Multiple Bilateral Extraocular Muscle Metastases as the Initial Manifestation of Breast Cancer

Successful management of bilateral orbital metastases from invasive lobular breast cancer with abemaciclib and letrozole: a case report and literature review

Breast cancer is a significant global health concern, contributing to substantial morbidity and mortality among women. Hormone receptor-positive (HR+)/HER2-negative (HER2-) breast cancer constitutes a considerable proportion of cases, and significant advancements have been made in its management. CDK4/6 inhibitors (CDK4/6is) are a new targeted therapy that has demonstrated efficacy in adjuvant, advanced and metastatic settings. The propensity of lobular breast carcinomas for estrogen-rich sites, such as periocular tissues and orbital fat, may explain their tendency for orbital metastases. Current treatment strategies for these cases are predominantly palliative, and the prognosis remains poor. This article presents a unique case of a 51-year-old female with progressive right periorbital edema, pain, and limited ocular motility. An imaging work-up showed bilateral intra and extraconal orbital infiltration, which was biopsied. The histopathologic analysis disclosed mild chronic inflammatory infiltrate with thickened fibrous tissue and moderately differentiated lobular carcinoma cells, positive for GATA3 and CK7 markers, with 100% of tumor nuclei expressing estrogen receptors (ER+). A systemic evaluation showed a multicentric nodular formation in both breasts. Further diagnostic assessments unveiled an HR+/HER2- bilateral lobular breast carcinoma with synchronous bilateral orbital metastases. Systemic treatment was initiated with abemaciclib 150mg twice daily and letrozole 2.5mg once a day. However, this regimen was interrupted due to toxicity. After two weeks, treatment was resumed with a reduced abemaciclib dose (100mg twice daily) alongside letrozole, with a reasonable tolerance. Nearly two years after the initial diagnosis of inoperable metastatic cancer, the patient remains on the same systemic treatment regimen with no signs of invasive disease. This case report is the first of a patient presenting with bilateral orbital metastases from bilateral lobular breast cancer, showing an impressive and sustained response to a first-line treatment regimen combining abemaciclib and letrozole. A literature review on bilateral orbital metastases from breast cancer is also presented.

Superior divisional third nerve palsy due to breast cancer metastasis to the orbital apex

PURPOSE

To report a case of breast cancer with metastasis to the orbital apex with manifestation of superior divisional third nerve palsy.

CASE DESCRIPTION

A 40-year-old female, a known case of breast cancer diagnosed 3 years ago, referred to our neuro-ophthalmology clinic with chief complaint of ptosis and diplopia. In ophthalmic examination, visual acuities of both eyes were 20/20 and there was no significant finding in the anterior and posterior segment ophthalmic examination. There was left eye ptosis with MRD1 of 2 mm. In ocular movement examination, there was limitation of motion in supraduction (-2 to -3) of the left eye. Orbital MRI with contrast was requested for the patient which demonstrated a lesion in the orbital apex of the left eye. At the end, the patient was diagnosed as having superior divisional third nerve palsy. Orbital radiotherapy was recommended for the patient.

CONCLUSION

In a patient with breast cancer who presents with diplopia, metastasis to the orbital apex with manifestation of divisional third nerve palsy should be kept in mind, and appropriate orbital imaging should be considered.

Evaluation of diplopia as a vital and remarkable ocular finding among cancer patients

BACKGROUND

Diplopia is an important and debilitating symptom of malignancies due to different pathogenetic mechanisms. Data is lacking in the literature because of the rarity of the diplopia in patients with cancer.

AIMS

We aimed to evaluate the etiological and clinical factors of diplopia in patients with different types of cancer.

METHODS

We retrospectively investigated 22 cancer patients with diplopia who were admitted between 2018 and 2021. The diagnosis of primary cancer, the underlying factors causing diplopia, and the life expectancy after diplopia were evaluated.

RESULTS

Among available data of 620 cancer patients applied to our ophthalmology department, 22 (3.55%) had diplopia. Paralytic strabismus was found in 19 patients and restrictive strabismus was found in 3 patients. Among the paralytic cases, 6th nerve palsy was found to be the most common with a rate of 68%. In 18 of 22 (82%) patients, the cause of diplopia was due to orbital or brain metastasis or local invasion. Two patients had diplopia secondary to radiotherapy and 2 had diplopia due to chemotherapy.

CONCLUSION

Metastasis is the most common cause of diplopia in patients with cancer and screening for metastasis is crucial as soon as diplopia begins for a better life expectancy.

Extraocular muscle enlargement

Extraocular muscle enlargement can occur secondary to a range of orbital and systemic diseases. Although the most common cause of extraocular muscle enlargement is thyroid eye disease, a range of other inflammatory, infective, neoplastic, and vascular conditions can alter the size and shape of the extraocular muscles. Imaging with computed tomography and magnetic resonance imaging plays an essential role in the workup of these conditions. This article provides an image-rich review of the wide range of pathology that can cause enlargement of the extraocular muscles.

Unilateral Orbital Metastasis as the Unique Symptom in the Onset of Breast Cancer in a Postmenopausal Woman: Case Report and Review of the Literature

The orbit represents an unusual metastases site for patients diagnosed with cancer, however, breast cancer is the main cause of metastases at this level. These orbital metastases were discovered in patients with a history of breast cancer as unique or synchronous lesions. We present a rare case of a unique retroocular metastasis as the first initial symptom of a tubulo-lobular mammary carcinoma in a postmenopausal woman. A 57-year-old patient complains of diplopia, diminishing visual acuity, orbital tenderness, slight exophthalmia and ptosis of the left eyelid, with insidious onset. Clinical examination and subsequent investigations revealed a left breast cancer cT2 cN1 pM1 stage IV. Breast conserving surgery was performed on the left breast. Pathological examination with immunohistochemistry staining established the complete diagnostic: pT2pN3aM1 Stage IV breast cancer, luminal B subtype. After two years from the initial breast cancer diagnosis, the patient was diagnosed by the psychiatrist with a depressive disorder and was treated accordingly. Orbital metastases are usually discovered in known breast cancer patients and they are found in the context of a multi-system end-stage disease. Most reports cite that up to 25% of the total orbital metastases cases are discovered before the diagnosis of the primary tumor, as our case did. MRI is the gold standard for evaluating orbital tumors. The ILC histological subtype metastasizes in the orbitals more frequently than invasive ductal carcinoma. The prognosis of patients with orbital metastases is poor. The median survival after diagnosis of orbital metastases from a breast cancer primary is ranging from 22 to 31 months. Overall survival of our patient was 56 months, longer than the median survival reported in literature. Orbital metastases must be taken into account when patients accuse ophthalmologic symptoms even in the absence of a personal history of cancer. Objective examination of every patient that incriminates these types of symptoms is essential, and breast palpation must be made in every clinical setting. Orbital biopsy is necessary for the confirmation of the diagnosis and for an adequate treatment. Although recommendations for management of orbital metastases are controversial, it appears that multidisciplinary treatment of both metastases and primary cancer improves overall survival.

Surgery for orbital metastasis from breast carcinoma initially presenting with progressive proptosis

We present a 45-year-old woman with metastatic breast disease who initially presented with progressive proptosis of her right eye causing limited motility, diplopia and eye pain. MRI done showed an avidly enhancing right sphenoorbital mass causing displacement in the lateral and superior recti muscles with lysis and infiltration of the greater sphenoid wing and lateral orbital wall. The patient underwent surgery resulting in immediate relief of proptosis and resolution of symptoms. Although surgery is not recommended for orbital metastasis as it is not curative, it should be considered as a treatment option as it can provide relief to patients and improve their quality of life.

Orbital Metastasis from Triple-Negative Breast Cancer: Case Report and Literature Review

Orbital metastases are rare. Breast cancer represents the first etiology to be evoked in carcinomas. We report a rare case of a young 43-year-old patient who developed significant orbital metastasis 2 months after the end of adjuvant treatment for triple-negative breast cancer. Good partial response was shown with an improvement of symptoms under chemotherapy (docetaxel combined with carboplatin), zoledronic acid and palliative radiotherapy. The patient quickly progressed in the pulmonary, hepatic and lymph nodes with mucocutaneous jaundice related to hepatic dysfunction after which she died within 20 days. Different etiologies are responsible for the orbital tumor syndrome. This orbital metastasis may constitute an inaugural mode of expression of the tumor affection. The frequency of metastases of breast cancer overexpressing estrogen receptor can be explained biologically by the presence of estrogen receptors in hormone acting as target choroid tissue steroids for lacrimal secretion. On the other hand, in triple-negative breast cancer, since the hormone receptors are negative, the pathophysiology of these orbital metastases remains unknown. At this stage, the treatment remains palliative, including radiotherapy, chemotherapy, and bisphosphonates, and the prognosis is grim.

Breast Carcinoma Metastasis to the Medial Rectus Muscle: Case Report

A 63-year-old woman with metastatic breast carcinoma presented to the ophthalmology clinic with diplopia and right abduction deficit. Magnetic resonance imaging showed isolated enlargement of the right medial rectus muscle. Biopsy of the enlarged muscle revealed metastasis of breast carcinoma. Ocular motility deficit in a patient with breast carcinoma should raise suspicion of metastasis to the orbit involving the extraocular muscles. Orbital imaging and biopsy are necessary for diagnosis and appropriate treatment.

Metastases to extraocular muscles from breast cancer: case report and up-to-date review of the literature

Background

Unilateral or bilateral metastases to extraocular muscles are very rare in breast cancer.

Case presentation

We describe a case of inferior rectus extraocular muscle involved by ductal luminal B/Her-2 neu negative breast cancer, observed in a cohort of 580 patients. Our patient had received chemotherapy and hormonal therapy (tamoxifen for 3 years and letrozole in the following 3 years) for her primary cancer and developed an orbital metastasis while she was under aromatase inhibitor-based therapy. Diagnosis was confirmed by MRI and biopsy. Orbital radiotherapy, combined with fulvestrant, resulted in shrinking of the secondary mass. A third line hormonal therapy using palbociclib was then started. Twelve-months later, MRI showed no residual tumor mass. Currently, the patient is alive and in good general conditions after 20 months.

Conclusions

Literature review yielded 57 patients with extraocular muscle metastases from breast cancer, mostly due to the invasive lobular subtype of carcinoma. In addition to the present case, only 4 other extraocular muscles metastases from invasive ductal carcinoma has been reported, pointing out to the rarity of ductal type spread to the orbit in the natural history of breast cancer. Surgery may be used as a single treatment, despite no improvement of symptoms. Radiotherapy alone or combined with chemotherapy, or with chemotherapy plus hormonal therapy are available options. Results are, however, missing or poor. The present case is the first one with complete and stable response after 20 months to radiotherapy, antiestrogen drug fulvestrant and selective inhibitor of CDK4 /CDK6 palbociclib. In this subset of patients, with unusual metastatic sites and frequent multi-organ metastatic impairment, a multidisciplinary approach is indicated in order to achieve the best therapeutic management and long-term surveillance.

Metastatic breast cancer to the adductor magnus: A case report and literature overview

Metastatic breast cancer is commonly found in the pectoralis major and minor muscles, ribs, spine, pelvis, long bones of the extremities, liver, lung, and the brain. It is unusual to see breast cancer metastases to distal skeletal muscle. We report a case of a patient with a history of stage IIA infiltrating lobular carcinoma of the right breast presenting with a metastatic lesion in the right adductor magnus. She was treated four years prior to the onset of the metastases with a modified radical mastectomy but refused postoperative chemotherapy or adjunctive radiation.

Metastatic Breast Carcinoma to the Superior Oblique in a Male

We describe a case of breast cancer metastatic to the superior oblique, in a male. The patient was a 66-year-old Caucasian male with a history of stage IIIB rectal adenocarcinoma and stage IIA left breast carcinoma diagnosed 12 years and 5 years prior, respectively, who presented with headaches and intermittent diplopia. He underwent left total mastectomy with sentinel lymph node biopsy 6 years prior, which showed ER/PR+, HER2/neu-, moderately-differentiated, infiltrating ductal carcinoma with 3/14 positive nodes. He completed adjuvant doxorubicin/cyclophosphamide and oral tamoxifen, and prior routine surveillance imaging had found no evidence of recurrent disease. MRI of the orbit revealed a 0.7 × 1.4 × 1.9 cm mass in the superomedial right orbit in the region of the superior oblique. Transcaruncular orbitotomy with biopsy of the superior oblique revealed metastatic breast carcinoma. Unfortunately, he developed new metastases. Post-operatively, he continues to have good vision with minimal diplopia.

Metastatic tumor to the extraocular muscles: report of 5 cases

We report the findings in 5 patients with metastases to the extraocular muscles. Familiarity with this condition will aid ophthalmologists in differentiating it from thyroid ophthalmopathy, the most common form of muscle enlargement. Palliative treatment is effective in ameliorating visual symptoms.

Intramuscular metastases on FDG PET-CT: a review of the literature

OBJECTIVE

Intramuscular metastases (IM) are both rare and difficult to detect using routine anatomical computed tomography (CT) imaging. However, since the introduction of 18F-fluoro-deoxy-glucose (FDG) PET-CT, the number of detected IM has increased. We review the available literature to illustrate the relevance of these findings for staging and patient management.

METHODS

In a review of the literature, we found one series and 33 case reports of IM shown on FDG PET-CT. No cases were reported before 2005. Furthermore, we present a patient with nonsmall cell lung cancer and a solitary distant metastasis in the left musculus infraspinatus that was not detected on diagnostic CT, but was found on FDG PET-CT.

RESULTS

For a total of 39 recorded cases of IM, we found that FDG PET-CT had a significant impact on patient management in at least 51% of cases. Where reported, lesions were either isodense or hypodense on CT compared with the surrounding muscle tissue. The lesions that were also analyzed with MRI showed heterogeneous intensity. Five out of 39 patients had metastases in the extraocular muscles of one or both orbits.

CONCLUSION

FDG PET-CT appears to be a sensitive tool for detecting IM, with important impact on management in many cases.

Metastatic breast carcinoma of the abdominal wall muscle: a case report

Metastasis from breast carcinoma is an uncommon occurrence in skeletal muscle, compared to local invasion into muscle from direct tumor spread. A 49-year-old woman was referred to our hospital with an 8.5-cm mass in the right breast. Core needle biopsy revealed metaplastic carcinoma with squamous metaplasia. The mass was rapidly growing and metaplastic, so mastectomy with dissection of axillary lymph nodes was performed. Pathological examination showed metaplastic carcinoma, histological grade 3, triple negative, and a MIB-1 labeling index of 80%. Six months postoperatively, during adjuvant chemotherapy treatment, she reported numbness and pain in the right lateral thigh and a mass in the right lower abdomen. Computed tomography revealed multiple lined masses in the abdominal wall and iliac muscle. Core needle biopsy showed metastatic breast carcinoma. Radio- and chemotherapy were administered, but the mass in the muscle became enlarged. To control her pain, a combined treatment with morphine, fentanyl, ketamine, antiepilepsy drug, and NSAIDs was administered. Liver metastasis appeared 9 months (15 months postoperatively) after recognition of muscle metastasis, and the patient died 16 months postoperatively. Skeletal muscle metastasis is uncommon, and therapeutic intervention is mainly palliative. The most common symptom of skeletal muscle metastasis is pain; thus, pain control is a pivotal goal of treatment.

Bilateral multiple extraocular muscle metastasis from breast carcinoma

We report a rare presentation of an initially misdiagnosed case of a pseudotumor, which on histopathology was diagnosed as bilateral breast metastases of lobular carcinoma involving multiple extraocular muscles. A 61-year-old lady presented with external ophthalmoplegia and diplopia. Incisional biopsy was performed using a lid crease approach and the patient received radiotherapy and hormonal therapy. Following prolonged hormonal therapy, complete remission was achieved, with improvement in ocular motility and resolution of diplopia, about 18 months after the initial presentation. Multiple extraocular muscle involvement by breast carcinoma metastasis is very rare and should be considered in the differential diagnosis, especially in patients with a prior history of breast carcinoma.

Carcinoid tumor metastases to the extraocular muscles: MR imaging and CT findings and review of the literature

Although a relatively rare neoplasm, primary carcinoid tumor has an unusual propensity to metastasize to the orbits. Within the orbit, metastatic EOM lesions have been described in scattered reports in the ophthalmology literature but have received little to no attention in the radiology literature. After a retrospective review, we identified CT and MR imaging studies of 7 patients with carcinoid tumor metastatic to the EOM. Our findings suggest that in patients with known carcinoid tumor, well-defined, round, or fusiform masses of the EOM should strongly suggest metastatic involvement. Our series suggests that bilateral lesions may occur and that any EOM can be involved. Knowledge of this pattern of metastatic disease may spare biopsies in some patients, and with current orbit-sparing therapy for patients with localized orbital disease, early and accurate diagnosis can significantly improve patient outcomes.

Adenocarcinoma metastasis causing discrete extraocular muscle enlargement

BACKGROUND

Discrete extraocular muscle (EOM) metastasis is rarely reported. Clinical signs and symptoms of EOM metastasis can often be indistinguishable from primary idiopathic orbital myositis, posing a significant clinical challenge.

CASE REPORT

A case of a 61-year-old man with acute-onset unilateral periorbital pain and diplopia is presented. Magnetic resonance imaging showed an isolated edematous superior rectus/levator muscle complex with an isointense T2-weighted signal, supporting a diagnosis of orbital myositis. He was started on corticosteroids, with resolution of pain and improved motilities. Subsequently, his condition worsened. Repeat imaging results suggested the possibility of neoplastic infiltration of the muscle because of the newly demonstrated hyperintensity of the T2-weighted signal and perineural extension along the trigeminal nerve. Fine-needle aspiration biopsy showed adenocarcinoma cytology in the muscle.

CONCLUSIONS

This case illustrates discrete adenocarcinoma metastasis of an EOM, initially displaying characteristics predominantly consistent with orbital myositis. There is a paucity of epidemiologic data on EOM cancer, and clinical characteristics are derived only from a selection of case reports in the literature. Thus, the predominant features of global orbital metastatic cancer versus primary inflammation are highlighted in this presentation. This case shows that the variable characteristics of each process prohibit identification of any clinical feature that would prove pathognomonic for either disorder. The varied practice philosophies and standard of care regarding the proper time to biopsy are reviewed. This case shows the importance of early referral for orbital biopsy, even in the presentation of isolated, discretely edematous, and painful EOM enlargement.