Metastatic Disease to Metastatic Disease to Extraocular Muscles of Extraocular Muscles of Undiscovered Primary Undiscovered Primary Breast CancerBreast 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 57 year old Caucasian femalefemaleHistory 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

Physical ExamPhysical ExamOD 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

Past Medical HistoryPast 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

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 CoursePatient CourseTreatment:

◦ 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.

Metastasis to the OrbitMetastasis to the OrbitPrevalence :1-13% of all orbital

tumors1. Often unilateralTypically involves orbital bone and fatMost 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.

Breast Cancer in the EOMBreast Cancer in the EOMLiterature 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.

Differential DiagnosisDifferential DiagnosisThyroid 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

In ConclusionIn ConclusionPatient presented with left eye limitation of

elevation and abductionNo 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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