date of Web Publication22-Nov-2019

Correspondence Address:
Dr. Manpreet Singh
R. No 504, 5th Floor, Advanced Eye Centre, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1275_19

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  Abstract 


Primary orbital chondromyxoid fibroma is a rarely reported entity. A 34-year-old lady presented with painless, non-axial proptosis of the left eye of 6 months duration. Orbital imaging showed a supero-temporal mass with calcific foci and bone erosion. The mass caused globe compression resulting in choroidal folds. Anterior orbitotomy with complete mass excision was performed. The histopathology revealed a chondromyxoid fibroma. At 12-months follow-up, the patient is doing fine with no clinical recurrence. Chondromyxoid fibroma is an important differential diagnosis for bony orbital tumors.

Keywords: Chondromyxoid fibroma, orbital calcification, orbitotomy, primary orbital tumorKey words:


How to cite this article:
Grewal AM, Singh M, Vishwajeet V, Thakur U, Das A, Gupta P. Primary chondromyxoid fibroma of the orbit: An orbital mass with calcification. Indian J Ophthalmol 2019;67:2110-3

How to cite this URL:
Grewal AM, Singh M, Vishwajeet V, Thakur U, Das A, Gupta P. Primary chondromyxoid fibroma of the orbit: An orbital mass with calcification. Indian J Ophthalmol [serial online] 2019 [cited 2019 Dec 14];67:2110-3. Available from: http://www.ijo.in/text.asp?2019/67/12/2110/271356



Primary orbital bone tumors constitute approximately 2% of all orbital masses.[1] Amongst these, the chondromyxoid fibromas (CMFs) arising from orbital bones are even rarer. The reported overall incidence of CMFs is <1% of all bone tumors, which commonly arise from the long bones of the limbs.[2],[3] Secondary orbital involvement due to the extension of craniofacial CMFs has been infrequently reported in the literature.[4],[5]

To the best of our knowledge, the primary orbital CMFs have been reported only thrice in the English literature (summarized in [Table 1]).[6],[7],[8] In 2009, the first case of primary orbital CMF was reported by Heindel et al.[6] We describe the clinical features, radiology, histopathology, and outcomes in the first report of primary orbital CMF from our country.
Table 1: Primary orbital chondromyxoid fibromas: a review of literature

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  Case Report Top


A 34-year-old lady had a 6-month history of painless, progressive, protrusion of the left eye. It was associated with diminution of vision for the last 3 months. On examination, the best-corrected visual acuity of the right and the left eye was 20/20 and 20/60, respectively. The left eyeball showed infero-medial displacement, 4 mm of proptosis, and limitation of elevation [Figure 1]a and [Figure 1]b. The fundus evaluation revealed choroidal folds at the posterior pole. A non-tender, firm-hard mass was palpable in supero-temporal quadrant of left orbit with raised retro-bulbar resistance.
Figure 1: (a) Abaxial proptosis of the left eye with infero-medial displacement, (b) Limitation of left elevation, (c) CT scan (coronal sections) showing mildly enhancing, well-circumscribed mass in supero-temporal orbit with hyperdense foci and erosion of the adjacent frontal bone, (d) The bony window of CT scan (axial, superior sections) shows the same lesion with prominent hyperdense specs of calcification

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A computed tomography (CT) scan showed a well-defined mass in supero-temporal orbit, showing irregular hyperdense foci with surrounding frontal bone erosion [Figure 1]c and [Figure 1]d. The mass was not separately visualized from the lacrimal gland. After obtaining informed consent, a transcutaneous anterior orbitotomy with mass excision was performed via a sub-brow Benedict's incision. Intraoperatively, a defect measuring 10mm × 12mm was identified in the supero-temporal orbital roof which was filled with bone wax.

The gross specimen measured 3 × 2.5 × 2.5 centimeters [Figure 2]a and [Figure 2]b. The histopathology showed the presence of a spindle/stellate type of cells in a chondroid matrix and hyaline cartilage with focal areas of ossification and few bony trabeculae [Fig. 2c and d]. The final diagnosis of chondromyxoid fibroma was established.
Figure 2: (a) Intraoperative picture showing expression of large mass with the smooth orbital surface, (b) The orbital bone side of the same mass shows irregular, bosselated surface, (c) (H and E, 40×) The section shows a lobular configuration with myxoid background and interspersed cartilage, (d) Higher magnification (H and E, 200×) shows spindle/stellate cells with few cartilaginous areas undergoing ossification

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Her postoperative course was uneventful with complete resolution of proptosis, significant improvement in visual acuity and restoration of elevation, although the choroidal folds persisted for 4 months. At 12-months follow-up, no clinical features of local recurrence were noted [Figure 3]a and [Figure 3]b.
Figure 3: (a) At 12 months follow-up, the left globe appears to be in normal position with a residual sub-brow scar, (b) The left elevation has also been restored to near normal

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  Discussion Top


Our case is a primary orbital CMF arising from the frontal bone with no extraorbital extension. CMFs are rare tumors presenting in 2nd to 3rd decade with a male preponderance.[2],[3] The differential diagnosis for orbital bone tumors includes both benign (osteomas, fibrous dysplasia, chondroma, osteoblastoma and giant cell tumor) and malignant lesions (osteosarcoma, chondrosarcoma and Ewing's sarcoma).[2],[3],[4],[5]

Any expansile and locally destructive lesion in the craniofacial skeleton must be evaluated and CMF should be thought of as a differential.[2],[3],[4],[5],[6],[7],[8] The CT scan features include an osteolytic lesion, well-defined lobulated margins with cortical erosion and septation (in long bones).[9] Foci of calcification may be noted in 13% cases.[2],[3] Calcification is more common in skull-base CMFs and the younger population.[3],[9],[10] On MRI, the lesion is isointense (T1W) to muscle and homogenously hyperintense (T2W) with characteristic contrast enhancement.[9],[10]

Histopathology provides the confirmative diagnosis and helps in planning further management. The histopathological differentials include both benign and malignant soft tissue, fibrous and fibro-histiocytic tumors like enchondromas, chondroblastoma, chondrosarcoma, chordoma, and myxofibrosarcoma [Table 2].[2],[3],[4],[5],[6],[7],[8] CMF is benign cartilage-forming tumors consisting of a collagenous to a myxoid matrix with the characteristic presence of stellate cells. On immunohistochemistry (IHC), they stain positive for smooth muscle antigen (SMA) and negative for keratin AE1/AE3.[2],[3] Although Mullen et al. reported that a tailored IHC might not be very helpful for diagnosing CMF.[8]
Table 2: Differentiating clinical, radiological, histopathological and immunohistochemical features of similar orbital lesions

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Enchondromas show a lobulated architecture but the presence of hyaline cartilage in these tumors is a good differentiating feature. Both CMF and chondrosarcoma stain positive for S-100 and vimentin, but the absence of fibrous stroma in orbital chondrosarcomas differentiate it from CMFs.[2],[3] Chordomas have infiltrative margins and are composed of nests/cords of large epithelial cells with eosinophilic or vacuolated cytoplasm, which may secondarily invade the orbital bone. On IHC, the chordomas express keratin and epithelial membrane antigen.[1],[2],[3] In myxofibrosarcoma, a multi-nodular proliferation of stellate fibroblasts within a myxoid stroma with curvilinear blood vessels is noted. On IHC, the myxofibrosarcoma stains positive for vimentin.[1],[2],[3]

Given the overlap of features, incisional biopsies or curettages may yield inadequate tissue leading to a possible erroneous diagnosis of malignant lesions like chondrosarcoma. This may change the further treatment course in the form of undue radiation and an unnecessary orbital exenteration. Moreover, an incomplete removal of a CMF can lead to a local recurrence. The reported recurrence rates range from 28% to 33% in the craniofacial sites.[2],[6] Hence complete excision is recommended for both better histopathological identification and to reduce the risk of recurrence.


  Conclusion Top


In conclusion, primary orbital chondromyxoid fibroma is an extremely rare orbital bony tumor having a few typical radiological characters, and total excision with proper histopathology should be the aim for complete management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has given her consent for her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Selva D, White VA, O'Connell JX, Rootman J. Primary bone tumors of the orbit. Surv Ophthalmol 2004;49:328-42.  Back to cited text no. 1
    
2.
Wu CT, Inwards CY, O'Laughlin S, Rock MG, Beabout JW, Unni KK. Chondromyxoid fibroma of bone: A clinicopathologic review of 278 cases. Hum Pathol 1998;29:438-46.  Back to cited text no. 2
    
3.
Meredith DM, Fletcher CDM, Jo VY. Chondromyxoid fibroma arising in craniofacial sites: A clinicopathologic analysis of 25 cases. Am J Surg Pathol 2018;42:392-400.  Back to cited text no. 3
    
4.
Cruz AA, Mesquita IM, Becker AN, Chahud F. Orbital invasion by chondromyxoid fibroma of the ethmoid sinus. Ophthal Plast Reconstr Surg 2007;23:427-8.  Back to cited text no. 4
    
5.
Morimura T, Nakano A, Matsumoto T, Tani E. Chondromyxoid fibroma of the frontal bone. AJNR Am J Neuroradiol 1992;13:1261-4.  Back to cited text no. 5
    
6.
Heindl LM, Amann KU, Hartmann A, Kruse FE, Holbach LM. Orbital chondromyxoid fibroma. Arch Ophthalmol 2009;127:1072-4.  Back to cited text no. 6
    
7.
Ditta LC, Qayyum S, O'Brien TF, Choudhri AF, Wilson MW. Chondromyxoid fibroma of the orbit. Ophthal Plast Reconstr Surg 2012;28:e105-6.  Back to cited text no. 7
    
8.
Mullen MG, Somogyi M, Maxwell SP, Prabhu V, Yoo DK. Primary orbital chondromyxoid fibroma: A rare case. Ophthal Plast Reconstr Surg 2017;33:S114-6.  Back to cited text no. 8
    
9.
Cappelle S, Pans S, Sciot R. Imaging features of chondromyxoid fibroma: Report of 15 cases and literature review. Br J Radiol 2016;89:20160088. doi: 10.1259/bjr.20160088.  Back to cited text no. 9
    
10.
Khalatbari MR, Hamidi M, Moharamzad Y. Chondromyxoid fibroma of the anterior skull base invading the orbit in a pediatric patient: Case report and review of the literature. Neuropediatrics 2012;43:140-5.V  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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