Transcript Metastatic Disease to the Extraocular Muscles of an

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.
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
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Negative for:
◦ Orbital/retroorbital pain
◦ Change in vision
Physical Exam
OD
OS
BCVA: 20/20
 Tonometry: 20
 SLE: NL
 Fundus:
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◦ flame hemmorrhage off disc noted
EOM movement: full in all
direction
 Hertel: 16 mm
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◦ 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
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
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◦ base setting 93
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PERRL
Past Medical History
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July 2006: Palpable left axillary
lymphadenopathy
Nov 2006: Left axillary lymph
node dissection
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◦ Pathology: poorly
differentiated adenocarcinoma
consistent with breast origin
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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
◦ ER (+), PR (-), Her-2/neu (-) in
14/15 nodes
◦ Treatment: capecitabine and
pamidronate
◦ Lymphoproliferative disease
markers (-)
◦ Right ureteral stent placement
◦ Patient received doxorubicin,
cyclophosphamide, paclitaxel x
5 months then radiation and
anastrozole.
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July 2009: Liver metastasis
◦ Treatment: gemcitabine and
paclitaxel
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Jan 2010: Worsening liver lesions
◦ Treatment: 3 cycles doxorubicin
MRI brain/orbits (Feb 11, 2010): Thickening of
the extraocular muscles bilaterally especially on
the medial inferior left side.
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.
Patient Course

Treatment:
◦ Radiation to the left eye and orbit
◦ Continued systemic treatment
◦ Developed thrombocytopenia secondary to therapy.
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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.
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
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◦ even fewer involve more than two muscles 3.
Breast Cancer in the EOM
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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.
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Differential Diagnosis
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Thyroid ophthalmoplegia
◦ Extraocular muscle swelling
◦ Exophthalmos with lid retraction and lid lag
◦ Systemic manifestation of hyperthyroidism
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Orbital pseudotumor
◦ Acute onset of pain 2
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Leptomeningeal or posterior fossa metastasis
◦ Typically involves cranial nerves or long nerve tracts
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8
Cranial nerve palsies
Lymphoma
◦ 10-15% of orbital lesions 2, 9
◦ Skeletal muscle metastasis commonly harbor leukemia or
lymphoma
In Conclusion
Patient presented with left eye limitation of elevation
and abduction
 No orbital biopsies, due to patient’s 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.
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References
1. Spitzer SG, Bersani TA, Mejico LJ. Multiple bilateral extraocular muscle metastases as the
initial manifestation of breast cancer. J Neuro-Ophthalmol. 2005; 25 (1): 37-9.
2. Lell M, Schulz-Wendtland R, Hafner A, et al. Bilateral orbital tumour as the presentation of
mammographically occult breast cancer. Neuroradiology. 2004; 46: 682 – 5.
3. Peckham EL, Giblen G, Kim AK, Sirdofsky MD. Bilateral extraocular muscle metastasis from
primary breast cancer. Neurology. 2005; 65 (1): 74.
4. Harnett AN, Kemp EG, Fraser G. Metastatic breast cancer presenting as tolosa-hunt
syndrome. Clinical Oncology. 1999; 11: 407-9.
5. Milman T, Pliner L, Langer PD. Breast carcinoma metastatic to the orbit: An unusually late
presentation. Ophthal Plast Reconstr Surg. 2008; 24 (6): 480-2.
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the orbit: the 2000 Robert M. Curts Lecture. Ophthalm Plast Reconstr Surg. 2001; 17:
346-354.
7. Luneau K, Falardeau J, Hardy I, Boulos PR, Boghen D. Ophthalmoplegia and lid retraction
with normal initial orbit CT imaging in extraocular muscle metastases as the presenting
sign of breast carcinoma. J Neuro-Ophthalmol. 2007; 27 (2): 144-6.
8. Heijden A, Twijnstra A, Lamers W, Hupperets P, Freling G. An unusual cause of diplopia in a
cancer patient. Eur J Cancer. 1991; 27(1): 1315-6.
9. Weiss R, Grisold W, Jellinger K, Muhlbauer J, Scheiner W,Vesely M. Metastasis of solid tumors
in extraocular muscles. Acta Neuropathol. 1984; 65: 168-71.