Typical smoker's pancoast, probably an epidermoid, with Horner's sdr. Best would be chemoradio followed by surgical salvage. In the old days it was just RT and surgery. Maybe not far off enter immunotherapy in first line. There are more and more new things.

A 60-year-old man, smoker of 40 packs/year, who consults for pain in the ulnar border of the left arm and left palpebral ptosis since one month ago. Chest X-ray shows a mass in the left upper lobe and CT scan confirms the lesion with invasion of the second rib. In relation to the suspected diagnosis, the most appropriate treatment is:

Neoadjuvant chemotherapy with combined chemoradiotherapy, followed by surgery.

Neoadjuvant chemotherapy without surgery, followed by radiotherapy.

Surgery followed by combined chemoradiotherapy.

Radiotherapy without chemotherapy, followed by surgery.

[A case of large-cell lung cancer successfully treated with docetaxel in combination with carboplatin and radiotherapy].

A 64-year-old male was referred to our hospital in September, 2000 for further examination of an abnormal chest shadow discovered in a regular health check-up. Chest X-P and CT revealed a large tumor in the left upper lobe, in association with hilar lymphadenopathy and costal invasion. Serum CEA was increased, and lung biopsy revealed a large-cell carcinoma. We performed chemoradiotherapy before surgery. Radiation (total 48 Gy) and 3 courses of chemotherapy with docetaxel (60 mg/m2) in combination with carboplatin (AUC = 6,600 mg) resulted in a remarkable reduction in the size of the mass, to less than 50%, and normalized serum CEA. Left upper lobectomy, lymphadenectomy and costectomy were performed. However, no tumor cells were detectable in the ablative specimen pathologically. These findings suggest the efficacy of chemoradiotherapy including docetaxel with carboplatin in patients with large-cell lung cancer.

Lung cancer

The vast majority (85%) of cases of lung cancer are due to long-term tobacco smoking. About 10–15% of cases occur in people who have never smoked. These cases are often caused by a combination of genetic factors and exposure to radon gas, asbestos, second-hand smoke, or other forms of air pollution. Lung cancer may be seen on chest radiographs and computed tomography (CT) scans. The diagnosis is confirmed by biopsy, which is usually performed by bronchoscopy or CT-guidance. The major method of prevention is the avoidance of risk factors, including smoking and air pollution. Treatment and long-term outcomes depend on the type of cancer, the stage (degree of spread), and the person's overall health. Most cases are not curable. Common treatments include surgery, chemotherapy, and radiotherapy. NSCLC is sometimes treated with surgery, whereas SCLC usually responds better to chemotherapy and radiotherapy.

[Guideline on 'non-small cell lung carcinoma; staging and treatment'].

A national, evidence-based guideline on the staging and treatment of patients with non-small cell lung carcinoma (NSCLC) has been compiled by the various disciplines involved. The initial diagnostic measures in patients with suspected lung cancer include history taking, physical examination and chest x-ray. Additional examinations include CT scan of the chest and upper abdomen, bronchoscopy, and 18F-fluorodeoxyglucose-positron-emission-tomography(FDG-PET)-scintigraphy, if curative therapy is planned. Cervical mediastinoscopy or endoscopic echography with fine needle aspiration can be performed for mediastinal tissue staging. The preferred treatment in stage I, II or limited III is radical resection. Postoperative radiotherapy is recommended in cases of incomplete resection and can be considered in patients in whom mediastinal lymph-node metastases are unexpectedly encountered. Chemoradiotherapy is recommended in locally advanced NSCLC. In patients with NSCLC stage I-III and poor performance status, palliative radiotherapy may be the only feasible treatment. Some patients with NSCLC stage III and stage IV can be offered palliative chemotherapy and supportive care. In cases of doubt about operability, resectability, significant pulmonary or cardiac comorbidity or combined treatment, a specialist centre should be consulted. Diagnostics should be completed within 3-5 weeks. Ensuing surgery or radiotherapy should be carried out within 2 weeks. Follow-up of patients with NSCLC includes history taking, physical examination and an optional chest x-ray. In the first year after treatment patient visits are planned quarterly, in the second year half-yearly and then yearly for at least five years.

Chemoradiotherapy

Chemoradiotherapy (CRT, CRTx, CT-RT) is the combination of chemotherapy and radiotherapy to treat cancer. Synonyms include radiochemotherapy (RCT, RCTx, RT-CT) and chemoradiation. It is a type of multimodal cancer therapy. Chemoradiation can be concurrent (together) or sequential (one after the other). The chemotherapy component can be or include a radiosensitizing agent. Chemoradiotherapy as neoadjuvant therapy before surgery has been shown to be effective in esophageal cancer. References Further reading External links Chemotherapy and chemoradiotherapy for rectal cancer. (Macmillan/NHS) Radiation therapy

[Radical resection following to concurrent chemoradiotherapy for eighty-five year-old patient with superior sulcus tumor].

An 85-year-old male with superior sulcus tumor was referred to our hospital complaining right brachial pain and omalgia. Chest computed tomography showed right apical lung tumor involving the 1st rib, and bronchoscopy established a diagnosis of squamous cell carcinoma, cT3NOM0. After concurrent chemoradiotherapy [cisplatin (CDDP) + 60 Gy], functional examination indicated him to be tolerable to lobectomy, and he underwent right upper lobectomy + chest wall resection (1st-3rd ribs) + lymph-node dissection. Pathological examination revealed that the effect of chemoradiotherapy was Ef. 3. The postoperative course was uneventful. He is free from recurrence for 7 years after the surgery.

Colorectal cancer

Radiation therapy While a combination of radiation and chemotherapy may be useful for rectal cancer, for some people requiring treatment, chemoradiotherapy can increase acute treatment-related toxicity, and has not been shown to improve survival rates compared to radiotherapy alone, although it is associated with less local recurrence. The use of radiotherapy in colon cancer is not routine due to the sensitivity of the bowels to radiation. As with chemotherapy, radiotherapy can be used as a neoadjuvant for clinical stages T3 and T4 for rectal cancer. This results in downsizing or downstaging of the tumour, preparing it for surgical resection, and also decreases local recurrence rates. For locally advanced rectal cancer, neoadjuvant chemoradiotherapy has become the standard treatment. Additionally, when surgery is not possible radiation therapy has been suggested to be an effective treatment against CRC pulmonary metastases, which are developed by 10-15% of people with CRC.

[Complete resection of Pancoast tumor while receiving preoperative concurrent chemoradiotherapy (CCRT) as an induction therapy--report of a case].

A 60-year-old man complaining of right shoulder pain and numbness of right arm was diagnosed with Pancoast tumor (invasive right apical lung cancer). Chest CT scan showed a tumor, 5 cm in diameter, in the right apex invading the right posterior chest wall. The patient received preoperative CCRT (RT: 40 Gy/20 Fr, cisplatin: CDDP and etoposide: ETP), resulting in tumor regression (PR). The patient underwent right upper lobectomy (ND 2a), partial resection of the 1st-3rd ribs and Th 1 nerve. Pathological examination demonstrated no live cancer cells and organization of necrotic tissue in the lung and intercostal region (Ef. 3). The patient received postoperative chemotherapy (CDDP+ETP) and was discharged. He did well without any tumor recurrence for 1 year postoperatively. CCRT seems effective and is one of the standard treatments for Pancoast tumor.

Sarcoma

Treatment Surgery is the most common form of the treatment for most sarcomas that have not spread to other parts of the body. Limb-sparing surgery, as opposed to amputation, can now be used to save the limbs of patients in at least 90% of extremity (arm or leg) sarcoma cases. Additional treatments, including chemotherapy, radiation therapy (also called "radiotherapy") and proton therapy, may be administered before surgery (called "neoadjuvant" chemotherapy or radiotherapy) or after surgery (called "adjuvant" chemotherapy or radiotherapy). The use of neoadjuvant or adjuvant chemotherapy and radiotherapy significantly improves the prognosis for many sarcoma patients. Treatment can be a long and arduous process, lasting about a year for many patients. Liposarcoma treatment consists of surgical resection, with chemotherapy not being used outside of the investigative setting. Adjuvant radiotherapy may also be used after surgical excision for liposarcoma.

[The operated case of 89 year-old patient with pleomorphic carcinoma of the lung].

A-89-year-old male patient who complained dry cough was detected lung mass of 3 cm size in diameter at the right upper lobe by CT. FDG-PET seemed to show hilar and mediastinum lymph nodes metastasis. After three weeks, the mass showed rapid growth with 5 cm diameter in size at CT. Therefore the original tumor was supposed to be undifferentiated carcinoma, above all, pleomorphic carcinoma. He had been done pulmonary resection after short period. The right upper lobectomy with combined resection of the partial middle lobe was performed. Hilar and mediastinum lymph nodes dissection was added. In pathological examination, the tumor was proved pleomorphic carcinoma, however, no lymph node metastasis was recognized. He did not refer any complications and discharged back home at the post-operative 11th day. Pleomorphic carcinoma of the lung is known to be difficult to obtain definite diagnosis in early stage because of rapid growth. Therefore many cases are detected in advanced stage. In addition, chemotherapy is generally not effective, so only operative resection seems to be useful. Our patient was 89-year-old, he tolerated the operation and was alive with no trouble during 6 months after resection. When complete resection seems to be possible, operation should be regarded as an initial treatment.

A mass of myxofibrosarcoma in the lung.

Fibrosarcoma is a mesenchymal tumor constituted by malignant fibroblasts. Myxofibrosarcoma is one of the fibrosarcoma variants that mostly develops from dermal/subcutaneous tissues. The most common locations are the limbs, with rare occurrences in the chest, head, and neck. Since, to best of our knowledge, there is no such report in English literature, we hereby present a case of lung myxofibrosarcoma. A 47-year-old man who had chest pain for 4 months was admitted to our clinic. The chest X-ray revealed a homogeneous density in the left upper lung. His chest computed tomography (CT) scan showed a solid mass lesion of 52 x 58 mm in size at the apical segment of the left upper lobe. There was tumor invasion at the second and third ribs. CT-guided fine-needle tru-cut lung biopsy was performed. Histopathological evaluation result was high grade myxofibrosarcoma. Surgery was conducted. Myxofibrosarcoma is a surgically curable disease. However, local recurrences occur in 50% to 60% of the cases. Therefore, chemotherapy and/or radiotherapy is the suggested approach following surgery.

[A Case of Resected Superior Sulcus Tumor with Pathological Complete Response after Trimodality Therapy].

The current case was 73-year-oldwoman. She was referredto our hospital for an abnormal shadow of chest X-ray in the upper right lung field. Chest CT showed 3.5 cm of tumor located at the apex of right lobe with invasion of the chest wall. The tumor was diagnosed as squamous cell carcinoma using CT guided needle biopsy(superior sulcus tumor, clinical T3N0M0, Stage II B). The neoadjuvant therapy, 4 courses of chemotherapy(CBDCA plus PTX)andconcurrent radiotherapy(45 Gy/25 Fr)was performed. Chest CT revealed that tumor size was decreased to 2.3 cm in a diameter, and therapeutic effect was decided as partial response(34%). Upper right lobectomy combinedwith the chest wall(1th to 3th ribs)andmed iastinal lymph node dissection were performed. The pathological specimens showed no residual cancer cells(Ef3, pathological complete response[pCR]). She discharged without complications at 10 days after surgery. It is important to collect cases which obtainedpCR for development of more effective preoperative therapy.

Esthesioneuroblastoma

Radiotherapy Radiotherapy alone is reserved only for small lesions not appropriate for either surgery or chemotherapy. Both photon and proton radiotherapy have been used effectively to treat esthesioneuroblastoma. Proton radiotherapy has recently been shown to be effective in a 10-person study with Kadish C tumors, while delivering less toxicity to the nervous system. Chemotherapy Chemotherapy is used in a multimodality treatment plan generally for more advanced, unresectable or reoccurring tumors. Cyclophosphamide, vincristine and doxorubicin have been used as neoadjuvant chemotherapy drugs for grade C esthesioneuroblastoma before surgical resection, producing fair outcomes. Cisplatin and etoposide are often used to treat esthesioneuroblastoma as neoadjuvants or adjuvants with radiotherapy or surgery.

[Surgically treated pancoast tumor].

A 40-year-old male was detected his right apical lung tumor by roentgenographic screening on January 1997, but he did not refer to a hospital since he had no symptom. He went a orthopedics because of his right chest, back, and arm pain on October 1997, and he received traction and physical therapy. He went roentgenographic screening again on January 1998 and he was pointed out that the tumor increased. He admitted our hospital. Biopsy using bronchofiberscopy revealed adenocarcinoma and induction radiotherapy (40 Gy) was performed. Right upper lobectomy with chest wall resection and lymph node dissection was performed under hook approach. This approach was useful to dissect the tumor from the invaded plexus brachialis. Postoperative radio-chemotherapy was added but the patient died 7-postoperative months because of multiple metastases. Early detection should be led to early starting of the therapy.

Pancreatic cancer

Chemotherapy After surgery, adjuvant chemotherapy with gemcitabine or 5-FU can be offered if the person is sufficiently fit, after a recovery period of one to two months. In people not suitable for curative surgery, chemotherapy may be used to extend life or improve its quality. Before surgery, neoadjuvant chemotherapy or chemoradiotherapy may be used in cases that are considered to be "borderline resectable" (see Staging) in order to reduce the cancer to a level where surgery could be beneficial. In other cases neoadjuvant therapy remains controversial, because it delays surgery.

[Superior sulcus cancer of the lung--report on 45 patients].

From 1960 to 1980, 45 patients with superior sulcus cancer of the lung were seen in our hospital. 39 were male and 6 were female. The youngest was 28 years old and the eldest was 75. The presenting symptoms and signs were back and shoulder pain in 32 patients, compression of the brachial plexus in 17, Horner's syndrome in 12, supraclavicular mass in 11, superior cava vena obstruction in 4, shadow in the apex in 45, destruction of the rib in 19 (10 in the second rib), destruction of the adjacent vertebra in 8 (5 in T3) and destruction of the clavicle in 1. In 18 patients proved by pathology and cytology, 8 were adenocarcinoma, 3 squamous cell carcinoma, 3 undifferentiated and 4 unclassified carcinoma. 27 patients were diagnosed by X-ray films. 40 patients were admitted for treatment. 3 recieved chemotherapy alone and all of them died in one year. Of the 6 treated by radiation plus chemotherapy, 3 survived for one year but all died in two years. 2 were treated by radiation plus operation and none survived for more than 3 years. 29 were treated by radiation only. The 1, 3 and 5 year survival rates were 51%, 13.7% and 6.9%. Destruction of the rib or the adjacent vertebral body was irrelative to the prognosis but the presence of supraclavicular mass reduced the survival rate. Cause of death was local recurrence in 48% (13/27) and distant metastasis in 48% (13/27). The authors suggest that radical en bloc resection together with radiation the worth further study.

Asbestos-related diseases

Malignant mesothelioma is an aggressive and incurable tumour caused by asbestos arising from mesothelial cells of the pleura, peritoneum (the lining of the abdominal cavity) and rarely elsewhere. Pleural mesothelioma is the most common type of mesothelioma, representing about 75 percent of cases. Peritoneal mesothelioma is the second most common type, consisting of about 10 to 20 percent of cases. Mesothelioma appears from 20 to 50 years after the initial exposure to asbestos. The symptoms include shortness of breath, chronic chest pain, cough, and weight loss. Diagnosing mesothelioma is often difficult and can include physical examination, chest X-ray and lung function tests, followed by CT scan and MRI. A biopsy is needed to confirm a diagnosis of malignant mesothelioma. Mesothelioma has a poor prognosis, with most patients dying within 1 year of diagnosis. The treatment strategies include surgery, radiotherapy, chemotherapy or multimodality treatment. Several tumour biomarkers

[Complete resection of Pancoast tumor following induction chemoradiotherapy improves survival].

Pancoast tumors are some of the most challenging thoracic malignant diseases to treat because of their proximity to vital structures at the thoracic inlet. We retrospectively analyzed 23 patients with pT3-4, N0-3 Pancoast tumors who underwent combined chest wall resection including the 1st rib, and discuss the anatomical considerations, assessment of induction therapy, and surgical approaches for these cancers. Between 1983 and 2006, 23 patients with Pancoast tumors underwent combined resection of the 1st rib at our institute. Of those, 21 were male and 2 were female, with an average age of 58 years. There were 10 each of squamous cell carcinoma and adenocarcinoma, 2 large cell carcinoma, and 1 adenosquamous carcinoma. Over the past decade, induction chemoradiotherapy (>40Gy) was employed before surgery. A posterior approach was employed in 14 patients, an anterior approach in 7, and a combined anterior and posterior approach in 2. Sixteen patients underwent complete resection. One of 7 patients undergoing incomplete resection (4.3%) died on the 45th postoperative day. The 3- and 5-year survival rates were 50 and 22%, respectively, for patients with complete resection. No case survived for more than 8 months out of the 7 patients with incomplete resection. Fourteen patients with pN0 showed significantly better survival than those with pN1-3 (p = 0.0053). Recent literature and our results suggest that patients with pN0 and/or a pathological complete response (pCR) after induction chemoradiotherapy could achieve long-term survival after complete resection.

Breast cancer management

Systemic therapy Systemic therapy uses medications to treat cancer cells throughout the body. Any combination of systemic treatments may be used to treat breast cancer. Standard of care systemic treatments include chemotherapy, endocrine therapy and targeted therapy. Chemotherapy Chemotherapy (drug treatment for cancer) may be used before surgery, after surgery, or instead of surgery for those cases in which surgery is considered unsuitable. Chemotherapy is justified for cancers whose prognosis after surgery is poor without additional intervention. Hormonal therapy Patients with estrogen receptor positive tumors are candidates for receiving endocrine therapy to reduce chance of relapse or of a new primary breast cancer. Endocrine therapy is usually administered after surgery, chemotherapy and radiotherapy have been given, but can also occur in the neoadjuvant or non-surgical setting. Hormonal treatments include:

[A radical resection of non-small cell lung cancer invading chest wall with ipsilateral axillary lymph node metastases].

A 41-year-old man who had non-small cell lung cancer invading his right 3rd, 4th and 5th ribs with hilum lymph node swelling(cT3N1M0, cStage III A), received chemoradiation therapy, cisplatin(CDDP)/docetaxel, and 2 Gy/Fr of irradiation prior to surgery. But the therapy was discontinued due to interstitial pneumonitis on day 24, during 28 Gy of radiation. At that time, a PET-CT scan revealed the accumulation of FDG in the primary tumor, hilar lymph node, and one of the ipsilateral axillar lymph nodes, in which cancer cell presence was proven by aspiration needle cytology. We organized a radical operation even though the node status was classified to cStage IV, because ipsilateral axillary lymph nodes may be regarded as regional nodes for tumors invading the chest wall. Right upper lobectomy and chest wall resection were performed, and the ipsilateral hilar, mediastinal, and axillary lymphnode were dissected. Pathological findings showed no active cancer cell in the primary lesion and hilar lymph nodes(Ef. 3), but obvious metastasis in one of the axillary lymph nodes(pT0N0M1b, pStage IV). The patient received adjuvant chemotherapy(CDDP/vinorelbine), and is alive and tumor-free 10months after the resection.

[A case of stage IIIB pulmonary pleomorphic carcinoma that responded well to chemoradiotherapy and surgery].

A 44-year-old man was admitted because he had a mass in the right upper lung field showing high uptake of FDG-PET. Although he had already received video-assisted thoracic surgery to remove the mass in another hospital, the procedure had been unsuccessful because of severe adhesion to the superior vena cava. The pathological diagnosis of a specimen obtained in surgery was pleomorphic carcinoma, clinical stage IIIb (c-T4N2M0). We performed concurrent chemoradiotherapy consisting of systemic chemotherapy twice with both cisplatin and vinorelbine, and radiation therapy (60Gy). The tumor size reduced by 46% immediately after chemoradiotherapy. Because there was still no evidence of distant metastasis, we performed a right upper lobectomy and resection of the superior vena cava to remove the tumor completely. We did not detect any microscopic cancer cells in the surgical specimens and the pathological diagnosis was complete response (CR). It is thought that chemotherapy and radiotherapy are ineffective for pulmonary pleomorphic carcinoma. However, in this case, concurrent chemoradiotherapy with surgical therapy was highly effective and no recurrence has been observed 13 months after surgery.

Thymoma

Surgery is the mainstay of treatment for thymoma. If the tumor is apparently invasive and large, preoperative (neoadjuvant) chemotherapy and/or radiotherapy may be used to decrease the size and improve resectability, before surgery is attempted. When the tumor is an early stage (Masaoka I through IIB), no further therapy is necessary. Removal of the thymus in adults does not appear to induce immune deficiency. In children, however, postoperative immunity may be abnormal and vaccinations for several infectious agents are recommended. Invasive thymomas may require additional treatment with radiotherapy and chemotherapy (cyclophosphamide, doxorubicin and cisplatin).. Recurrences of thymoma are described in 10-30% of cases up to 10 years after surgical resection, and in the majority of cases also pleural recurrences can be removed. Recently, surgical removal of pleural recurrences can be followed by hyperthermic intrathoracic perfusion chemotherapy or intrathoracic hyperthermic perfused

[Successful multimodal therapy of a locally advanced non-small-cell bronchial cancer].

A chest radiogram, performed on a 60-year-old man with unproductive cough for 3 months, showed a space-occupying lesion in the right upper lobe, and breath sounds were diminished in this area. He had been a heavy smoker. His general condition and nutritional state were good. Computed tomography, skeletal scintigraphy, bronchoscopy with biopsy and mediastinoscopy established the diagnosis of a locally advanced non-small-cell bronchial carcinoma (stage IIIB or T2N3M0). Combined adjuvant treatment was begun in the hope of improving the median survival time of 8 months predicted for this tumour stage. After two cycles of a combined chemotherapy scheme (ifosfamide, carboplatin, etoposide) he received hyperfractionated-accelerated radiotherapy (total dose 45 Gy; 1.5 Gy twice daily) together with carboplatin and vindesine. This was followed by a right upper lobectomy with lymphadenectomy. Full remission was confirmed in both the resected specimen and the lymph nodes. The patients remains free of tumour 30 months after the diagnosis. Neoadjuvant treatment can significantly improve the prognosis of non-small-cell bronchial carcinoma in stage III. Such patients should therefore be treated according to the appropriate study protocol, if possible.

Neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy or surgery for operable thoracic esophageal carcinoma.

A prospective clinical trial was undertaken to investigate the feasibility of concurrent chemoradiotherapy for esophageal carcinomas. Between June 1989 and May 1996, forty patients with operable squamous cell carcinoma of the thoracic esophagus (Stage 0 to III: UICC 1987), ages 45 to 78 years (mean: 64), were enrolled in a study of neoadjuvant concurrent chemoradiotherapy followed by definitive high-dose radiotherapy (CRT group) or surgery (CRT-S group). Neoadjuvant chemoradiotherapy consisted of 44 Gy in 40 fractions for 4 weeks (2.2 Gy/2 Fr/day) through 10-MVX rays, with 2 courses of cisplatin (80-100 mg/body, mean: 60 mg/m2, Day 1, bolus injection) and 5-fluorouracil (500-1000 mg/body/day, mean: 400 mg/m2, Days 1-4, continuous infusion). After completion of neoadjuvant chemoradiotherapy, an intermediate clinical response was assessed by barium swallow, esophagoscopy with/without biopsy, EUS in most cases, thoracic and upper abdominal CT scan, and cervical US. Definitive chemoradiotherapy was performed in patients when regression of more than 75% was evident (CRT Group), and esophageal resection was indicated in those who remained at less than 75% (CRT-S Group). In CRT Group, a cumulative dose of 60-70 Gy for Tis, T1 and 65-75 Gy for T2-T4 tumor with high-dose-rate intraluminal brachytherapy and a total of 3 courses of chemotherapy were planned. In CRT-S Group, intraoperative radiotherapy for abdominal lymphatic system and postoperative supraclavicular irradiation were added. At the time of intermediate assessment, complete response (CR) was observed in 16 patients, a partial response (PR) in 22, and no change (NC) in 2. Thirty responding patients (CR, 16; PR, 14) entered the CRT Group, and 10 nonresponding patients (PR, 8; NC, 2) were followed by surgery (CRT-S Group). Radiotherapy was completed satisfactorily, but chemotherapy was suspended in 26 patients (65%) because of acute toxicity. Clinical CR rate at the completion of treatment showed 90% in CRT Group, and pathologic CR rate 10% in CRT-S Group. The overall median survival was 45 months, survival at 1, 2, and 3 years being 100%, 72%, and 56%, respectively. Local-regional failure was observed in 7 patients (all in CRT Group), distant failure in 6 (3 in CRT Group, 3 in CRT-S Group) and local-regional with distant failure in 1 (CRT Group). Four patients with local-regional recurrence in the CRT Group were salvaged by surgery. Overall survival at 2 and 3 years for CRT vs. CRT-S Group was 72%, 64% vs. 75%, 38%, respectively. No treatment-related mortality was observed. The rate of the 'esophagus conservation' was 65% (Stage 0: 1 of 1, 100%; Stage I: 11 of 12, 92%; Stage II: 8 of 17, 47%; Stage III: 6 of 10, 60%). Our results demonstrated that almost all early disease (Stage 0-I) and about half of advanced disease (Stage II-III) could be conserved, their esophagus treated by the multidisciplinary approach centering on high-dose radiotherapy and concurrent chemotherapy.

[Surgical treatment of lung cancer with chest wall invasion].

From January 1986 to May 1998, 45 lung cancer patients with chest wall invasion (P3) underwent resection (40 male, 5 female), (median age 63.2 yrs (30-79)). Histological types were squamous cell carcinoma in 20, adenocarcinoma in 14, large cell carcinoma in 7, adenosquamous cell carcinoma in 2, and unknown in 2. Operative methods of lung resection were total pneumonectomy in 2, bilobectomy in 3, lobectomy in 38, and partial lung resection in 2. Resection was regarded as complete in 35 and incomplete in 10 patients. Thirty one patients had negative lymph nodes (N0), 9 had peribronchial or hilar lymph node metastases (N1), and 5 had mediastinal lymph node metastases (N2). The extent of tumor invasion to chest wall was P3a (invasion within parietal pleura) in 11, P3b-c (invasion to intercostal muscle) in 16, P3d (invasion to rib) in 18, patients. 5-year survival rate was totally 19.7%. Cisplatin based chemotherapy and concurrent thoracic radiation following surgery (CCRT) was performed in latest nine P3d cases. Partial response was observed in 5 of 9 cases (response rate 56%) and viable tumor cell in the primary site was not seen histologically in 5 of 9 cases. Three year survival rate was 46.9% for CCRT(+) 11.1% for CCRT(-). Acturial 5-year survival rate in P3a-d was 19.76%. P3d cases had poor survival, but CCRT improved prognosis of P3d cases.

Sister Mary Joseph's nodule as a presenting sign of internal malignancy.

CASE 1: A 64-year-old, otherwise healthy woman was referred to the surgery clinic for a presumed umbilical hernia. On physical examination, a cutaneous nodule was noted on the umbilical region and the patient was referred to the dermatology clinic. The patient was reexamined and an erythematous nodule was observed in the umbilicus measuring 2.5 cm in diameter. The patient denied pain, change in bowel habits, or weight loss. There were no other abdominal masses, no sign of ascites, and no regional lymphadenopathy. A skin biopsy from the nodule showed mucinous adenocarcinoma. Immunohistochemical staining was positive for carcinoembryonic antigen, and negative for cytokeratin (CK)7 and CK20. These results were consistent with a Sister Mary Joseph's nodule and led to the diagnosis of an occult colon carcinoma. The patient had no risk factors for colorectal carcinoma. The patient underwent surgery in another hospital, and died 3 months after the initial diagnosis of Sister Mary Joseph's nodule. CASE 2: A 73-year-old woman was referred to the dermatology clinic for evaluation of a painful, ulcerated, 3-cm lesion in the umbilicus (Figure 1). She was otherwise asymptomatic. A skin biopsy showed neoplastic glandular cells infiltrating among collagen bundles (Figure 2). Stainings for mucin and for CK7 were positive, while staining for CK20 was negative. An abdominopelvic CT scan demonstrated a 3.5-cm space-occupying lesion in the liver. Results of gastroscopy, colonoscopy, chest computed tomographic (CT) scan, and mammography were normal. Serum levels of the tumor-associated protein CA125 were elevated to 164 units, while those of CA 19-9 and carcinoembryonic antigen were within normal range. A gynecologic examination and a transvaginal ultrasound were normal. The patient had no personal or family history of any malignancy or any risk factors for developing a carcinoma. The patient was scheduled for a palliative resection of the umbilical nodule, combined with a laparoscopic inspection in search of the undetected primary tumor. She refused surgery and was lost to follow-up. She died 4 months after the initial diagnosis of umbilical metastasis. CASE 3: A 51-year-old man was aware of a silent mass in his umbilicus for 2 years without seeking medical advice. Following 2 weeks of increasing pain in this area, he was referred to the emergency room for a suspected incarcerated umbilical hernia. Surgery revealed a mass attached to the fascia and peritoneal fat. The mass was removed and diagnosed as a poorly differentiated adenocarcinoma, staining positively for carcinoembryonic antigen, and negatively for CK20, CK7, prostate-specific antigen, and prostatic acid phosphatase. Both gastroscopy and colonoscopy failed to detect the primary tumor. An abdominopelvic CT scan was normal, but a CT scan of the chest disclosed a nodule measuring 2.5 x 1.5 cm in the lower lobe of the right lung. On bronchoscopy, it was found to be an invasive adenocarcinoma, consistent with a primary tumor of the lung. The patient was a heavy smoker (45 pack-years). The patient received 4 cycles of combined chemotherapy with carboplatine and gemcitabine, with no improvement. A month later, the patient complained of abdominal pain. Following demonstration of intra-abdominal spread of disease by CT scan, a second line chemotherapy was instituted with paclitaxel. A month later the patient's condition deteriorated and he complained of cough, sweating, and pain along the right leg. A bone scan revealed bone metastases in the right femur and left tibia. Two weeks later he was admitted to the hospital with intestinal obstruction and underwent laparotomy. He had massive intra-abdominal spread of cancer and ascites. Only a palliative colostomy was performed. The patient died 3 weeks later, 9 months after the diagnosis of adenocarcinoma of the lung. The clinical data on the three patients are summarized in Table I.

[A 67-year old man with right arm paresthesias].

A 63-year-old man was admitted to the emergency room with chest pain. He had experienced a painful, tingling sensation in the right arm for the last three months, as well as pain in the right scapula. ECG and standard blood samples were normal. An X-ray of the thorax showed a mass in the superior sulcus on the right side. Further investigation with CT and MRI identified a large tumour, about 6 cm in size, with infiltrative growth involving the upper costae. Biopsy revealed a non-small cell carcinoma of the lung. The patient underwent a tri-modal treatment regimen with induction chemotherapy (two courses of cisplatin and etopside) and concomitant radiotherapy (50 Gy in 2 Gy fractions) before a right upper lobectomy was performed. 1 year after surgery the patient is alive, with no signs of recurrent or metastatic disease. Pancoast tumours are an infrequent subtype of lung cancers. Diagnostic delay is not uncommon. The peripheral location of the tumour generates symptoms that may easily be attributed to other causes, such as those of a musculoskeletal origin. Pre-operative chemo-radiotherapy has showed improved survival outcomes compared to pre-operative radiotherapy alone.

[A Patient with Primary Intraventricular Gliosarcoma and Long-term Survival - a Case Report].

Gliosarcoma is a rare, malignant CNS tumor with a very poor prognosis. Gliosarcoma is a variant of glioblastoma multiforme, which is characterized by the presence of both glial and mesenchymal components. The treatment strategy for gliosarcomas has not yet been determined clearly. This case report presents a 23-year-old female patient who complained of increasing headaches, nausea and vomiting, and slight motor weakness in her left arm. An MRI scan of the brain showed a tumor filling the anterior part of the right lateral ventricle and extending into the right frontal lobe. Tumor extirpation was performed. Histology revealed gliosarcoma. Subsequently, the patient received concomitant chemoradiotherapy with temozolomide in the Stupp regimen. Following the fourth cycle of maintenance temozolomide chemotherapy, at eight months after diagnosis, an MRI scan detected progression of the tumor residue. The patient underwent another surgery and then received 10 cycles of second-line chemotherapy in the ICE (ifosfamide, carboplatin, and etoposide) regimen. She completed oncological therapy with minimal toxicity and follow-up MRI scans showed virtually no residual tumor. Another follow-up MRI scan, performed 28 months after diagnosis, demonstrated progression of the tumor residue again. A third tumor resection was performed 29 months after initial diagnosis. Histology again confirmed gliosarcoma. An early postoperative MRI scan showed subtotal resection with a tumor residue in eloquent areas and also suspected implantation metastasis in the spinal canal at the C2 level. From the neurological perspective, the patient was fully self-sufficient, and had only a very mild motor deficit in her left arm. Currently, at 31 months after initial diagnosis, the patient is in a stable condition and fully self-sufficient. Our case report shows that long-term survival can be achieved in a gliosarcoma patient exhibiting all the unfavorable features in clinical-pathological terms. The minimal recommended treatment is maximal resection followed by adjuvant radiotherapy. Our patient also underwent chemoradiotherapy with temozolomide in the Stupp regimen. Recurrence at eight months after diagnosis was managed by a repeat operation and high-dose combination chemotherapy, which kept the disease in remission for 20 months after the initial relapse. The lack of unequivocal rules for chemotherapy provides an opportunity to test less common treatment regimens.Key words: gliosarcoma - surgery - chemotherapy - radiotherapy - survivalThis study was supported in part by the grant No. NT13581-4/2012(86-91) of the Internal Grant Agency of the Czech Ministry of Health.The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 26. 3. 2016Accepted: 27. 4. 2016.

Three cases of resected pleomorphic carcinoma.

Pleomorphic carcinoma (PC) is a rare malignancy of the lung. We present 3 cases that were resected. Case 1: The patient was a 75-year-old asymptomatic man whose chest roentgenogram showed a cavity at the right apex. A right upper lobectomy was performed, and the pathological stage was IB (pT2N0M0). After 3 courses of adjuvant chemotherapy, he is alive without relapse 56 months after the operation. Case 2: The patient was a 60-year-old man with left high back pain whose chest roentgenogram showed a mass shadow in the left upper lung field. A left upper lobectomy with partial resection of S6 was performed after induction chemotherapy. The pathological stage was IIIA (pT2N2M0). He died of infection 4 months after the operation during adjuvant chemotherapy. Case 3: A 78-year-old man with hemoptysis underwent aortic arch replacement after a diagnosis of impending rupture of an aortic aneurysm. During the operation, a tumor in the left upper lung lobe was detected. A left upper division segmentectomy was performed one month later. The pathological stage was IIB (pT3N0M0). Despite adjuvant radiotherapy, the patient died of cancer 9 months after the segmentectomy. The final pathological diagnoses for all 3 cases were PC. More cases of PC should be reported to establish optimal management.

Induction chemotherapy

Induction chemotherapy is the first-line treatment of cancer with a chemotherapeutic drug. The goal of induction chemotherapy is to cure the cancer. It may be contrasted with neoadjuvant therapy, with consolidation chemotherapy (intended to kill any cancer cells that survived the initial treatment), and with maintenance chemotherapy given at lower doses after the consolidation phase of treatment is over. Induction chemotherapy relies on the principle of spatial cooperation. It is beneficial in the control of malignant lymphomas and head and neck squamous cell carcinomas when followed by radiotherapy or when treated concurrently with chemoradiotherapy. References Chemotherapy

[A five-year survivor of small cell lung carcinoma stage IIIB treated with surgical resection and an adjuvant chemoradiotherapy--a case report].

A 56-year-old woman was admitted to our hospital with the complaint of cough. She had a rt. supraclavicular lymph node swelling, and her chest X-ray showed masses at the rt. hilum and the mediastinum. On bronchofiberscopy, a tumor was detected at the orifice of the lt. B3b, and the biopsy revealed small cell lung cancer (SCLC). With the peroperative diagnosis of stage IIIB SCLC, a neoadjuvant chemotherapy followed by surgical resection was performed. Because of the presence of malignant cells in the pericardial effusion, the operation turned out to be an absolutely non-curative one. As the recurrence of mediastinal lymph node swelling occurred after the surgery, an intensive chemoradiotherapy was performed successfully. Then the patient has been free from disease for five years. This case indicates the possibility that some of SCLC patients can be long-term survivors by the treatment of an appropriate adjuvant therapy combined with radical resection, even if the clinical stage is advanced. Therefore an extended operative indication for SCLC should be considered.

[An initial exploration of the application of transanal endoscopic microsurgery in rectal cancer patients with clinical complete response after neoadjuvant chemoradiotherapy].

<bObjective:</b To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT). <bMethods:</b Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients. <bResults:</b There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (<in</i=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead. <bConclusion:</b For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.

Induction chemoradiation therapy followed by surgical resection for non-small cell lung cancer (NSCLC) invading the thoracic inlet.

The role of induction therapy for non-small cell lung cancer (NSCLC) invading the thoracic inlet is unclear. We reviewed our experience with induction chemoradiation followed by surgical resection for NSCLC invading the thoracic inlet. We performed a retrospective review of 44 consecutive patients with NSCLC invading the thoracic inlet, treated with induction chemoradiation (two cycles of cisplatin and etoposide concurrently with 45Gy of radiation) followed by surgical resection between 1996 and 2007. All patients underwent chest wall resection (1-5 ribs, mean 3) with resection of the first rib through an anterior (n=15), a posterior (n=18), or a combined approach (n=11). Lobectomy was performed in 40 cases (90%), pneumonectomy in two (5%), and wedge resection in two (5%). Resection of subclavian vessels or portions of vertebrae was performed in five (11%) and 15 (34%) patients, respectively. Hospital mortality was 5% (n=2). R0-resection was achieved in 39 patients (89%). On pathologic examination, 13 patients (30%) showed complete response (pCR) to induction therapy, and 15 (34%) showed minimal microscopic residual disease (90-99% tumor necrosis). The median follow-up was 2 years (range, 2 month-10 years) with an overall cumulative 5-year survival of 59%. Sixteen patients (36%) developed recurrence, which was local in five cases and distant in 11 patients. The 5-year survival in patients with pCR was 90%; 69% in those with minimal residual disease, and 12% in patients with no relevant response (p=0.0005). Resection of NSCLC invading the thoracic inlet can be performed safely after induction chemoradiation therapy. The response rate after induction therapy is a strong predictor of survival.


The superior wall ruptures very rarely.

This question has a small typo (one would say "tennis"), but personally I am a little more bothered by the error in the description of the scan. Specifically when they say "diplopia to superior vision with limitation of the superior version of the eyeball". Versions are bilateral conjugated movements of both eyes. That is, a version is composed of the sum of two ductions, since duction is the movement of only one eye. When you explore the versions, specifically the superior version or supraversion, both eyes rotate upward. At that time, you may encounter a limitation of the movement of one eye. In this case, when you scan the supraversion, you suspect or you detect a limitation in the movement of the left eye. And we would call this a limitation to the supraversion of that eye. It doesn't make sense to talk about limitation to the version of the eyeball, because the version is always of both eyeballs. Okay, it is understood, but it is an important misconception that should not be made by the person writing the question (who is supposed to be an expert on the subject), but well, as I do not think it is a reason to challenge the question, let's go on. It is about a patient who has received a blow. All four answers are fractures, so we have a pretty definite picture. The palpebral hematoma and hyposphagma (subconjunctival hemorrhage) does not give us the key data. What is important is that the eye that has received the blow does not go up, and therefore there is double vision in the superior gaze. It might be tempting to answer 3, thinking that because the superior rectus is trapped, it does not work and therefore the eye cannot go up. However, muscles trapped in a fracture do not automatically lose their muscular action. What happens is that they become trapped, they are "hooked", and cannot stretch. The problem is that the inferior wall has been broken, the inferior rectus has been trapped, and when the eye must look up, this inferior rectus cannot stretch as it should. It is not paralysis, but a restrictive problem. This question could also be answered by discarding. Options 2 and 4 can be ignored because they are too far away from the extraocular muscles to produce diplopia. And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall. The superior wall ruptures very rarely.

This question has a small typo (one would say "tennis"), but personally I am a little more bothered by the error in the description of the scan. Specifically when they say "diplopia to superior vision with limitation of the superior version of the eyeball". Versions are bilateral conjugated movements of both eyes. That is, a version is composed of the sum of two ductions, since duction is the movement of only one eye. When you explore the versions, specifically the superior version or supraversion, both eyes rotate upward. At that time, you may encounter a limitation of the movement of one eye. In this case, when you scan the supraversion, you suspect or you detect a limitation in the movement of the left eye. And we would call this a limitation to the supraversion of that eye. It doesn't make sense to talk about limitation to the version of the eyeball, because the version is always of both eyeballs. Okay, it is understood, but it is an important misconception that should not be made by the person writing the question (who is supposed to be an expert on the subject), but well, as I do not think it is a reason to challenge the question, let's go on. It is about a patient who has received a blow. All four answers are fractures, so we have a pretty definite picture. The palpebral hematoma and hyposphagma (subconjunctival hemorrhage) does not give us the key data. What is important is that the eye that has received the blow does not go up, and therefore there is double vision in the superior gaze. [HIDDEN] However, muscles trapped in a fracture do not automatically lose their muscular action. What happens is that they become trapped, they are "hooked", and cannot stretch. The problem is that the inferior wall has been broken, the inferior rectus has been trapped, and when the eye must look up, this inferior rectus cannot stretch as it should. It is not paralysis, but a restrictive problem. This question could also be answered by discarding. [HIDDEN] And as for the walls of the orbit, the ones that break most frequently are the inferior and medial wall. The superior wall ruptures very rarely.

A 34-year-old patient playing tennis is hit by a ball at the level of the left orbit. On examination he presents significant palpebral hematoma, hyposphagmia, diplopia to superior vision with limitation of the upper version of the eyeball. What would you suspect?

Fracture of the inferior wall of the floor of the orbit with trapping of the inferior rectus muscle.

Fracture of the superior wall of the orbit with entrapment of the superior rectus muscle.

Clinico-radiologic findings of entrapped inferior oblique muscle in a fracture of the orbital floor.

A 51-year old man presented with vertical and torsional diplopia after reduction of a blowout fracture at another hospital one year ago. He had no anormalies of head position and 14 prism diopters (PD) right hypertropia (RHT) in the primary position. In upgaze no vertical deviation was found, and hyperdeviation on downgaze was 35PD. Bielschowsky head tilt test showed a negative response. Distinct superior oblique (SO) and inferior rectus (IR) underaction of the right eye was noted but IO overaction was mild on the ocular version test. Double Maddox rod test (DMRT) revealed 10-degree extorsion, but fundus extorsion was minimal in the right eye.Thin-section coronal CT scan showed that there was no fracture line on the anterior orbital floor, but a fracture remained on the posterior orbital floor. Also, the anterior part of the right inferior oblique muscle was vertically reoriented and the medial portion of the inferior oblique muscle was not traced on the coronal CT scan. The patient underwent 14 mm right IO recession and 3 mm right IR resection. One month after the surgery, his vertical and torsional diplopia were eliminated in the primary position.

Orbital blowout fracture

Signs & Symptoms Some clinically observed signs and symptoms include: Orbital pain Eyes displaced posteriorly into sockets (enophthalmos) Limitation of eye movement Loss of sensation (hypoesthesia) along the trigeminal (V2) nerve distribution Seeing-double when looking up or down (vertical diplopia) Orbital and lid subcutaneous emphysema, especially when blowing the nose or sneezing Nausea and bradycardia due to oculocardiac reflex inability to elevate eye ball, and move eyeball downward due to inferior rectus entrapment Causes Common medical causes of blowout fracture may include: Direct orbital blunt injury Sports injury (squash ball, tennis ball etc.) Motor vehicle accidents

Orbital blowout fracture

History Orbital floor fractures were investigated and described by MacKenzie in Paris in 1844 and the term blow out fracture was coined in 1957 by Smith & Regan, who were investigating injuries to the orbit and resultant inferior rectus entrapment, by placing a hurling ball on cadaverous orbits and striking it with a mallet. References External links CT Scans of Blowout Fracture from MedPix Bone fractures

Anatomical implication of less occurrence of inferior oblique muscle entrapment in orbital floor trapdoor fracture.

To examine the anatomy of the inferior oblique (IO) muscle and its surrounding structures to clarify why IO muscle entrapment develops less in orbital floor trapdoor fractures. Computed tomographic (CT) images on the unaffected sides were obtained from 64 patients with unilateral orbital fractures. On coronal planes, presence or absence of an infraorbital groove below the IO muscle was confirmed. At the level of the medial margin of the infraorbital groove/canal, the distance from the orbital floor to the IO muscle (IO-floor distance), the thickness of the orbital floor, and the shortest distance from the inferior rectus (IR) muscle to the orbital floor (shortest IR-floor distance) were measured. On quasi-sagittal planes, the distances from the inferior orbital rim to the inferior margin of the IO muscle (IO-rim distance) and the most anterior point of the infraorbital groove (groove-rim distance) were measured. The infraorbital groove was found below the IO muscle in eight patients (12.5%), and the IO-rim and IO-floor distances were significantly longer than the groove-rim and shortest IR-floor distances, respectively (p < 0.001). The orbital floor below the IO muscle was significantly thicker than that below the IR muscle (p < 0.001). Although the medial margin of the infraorbital groove is the most common fracture site, the IO muscle was not located above the groove in most cases. A longer IO-floor distance and thicker orbital floor below the IO muscle may also contribute to less occurrence of IO muscle entrapment in orbital floor trapdoor fractures.

An Uncommon Case of Isolated Superior Rectus Palsy.

Head injury associated with orbital trauma is commonly encountered in day-to-day practice. We report a rare case of orbital trauma resulting in isolated orbital "roof blow" in fracture in a 14-year-old child. The patient presented to us with diplopia and limitation of elevation of right eye after orbital trauma. Computed tomography of the orbits (2 mm sections) did not reveal fracture of the orbital floor. However, there was orbital roof "blow in" fracture with fracture fragment impingement on the superior rectus muscle. Patient was treated conservatively and spontaneous recovery of ocular motility was noted after a month.

Facial trauma

Nerves and muscles may be trapped by broken bones; in these cases the bones need to be put back into their proper places quickly. For example, fractures of the orbital floor or medial orbital wall of the eye can entrap the medial rectus or inferior rectus muscles. In facial wounds, tear ducts and nerves of the face may be damaged. Fractures of the frontal bone can interfere with the drainage of the frontal sinus and can cause sinusitis. Infection is another potential complication, for example when debris is ground into an abrasion and remains there. Injuries resulting from bites carry a high infection risk.

Lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy resulting from reduction malarplasty.

I report here on a patient with serious complications (lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy) that were caused by reduction malarplasty. A 32-year-old woman was referred to our department with complaints of inability to move her right eyeball laterally and inability to open her mouth. She has undergone reduction malarplasty 30 days previously at a local clinic. On examination, her maximal mouth opening was less than 3 mm. Her upper lip deviated to the left side when whistling. The orbit was displaced laterally and inferiorly. The upward and lateral gaze were limited. Computed tomography revealed fracture of the right orbital floor and lateral orbital wall extending to the orbital roof. The right lateral rectus muscle showed disconnection. The osteotomized segments were displaced inferiorly, and they pressed on the masseter muscle and coronoid process on the left side. On the 43rd postoperative day, a revision operation for the zygoma and orbit was carried out. Four days after the revision operation, surgery was performed for the myorrhaphy of the lateral rectus muscle and transposition of the medial rectus muscle. This case suggests the possibility of orbital fracture that can occur as a result of sawing in the wrong direction when using the intraoral approach. Although orbital fracture is extremely rare, it is hoped that this case will heighten the awareness of surgeons for this potential orbital fracture.

Resolution of Vertical Gaze Following a Delayed Presentation of Orbital Floor Fracture With Inferior Rectus Entrapment: The Contributions of Charles E. Iliff and Joseph S. Gruss in Orbital Surgery.

Orbital floor fractures occur commonly as a result of blunt trauma to the face and periorbital region. Orbital floor fractures with a "trapdoor" component allow both herniation and incarceration of contents through a bone defect into the maxillary sinus as the bone rebounds faster than the soft tissue, trapping muscle, fat, and fascia in the fracture site. In children, the fractured floor, which is often hinged on one side, tends to return toward its original anatomical position due to the incomplete nature of the fracture and elasticity of the bone. The entrapment of the inferior rectus muscle itself is considered a true surgical emergency-prolonged entrapment frequently leads to muscle ischemia and necrosis leading to permanent limitation of extraocular motility and difficult to correct diplopia. For this reason, prompt surgical intervention is recommended by most surgeons. In adults, true entrapment of the muscle itself is not as common because the orbital floor is not as elastic and fractures are more complete. We present an adult patient with an isolated orbital floor fracture with clinical and radiologic evidence of true entrapment of the inferior rectus muscle itself. Despite the delayed surgical repair (4 days after the injury), the patient's inferior rectus muscle function returned to near normal with mild upward gaze diplopia. Inferior rectus entrapment in adults may more likely be associated with immobilization of the muscle without total vascular compression/incarceration significant enough to lead to complete ischemic necrosis.

Anatomy, Head and Neck: Eye Inferior Rectus Muscle -- Clinical Significance

Because the inferior rectus is near the orbital floor, orbital floor fractures may involve this muscle. Inferior rectus muscle paresis can result from trauma to the inferior rectus muscle or nerve. This can occur either at the time of initial injury or during surgical repair of the orbital floor. If inferior rectus muscle paresis is present without entrapment, the patient may display hypertropia in the primary position. If paresis is present with entrapment, the patient may have a slight deviation or hypotropia, which decreases with downgaze. The initial management of inferior rectus paresis is observation for six months. Muscle surgery may be recommended if there is no improvement during this time. [9] [10]

[Types and treatments of blow-out fractures].

A total of ten cases of blow-out fractures of the orbit was investigated as to the signs and symptoms, image findings of conventional views of Caldwell and Waters' and of coronal CT. According to the locations of fractures, medial, floor and medial-floor types were classified. Fractured bone tips were classified to depressive and trapdoor types. Fractures often occur posterior to the eyeball, the inferior rectus muscle showed dislocation and cylinder-like hypertrophy. Contrary to the reports in the past, the inferior rectus muscle did not show entrapment in the herniated portion. Caldwell view is superior to Waters' view in demonstrating fractures at the medial orbital wall. As to the choice of treatment in the majority of cases, conservative methods are indicated. Images by CT are used in determining surgical methods, the depressive type without clinical improvement after two weeks is the indication for the surgical treatments.

Less common orbital fracture patterns: the role of computed tomography in the management of depression of the inferior oblique origin and lateral rectus involvement in blow-in fractures.

During the past decade, advances in radiographic imaging have made it possible for the surgeon managing orbital fractures to adopt a rational therapeutic strategy based on a knowledge of alterations in surgical anatomy secondary to traumatic injury. To illustrate the value of computed tomography in the surgeon's armamentarium for management of orbital fractures, cases are presented in which imaging proved decisive in planning a course of therapy. Two patients presented with two types of isolated lateral blow-in fracture, an uncommon fracture pattern. The other cases underscore the value of defining involvement of the inferior oblique origin and lateral rectus muscles in imaging complex orbital fractures, issues not emphasized in earlier literature. Although diplopia alone does not always warrant surgical intervention, diplopia in the context of computed tomography-defined muscle entrapment or muscle origin displacement justifies operative therapy. These cases demonstrate the value of computed tomography in directing surgical therapy with resolution of diplopia and prevention and correction of enophthalmos.

Medial rectus muscle

Compression The medial rectus muscle lies directly adjacent to the orbit of the skull. This leaves it vulnerable to being compressed (incarcerated) during skull fractures, which can prevent movement of the eye. This usually resolves when skull fractures are fixed. Surgical damage The medial rectus muscle may be damaged during eye surgery or skull surgery, such as functional endoscopic sinus surgery. The damage can be minor, such as bruising, or sever, such as cutting through the muscle partially or completely, and nerve injury. Additional images See also Extraocular muscles References External links () Diagram at howstuffworks.com Muscles of the head and neck Human eye anatomy de:Augenmuskeln#Musculus rectus medialis

Intraoperative Findings of Extraocular Muscle Necrosis in Linear Orbital Trapdoor Fractures.

Orbital trapdoor fractures can constitute a relative surgical emergency. The reason for poor surgical outcomes in ocular motility disturbances and diplopia is not apparent in these fractures. The purpose of this retrospective study was to analyze the possibility of ischemic necrosis of the orbital contents in linear trapdoor fracture of the orbital floor and to evaluate the recovery period of trapdoor fractures. The study included 11 patients with linear trapdoor fracture of the orbital floor over 5 years with minimum 1-year follow-up. Patients with associated facial bone fractures were excluded. Demographic, etiologic, and radiologic characteristics, interval from trauma to surgery, and surgical techniques were recorded. Patients' age range was 9 to 29 years (mean, 16.3 yr). Mean time to surgical intervention from time of injury was 3.9 days (range, 0 to 11 days). Intraoperatively, macroscopic segmental necrosis of the entrapped inferior rectus muscle was observed in 3 patients. Postoperative review was conducted for a minimum of 12 months at 1-week and 1-, 3-, 6-, and 12-month intervals. At the end of the follow-up period, incomplete recovery was observed in 5 patients, including the 3 patients with intraoperative necrosed muscle, and the other 2 patients were operated on at days 7 and 8 from time of injury. This study showed that segmental necrosis of the entrapped inferior rectus muscle is possible in linear trapdoor fracture of the orbital floor. In addition, incomplete recovery correlated with clinical evidence of inferior rectus muscle necrosis and late surgical intervention.

Clinical findings and surgical outcomes of patients with traumatic isolated inferior rectus muscle paresis.

To evaluate clinical findings and surgical outcomes of patients with traumatic isolated inferior rectus muscle paresis. The medical records of patients with traumatic isolated inferior rectus paresis who underwent strabismus surgery at Farabi Eye Hospital between 2011 and 2018 were reviewed retrospectively. Clinical features, type of surgery, and surgical outcomes were extracted from the record for analysis. A total of 19 patients (14 males [74%]) were included. Mean patient age was 34.8 ± 14.6 years. Left eyes in 13 patients (68%) were involved. Thirteen cases (68%) underwent orbital reconstruction surgery for blow-out fracture. Preoperative limitation of duction in the gaze of the inferior rectus muscle was -2 to -3 in all cases. Four patients (21%) had a paradoxical contralateral compensatory head tilt. Inferior rectus muscle resection alone was the first surgical intervention in 12 patients (63%). At the final follow-up, 12 patients (63%) were orthotropic, without any deviation or diplopia in primary position and downgaze. Three patients (16%) had a residual hypertropia of 3<supΔ</sup at distance and near without diplopia, and 4 patients (21%) required reoperation. In our patients with traumatic isolated inferior rectus paresis with persistent deviation at least 6 months after trauma, a stepwise approach based on size of the vertical deviation was employed, with good outcomes: inferior rectus resection alone for hypertropia of 6<supΔ</sup-20<supΔ</sup and inferior rectus resection and superior rectus recession for hypertropia of ≥20<supΔ</sup or significant hypertropia in the field of the superior rectus muscle.

[Blow out fracture of the medial orbital wall--plastic repair with tantalum mesh].

Two cases of blow out fracture of the medial orbital wall were reported. The one was a 14 year-old boy and the other was a 32 year-old man. After hitting the eye against another man or a hard object, the patients felt diplopia, especially on lateral gaze toward the injured side. The blow out fracture was able to be diagnosed by plain roentgenography or tomography. The fractured bone as well as the entrapped soft tissue were clearly detected by CT scan. The fractures occurred at the thinnest part of the Lamina orbitalis ossis ethmoidalis (Lamina papyracea) in both cases. Objects with diameter larger than that of the bony orbit pressed the eye ball and other soft tissue into the orbital cavity, and the blow out fracture occurred in the medial orbital wall in each case. The skin was incised along the supero-medial margin of the orbit and subperiostial dissection was done. The entrapped medial rectus muscle was observed in one case and unverified in the other. Entrapment of the orbital soft tissue other than medial rectus muscle may also have caused diplopia. Tantalum mesh, used for repair is quite thin material. It has much plasticity and little possibility of damaging the orbital tissue and of causing postoperative bleeding. No complication occurred after operation and diplopia disappeared completely or nearly completely in the cases reported.

Incarceration of the inferior oblique muscle branch of the oculomotor nerve in two cases of orbital floor trapdoor fracture.

Incarceration of the inferior oblique muscle (IO) branch of the oculomotor nerve may occur in cases of orbital floor trapdoor fracture. Two orbital floor trapdoor fracture cases, with lesions located just outside of the inferior rectus muscle but without its incarceration, were examined pre- and postoperatively for visual acuity, intraocular details, the nine diagnostic ocular positions of gaze, binocular single vision field with the Hess chart, and by computed tomography (CT). One case was also examined by magnetic resonance imaging (MRI; T1-weighted images). A forced duction test was conducted intraoperatively. Each case presented good visual acuity and neither globe showed any injury. Motility disturbance of the IO was shown in each case by binocular single vision field testing and the Hess chart. The possibility of the incarceration of the IO branch of the oculomotor nerve, which runs from the incarcerated lesion to the superior belly of the IO, in an orbital floor trapdoor fracture was shown on CT and MRI. Intraoperative forced duction testing revealed a restriction due to the incarceration of the connective tissue septa. As inferred from the CT and MRI analyses conducted in this study, IO palsy may be one of the causes of ocular motility disturbance of the IO in an orbital floor trapdoor fracture, in addition to the ocular motility disturbance due to the connective tissue septa.

Incidence of diplopia after division and reattachment of the inferior oblique muscle during orbital fracture repair.

Wide surgical access to the orbital floor and medial wall is often impaired by the course of the inferior oblique muscle. There is no current consensus on the optimal surgical approach for exposure, and techniques involving inferior oblique division are generally shunned for concern of possible complications. To determine the safety and outcomes of inferior oblique division and reattachment for surgical access to the orbital floor and medial wall during orbital fracture repair. Retrospective, single-center, review of 85 patients that underwent orbital floor, medial wall or combined fracture repair with division and reattachment of the inferior oblique near its origin. Measured characteristics include surgical approach, type of surgery, time to surgery, pre- and post-operative diplopia, enophthalmos, and complications. Forty-five patients (52.9%) with no pre-operative diplopia were followed up for a mean of six months. Of these, six patients (13.3%) developed post-operative binocular diplopia that resolved in all patients on an average of three months (range 2-6 months). No patients developed torsional diplopia. One patient developed a hematoma two years later attributable to capsular contraction around the implant. Division and reattachment of the inferior oblique muscle is a safe method that allows for panoramic surgical visualization of the inferior and medial orbit.

Extraocular Muscle Management With Orbital and Globe Trauma -- Anatomy and Physiology

The oblique muscles course inferior to their corresponding rectus muscles and insert laterally onto the globe. The superior oblique muscle arises from the periosteum of the sphenoid bone body, but its functional origin is the trochlea. The trochlea acts as a pulley for the superior oblique and is situated on the superomedial aspect of the frontal bone, rendering it prone to trauma from penetrating hook injuries in the medial canthus. [10] The inferior oblique originates from the orbital portion of the maxillary bone, crosses the inferior rectus laterally, and inserts over the macula. Incarceration of the inferior oblique muscle or its branch of the oculomotor nerve (CN III) can occur with "trapdoor" fractures. [11] Additionally, the lateral inferior oblique runs with pupillomotor preganglionic parasympathetic nerves. Damage here can result clinically in a dilated pupil. Intraoperative considerations, such as a broad arc of contact with the globe and the possibility of the inferior oblique having more than one muscle belly, are likewise important. [12] [13]

Superior orbital fissure

Superior orbital fissure syndrome Superior orbital fissure syndrome, also known as Rochon-Duvigneaud's syndrome, is a neurological disorder that results if the superior orbital fissure is fractured. Involvement of the cranial nerves that pass through the superior orbital fissure may lead to diplopia, paralysis of extraocular muscles, exophthalmos, and ptosis. Blindness or loss of vision indicates involvement of the orbital apex, which is more serious, requiring urgent surgical intervention. Typically, if blindness is present with superior orbital syndrome, it is called orbital apex syndrome. See also Foramina of skull Inferior orbital fissure References External links () (#2) Foramina of the skull Medical mnemonics

Complete inferior rectus muscle transection secondary to orbital blowout fracture.

Complete extraocular muscle transection is uncommon in the setting of blunt trauma. We report a case of a 53-year-old male that developed diplopia after hitting his face directly on a concrete slab after a fall. On examination, he had a right hypertropia with a complete infraduction deficit. A CT scan of the face showed an orbital floor blowout fracture with complete inferior rectus transection. On surgical exploration, the distal and proximal ends of the muscle were identified and sutured together, and the floor fracture was repaired. At his post-operative visits, the patient had a persistent infraduction deficit, but subjectively had improved diplopia.

Morphological characteristics and clinical manifestations of orbital emphysema caused by isolated medial orbital wall fractures.

To investigate the morphological characteristics and clinical manifestations of orbital emphysema in patients with isolated medial orbital wall fractures. This was a retrospective observational case series of 348 orbits of 348 patients with isolated medial orbital wall fractures. Medical charts were reviewed, and computed tomographic (CT) images were examined to determine the morphological characteristics of orbital emphysema. Orbital emphysema was detected in 70 orbits (20.1%). Large and communited type fracture was related with the presence of orbital emphysema (P<0.05). Orbital air pockets were detected in medial or superior extraconal orbital segment in all cases with orbital emphysema. Swollen eyelid with crepitus (90.0%) and supraduction limitation (31.4%) were developed with orbital emphysema. All cases with supraduction limitation accompanied with superior extraconal orbital emphysema and superior rectus muscle deviation, and these eyes were fully recovered with conservative management without surgery. Orbital emphysema can be a cause of ocular motility restriction following orbital wall fracture. If supraduction limitation is noted with isolated medial wall fracture and superior orbital emphysema with superior rectus muscle deviation is detected by CT scan, conservative management can be a good choice for spontaneous recovery delaying the surgery.

Image analysis of the inferior rectus muscle in orbital floor fracture using cine mode magnetic resonance imaging.

The main cause of diplopia induced by orbital floor fracture is strangulation or damage of the extraocular muscles, and the outcome varies depending on the severity of trauma. In this study, we evaluated the dynamics of the eyeball and inferior rectus muscle based on cine magnetic resonance (MR) images acquired before surgery. The preoperative images and outcomes were retrospectively investigated. The subjects were 20 patients with orbital floor fracture. The patients repeated upgaze and downgaze, and images of these were acquired using cine mode magnetic resonance imaging (MRI). Image series were obtained in the sagittal direction including the eyeball and long axis of the optic nerve. The eyeball rotation angle, strangulation, and morphology of the inferior rectus muscle were evaluated in each phase. On cine mode MRI, the outcome was poor in cases with a maximal inferior rectus muscle thickness of 5 mm or greater on extension (two or more times thicker than on the healthy side). Our results suggest that the development of sequelae can be predicted by preoperative image analysis using cine MRI, which may be beneficial to help surgeons understand the mechanism of contracture.

A protocol for extraocular muscle surgery after orbital floor fracture ("blow-out")

If, after primary repair of an orbital fracture by maxillo-facial surgeons, diplopia persists, extraocular muscle surgery may be necessary. It was the purpose of this study to examine proposed surgical treatment in these cases to determine their efficacy. We analyzed, retrospectively, the files of 14 patients who were treated in our strabismological department for persistent diplopia caused by injury to the extraocular muscles and/or to the surrounding structures. The aim of our treatment protocol was to restore comfortable binocular single vision in primary position and downgaze. The selection of the surgical procedure depended on the deviation in primary position and on the degree of ocular muscle imbalance. Surgery consisted of recession of the inferior rectus muscle of the affected eye in 4 cases, resection of the inferior rectus muscle of the affected eye in 4 other cases, and large recessions of the vertical muscles of the contralateral normal eye in 6 cases. In all 14 patients, we obtained the desired comfortable field of binocular single vision, considered "good" (20 degrees up to 30 degrees downgaze) or "satisfactory" (a useful field). In 11 cases this was achieved in one procedure. Two patients needed a reintervention because of initial overcorrection, and one patient for an initial undercorrection. All 14 patients had a "good" or "satisfactory" final result (useful binocular single vision). When extraocular muscle surgery is necessary, we recommend in patients with limited forced elevation, recession of the taut rectus inferior muscle; in patients with the clinical characteristics of an inferior rectus palsy, a resection of this muscle; and in cases with a normal or only slightly limited forced duction test, weakening the contralateral synergists.

EOM entrapment or flap tears may follow orbital fractures, which comprise the most common cause of traumatic strabismus. [14] The resultant strabismus depends on the fracture location and extent of EOM involvement. The orbit is pyramidally shaped with the apex posteriorly and the base anteriorly. Seven bones form its boundaries (Table 2). Frontal force to the orbit or globe first impacts the orbital rim but can be transmitted posteriorly before buckling downwards. The orbital floor and medial wall are commonly affected, resulting in a blowout fracture. This type of injury usually results in a comminuted fracture pattern in adults. [15]

Blunt trauma to the eye.

1. Blunt trauma to the orbital region may result in a blowout fracture, characteristically found in the orbital floor, which may contain herniated orbital contents including both inferior muscles of the eye. Persistent diplopia continues as a problem in a significant number of patients following the surgical management of a blowout fracture of the orbit. 2. Prompt recognition and treatment of blowout fractures exhibiting diplopia is usually successful. Inferior rectus and inferior oblique muscles incarcerated in a blowout fracture site for periods varying from two months to nine years may fail to function properly even following successful release of the entrapped muscles. There is some presumptive evidence to suggest a myogenic or neurogenic cause for such dysfunction. 3. Vertical diplopia that persists beyond three months following release of entrapped muscle tissue requires surgical correction, depending on the degree of vertical dissociation. 4. Motility surgery was required in 18 of 20 cases of persistent diplopia. Multiple muscle combinations are frequently required to achieve success. The criterion for a successful result was elimination of vertical diplopia in the primary and reading positions.

Orbital blowout fractures. The prognostic significance of computed tomography.

Nineteen patients with orbital floor fractures were examined and underwent computed tomography of both orbits. By evaluating the amount of orbital expansion and soft tissue herniation, we were able to identify a group of patients at high risk for developing enophthalmos (3/7 in the group with the largest amount vs. 0/7 and 0/5 in the two other groups). By studying the appearance of the inferior rectus muscle, we were also able to identify a group of patients at high risk for developing persistent diplopia (5/5 with entrapped muscles, 0/2 with hooked muscles and 0/12 of patients with free inferior rectus positions).

Orbital Floor Fracture -- History and Physical

Decreased sensation over the inferior orbital rim that may extend nasolabially signifies trigeminal nerve damage Subcutaneous emphysema is a sign of a maxillary sinus fracture Inferior rectus entrapment between inferior orbital fragments may have associated oculomotor nerve palsy Enopthalmos, exophthalmos, or swelling behind the globe indicates displacement of the fractured orbital bones Early referral to an ophthalmologist or orbital specialist may be necessary for further evaluation and treatment planning.

Orbital blowout fracture

Imaging Thin cut (2-3mm) CT scan with axial and coronal view is the optimal study of choice for orbital fractures. Plain radiographs, on the other hand, do not have the sensitively capture blowout fractures. On Water's view radiograph, polypoid mass can be observed hanging from the floor into the maxillary antrum, classically known as teardrop sign, as it usually is in shape of a teardrop. This polypoid mass consists of herniated orbital contents, periorbital fat and inferior rectus muscle. The affected sinus is partially opacified on radiograph. Air-fluid level in maxillary sinus may sometimes be seen due to presence of blood. Lucency in orbits (on a radiograph) usually indicate orbital emphysema. Treatment

Anatomy, Head and Neck, Orbit -- Muscles

The levator palpebrae superioris muscle, which receives nerve supply from CN III, elevates the upper eyelid. It is superior to the superior rectus muscle at the roof of the orbit, and these two muscles join in a common aponeurosis anteriorly. This intimate muscular relationship explains why the eye elevates as the upper eyelid is retracted. The extraocular muscles and their actions are as follows: [2] Superior rectus: Elevates, adducts and rotates medially Medial rectus: Adducts Inferior rectus: Depresses, adducts and rotates laterally Lateral rectus: Abducts Superior oblique: Depresses, abducts, and rotates medially Inferior oblique: Elevates, abducts, and rotates laterally

Greater wing of sphenoid bone

Orbital surface The orbital surface of the great wing [Fig. 2], smooth, and quadrilateral in shape, is directed forward and medially and forms the posterior part of the lateral wall of the orbit. Its upper serrated edge articulates with the orbital plate of the frontal bone. Its inferior rounded border forms the postero-lateral boundary of the inferior orbital fissure. Its medial sharp margin forms the lower boundary of the superior orbital fissure and has projecting from about its center a little tubercle that gives attachment to the inferior head of the lateral rectus muscle; at the upper part of this margin is a notch for the transmission of a recurrent branch of the lacrimal artery. Its lateral margin is serrated and articulates with the zygomatic bone. Below the medial end of the superior orbital fissure is a grooved surface, which forms the posterior wall of the pterygopalatine fossa, and is pierced by the foramen rotundum.

Orbital blowout fracture

An orbital blowout fracture is a traumatic deformity of the orbital floor or medial wall, typically resulting from impact of a blunt object larger than the orbital aperture, or eye socket. Most commonly the inferior orbital wall i.e. the floor is likely to collapse, because the bones of the roof and lateral walls are robust. Although the bone forming the medial wall is thinnest, it is buttressed by the bone separating the ethmoidal air cells. The comparatively thin bone of the floor of the orbit and roof of the maxillary sinus has no support and therefore it is the inferior wall that collapses mostly. So the medial wall blowout fractures are second most common, whereas superior wall i.e. the roof and lateral wall blowout fractures are uncommon & rare respectively. There are two broad categories of blowout fractures: open door, which are large, displaced and comminuted, and trapdoor, which are linear, hinged, and minimally displaced. They are characterized by double vision, sunken

Overcorrection of a Medial Orbital Wall Fracture Using the Endonasal Approach.

Although the endonasal approach is frequently used, and the inadvertent displacement of a bone fragment into the orbital cavity is possible, no reports have yet described the overcorrection of medial orbital wall fractures using the endonasal approach. The authors report 2 patients of the overcorrection of a medial orbital wall fracture using an endonasal approach.In the first patient, a 26-year-old Chinese-Korean woman experienced a fracture of the right medial orbital wall without entrapment of the medial rectus muscle. Eleven days after the trauma, endonasal reduction was performed. Postoperative computed tomography revealed overcorrection of the medial orbital wall and lateral displacement of the medial rectus muscle. On postoperative day 19, exophthalmos of the operated side was still observed (o.d. 20 mm/o.s. 17 mm). In the second patient, a 25-year-old Korean man experienced a fracture of the left medial orbital wall without entrapment of the medial rectus muscle. Postoperative computed tomography showed overcorrection of the medial orbital wall and a laterally displaced medial rectus muscle. On postoperative day 4, exophthalmos of the operated side was observed (o.d. 23 mm/o.s. 26 mm).For fractures of the medial wall, surgery should be performed according to the recommended indications. When the endonasal approach is used to treat medial orbital wall fractures, great care is required in reducing the herniated orbital tissue and inserting the sheet to avoid overcorrection.