Orbital metastasis from a gastrointestinal stromal tumor: A case report

Metastastic Tumors to the Lacrimal Gland from Distant Primary Cancer

PURPOSE

To characterize the clinical, radiological, and pathological features of patients with metastases to the lacrimal gland from distant primaries.

METHODS

Multicentre retrospective case series and a review of the literature of cases of metastases to the lacrimal gland.

RESULTS

We present 4 cases of lacrimal gland metastases, with the primaries being renal cell (n = 2) and breast (n = 2) carcinoma. The literature review identified 40 additional cases (19 male, mean age, range 21-84 years) of lacrimal gland metastasis. Based on these 44 cases, including 4 from the present study, 2 patterns of metastasis were identified: 23 cases (52.3%, 23/44) with lacrimal gland enlargement without bony erosion, and 21 cases (47.7%, 21/44) with associated bony erosion of the superolateral orbit of whom 12 (57.1%, 12/21) had intracranial extension. The most common primary for lacrimal gland metastasis without bony erosion was breast cancer (56.5%, 13/23), whereas hepatocellular carcinoma was the most common cause of lacrimal gland metastasis with bony erosion (52.4%, 11/21). Lacrimal gland metastasis was the first presentation of cancer in 15 cases (34.1%, 15/44) and was the first presentation of metastasis in 12 cases (27.3%, 12/44).

CONCLUSIONS

Metastasis to the lacrimal gland is a potential cause of lacrimal gland enlargement. It may be the initial sign of distal occult cancer or occult metastatic disease. Different patterns of metastasis may be seen with different underlying primaries.

Surgical resection of intraorbital metastasis of a gastrointestinal stromal tumor resistant to chemotherapy

Purpose

We present a case of a gastrointestinal stromal tumor (GIST) metastasis of the rectal primary resisting chemotherapy to the right orbit 15 years after excision of the primary lesion.

Observations

A 79-year-old man was diagnosed with rectal GIST at the age of 65 years and underwent rectal amputation. He underwent hepatectomy for GIST liver metastases at the age of 69 years and pericardiectomy for GIST pericardial metastases at 72 years of age. At the age of 79 years, positron emission tomography-computed tomography revealed the possibility of liver metastasis and metastasis to the right orbit of 10 mm in size. Magnetic resonance imaging revealed a well-circumscribed mass of 10 mm × 12 mm in the deep medial rectus muscle of the right orbit, which was referred to our department for ophthalmic examination. The latter revealed only mild abduction disorder in the right eye. Although chemotherapy was initiated, the tumor gradually increased, causing exophthalmos in the right eye, visual field impairment due to optic nerve exclusion, and decreased visual acuity. Due to repeated multiple metastases, the patient underwent right orbital exenteration and free flap reconstruction at the age of 83 years for radical cure. Pathological examination revealed c-Kit positive, CD34 positive, S100 protein minority positive, MIB-1 positive rate of 10% or more, and α-SMA negative, and the diagnosis was intraorbital metastasis of GIST.

Conclusions and importance

Orbital metastases in GISTs are extremely rare, and there is no established standard treatment. Therefore, a comprehensive decision must be made based on the final treatment goal and the patient's background when selecting treatment.

Gastrointestinal stromal tumor metastatic to the orbit

A 53-year-old woman was referred to the authors with a history of left eyelid swelling and retro-orbital pain. She had a history of a prior stomach gastrointestinal stromal tumor (GIST) with metastasis to the liver and intrahepatic bile duct. Examination showed global motility restriction with no relative afferent pupillary defect, and exophthalmometry confirmed 4 mm of left-sided proptosis. Computed tomography imaging showed a heterogeneous mass involving the left inferior rectus muscle with extension to the optic nerve measuring 32.5 mm anterior to posterior and abnormal thickening of the right inferior rectus muscle. An incisional biopsy was performed through a left inferior orbitotomy. Histopathological examination revealed an orbital mass with epithelioid morphology consistent with a metastatic GIST. Immunohistochemical analysis revealed positivity for CD-117 and Dog-1, and negativity for Myogenin. This represents the fifth biopsy-proven GIST metastatic to the orbit in the literature, only the second case with predominantly epithelioid morphology, and only the second case with bilateral orbital metastasis. The authors detail the relevant clinical history, imaging, and pathology.

Masses of the Lacrimal Gland: Evaluation and Treatment

Lacrimal gland lesions account for approximately 9 to 10% of all biopsied orbital masses. Potential causes include nongranulomatous and granulomatous inflammation, autoimmune disease, lymphoproliferative disorders, benign epithelial proliferation, malignant neoplasia, and metastatic disease. Inflammatory lesions and lymphoproliferative disorders are the most common and may be unilateral or bilateral; they may also be localized to the orbit or associated with systemic disease. Both benign and malignant epithelial lacrimal gland masses tend to be unilateral and involve the orbital lobe, but a more rapid onset of symptoms and periorbital pain strongly suggest malignant disease. On orbital imaging, both inflammatory and lymphoproliferative lesions conform to the globe and surrounding structures, without changes in adjacent bone, whereas epithelial lacrimal gland masses often show scalloping of the lacrimal gland fossa. Malignant epithelial lacrimal gland tumors can also have radiographic evidence of bony invasion and destruction. Masses of the lacrimal gland may be due to a broad range of pathologies, and a good working knowledge of common clinical characteristics and radiographic imaging findings is essential for diagnosis and treatment. All patients with inflammatory, lymphoproliferative, and epithelial neoplastic lesions involving the lacrimal gland require long-term surveillance for disease recurrence and progression.