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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 37

Metastatic breast carcinoma to orbit causing enophthalmos


Department of Ophthalmology, Pontifical Catholic University of Campinas, Campinas, São Paulo, Brazil

Date of Submission25-May-2022
Date of Decision25-May-2022
Date of Acceptance18-Jul-2022
Date of Web Publication30-Jul-2022

Correspondence Address:
Catherine Pancini Rezende
Pedro de Alcantara Camargo, 480, 13690000, Descalvado, Sao Paulo
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pajo.pajo_28_22

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  Abstract 


This is a case report of a 61-year-old woman who was referred to the PUC Campinas Hospital due to a femoral fracture. Ophthalmological evaluation was requested due to complaints of enophthalmos and low visual acuity, which showed signs suggestive of an orbital tumor. Physical and complementary examinations were important for the confirmation of metastatic orbital carcinoma. Knowing that breast cancer is the most common primary tumor site involved in orbital metastasis in women, this study aimed to highlight the importance of prompt recognition and appropriate diagnostic and therapeutic management in these cases.

Keywords: Breast cancer, enophthalmos, immunohistochemistry, metastatic carcinoma, orbital tumors


How to cite this article:
Rezende CP, Peixoto BC, de Souza FB, de Mattos AC, Andrade Sobrinho MV. Metastatic breast carcinoma to orbit causing enophthalmos. Pan Am J Ophthalmol 2022;4:37

How to cite this URL:
Rezende CP, Peixoto BC, de Souza FB, de Mattos AC, Andrade Sobrinho MV. Metastatic breast carcinoma to orbit causing enophthalmos. Pan Am J Ophthalmol [serial online] 2022 [cited 2022 Dec 3];4:37. Available from: https://www.thepajo.org/text.asp?2022/4/1/37/353005




  Introduction Top


Metastasis is the most common type of intraocular or orbital tumor in adults.[1] Enophthalmos can be a sign of serious systemic disease and should be appropriately investigated to rule out underlying subclinical malignancy.[2] The objective of this study was to present a rare case of a patient with a pathologic femur fracture who was diagnosed with metastatic breast carcinoma due to ophthalmological signs that indicated the possibility of a metastatic orbital tumor, and the screening was able to identify the primary lesion.


  Case Report Top


A 61-year-old female patient was referred to the PUC Campinas Hospital service due to a fracture of the right femur. The patient was kept in the intensive care unit after surgical correction of the fracture by the orthopedic team, and an ophthalmologic evaluation was requested due to left enophthalmos and low visual acuity (VA) reported for approximately 6 months, with progressive worsening during this period, without looking for medical evaluation of the condition. Her medical history was negative, except for systemic arterial hypertension, and her last mammogram was 15 years ago.

On ophthalmological examination performed at the bedside due to her clinical condition, the VA was counting fingers 3 m in the right eye (OD) and hand movement in the left eye (OS). There was adduction limitation of the right globe, left enophthalmos with severely limited ductions, and periorbital region with an atrophic and endured appearance [Figure 1]. The ophthalmoscopic examination was not possible in OS due to restricted eye-opening, and the OD showed papilledema. The diagnostic hypothesis of an orbital tumor was raised, and clinical and complementary examinations were requested for investigation.
Figure 1: Left enophthalmos secondary to metastatic scirrhous breast cancer to the orbit

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Computed tomography (CT) of the orbits and face showed an infiltrative, expansive, intra- and periorbital lesion on the left, intraorbital soft tissue on the right, obliterating and involving the extrinsic ocular musculature partially on the right and completely on the left, and lytic and sclerotic bone lesions at the base of the skull, orbital walls, and cervical spine [Figure 2]. Chest CT also showed osteolytic lesions spread across the thoracic wall and an irregular lesion in the right breast with axillary lymph node enlargement on the same side. In view of the clinical and CT findings, a general physical examination was performed that revealed a right breast nodule with hard consistency, adhered to deep planes, and painful on palpation. These findings indicated a probable primary breast neoplasm with secondary lesions in the orbit, bones, and lymph nodes. A biopsy of the breast lump was performed to complement the diagnosis.
Figure 2: Axial computed tomography. (a) Intraorbital soft tissue with retraction of the left orbit producing enophthalmos. (b) Lytic and sclerotic bone lesions in the skull

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Histological examination revealed invasive lobular carcinoma with tumor cells in single-file targetoid infiltration and scirrhous growth [Figure 3]. Immunohistochemistry showed positivity for estrogen and progesterone receptors, diffuse staining for mammaglobin, and Ki67 positivity in approximately 40% of the neoplastic samples, suggesting high proliferative activity [Figure 4]. The diagnosis of breast carcinoma with bone, lymph node, and orbital metastasis was then established. After discussion by the multidisciplinary team with the patient and family members, proportional palliative care was chosen and the family members underwent cancer investigation.
Figure 3: Invasive lobular carcinoma. (a) Single-file targetoid lobular infiltration (H and E, ×200). (b) Single file cells with targetoid infiltration and extensive fibrosis, characterizing scirrhous tumor (H and E, ×400)

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Figure 4: Positive immunohistochemistry: (a) Estrogen receptor (×400); (b) Progesten receptor (×400); (c) Mammaglobin receptor (×400); (d) Ki-67 marker (×400)

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  Discussion Top


The orbit is an unusual site for metastatic cancer.[3] Even so, different types can reach the orbital soft tissues or bones through hematogenous routes.[4] In adults, the most common primary cancers that metastasize to the orbit are breast, prostate gland, and lung carcinomas.[3],[4] Most patients have a history of cancer; however, an orbital mass is often the first sign of malignancy.[3]

Breast cancer accounts for most orbital metastases.[4],[5],[6] The classic presentation, such as other metastatic orbital carcinomas, is the onset of proptosis, pain, blepharoptosis, ocular globe displacement, and eyelid edema.[4] However, some scirrhous tumors can produce paradoxical enophthalmos with a progressively immobilized globe due to desmoplasia and fibrosis, which cause contraction of the orbital contents.[3],[4],[7] Other ophthalmic manifestations include pseudoinflammatory involvement of the ocular adnexa, intracranial metastasis with papilledema, Horner's syndrome, and choroidal tumors.[5]

The causes of enophthalmos are related to structural abnormalities, atrophy, and cicatrizing processes.[8] Scirrhous tumors, particularly from breast and stomach cancers, can produce retraction of the orbit.[4] They are a pathological subtype of cancer and histologically characterized by fibrous, invasive tumors in which the malignant cells occur singly or in small clusters or strands in dense connective tissue.[9]

Suspected orbital metastasis should have a history taken, systemic evaluation, and imaging studies to rule out primary cancer.[4] The diagnosis should usually be confirmed by orbital biopsy, and the histopathology is generally similar to that of primary neoplasia.[4],[10] Management involves treatment of the associated systemic malignancy with chemotherapy or hormone therapy and orbital irradiation.[3] Tumors are usually controlled locally, but the systemic prognosis is usually poor.[3]

In summary, enophthalmos is an important and frequently subtle clinical sign that must be accurately diagnosed.[8] With adequate ocular and systemic evaluation, imaging studies, and biopsy, a diagnosis of metastatic orbital carcinoma can be made, even when there is no history of cancer.[5] This case emphasizes the potential role of ophthalmologists in the initial diagnosis and management of disseminated occult malignancies.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ophthalmic pathology and intraocular tumors. In: Basic and Clinical Science Course. Ch. 20, Sec.04. San Francisco, CA: American Academy of Ophthalmology; 2020-2021.  Back to cited text no. 1
    
2.
Shields CL, Stopyra GA, Marr BP, Moster ML, Shields JA. Enophthalmos as initial manifestation of occult, mammogram-negative carcinoma of the breast. Ophthalmic Surg Lasers Imaging 2004;35:56-7.  Back to cited text no. 2
    
3.
Shields JA, Shields CL, Brotman HK, Carvalho C, Perez N, Eagle RC Jr. Cancer metastatic to the orbit: The 2000 Robert M. Curts Lecture. Ophthalmic Plast Reconstr Surg 2001;17:346-54.  Back to cited text no. 3
    
4.
Eyelid, Conjunctival, and Orbital Tumors: An Atlas and Textbook. Ch. 38. Shields JA, Shields CL, Kluwer W. Lippincott Williams & Wilkins; 2015.  Back to cited text no. 4
    
5.
Reifler DM, Davison P. Histochemical analysis of breast carcinoma metastatic to the orbit. Ophthalmology 1986;93:254-9.  Back to cited text no. 5
    
6.
Bullock JD, Yanes B. Ophthalmic manifestations of metastatic breast cancer. Ophthalmology 1980;87:961-73.  Back to cited text no. 6
    
7.
Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97:620-4.  Back to cited text no. 7
    
8.
Cline RA, Rootman J. Enophthalmos: A clinical review. Ophthalmology 1984;91:229-37.  Back to cited text no. 8
    
9.
Page DL, Anderson TJ. Diagnostic Histopathology of the Breast. New York: Churchill Livingstone; 1987. p. 193-7.  Back to cited text no. 9
    
10.
Allison KH, Hammond ME, Dowsett M, McKernin SE, Carey LA, Fitzgibbons PL, et al. Estrogen and progesterone receptor testing in breast cancer: ASCO/CAP guideline update. J Clin Oncol 2020;38:1346-66.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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