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Rodrigues Alves N, Duarte AF, Ribeiro DF, Silva RS, Carvalho BA, Alpuim Costa D. Successful management of bilateral orbital metastases from invasive lobular breast cancer with abemaciclib and letrozole: a case report and literature review. Front Oncol 2024; 14:1286910. [PMID: 38322413 PMCID: PMC10845133 DOI: 10.3389/fonc.2024.1286910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/03/2024] [Indexed: 02/08/2024] Open
Abstract
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.
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Affiliation(s)
- Nuno Rodrigues Alves
- Department of Ophthalmology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Department of Ophthalmology, Unidade Local de Saúde de São José, Lisbon, Portugal
| | - Ana Filipa Duarte
- Department of Ophthalmology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Department of Ophthalmology, Unidade Local de Saúde de São José, Lisbon, Portugal
- Department of Ophthalmology, Hospital CUF Descobertas, Lisbon, Portugal
| | | | - Rita Sousa Silva
- Department of Ophthalmology, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
- Department of Ophthalmology, Unidade Local de Saúde de São José, Lisbon, Portugal
- Department of Ophthalmology, Hospital Lusíadas de Lisboa, Lisbon, Portugal
| | - Bruno Almeida Carvalho
- Department of Ophthalmology, Hospital CUF Descobertas, Lisbon, Portugal
- Deparment of Ophthalmology, Clínica de São João de Deus, Lisbon, Portugal
| | - Diogo Alpuim Costa
- Department of Haematology and Oncology, CUF Oncologia, Lisbon, Portugal
- Department of Medical Oncology, Hospital de Cascais, Cascais, Portugal
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade NOVA de Lisboa (UNL), Lisbon, Portugal
- Department of Medical Oncology, AIM Cancer Center, Lisbon, Portugal
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Safi M, Fethat K, Silkiss RZ. A 'never miss' diagnosis: Ptosis secondary to metastatic breast cancer diagnosed as involutional ptosis and a review of the literature. SAGE Open Med Case Rep 2021; 9:2050313X211040680. [PMID: 34457303 PMCID: PMC8385588 DOI: 10.1177/2050313x211040680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/20/2021] [Indexed: 11/24/2022] Open
Abstract
We present a case of ptosis secondary to metastatic lobular carcinoma of the breast which was initially diagnosed as involutional ptosis. A 67-year-old woman previously diagnosed with lobular carcinoma of the breast presented to our clinic with mild restriction of lateral gaze and persistent droopiness of her right eyelid (associated with decreased levator function) despite recent repair of a suspected involutional ptosis. Orbital magnetic resonance imaging revealed a mass in the right orbit which was biopsied and diagnosed as lobular carcinoma of the breast. Poor levator function is rarely present in involutional ptosis. Especially in conjunction with abnormal extraocular motility, other etiologies of acquired ptosis must be considered. This case highlights the importance of patient history and ocular examination in identifying the underlying etiology of ptosis. A review of the literature to evaluate the incidence of signs and symptoms associated with metastatic breast cancer to the orbit is included.
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Affiliation(s)
- Mustafa Safi
- California Pacific Medical Center, San Francisco, CA, USA
| | | | - Rona Z Silkiss
- California Pacific Medical Center, San Francisco, CA, USA.,Silkiss Eye Surgery, San Francisco, CA, USA
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El-Khazen Dupuis J, Marchand M, Javidi S, Nguyen TQT. Enophthalmos as the Initial Systemic Finding of Undiagnosed Metastatic Breast Carcinoma. Int Med Case Rep J 2021; 14:25-31. [PMID: 33536796 PMCID: PMC7850410 DOI: 10.2147/imcrj.s282113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/05/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose To report on the importance of detecting and investigating non-traumatic enophthalmos, which occurred as the first presenting sign of an undiagnosed metastatic breast carcinoma in two patients with no prior history of neoplasia. Design Case series. Observations The first case consists of a 74-year-old woman with no significant past medical history, who presented with a non-traumatic enophthalmos and ptosis of her left eye, and horizontal diplopia on right-gaze. Imaging revealed an intraconal lesion of her left orbit, with orbital fat atrophy. Transcutaneous anterior orbitotomy was performed for tumor biopsy, and the histopathology study concluded on a diagnosis of orbital metastasis consistent with infiltrative breast carcinoma. Thorough breast imaging and multiple breast biopsies were not able to localize the primary tumor. The second case consists of a 76-year-old woman, with no prior relevant medical history, who presented for progressive enophthalmos and ptosis of her right eye. Imaging revealed an osteolytic lesion of her right frontal bone, and multiple infiltrative lesions implicating both orbits. A biopsy was performed through a transcutaneous anterior orbitotomy and histopathology study lead to a diagnosis of metastatic lobular breast carcinoma. The primary breast tumor was localized using positron emission tomography, and further biopsy confirmed the diagnosis. Conclusion Although uncommon, non-traumatic enophthalmos has a broad differential diagnosis. In some rare instances, it may be the initial presentation of orbital metastases in patients with no prior history of cancer, and in the absence of other systemic symptoms. Clinicians must be thorough when assessing and investigating this clinical entity. A comprehensive eye exam, systemic evaluation, orbit imaging, biopsy and immunohistochemistry analysis are essential to promptly diagnose orbital metastases and plan the appropriate treatment.
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Affiliation(s)
- Jessica El-Khazen Dupuis
- Department of Ophthalmology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC H2X 3E4, Canada
| | - Michael Marchand
- Department of Ophthalmology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC H2X 3E4, Canada
| | - Simon Javidi
- Department of Ophthalmology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC H2X 3E4, Canada
| | - Tuan Quynh Tram Nguyen
- Department of Ophthalmology, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC H2X 3E4, Canada
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Alameddine RM, Ko AC, Mimura M, Parker BA, Lin JH, Korn BS, Kikkawa DO. Orbital fat regeneration following hormonal treatment of metastatic breast carcinoma. Orbit 2017; 37:187-190. [PMID: 29072521 DOI: 10.1080/01676830.2017.1383468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Enophthalmos in the setting of breast cancer metastatic to the orbit results primarily from the disease pathogenesis, or secondary to treatment effects. Orbital volume restoration and fat regeneration following endocrine treatment monotherapy has not been previously reported. A 76- year-old previously healthy female presented with progressive right enophthalmos secondary to metastatic lobular breast carcinoma. Treatment with an aromatase inhibitor (letrozole) resulted in tumor regression and orbital fat restoration with a corresponding improvement in orbital volume and enophthalmos on clinical exam. The patient is alive on continued letrozole with no progressive disease ten years after diagnosis. This case illustrates the resilience of orbital soft tissues and ability of orbital fat to regenerate in face of breast cancer metastasis. We hypothesize that endocrine monotherapy, and avoidance of radiation therapy, allowed for differentiation of remaining orbital stem cells, and facilitated the fat regenerative process.
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Affiliation(s)
- Ramzi M Alameddine
- a Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology , Shiley Eye Institute , La Jolla , CA , USA.,b Department of Ophthalmology , American University of Beirut Medical Center , Beirut , Lebanon
| | - Audrey C Ko
- a Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology , Shiley Eye Institute , La Jolla , CA , USA
| | - Masashi Mimura
- a Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology , Shiley Eye Institute , La Jolla , CA , USA
| | - Barbara A Parker
- c Department of Medicine , UC San Diego Moores Cancer Center , La Jolla , CA , USA
| | - Jonathan H Lin
- d UC San Diego Department of Pathology , San Diego , California , USA.,f Veterans Affairs San Diego Healthcare System , San Diego , California , USA
| | - Bobby S Korn
- a Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology , Shiley Eye Institute , La Jolla , CA , USA.,e Division of Plastic Surgery , UC San Diego Department of Surgery , La Jolla , CA , USA
| | - Don O Kikkawa
- a Division of Oculofacial Plastic and Reconstructive Surgery, UC San Diego Department of Ophthalmology , Shiley Eye Institute , La Jolla , CA , USA.,e Division of Plastic Surgery , UC San Diego Department of Surgery , La Jolla , CA , USA
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Latting MW, Huggins AB, Marx DP, Giacometti JN. Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions. Semin Plast Surg 2017; 31:5-16. [PMID: 28255284 DOI: 10.1055/s-0037-1598188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Aponeurotic ptosis accounts for the majority of acquired ptosis encountered in clinical practice. Other types of ptosis include traumatic, mechanical, neurogenic, and myogenic. In addition to true ptosis, some patients present with pseudoptosis caused by globe dystopia, globe asymmetry, ocular misalignment, or retraction of the contralateral lid. It is particularly important for the clinician to rule out neurologic causes of ptosis such as dysfunction of the third cranial nerve, Horner's syndrome, and myasthenia gravis, as these conditions can be associated with significant systemic morbidity and mortality. A thorough history and physical examination is necessary to evaluate each patient presenting with a complaint of ptosis. Correctly identifying the cause of the patient's complaint allows the ptosis surgeon to plan for appropriate surgical repair when indicated and to defer surgery when observation or additional clinical evaluation is warranted.
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Affiliation(s)
- Michelle W Latting
- Wills Eye Hospital, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alison B Huggins
- Wills Eye Hospital, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Douglas P Marx
- Division of Oculoplastic and Reconstructive Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph N Giacometti
- Department of Oculoplastic and Orbital Surgery, Wills Eye Hospital, Philadelphia, Pennsylvania; Morgenstern Center for Orbital and Facial Plastic Surgery, Wayne, Pennsylvania
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Hwang TN, Rofagha S, McDermott MW, Hoyt WF, Horton JC, McCulley TJ. Sunken Eyes, Sagging Brain Syndrome: Bilateral Enophthalmos from Chronic Intracranial Hypotension. Ophthalmology 2011; 118:2286-95. [DOI: 10.1016/j.ophtha.2011.04.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 04/17/2011] [Accepted: 04/26/2011] [Indexed: 10/17/2022] Open
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Gupta S, Bhatt VR, Varma S. Unilateral orbital pain and eyelid swelling in a 46-year-old woman: orbital metastasis of occult invasive lobular carcinoma of breast masquerading orbital pseudotumour. BMJ Case Rep 2011; 2011:2011/mar10_1/bcr1220103580. [PMID: 22698907 DOI: 10.1136/bcr.12.2010.3580] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Orbital metastasis is very infrequent in breast cancer; more so as an initial and sole presenting feature. The authors report a case of orbital metastasis of occult breast carcinoma in a 46-year-old woman, who presented with unilateral orbital pain and eyelid swelling. This was initially diagnosed as orbital pseudotumour and treated with steroids. The development of breast symptoms and finding of breast nodule, 3 months later, led to the diagnosis of invasive lobular carcinoma of the breast with orbital metastases, confirmed on biopsy.
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Affiliation(s)
- Shilpi Gupta
- Division of Hematology and Oncology, Department of Medicine, Sanford R Nalitt Institute for Cancer and Blood Related Diseases, Staten Island University Hospital, Staten Island, New York, USA
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Gross Enophthalmos After Cerebrospinal Fluid Shunting for Childhood Hydrocephalus: The “Silent Brain Syndrome”. Ophthalmic Plast Reconstr Surg 2009; 25:434-6. [PMID: 19935243 DOI: 10.1097/iop.0b013e3181b80d2d] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Polito E, Pichierri P, Occhini R, Loffredo A, Moramarco A, Balestrazzi A. Orbital metastasis associated with primary breast carcinoma in a man detected during peribulbar anesthesia for cataract surgery. Eur J Ophthalmol 2008; 18:1031-3. [PMID: 18988185 DOI: 10.1177/112067210801800633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE A case of orbital infiltration by breast carcinoma in a male patient causing mild enophthalmos and subcutaneous mass detected accidentally during peribulbar anesthesia for cataract surgery is discussed. METHODS The authors report a case of a 65-year-old man who came to the Ophthalmology Department for cataract surgery. During the presurgery peribulbar injection, a hard palpable mass located under the inferior left eyelid was noted, together with mild enophthalmos. A historical clinical screening revealed that 5 years previously the patient had undergone a right radical mastectomy to treat a ductal carcinoma of the breast. RESULTS The patient underwent an incisional biopsy of the orbital mass that confirmed the clinical hypothesis of a metastasis. DISCUSSION This case highlights the importance of the collection and screening of detailed clinical information on the patient before every ophthalmic operation including cataract surgery. The occurrence of progressive enophthalmos can represent an unusual symptom of orbital metastasis, commonly presenting with proptosis and diplopia.
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Affiliation(s)
- E Polito
- Dipartimento di Scienze Oftalmologiche e Neurochirurgiche, University of Siena, Siena, Italy
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