Fortschr. Röntgenstr. 128, 2 Fortschr. Röntgenstr. 128, 2 (1978) 165---170
Einfluß der Lokalisierung, Größe und Form der simulierten intraorbitalen Tumoren an Orbitalvenen Das Ausmaß der Veränderungen
The influence of localization, size and shape of the simulated intraorbital tumors on orbital veins 10 Figures
und medial gelegenen Tumoren leichte Veränderungen in der Orbitalvene verursachen. Die Lokalisierung des Tumors ist ein weiterer wichtiger Faktor. Die oberen Tumoren sind durch den Winkel zwischen dem 2. und 3. 5upraorbitalvenensegment, der 1000 nicht überschreitet, und durch die durchschnittliche Quadrantenoberfläche charakterisiert. Durch die tiefer gelegenen Tumoren werden nur leichte Veränderungen in den Supraorbitalvenen hervorgerufen. Die medialen Tumoren vergrößern den Winkel zwischen dem 2. und 3. Supraorbitalvenensegment oberhalb 130°, während die Oberfläche des Supraorbitalvenenquadranten bis auf 550 mm2 vergrößert wird. Das charakteristischste Merkmal der intrakonisehen Tumoren ist die normale X-Punkt-Position. Die Form des Tumors ist für die Veränderungen an den Orbitalvenen von untergeordneter Bedeutung.
Institute of Diagnostic Radiology Medical School, Poznan, Poland (Director: Prof. Dr. J. Wójtowicz)
The extent of changes in orbital veins depends primarily on the size of the space-occupying lesion. Large tumors, irrespective of their position, produced change in the orbital vein, but among small tumors only the superior and medial tumors produce slight changes in the orbital vein. Localization of the tumor is also an important factor. The superior tumors are characterized by the angle between the 2nd 3rd SOY segments not exceeding 100° and by the quadrangle surface of 419 mm2 in average. The inferior tumors elicit slight changes in SOV. The medial tumors cause an increase of the angle between the 2nd and 3rd SOV segments above 130° and the surface area of SOY quadrangle up to 550 mm2. The most characteristic feature of the intraconic tumors is the normal X point position. Shape of the tumor plays a minor role in producing changes in orbital veins. The value of orbital phiebography in diagnosing expansive lesions of vascular origin within the orbit is well known (2, 7, 10, 13, 16). Opposing opinions exist, however, about the diagnostic usefulness of orbital phiebography in avascular space-occupying lesions (3, 6, 14, 18). Investigations carried
out so far with orbital phiebography in clinical cases do not solve several problems connected with the symptomatology and topography of avascular tumors. Thus for example Dayton and Hanafee (6) believe that tumors of the orbital
fundus cannot be diagnosed by phlebography because of the absence of a single great vein in that region. According to Offret, Aron-Rosa, Dilenge (14) small orbital tumors do not change the course of the superior ophthalmic vein (SOV) and are phlebografically undectable. The reasons for the differences in opinions lie perhaps in the qualitative evaluation and also in the inaccurate criteria of evaluation. Thus the purpose of these investigations was to evaluate systematically the influence of position, size and shape of avascular space-occupying lesions on the orbital venous
examined orbits within each tumor size group amounted to 10 orbits. The extraconic tumors were placed in the
upper, lower, lateral and medial part of the orbit. The venous orbit system was then injected with 10 corn of 75% Uropolinum (Polf a) through the catheter. Radiograms were
made in a.-p. and lateral projections. Tumor localization was proved by autopsy. The following parameters within the orbit were determined in a.-p. projection (Fig. 1).
a
system by using quantitative methods.
2.0 Material and method Ninety cadaver heads were examined in the following way. After dissection of the superior petrosal sinus, a thin catheter, was introduced into it as close as possible to the cavernous sinus and ligated on the catheter. Subsequently the asymetrical tumors of two sizes small (3 ml) and large (6 ml) made of a plastic substance (Zelgan) were introduced extra- and intraconically within the orbit. The number of 0340-1618/78
4
C
Fig. t.
/
\
d
Parameters of the superior ophthalmic vein a - a chord of the arch of 2nd segment of SOV, b - an angle between 2nd and 3rd SOV segment, c - Position of the X point, d - surface area of SOV quadrangle.
0232 - 0165 $ 05.00 © 1978 Georg Thieme Publishers
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an den Orbitalvenen hängt in der Hauptsache von der Größe der raumfordernden Läsion ab. Große Tumoren, ungeachtet ihrer Lage, verursachen Veränderungen in der Orbitalvene, während von den kleineren Tumoren nur die oberen
By A. Ziemianski
1.0 Purpose of study
165
A. Ziemianski
Fortschr. Röntgenstr. 128, 2
Superior extraconic tumor of small size. P.m. orbital phlebography. A) before the tumor introduction, B) after the tumor (T) introduction, a - first segment, b - second segment, Fig. 2.
e - third segment of the 80V, h - connecting middle vein, - connecting lateral vein, n - lacrimal vein.
Medial extraconic tumor of small size. P.m. orbital phlebography. A) before the tumor introduction, B) after the tumor (T) introduction, h - second segment, e - third segment of the SOy, e - middle ophthalmic vein, f inferior ophthalmic vein, h - middle connecting vein, i lateral connecting vein, n - lacrimal vein. Fig. 3.
Table 1. Mean values (x) of some phiebographical symptoms of tumors of the orbit. Feature
Norm superior
Position of tumor lateral
inferior
medial
introconic
Chord of 2 nd SOV segment
Angle of 2nd/3rd SOV segments
X point Surface of area SOV quadrangle
18,4
20,8
18,3
18,9
19,5
18,7
114,5
94,5
117,5
120,0
118,5
118,5
20,8
21,7
19,7
21,6
21,2
20,6
466
419
483
A chord of the arch of the 2nd segment of SOV. In a.-p.
view it equals the distance between the point where the first segment of the SOV enters below the stiperior rectus muscle and the point X corresponding to the chord of the concavity of 2nd segment of SOy. An angle between the 2nd and 3nd SOV segment,
e) Position of the X point. This is a point at which the second SOV segment passes into the third one. Its position
was measured as a distance to the highest point of the bony edge of the orbit,
d) Surface of SOy quadrangle formed by the superior ophthalmoc vein with the angular vein. The basic statistical
509
486
493
characteristics of these naranieters were calculated for each finding and compared to the values obtained in the control group. The statistical significance of the differences between the arithmetic mean values evaluated by Fischer's "t" test. Coefficients of linear correlation between chosen pairs of
parameters were also computed. Relationships between the changes in the orbital venous system and the shape, size and position of the tumor were also investigated in 100 orbits of a calf. After dissection of the ophthalmic venous
plexus tumors of a round and asymmetrical shape and size 1. e.: small (5%) and large (20%) of the orbital volume, were introduced into the various regions of the orbit (medial, lateral, superior). Injections of veins with contrast medium and radiographic projections were similar to those in man.
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166
The influence of localization, size and shape of the simulated intraorbit-al tumors
Fortschr. Röntgenstr. 128, 2
167
3.0 Results 3.1 Superior orbital tumors
Small superior tumors caused in most instances a deepening
of the arch of 2nd SOV segment, with an increase of its chord, a decrease of the angle between the 2nd and 3rd SOV segment and a slight lowering of X point and a decrease of
the SOV quandrangle (Fig. 2). In the lateral projection a slight widening of the arch formed by the ist and 2nd 50V segments and a deepening of the posterior part of the 2nd segments were found. Large tumors (Table 1) in the majority of cases caused a significant deepening of the concavity of
the 2nd SOV segment and an increase of the chord of the concavity.
Statistical
significant decrease of the angle
between the 2nd and 3rd SOV segments and a decrease of
the SOV quadrangle surface area were also noted. The position of X point was lowered in 7 out of 10 cases. In the
lateral projection, the deepening of the whole 2nd SOV segment was observed in the majority of cases. All tumors irrespective of their size compressed and displaced the lacrimal vein and the connecting lateral vein. 3.2 Inferior orbital tumors
Fig. 4. Medial extraconic tumor of large size. P.m. orbital phlehographv. A) before the tumor introduction, B) after the tumor (T) introduction, a flrst segment, h - second segment, e - third segment of the SOy, e - middle ophthalmic vein, middle connecting vein, i - lateral connecting vein, il h lacrimal vein, p - angular vein. Downloaded by: NYU. Copyrighted material.
Small inferior tumors did not compress the SOV system. Large inferior tumors in half of the cases, caused in a.-p. projection, a slight increase of the angle between the 2nd and 3rd SOV segments, a slight increase of the angle between
the 2nd and 3rd segments, a slight displacement of the X point upwards and an increase in the surface area the SOV quadrangle. In most cases the chord of the 2nd 50V segment was normal. No changes the SOV system were found in the
lateral projection. Small inferior tumors did not displace the smaller orbital veins whereas the large tumors displaced
upwards and widened the connecting lateral vein in two cases.
3.3 Medial orbital tumors Small medial tumors did not produce unequivocal findings. In 4 cases they cauded a slight bulge in the 2nd SOV segment
and its chord increased. In another 2 cases they decreased and in 3 cases they increased the angle between the 2nd and 3rd SOV segments. The surface area of the 50V quadrangle was increased in 2 cases and in 2 other cases a decrease
was observed (Fig. 3). Large medial tumors caused in most cases, a bulge in the 2nd SOV segment, elongation of its
chord, as well as an increase in the surface area of the quadrangle. An increase of the angle between the 2nd and
3rd segments of that vein occurred in half of the cases (Fig. 3). These changes were significantly pronounced. Position of the X point was lowered in most of the cases.
In the lateral projection, a slight widening of the arch formed by the 1st and 2nd SOV segments was observed in 3 cases. Small medical tumors did not cause distinct changes within the small veins whereas the large tumors produced
a filling defect in the connecting middle vein in 3 cases
Lateral exrraconlc of small size tumor P.m. orbital phlebography. A) Before the tumor introduction. B) After the tumor (T) introducriom a first segment, b second segment, e third segment of the superior ophthalmic vein, d - superaorbital branch, e - middle ophthalmic vein, f - inferior ophthalmic vein, g anterior connecting vein, h - middle connecting vein, i - lateral connecting vein, J posterior connecting Figs. 5.
vein, p - angular vein, r - facial vein.
(Fig. 4).
3.4 Lateral orbital tumors
Moreover, the large lateral tumors caused a filling defect
Small lateral tumors did not displace the SOV (Fig. 5).
of the connecting middle vein.
Large lateral tumors in most cases elongated the 2nd SOV segment chord increased the angle between the 2nd and 3rd
SOV segments and lowered the X point. In. half of the cases, an increase of the SOV quadrangle was found. Small lateral tumors widened and slightly displaced downwards the lacrimal vein and the connecting lateral vein (Fig. 5).
3.5 Intraconic orbital tumors Tumors within muscular cone produced variable findings. In n-lost cases an elongation of the chord of the 2nd SOV segment, an increase of the angle between the 2nd and 3rd 50V segments, as well as an increase of the SOV quadrangle
168
Fortschr. Rönrgenstr. 128, 2
A. Ziemianski
surface area were observed (Fig. 6). In the remaining cases
various findings appeared. The distinct concavity of the 2nd SOV segment with a shortening of its chord was found in 4 cases a decrease in surface area of the quadrangle in
2 cases, and in the angle between the 2nd and 3rd soy segments was decreased in 4 cases. In most of the intraconic tumors, changes in the X point position were not found.
3.6 Linear correlations of parameters Linear correlations between pairs of parameters (Table 2) was found to be significant between the angle of the 2nd/3rd 50V segments and the surface area of the SOV quadrangle.
The highest correlation coefficient was obtained for the superior tumors and the lowest for medial tumors. Fig. 7 shows the correlation between the angle of the 2nd/3rd SOV segments and the surface area of the quadrangle with a grouping of the results for the superior and medial tumors in opposite positions. A correlation between the chord of the 2nd segment of SOV and the X point (Fig. 8) shows a
grouping of results about the norm irrespective of the tumor position. The remaining groups of tumors were
h - middle connecting vein, i - lateral connecting vein, ri - lacrimal vein, p - angular vein.
found near the normal values. 3.7 The influence of shape Small round tumors were introduced in calf orbit from the
medial and lateral side. They neither compressed nor dislocated the ophthalmic plexus. However, the same tumors
2ncP 1d569 angle
00jO
130
0 120
0
QC0 G
2nd,
e QQ O
seg7,7e chord
/mm/
24-
K,
22
O0(Q0
20-
0
S
0
e
90- e
O
e
QQ
00
99 Q
18-
e
between
Fig. 7.
e
2nd/3rd SOV versus an quad40 44Ô 40
o norm e superior tumor Q inferior tumcr medial turnar lateral tumor
An
angle
rangle surface.
5&i 5O 50
Ot 00
16 1L
VS qoaangIe surface/mm/
1
20
22
2 X point pos,tion/mm/
o fl(7
A chord of the 2nd SOV segment versus X point. Fig. 8.
intrconic tumor
OQ
the
e
Table 2.
e
0
0
110-
o superior tumor Q ir,fencr tumor e meiia! fumar
ht&al turnar
e intnsxwic tumor
Linear correlation coefficients (%) between pairs of features n particular tumors of the orbit.
Features
superior
inferior
Position of tumor medial lateral
introconic
Norm
2nd segment chord X point
59,1
70,5K
60,7
65,10
64,2°
60,3
Angle of 2nd/3rd seg. SOy quadrangle
80,9
82,5
79,1
76,7
77,100
80,6°°
00
r > 63,19 One star determines the significance on 95% confidence level. r > 76,46 Two stars determine the significance on 99% confidence level.
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Figs. 6. Intraconic orbital tumor. P.m. orbital phiehography. A) Before the tumor introduction. B) After the tumor (T) introduction. a - first segment, h - second segment, e - third segment of the superior ophthalmic vein, d - supraorbital branch,
The influence of localization, size and shape of the simulated intraorbital tumors
Fig. 9a.
Small tumor.
Medial round tumor of the calf orbit.
169
Large tumor. T = rumor. The place of compression
or displacement ate pointed with arrows.
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Figs. 9a and b.
Fig. 9b.
Fortschr. Röntgenstr. 128, 2
Fig. lOa.
Small tumor.
Figs. lOa and b.
Medial asymmetrical tumor of the calf orbit.
introduced from the upper side produced an evident compression of the ophthalmic plexus. Large tumors introduced from the medial, lateral and upper sidescaused significant
compression of the whole ophthalmic plexus (Fig. 9a and b).
tumor. The place of compression Fig. lob. Large tumor. T or displacement are pointed with arrows.
segment, the angle between the 2nd and 3rd soy segments,
the X point and the 50V quadrangle. They are easy to determine in routine projections and fairly constant in normal subjects. These parameters were measured before and after the introduction of a tumor into the orbt of thet
Small asymmetrical medial, lateral and upper tumors of the calf orbit caused moderate compression of the ophthalmic plexus in half of the cases. Large asymmetrical medial, lateral
same subject. Under these circumstances the main difference between the phlebographic examination of a livingi patien
diagnosis of tumors of the orbit, is a descriptive presentation
ficantly increased only in the superior tumors. The position of the X point was found to be more charac-
and a subject investigated with p.m. phlebography is the as well as upper tumors caused significant compression cessation of circulation and in the instantaneous introducof the ophthalmic plexus in almost all cases (Fig. lOa tion of the simulated tumor and sudden increase of the and b). Thus the shape of the introduced tumor was of no tumor within the orbita. This eliminates the adoptation mechanisms which develop in the slowly growing intraimportance under these experimental conditions. orbital tumors. On the other hand the advantages of these experiment are obvious; changes in isolated parameters 4.0 Discussion can be made and systematically observed. As we have It seems that one of the sources of the inaccuracy in the shown above the chord of the 2nd SOV segment is signiof the knowledge gathered so far. Wc felt that an attempt to describe and classify these findings would be of practical teristic: it has its lowermost position in the superior and importance. Therefore four parameters as described pre- medial tumors, but remains unaltered in the intrasonic viously (1, 15) were chosen: the chord of the 2nd soy tumors, where it approaches the normal value.
Fortschr. Röntgenstr. 128,2
A. Ziemiansk: Localization, size and shape of the isimulated ntraorbital tumors
The angle between the 2nd and 3rd SOV segments varies significantly. The lowest values were noted in the superior
obvious influence of the tumor size on the venous system of the orbit is proved by the fact that small, medial and lateral
tumors and the highest ones in the nedial tumors.
tumors do not compress the veins. The large tumors,
The surface area of the SOV quadrangle changes in the same way as the angle between the 2nd and 3rd SOV segments. A slightly lower correlation occurs between the
however, produce evident dislocation and compression of the whole ophthalmic plexus. The shape of the tumor is the least important factor in producing changes in position and the course of the orbital veins,
2nd segment chord and the X point. In the literature (1, 9, 17)
various proposals of classification of avascular tumors of the orbit can be found. Vignaud, Clay (18) assume that classification should take into account the topographical information essential for the surgical approach. Thus, according to these authors all orbital tumors can be divided
into the extra and intraconic ones. Extraconic tumors, depending on localization are further divided into the superior, inferior, medial and lateral tumors. We found that superior tumors are characterised by several findings
which differentiate them distinctly from the remaining tumors. We found that inferior tumors were difficult to detect with orbital phlebography which is in agreement with other authors (3, 6, 18). The rare localizations of tumors within the orbital fundus are not taken into account. The diagnostic difficulties are increased by the inconstant occurrence of the inferior ophthalmic vein and the distant position of the SOy. Therefore, particular attention should be paid also to the smaller veins of the orbit especially the connecting lateral vein (S). Medial tumors, besides the characteristically increased angle between the 2nd and 3rd
SOY segments and the SOV quandrangle do not reveal any other discriminative features. Similarly lateral tumors
do not present features distinguishing them from other tumors. In agreement with other authors (1, 3, 15), we believe that intraconic tumors can be correctly diagnosed, based on the normal position of the X point in combination with the other characteristic features. The tumors discussed here are localized in the anterior and middle segments of the orbit. However the posterior tumor close to the apex
does not dislocate the SOy. According to some authors (8, 11, 12) small tumors do not produce phlebographic symptoms. In our opinion it holds true only in relation to inferior and lateral tumors. Small superior and medial tumors produce distinct findings in half of the cases. The
Literature Aron-Rosa,
D.:
litilite de la
phlebographic orbitaire dans l'étude anatomique et pathologique du sinus coverneux. Bull. Soc. Ophtal. (Paris) 66 (1966) 912 Arseni, C., N. Michalescu, M. Simonescu: Orbital phlebography.
Acta Neurochir. ('sVien) 12 (1965) 521
Bouder, C.: La place du phlebogramme orhitaire dans de diagnostic des tumeurs de l'orbite. Arch. Ophtalmo1. 15 (1955) 697
Boulay, G.: Orbital phlebography in the diagnosis of intraorbital harmangiomas. Trans. ophthal. Soc. U. K. 11)1962) 245
Brismar, J.: Orbital phlehography ill ronography of intraorbital reins. Acta Radiol. (Diagn.) )Stockh.) 15 (1974) 577
Dayton, G., W. 1-lanafee: Orbital venography in surgery of the orbit. Amer. J. Ophthal. 67 (1969) 512
Dejean, C., C. Boudet: Du diagnostic des varices de l'orbite et de leurs complications par la phlehographie. Bull. Soc. 64 (1951) 374
franç.
Ophtal.
Hanafee, W., G. Shiu, G. Dayton: Orbital venography. Amer. J. Roentgenol. Radium Thcr. Nun. Med. 107 (1968) 29
Haye, C., C. Clay, J. Vignand: L'exploration radiologique de l'orbite.
Arch. Ophtal. (Paris) 30 (1970) 179 Hobbs, H., G. Boulay: Orbital angioma diagnosed by phiebography. Brit. J. Ophthal. 44 (1960) 551 Lloyd, G.: The localization of lesions in the orbital apex and cavernous sinus by frontal veoography. Brit. J. Radiol. 45 (1972) 402 Lombardi, G.: Orbital Pathology
and Contrast. Media. Radiol.
Clin.
(N. A.) 10 (1972) 115 Neubauer, H., J. Süsse: Die Phlebographie der Orbita über die Vena frontalis. KIm. Mbl. Augenhk. 148 (1966) 2021 Offret, G., D. Aron-Rosa, D.
Dilenge: Intérêt de l'opacification des vaisseaux dans le angiomes orbitopalpebrale. Arch. Ophtal. (Paris) 23 (1963) 275 (IS) Offret, G., D. Aron-Rosa: Le
phlebograrnnse orhitaire. Arch. Ophtal. (Paris) 25 (1965) 85
Otto, A.: Angular-vein phlebo. graphy as an aid to the diagnosis of intraorbital processes. Ophthalmologica 165 (1972) 567 Piscol, K.: Die perkutane Katheterisierung der Vena frontalis zur
Darstellung der orhitalen Venen und des Sinus cavernosos. Fortschr. Röntgenol. 104 (1966) 184 Vignaud, J. C., C. L. Bilaniuk:
Venography of the orbit. Radiology 110 (1974) 373
Dr. A. Ziemianski, Institute of Diagnostic Radiology, Medical School, Szkolna 8/12, 61-832 Poznan, Poland
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170
Einfluß der Lokalisierung, Größe und Form der simulierten intraorbitalen Tumoren an Orbitalvenen Das Ausmaß der Veränderungen
The influence of localization, size and shape of the simulated intraorbital tumors on orbital veins 10 Figures
und medial gelegenen Tumoren leichte Veränderungen in der Orbitalvene verursachen. Die Lokalisierung des Tumors ist ein weiterer wichtiger Faktor. Die oberen Tumoren sind durch den Winkel zwischen dem 2. und 3. 5upraorbitalvenensegment, der 1000 nicht überschreitet, und durch die durchschnittliche Quadrantenoberfläche charakterisiert. Durch die tiefer gelegenen Tumoren werden nur leichte Veränderungen in den Supraorbitalvenen hervorgerufen. Die medialen Tumoren vergrößern den Winkel zwischen dem 2. und 3. Supraorbitalvenensegment oberhalb 130°, während die Oberfläche des Supraorbitalvenenquadranten bis auf 550 mm2 vergrößert wird. Das charakteristischste Merkmal der intrakonisehen Tumoren ist die normale X-Punkt-Position. Die Form des Tumors ist für die Veränderungen an den Orbitalvenen von untergeordneter Bedeutung.
Institute of Diagnostic Radiology Medical School, Poznan, Poland (Director: Prof. Dr. J. Wójtowicz)
The extent of changes in orbital veins depends primarily on the size of the space-occupying lesion. Large tumors, irrespective of their position, produced change in the orbital vein, but among small tumors only the superior and medial tumors produce slight changes in the orbital vein. Localization of the tumor is also an important factor. The superior tumors are characterized by the angle between the 2nd 3rd SOY segments not exceeding 100° and by the quadrangle surface of 419 mm2 in average. The inferior tumors elicit slight changes in SOV. The medial tumors cause an increase of the angle between the 2nd and 3rd SOV segments above 130° and the surface area of SOY quadrangle up to 550 mm2. The most characteristic feature of the intraconic tumors is the normal X point position. Shape of the tumor plays a minor role in producing changes in orbital veins. The value of orbital phiebography in diagnosing expansive lesions of vascular origin within the orbit is well known (2, 7, 10, 13, 16). Opposing opinions exist, however, about the diagnostic usefulness of orbital phiebography in avascular space-occupying lesions (3, 6, 14, 18). Investigations carried
out so far with orbital phiebography in clinical cases do not solve several problems connected with the symptomatology and topography of avascular tumors. Thus for example Dayton and Hanafee (6) believe that tumors of the orbital
fundus cannot be diagnosed by phlebography because of the absence of a single great vein in that region. According to Offret, Aron-Rosa, Dilenge (14) small orbital tumors do not change the course of the superior ophthalmic vein (SOV) and are phlebografically undectable. The reasons for the differences in opinions lie perhaps in the qualitative evaluation and also in the inaccurate criteria of evaluation. Thus the purpose of these investigations was to evaluate systematically the influence of position, size and shape of avascular space-occupying lesions on the orbital venous
examined orbits within each tumor size group amounted to 10 orbits. The extraconic tumors were placed in the
upper, lower, lateral and medial part of the orbit. The venous orbit system was then injected with 10 corn of 75% Uropolinum (Polf a) through the catheter. Radiograms were
made in a.-p. and lateral projections. Tumor localization was proved by autopsy. The following parameters within the orbit were determined in a.-p. projection (Fig. 1).
a
system by using quantitative methods.
2.0 Material and method Ninety cadaver heads were examined in the following way. After dissection of the superior petrosal sinus, a thin catheter, was introduced into it as close as possible to the cavernous sinus and ligated on the catheter. Subsequently the asymetrical tumors of two sizes small (3 ml) and large (6 ml) made of a plastic substance (Zelgan) were introduced extra- and intraconically within the orbit. The number of 0340-1618/78
4
C
Fig. t.
/
\
d
Parameters of the superior ophthalmic vein a - a chord of the arch of 2nd segment of SOV, b - an angle between 2nd and 3rd SOV segment, c - Position of the X point, d - surface area of SOV quadrangle.
0232 - 0165 $ 05.00 © 1978 Georg Thieme Publishers
Downloaded by: NYU. Copyrighted material.
an den Orbitalvenen hängt in der Hauptsache von der Größe der raumfordernden Läsion ab. Große Tumoren, ungeachtet ihrer Lage, verursachen Veränderungen in der Orbitalvene, während von den kleineren Tumoren nur die oberen
By A. Ziemianski
1.0 Purpose of study
165
A. Ziemianski
Fortschr. Röntgenstr. 128, 2
Superior extraconic tumor of small size. P.m. orbital phlebography. A) before the tumor introduction, B) after the tumor (T) introduction, a - first segment, b - second segment, Fig. 2.
e - third segment of the 80V, h - connecting middle vein, - connecting lateral vein, n - lacrimal vein.
Medial extraconic tumor of small size. P.m. orbital phlebography. A) before the tumor introduction, B) after the tumor (T) introduction, h - second segment, e - third segment of the SOy, e - middle ophthalmic vein, f inferior ophthalmic vein, h - middle connecting vein, i lateral connecting vein, n - lacrimal vein. Fig. 3.
Table 1. Mean values (x) of some phiebographical symptoms of tumors of the orbit. Feature
Norm superior
Position of tumor lateral
inferior
medial
introconic
Chord of 2 nd SOV segment
Angle of 2nd/3rd SOV segments
X point Surface of area SOV quadrangle
18,4
20,8
18,3
18,9
19,5
18,7
114,5
94,5
117,5
120,0
118,5
118,5
20,8
21,7
19,7
21,6
21,2
20,6
466
419
483
A chord of the arch of the 2nd segment of SOV. In a.-p.
view it equals the distance between the point where the first segment of the SOV enters below the stiperior rectus muscle and the point X corresponding to the chord of the concavity of 2nd segment of SOy. An angle between the 2nd and 3nd SOV segment,
e) Position of the X point. This is a point at which the second SOV segment passes into the third one. Its position
was measured as a distance to the highest point of the bony edge of the orbit,
d) Surface of SOy quadrangle formed by the superior ophthalmoc vein with the angular vein. The basic statistical
509
486
493
characteristics of these naranieters were calculated for each finding and compared to the values obtained in the control group. The statistical significance of the differences between the arithmetic mean values evaluated by Fischer's "t" test. Coefficients of linear correlation between chosen pairs of
parameters were also computed. Relationships between the changes in the orbital venous system and the shape, size and position of the tumor were also investigated in 100 orbits of a calf. After dissection of the ophthalmic venous
plexus tumors of a round and asymmetrical shape and size 1. e.: small (5%) and large (20%) of the orbital volume, were introduced into the various regions of the orbit (medial, lateral, superior). Injections of veins with contrast medium and radiographic projections were similar to those in man.
Downloaded by: NYU. Copyrighted material.
166
The influence of localization, size and shape of the simulated intraorbit-al tumors
Fortschr. Röntgenstr. 128, 2
167
3.0 Results 3.1 Superior orbital tumors
Small superior tumors caused in most instances a deepening
of the arch of 2nd SOV segment, with an increase of its chord, a decrease of the angle between the 2nd and 3rd SOV segment and a slight lowering of X point and a decrease of
the SOV quandrangle (Fig. 2). In the lateral projection a slight widening of the arch formed by the ist and 2nd 50V segments and a deepening of the posterior part of the 2nd segments were found. Large tumors (Table 1) in the majority of cases caused a significant deepening of the concavity of
the 2nd SOV segment and an increase of the chord of the concavity.
Statistical
significant decrease of the angle
between the 2nd and 3rd SOV segments and a decrease of
the SOV quadrangle surface area were also noted. The position of X point was lowered in 7 out of 10 cases. In the
lateral projection, the deepening of the whole 2nd SOV segment was observed in the majority of cases. All tumors irrespective of their size compressed and displaced the lacrimal vein and the connecting lateral vein. 3.2 Inferior orbital tumors
Fig. 4. Medial extraconic tumor of large size. P.m. orbital phlehographv. A) before the tumor introduction, B) after the tumor (T) introduction, a flrst segment, h - second segment, e - third segment of the SOy, e - middle ophthalmic vein, middle connecting vein, i - lateral connecting vein, il h lacrimal vein, p - angular vein. Downloaded by: NYU. Copyrighted material.
Small inferior tumors did not compress the SOV system. Large inferior tumors in half of the cases, caused in a.-p. projection, a slight increase of the angle between the 2nd and 3rd SOV segments, a slight increase of the angle between
the 2nd and 3rd segments, a slight displacement of the X point upwards and an increase in the surface area the SOV quadrangle. In most cases the chord of the 2nd 50V segment was normal. No changes the SOV system were found in the
lateral projection. Small inferior tumors did not displace the smaller orbital veins whereas the large tumors displaced
upwards and widened the connecting lateral vein in two cases.
3.3 Medial orbital tumors Small medial tumors did not produce unequivocal findings. In 4 cases they cauded a slight bulge in the 2nd SOV segment
and its chord increased. In another 2 cases they decreased and in 3 cases they increased the angle between the 2nd and 3rd SOV segments. The surface area of the 50V quadrangle was increased in 2 cases and in 2 other cases a decrease
was observed (Fig. 3). Large medial tumors caused in most cases, a bulge in the 2nd SOV segment, elongation of its
chord, as well as an increase in the surface area of the quadrangle. An increase of the angle between the 2nd and
3rd segments of that vein occurred in half of the cases (Fig. 3). These changes were significantly pronounced. Position of the X point was lowered in most of the cases.
In the lateral projection, a slight widening of the arch formed by the 1st and 2nd SOV segments was observed in 3 cases. Small medical tumors did not cause distinct changes within the small veins whereas the large tumors produced
a filling defect in the connecting middle vein in 3 cases
Lateral exrraconlc of small size tumor P.m. orbital phlebography. A) Before the tumor introduction. B) After the tumor (T) introducriom a first segment, b second segment, e third segment of the superior ophthalmic vein, d - superaorbital branch, e - middle ophthalmic vein, f - inferior ophthalmic vein, g anterior connecting vein, h - middle connecting vein, i - lateral connecting vein, J posterior connecting Figs. 5.
vein, p - angular vein, r - facial vein.
(Fig. 4).
3.4 Lateral orbital tumors
Moreover, the large lateral tumors caused a filling defect
Small lateral tumors did not displace the SOV (Fig. 5).
of the connecting middle vein.
Large lateral tumors in most cases elongated the 2nd SOV segment chord increased the angle between the 2nd and 3rd
SOV segments and lowered the X point. In. half of the cases, an increase of the SOV quadrangle was found. Small lateral tumors widened and slightly displaced downwards the lacrimal vein and the connecting lateral vein (Fig. 5).
3.5 Intraconic orbital tumors Tumors within muscular cone produced variable findings. In n-lost cases an elongation of the chord of the 2nd SOV segment, an increase of the angle between the 2nd and 3rd 50V segments, as well as an increase of the SOV quadrangle
168
Fortschr. Rönrgenstr. 128, 2
A. Ziemianski
surface area were observed (Fig. 6). In the remaining cases
various findings appeared. The distinct concavity of the 2nd SOV segment with a shortening of its chord was found in 4 cases a decrease in surface area of the quadrangle in
2 cases, and in the angle between the 2nd and 3rd soy segments was decreased in 4 cases. In most of the intraconic tumors, changes in the X point position were not found.
3.6 Linear correlations of parameters Linear correlations between pairs of parameters (Table 2) was found to be significant between the angle of the 2nd/3rd 50V segments and the surface area of the SOV quadrangle.
The highest correlation coefficient was obtained for the superior tumors and the lowest for medial tumors. Fig. 7 shows the correlation between the angle of the 2nd/3rd SOV segments and the surface area of the quadrangle with a grouping of the results for the superior and medial tumors in opposite positions. A correlation between the chord of the 2nd segment of SOV and the X point (Fig. 8) shows a
grouping of results about the norm irrespective of the tumor position. The remaining groups of tumors were
h - middle connecting vein, i - lateral connecting vein, ri - lacrimal vein, p - angular vein.
found near the normal values. 3.7 The influence of shape Small round tumors were introduced in calf orbit from the
medial and lateral side. They neither compressed nor dislocated the ophthalmic plexus. However, the same tumors
2ncP 1d569 angle
00jO
130
0 120
0
QC0 G
2nd,
e QQ O
seg7,7e chord
/mm/
24-
K,
22
O0(Q0
20-
0
S
0
e
90- e
O
e
00
99 Q
18-
e
between
Fig. 7.
e
2nd/3rd SOV versus an quad40 44Ô 40
o norm e superior tumor Q inferior tumcr medial turnar lateral tumor
An
angle
rangle surface.
5&i 5O 50
Ot 00
16 1L
VS qoaangIe surface/mm/
1
20
22
2 X point pos,tion/mm/
o fl(7
A chord of the 2nd SOV segment versus X point. Fig. 8.
intrconic tumor
OQ
the
e
Table 2.
e
0
0
110-
o superior tumor Q ir,fencr tumor e meiia! fumar
ht&al turnar
e intnsxwic tumor
Linear correlation coefficients (%) between pairs of features n particular tumors of the orbit.
Features
superior
inferior
Position of tumor medial lateral
introconic
Norm
2nd segment chord X point
59,1
70,5K
60,7
65,10
64,2°
60,3
Angle of 2nd/3rd seg. SOy quadrangle
80,9
82,5
79,1
76,7
77,100
80,6°°
00
r > 63,19 One star determines the significance on 95% confidence level. r > 76,46 Two stars determine the significance on 99% confidence level.
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Figs. 6. Intraconic orbital tumor. P.m. orbital phiehography. A) Before the tumor introduction. B) After the tumor (T) introduction. a - first segment, h - second segment, e - third segment of the superior ophthalmic vein, d - supraorbital branch,
The influence of localization, size and shape of the simulated intraorbital tumors
Fig. 9a.
Small tumor.
Medial round tumor of the calf orbit.
169
Large tumor. T = rumor. The place of compression
or displacement ate pointed with arrows.
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Figs. 9a and b.
Fig. 9b.
Fortschr. Röntgenstr. 128, 2
Fig. lOa.
Small tumor.
Figs. lOa and b.
Medial asymmetrical tumor of the calf orbit.
introduced from the upper side produced an evident compression of the ophthalmic plexus. Large tumors introduced from the medial, lateral and upper sidescaused significant
compression of the whole ophthalmic plexus (Fig. 9a and b).
tumor. The place of compression Fig. lob. Large tumor. T or displacement are pointed with arrows.
segment, the angle between the 2nd and 3rd soy segments,
the X point and the 50V quadrangle. They are easy to determine in routine projections and fairly constant in normal subjects. These parameters were measured before and after the introduction of a tumor into the orbt of thet
Small asymmetrical medial, lateral and upper tumors of the calf orbit caused moderate compression of the ophthalmic plexus in half of the cases. Large asymmetrical medial, lateral
same subject. Under these circumstances the main difference between the phlebographic examination of a livingi patien
diagnosis of tumors of the orbit, is a descriptive presentation
ficantly increased only in the superior tumors. The position of the X point was found to be more charac-
and a subject investigated with p.m. phlebography is the as well as upper tumors caused significant compression cessation of circulation and in the instantaneous introducof the ophthalmic plexus in almost all cases (Fig. lOa tion of the simulated tumor and sudden increase of the and b). Thus the shape of the introduced tumor was of no tumor within the orbita. This eliminates the adoptation mechanisms which develop in the slowly growing intraimportance under these experimental conditions. orbital tumors. On the other hand the advantages of these experiment are obvious; changes in isolated parameters 4.0 Discussion can be made and systematically observed. As we have It seems that one of the sources of the inaccuracy in the shown above the chord of the 2nd SOV segment is signiof the knowledge gathered so far. Wc felt that an attempt to describe and classify these findings would be of practical teristic: it has its lowermost position in the superior and importance. Therefore four parameters as described pre- medial tumors, but remains unaltered in the intrasonic viously (1, 15) were chosen: the chord of the 2nd soy tumors, where it approaches the normal value.
Fortschr. Röntgenstr. 128,2
A. Ziemiansk: Localization, size and shape of the isimulated ntraorbital tumors
The angle between the 2nd and 3rd SOV segments varies significantly. The lowest values were noted in the superior
obvious influence of the tumor size on the venous system of the orbit is proved by the fact that small, medial and lateral
tumors and the highest ones in the nedial tumors.
tumors do not compress the veins. The large tumors,
The surface area of the SOV quadrangle changes in the same way as the angle between the 2nd and 3rd SOV segments. A slightly lower correlation occurs between the
however, produce evident dislocation and compression of the whole ophthalmic plexus. The shape of the tumor is the least important factor in producing changes in position and the course of the orbital veins,
2nd segment chord and the X point. In the literature (1, 9, 17)
various proposals of classification of avascular tumors of the orbit can be found. Vignaud, Clay (18) assume that classification should take into account the topographical information essential for the surgical approach. Thus, according to these authors all orbital tumors can be divided
into the extra and intraconic ones. Extraconic tumors, depending on localization are further divided into the superior, inferior, medial and lateral tumors. We found that superior tumors are characterised by several findings
which differentiate them distinctly from the remaining tumors. We found that inferior tumors were difficult to detect with orbital phlebography which is in agreement with other authors (3, 6, 18). The rare localizations of tumors within the orbital fundus are not taken into account. The diagnostic difficulties are increased by the inconstant occurrence of the inferior ophthalmic vein and the distant position of the SOy. Therefore, particular attention should be paid also to the smaller veins of the orbit especially the connecting lateral vein (S). Medial tumors, besides the characteristically increased angle between the 2nd and 3rd
SOY segments and the SOV quandrangle do not reveal any other discriminative features. Similarly lateral tumors
do not present features distinguishing them from other tumors. In agreement with other authors (1, 3, 15), we believe that intraconic tumors can be correctly diagnosed, based on the normal position of the X point in combination with the other characteristic features. The tumors discussed here are localized in the anterior and middle segments of the orbit. However the posterior tumor close to the apex
does not dislocate the SOy. According to some authors (8, 11, 12) small tumors do not produce phlebographic symptoms. In our opinion it holds true only in relation to inferior and lateral tumors. Small superior and medial tumors produce distinct findings in half of the cases. The
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Dr. A. Ziemianski, Institute of Diagnostic Radiology, Medical School, Szkolna 8/12, 61-832 Poznan, Poland
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