Nothing beats the feeling of being able to remove a skull base tumour through a small incision in the upper eyelid crease. This here is after the tumour has been completely excised. This picture shows the amount of exposure we can achieve by just the orbital route and also that’s me admiring the orbital anatomy for a few seconds before closing up.
This below are the CT and MRI collages showing the tumour occupying the supero-lateral part of the right orbit causing lytic bone destruction of the lateral orbital wall up to the lateral skull base. It is present in the extra-conal space of the orbit extending to the epidural space and infiltrating the right temporalis muscle. It is important to note here that there is no infiltration into the peri-orbita as well as the dura. This was confirmed intra-operatively.
The following picture shows the surgical steps performed using the eyelid crease incision approach. Periosteal incision, lateral orbital rim window, debulking of the tumour with frozen section margin control and finally closure. Needless to say my Neurosurgical colleague was assisting me during the procedure and fortunately he didn’t have to take over the case. We could avoid both a craniotomy and need for any dural repair in this patient. A win-win for everyone.
Histopathology of the clinical specimen turned out to be Plasmacytoma. The ImmunoHistoChemistry (IHC) of the specimen revealed CD138 being positive with kappa chain restriction. A systemic work up which included among other things a PET-CT, Bone Marrow Aspiration (BMA) and Bone Marrow Biopsy (BMB) revealed no evidence of Multiple myeloma. Plasma cells were less than 4% and were all well differentiated. So the final diagnosis was Extra-medulary Primary Orbital Plasmacytoma. It is very rare to find isolated extra-medulary plasmacytoma in the orbit.
This case was taken up by the tumour board. In view of the complete excision of the tumour with margins and no systemic involvement, it was decided to observe the patient with close follow up.