Metastatic Disease to Extraocular Muscles of Undiscovered Primary Breast Cancer

1
Metastatic Disease to Extraocular Muscles of
Undiscovered Primary Breast Cancer

• Maria E. Lim, BS 1
• Sergul A. Erzurum, MD, FACS 1, 2
• 1. Department of Surgery, Northeastern Ohio
  Universities College of Medicine, Rootstown, OH
  44272
• 2. Section of Ophthalmology in the Department of
  Surgery at St. Elizabeth Health Center,
  Youngstown, OH 44501
• Authors acknowledge the financial support of the
  Polena Trust for Ocular Research at the St.
  Elizabeth Development Foundation, Youngstown,
  Ohio. Statements are the sole responsibility of
  the authors. Authors have no financial conflict
  of interest associated with products described in
  the report.

2
57 year old Caucasian female

• History of Present Illness (Feb 2010)
• Chief complaint diplopia at distance x 3-5 weeks
• Resolved when left eye closed
• Negative for
• Orbital/retroorbital pain
• Change in vision

3
Physical Exam

• OD
• BCVA 20/20
• Tonometry 20
• SLE NL
• Fundus
• flame hemmorrhage off disc noted
• EOM movement full in all direction
• Hertel 16 mm
• base setting 93
• PERRL
• Neurologic exam
• Cranial nerve exam, strength, movement, deep
  tendon reflexes, sensation, and coordination were
  all within normal limits.
• Lumbar puncture
• No malignant cells

• OS
• BCVA 20/20
• Tonometry 23
• SLE NL
• Fundus NL
• EOM movement
• -3 limitation of abduction
• -4 limitation of elevation
• Distance fixation 10? RHT
• Near fixation 1-2? intermittent RHT
• Right gaze 8? RHT
• Left gaze 14? RHT, 2? XT
• Upward gaze approximately 25-20? RHT
• () retropulsion
• Hertel 16 mm
• base setting 93
• PERRL

4
Past Medical History

• July 2006 Palpable left axillary
  lymphadenopathy
• Nov 2006 Left axillary lymph node dissection
• Pathology poorly differentiated adenocarcinoma
  consistent with breast origin
• ER (), PR (-), Her-2/neu (-) in 14/15 nodes
• Lymphoproliferative disease markers (-)
• Patient received doxorubicin, cyclophosphamide,
  paclitaxel x 5 months then radiation and
  anastrozole.

• Oct 2007 ? CEA CA 27-29
• PET scan, B/L breast MRI, CT abdomen pelvis
• All findings benign
• May 2008 Bone metastasis, right ovarian
  metastasis, and retroperitoneal adenopathy
• Treatment capecitabine and pamidronate
• Right ureteral stent placement
• July 2009 Liver metastasis
• Treatment gemcitabine and paclitaxel
• Jan 2010 Worsening liver lesions
• Treatment 3 cycles doxorubicin

5
MRI brain/orbits (Feb 11, 2010) Thickening of
the extraocular muscles bilaterally especially on
the medial inferior left side.
6
CT scan orbits (Feb 27, 2010) Soft tissue masses
of the left medial and inferior rectus muscle
sheaths displacing the optic nerve superiorly and
laterally. No involvement of the optic nerve or
orbital bones. Mild hypertrophy of the right
rectus muscles was noted.
7
Patient Course

• Treatment
• Radiation to the left eye and orbit
• Continued systemic treatment
• Developed thrombocytopenia secondary to therapy.
• March 2010 admitted to the Medical ICU for
  profuse rectal bleeding and hypovolemic shock
• Received packed red blood cells, platelets, and
  IV resuscitation.
• Mental status deterioration
• MRI of the brain Multi-infarct changes.
• After much discussion, the patient and her family
  opted for Hospice care and she soon passed away.

8
Metastasis to the Orbit

• Prevalence 1-13 of all orbital tumors1.
• Often unilateral
• Typically involves orbital bone and fat
• Most common primary origins from the breast,
  prostate, lung 2.
• 9 of all metastatic disease involves extraocular
  muscles
• even fewer involve more than two muscles 3.

9
Breast Cancer in the EOM

• Literature classically describes scirrhous type
  breast cancer
• presents with enophthalmos from fibrosis
  contracture of invaded tissue
• localize in orbital fat 4, 5.
• 75 of breast cancer metastases to the orbit have
  a primary tumor
• Average time between discovery of primary tumor
  ophthalmic presentation 3 years 5.
• Mean survival time after orbital manifestation of
  metastasis 22 months 6.

10
Differential Diagnosis

• Thyroid ophthalmoplegia
• Extraocular muscle swelling
• Exophthalmos with lid retraction and lid lag
• Systemic manifestation of hyperthyroidism
• Orbital pseudotumor
• Acute onset of pain 2
• Leptomeningeal or posterior fossa metastasis
• Typically involves cranial nerves or long nerve
  tracts 8
• Cranial nerve palsies
• Lymphoma
• 10-15 of orbital lesions 2, 9
• Skeletal muscle metastasis commonly harbor
  leukemia or lymphoma

11
In Conclusion

• Patient presented with left eye limitation of
  elevation and abduction
• No orbital biopsies, due to patients overall
  prognosis
• Images showed extraocular muscle thickening
  bilaterally
• Metastatic disease was presumed
• Patient had a four year course of metastatic
  spread to the bone, liver, retroperitoneal lymph
  nodes, and ovaries
• While the patient was initially diagnosed with
  breast cancer from axillary lymph node
  involvement in 2006, no primary tumor in the
  breast was found after repeated MRI, mammography,
  or physical exam.

12
References

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