Metastasis of small cell lung cancer to bilateral extraocular muscles: a case report

BACKGROUND

Orbital metastasis is a possible complication of small cell lung cancer and a pattern of bilateral invasion of the extraocular muscles has rarely been reported in literature.

CASE PRESENTATION

A 46-year-old white male with a past medical history of smoking and stage IV small cell lung carcinoma presented with loss of vision and pain in the left eye. Examination revealed bilateral proptosis and left afferent pupillary defect, and visual acuity was hand motion on the left eye and 4/10 on the right eye. An orbital computed tomography scan showed a compression of the left optic nerve between the extraocular muscles at the apex, and a lateral canthotomy was performed for a new-onset compressive optic neuropathy, with residual visual improvement. There was also significant enlargement of the extraocular muscles in the right orbit. The patient was maintained in palliative treatment with both chemotherapy and local medical and surgical (amniotic membrane cover for exposure keratopathy) ophthalmological treatments until he eventually died 5 months after.

CONCLUSION

Bilateral metastasis to the extraocular muscles is a very rare manifestation of small cell lung cancer and the palliative treatment in these cases is challenging.

A Case Series of Choroidal and Orbital Neuroendocrine Tumors: Metastasis: Two Patients Treated With Peptide Radionuclide Therapy

ABSTRACT

Neuroendocrine tumors (NETs) are rare cancers with heterogeneous histologies, response to treatments, and prognoses. Majority of these cancers originate in the gastrointestinal tract and metastasize to the liver. We report the cases of 5 patients with low-grade NET disease with rare metastases to the choroids. Two of the patients were treated with peptide receptor radionuclide therapy (lutetium 177 [ 177 Lu]). This is the first report confirming peptide radionuclide therapy safety in patients with low-grade NET with ocular metastases.

Metastatic Merkel cell carcinoma presenting as an orbital mass

A 67-year-old female presented with 2 weeks of right eye pain, redness, and diplopia. An orbital mass was found on magnetic resonance imaging (MRI), and biopsy revealed Merkel cell carcinoma (MCC). She had no primary head or neck lesion and no previous history of MCC. Positron emission tomography (PET) scan showed hypermetabolic subcutaneous lesions of the lower extremity andmultiple osseous lesions of the axial and appendicular skeleton. She received palliative external radiation of 20 Gy in 5 fractions to the orbit. After discussing immunotherapy, she opted for comfort care and expired 1 month later. To the best of our knowledge, this is only the third case of MCC with distant metastasis to the orbit and the first case in which the patient had no previous diagnosis of MCC and no known primary tumor.

Uncommon Hematogenous Metastasis: Orbital Involvement in Uterine Cervical Cancer

BACKGROUND Although screening for uterine cervical cancer (UCC) and vaccination programs for human papilloma virus (HPV) have been implemented in many countries, women >65 years may not have access to or comply with cervical cancer screening. Women >65 years may present with advanced-stage cervical carcinoma with a poor outcome. Metastatic UCC is often diagnosed, and there are 2 types of metastases related to different treatments and survival rate: hematogenous metastasis and lymphatic metastasis. Hematogenous metastasis is relatively unusual, and it most commonly involves lung and bone locations. Orbital metastasis is an extremely rare hematogenous metastasis in patients with UCC. CASE REPORT A 70-year-old woman receiving dialysis presented to a local hospital due to general fatigue for 5 months. She was diagnosed with locally advanced UCC and underwent radiation therapy (RT). Twenty days after RT, skin masses appeared, and 34 days after RT, right exophthalmos induced by an orbital mass appeared. We diagnosed skin and orbital masses as metastases from UCC, and performed RT to the orbital tumor. The tumor shrank and the visual symptoms disappeared. Regrettably, the patient died of cancer 7 months after the orbital RT; however, no eye symptoms recurred until her death. CONCLUSIONS This report describes a rare presentation of UCC with metastasis to the orbit, and highlights that cervical cancer may still present at an advanced stage, particularly in older women. In this case, RT to the orbital metastasis from UCC was effective and contributed to the patient's quality of life.

Metastatic neuroendocrine tumor masquerading as orbital cysticercosis

Orbital metastases secondary to neuroendocrine tumors are exceedingly rare. We present a unique case of a 30-year-old female initially presenting with fever, chills, periorbital swelling, and painful proptosis. CT orbits revealed two ovoid-shaped ring-enhancing lesions in the right lateral and superior rectus muscles and clear sinuses, atypical for infectious post-septal cellulitis. Further work-up included serologic analysis, auto-immune panel, and MRI. Further imaging showed pseudocystic orbital lesions mimicking orbital cysticercosis. Additionally, given the bilateral nature of the lesions and patient's country of origin, this parasitic process was highly suspected. A course of albendazole and steroids led to resolution of symptoms. With a presentation at age 30, this is by far the youngest case reported in literature to date.

Sino-orbital metastasis as the initial presentation of advanced breast cancer

A woman in her 70s presented with reduced vision in her left eye, progressive narrowing of right eye opening for 6 months and anosmia. On examination, she had right enophthalmos and pseudoptosis with inferior globe dystopia. Her visual acuity was 6/9 and nil light perception in the right and left eyes, respectively. Extraocular muscle examination showed limited right up gaze. Funduscopy showed a normal right optic disc and left optic disc atrophy. Systemic examination revealed left breast ulceration with skin tethering. CT revealed an infiltrative mass invading the ethmoidal sinuses, frontal sinuses and both orbits. A histological diagnosis of infiltrative ductal breast carcinoma was made after nasal endoscopic and left breast biopsy. She underwent palliative chemoradiotherapy and survived with good disease control after 1 year. Metastatic carcinoma is a differential diagnosis of a sino-orbital mass, and comprehensive clinical assessment is indicated for all patients presenting with non-acute eye injury.

Uveal Melanoma Metastasis to the Contralateral Eye Structures: A Retrospective Comparative Analysis of 13 Consecutive Patients

PURPOSE

To report uveal melanoma (UM) metastasis to the contralateral ocular and periocular structures.

DESIGN

Retrospective study.

PARTICIPANTS

Thirteen patients with UM metastasis to the contralateral ocular and periocular structures were included.

METHODS

Clinical records were reviewed retrospectively.

MAIN OUTCOME MEASURES

The development and time to onset of contralateral ocular and periocular metastasis, systemic metastasis, and death.

RESULTS

Of the 13 000 treated UM patients, 13 patients were diagnosed with UM metastasis to the contralateral ocular and periocular structures. Mean patient age at primary UM diagnosis was 60 years (median, 60 years; range, 37-87 years). The primary uveal melanoma was in the choroid (n = 11) or ciliary body (n = 2) and was treated with brachytherapy (n = 11), proton beam radiotherapy (n = 1), or enucleation (n = 1). Systemic metastasis developed in 11 patients (85%) at a mean of 66 months (median, 34 months; range, 12-216 months) after diagnosis of the primary UM. All 11 patients (100%) showed liver metastasis and 8 patients (62%) also showed extrahepatic metastasis. The sites of metastasis to the contralateral ocular or periocular structures included the choroid in 4 patients (31%), the orbit in 7 patients (54%), and the eyelid in 2 patients (15%). One patient with eyelid metastasis demonstrated concurrent conjunctival nodule. Mean time to diagnosis of contralateral ocular or periocular metastasis was 94 months (median, 48 months; range, 9-375 months). Contralateral choroidal metastasis was multifocal in 3 of 4 patients (75%). Of 7 patients with orbital metastasis, 5 showed extraocular muscle involvement with restricted ocular motility. Treatment for contralateral choroidal metastasis included brachytherapy (n = 2), transpupillary thermotherapy (n = 1), and observation (n = 1). Treatment for contralateral periocular (orbit or eyelid) metastasis was excision (n = 5), external beam radiotherapy (n = 2), and observation (n = 2). Of 13 patients, death was documented in 11 patients at a mean of 17 months (median, 9 months; range, 3-54 months) as a result of systemic UM metastasis (n = 10) or unrelated cause (n = 1).

CONCLUSIONS

Metastasis resulting from UM to the contralateral ocular and periocular structures is rare and generally occurs in patients with disseminated metastasis. Orbital tissue is the most common site of involvement, and these patients have short life expectancy.

Isolated Unilateral Orbital Metastasis From Ewing Sarcoma Detected on FDG PET/CT Scan

ABSTRACT

Ewing sarcoma is the second most common primary malignant bone tumor that usually affects diaphysis of long bones during the second decade of life. Isolated unilateral orbital metastasis from this tumor presenting as proptosis is extremely rare. Here we report a case of 11-year-old boy where whole-body FDG PET/CT scan detected primary an Ewing sarcoma site in the left femur and isolated orbital metastasis in the left eye. Follow-up PET/CT scan after 6 cycles of chemotherapy showed resolution of the previously seen lesions.

Metastatic Orbital Tumor From Breast Ductal Carcinoma With Neuroendocrine Differentiation Initially Presenting as Ocular Symptoms: A Case Report and Literature Review

BACKGROUND

Orbital metastases from cancers of various organs can arise via the hematogenous route, and many originate from breast, prostate, and lung cancers. Such metastatic orbital tumors may be diagnosed before the primary tumor. We have encountered a case of breast ductal carcinoma with neuroendocrine differentiation that metastasized to the orbit and responded to chemotherapy, with improvement in visual function.

CASE PRESENTATION

A woman in her fifties visited our ophthalmology department with a chief complaint of foreign body sensation and exophthalmos in her right eye. An elastic soft mass was palpated from the lateral orbit to the temporal region. A systemic examination revealed breast cancer and a metastatic orbital tumor. Excisional biopsy of the breast revealed a diagnosis of invasive ductal carcinoma with neuroendocrine differentiation, and immunohistochemical examination was negative for cytokeratin 7, making the case unusual. Chemotherapy was remarkably effective, and the tumor size decreased, resulting in improvement of visual function. Her general condition and quality of life are still good at present. We searched the PubMed English language literature focusing on metastatic orbital tumors from breast cancer in which ocular symptoms had been the initial presenting sign. No previous reports have documented neuroendocrine differentiation or cytokeratin 7 expression in isolated orbital metastases from breast cancer. Although it is not possible to be certain from this case alone, we speculated that some such cases might involve cytokeratin 7-negative invasive breast cancer with neuroendocrine differentiation.

CONCLUSION

We have described our experience of a very rare case of cytokeratin 7 negative breast ductal carcinoma with neuroendocrine differentiation that metastasized to the orbit and formed a solitary giant tumor initially manifesting as ocular symptoms.

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.

Patient treatment and outcome after breast cancer orbital and periorbital metastases: a comprehensive case series including analysis of lobular versus ductal tumor histology

BACKGROUND

Breast cancer is the most common malignancy to spread to the orbit and periorbit, and the invasive lobular carcinoma (ILC) histologic subtype of breast cancer has been reported to form these ophthalmic metastases (OM) more frequently than invasive ductal carcinomas (IDC). We herein report our single academic institution experience with breast cancer OM with respect to anatomical presentation, histology (lobular vs. ductal), treatment, and survival.

METHODS

We employed the natural language processing platform, TIES (Text Information Extraction System), to search 2.3 million de-identified patient pathology and radiology records at our institution in order to identify patients with OM secondary to breast cancer. We then compared the resultant cohort, the "OM cohort," to two other representative metastatic breast cancer patient (MBC) databases from our institution. Histological analysis of selected patients was performed.

RESULTS

Our TIES search and manual refinement ultimately identified 28 patients who were diagnosed with breast cancer between 1995 and 2016 that subsequently developed OM. Median age at diagnosis was 54 (range 28-77) years of age. ER, PR, and HER2 status from the 28 patients with OM did not differ from other patients with MBC from our institution. The relative proportion of patients with ILC was significantly higher in the OM cohort (32.1%) than in other MBC patients in our institution (11.3%, p = 0.007). Median time to first OM in the OM cohort was 46.7 months, and OM were the second most frequent first metastases after bony metastases. After diagnosis of the first distant metastasis of any kind, median survival of patients with ILC (21.4 months) was significantly shorter than that of patients with IDC (55.3 months, p = 0.03). Nine patients developed bilateral OM. We observed a significant co-occurrence of OM and central nervous system metastases (p = 0.0053). The histological analysis revealed an interesting case in which the primary tumor was of a mixed ILC/IDC subtype, while only ILC was present in the OM.

CONCLUSIONS

OM from breast cancer are illustrative of the difference in metastatic behavior of ILC versus IDC and should be considered when treating patients with ILC, especially in those with complaints of visual acuity changes.

Pseudocystic appearance of an orbital carcinoid metastasis

Carcinoid tumours are a low-grade neuroendocrine malignancy that infrequently metastisizes to orbital structures. The typical radiological appearance of carcinoid is a solid, well-circumscribed mass that enhances with contrast. We present a case of orbital carcinoid metastasis with pseudocystic radiological appearance and review of the literature.

Case report of periorbital metastasis from rectal cancer

INTRODUCTION

Periorbital metastasis of colorectal cancer is rare. Therefore, herein, we report a patient with rectal cancer who presented with periorbital metastasis without any systemic metastasis.

PATIENT CONCERNS

The patient was a 57-year-old man who had a painless nodule on his left eyelid.

DIAGNOSIS

The patient presented with loose and frequent stools and was diagnosed with rectal adenocarcinoma via colonoscopic biopsy at the local clinic. Curative resection (low anterior resection with temporary ileostomy formation) was performed 4 weeks after completing chemoradiotherapy. The final TNM stage was yp stage T2N0M0. Eight months after the diagnosis of rectal cancer, a protruding lesion was noticed on the patient's left eyelid. Histologic evaluation of the nodule revealed metastatic adenocarcinoma of rectal cancer.

INTERVENTIONS

The patient received neoadjuvant chemoradiotherapy and curative resection for rectal cancer. After excision of the periorbital nodule, he received 5 cycles of chemotherapy.

OUTCOMES

The patient underwent regular follow-up because he was not able to endure chemotherapy; no recurrence has been observed 21 months after the diagnosis of rectal cancer. Histologic examination revealed metastatic adenocarcinoma of rectal cancer on the patient's left eyelid. However, consecutive imaging studies revealed no other metastatic lesions. Finally, the patient was diagnosed with a solitary periorbital metastasis of rectal cancer.

CONCLUSION

This case report helps in understanding the course of progression from rectal cancer to periorbital metastasis.

Rare Orbital Metastasis Originating From a Neuroendocrine Tumor

BACKGROUND

This case study details a rare orbital metastasis originating from the gastrointestinal tract. A patient presented with proptosis of the right eye precipitated by a slow-growing orbital tumor. A biopsy confirmed a low-grade neuroendocrine tumor. Imaging studies were completed, with magnetic resonance (MR) imaging of the orbits providing the most detailed images of the mass. Fusion software images were created from the MR images and indium In 111 pentetreotide (octreoscan) studies, which confirmed the presence of the neuroendocrine carcinoid tumor.

DISCUSSION

Orbital metastases are a rare condition associated with various symptoms, most commonly proptosis and diplopia. Imaging modalities, such as MR, computed tomography, and nuclear medicine technology, are instrumental in detecting and assessing these masses. Fusion imaging software can provide additional opportunities for facilities without hybrid scanners. The treatment of choice for orbital metastases is octreotide therapy; however, radiation therapy, partial or complete surgical removal of the tumor, and chemotherapy also are used.

CONCLUSION

Traditional imaging techniques and fusion imaging techniques are essential for diagnosing and treating orbital metastases.

Orbital neuroblastoma metastasis: A case report and literature review

RATIONALE

Neuroblastoma is one of the most common tumors found in children, and mostly arises in the adrenal gland and paravertebral regions. Orbital neuroblastoma metastasis is relatively rare, and is associated with poor prognosis. Since the symptoms and signs of orbital neuroblastoma are not specific, its diagnosis remains challenging.

PATIENT CONCERNS

A 3-year-old girl presented with periorbital ecchymoses (raccoon eyes) and proptosis for 40 days.

DIAGNOSES

Abdominal magnetic resonance imaging (MRI) and sonography analysis revealed a large mass in the left adrenal gland (primary tumor). The computed tomography and MRI further revealed multiple soft tissue masses in the skull and both orbits with erosion of the adjacent bones (the metastasis). The histological analysis of the tumor removed from the right orbit confirmed the diagnosis of neuroblastoma.

INTERVENTIONS

The mass on the right face was surgically removed.

OUTCOMES

The patient exhibited no deteriorative signs at the 6-month follow-up.

LESSONS

Clinical manifestations, such as periorbital ecchymoses and proptosis, in combination with radiological analysis and histological findings, are important for the diagnosis of orbital neuroblastoma metastasis.

Intraorbital, Infratemporal And Intracranial Extensions As The First Presentation Of Follicular Thyroid Carcinoma

Metastatic skull deposits from follicular thyroid carcinoma are rare, and let alone this being the primary presenting symptom with no history of thyroid cancer is exceptionally rarer. A 40-yearold female patient presented with a mass in the temporal and occipital region of the skull. Fine needle aspiration cytology confirmed multiple fragments of a neoplasm composed of variably sized follicles lined by tumour cells having pleomorphic hyperchromatic nuclei. Further workup revealed Follicular thyroid carcinoma and subsequently, total thyroidectomy was done. Skull resection was not possible due to the extensive nature of disease and patient was advised radioactive iodine ablation therapy but couldn't survive past 4 months.

Ophthalmologic aspects of Dermatofibrosarcoma Protuberans: A systematic review in the context of a rare case of primary orbital involvement

OBJECTIVE

To provide a systematic review on ophthalmologic presentations of dermatofibrosarcoma protuberans (DFSP) in conjunction with a case report of primary orbital involvement by this tumor.

METHODS

A thorough electronic search on PubMed, Medline, Scopus, EMBASE and web of science databases was performed. All available data from reported cases along with our described case were extracted and analyzed.

RESULTS

We describe a 66-year-old male with primary orbital DFSP who was managed by total excision of the tumor without recurrence after 18 months of follow-up. In the literature, 14 studies reporting 15 cases were identified and reviewed. Our review topics included epidemiology, clinical presentations, pathologic features, differential diagnosis, imaging, treatment and prognosis.

CONCLUSION

Rarely, but crucially, ophthalmologists may encounter DFSP in the orbital or periorbital area. They should be familiar with the pathologic nature and treatment options for this tumor. This diagnosis should be kept in mind when approaching a case with a non-tender, nodular, firm, mass or more rarely an indenting orbital mass.

Orbital metastases of invasive lobular breast carcinoma

Breast cancer is the main site of origin of orbital metastatic disease. Although invasive lobular breast carcinoma accounts for 10-15% of all breast cancer cases, it has been noticed that it metastasizes to the orbit more often compared to breast cancer of no special type (NST). The pathogenesis of this metastasis is not entirely understood; however, it seems that the unique tissue-specific characteristics of orbital microenvironment might contribute to metastatic disease in this particular site. Given the increasing survival of breast cancer patients and the prolonged metastatic potential of invasive lobular breast carcinoma, it is possible that the incidence of this rare metastasis might increase in the future. The purpose of this review is to present clinical manifestations, immunohistochemical characteristics and therapeutic options for orbital metastases from invasive lobular carcinoma.

[A Case of Advanced Gastric Cancer with Ptosis Caused by Orbital Metastasis]

Orbital metastasis of gastric cancer occurs very rarely.A 76-year-old woman, who consulted another doctor with the chief complaints of palpitation, shortness of breath, and anorexia 1 month previously, was referred to our clinic for workup and treatment.Workup revealed type III advanced gastric cancer at the lesser curvature of the gastric antrum.Biopsy revealed a diagnosis of poorly differentiated adenocarcinoma.As computed tomography suggested periaortic lymph node metastasis, a diagnosis of T4a(SE)N3aM1(LYM), cStage IV was made.Two weeks later, ptosis was observed in the right eye, and positron emission tomography-computed tomography(PET-CT)revealed metastasis to the right superior rectus muscle.No intracranial tumor progression was observed.The Cyberknife system(20 Gy/1 Fr)was used for treating the orbital tumor. Increased LYM was observed even after 2 courses of S-1 plus oxaliplatin(SOX)therapy.Therefore, weekly combination therapy of paclitaxel and ramucirumab(wPTX plus Rmab)was administered as second-line therapy.No new distal metastasis has been detected in the 10 months since the orbital metastasis development, and the patient is still alive.

Orbital disorder revealing a lung cancer: a case report

INTRODUCTION

Orbital metastases are rare and they are even rarer to be the first sign of the disease, which can lead to misdiagnosis and delay of management.

OBSERVATION

Our patient consulted for a diplopia and a ptosis of the upper eyelid of the right eye since one month, without any other systemic symptoms. After ophthalmological examination and orbital tomography, the diagnosis of orbital metastasis was suspected. Lung cancer was revealed by thoracic tomography and confirmed by an anatomopahological examination.

CONCLUSION

Because of the increased incidence of neoplasia, the diagnosis of orbital metastasis should be considered in any elderly patient who consults for symptomatology related to orbital involvement.

Metastasis from pancreatic adenocarcinoma to the cheekbone

Skeletal metastasis by pancreatic adenocarcinoma are infrequent, and those located in the craniofacial region are very rare. We report the case of a 63-year-old Caucasian woman with a metastatic adenocarcinoma of the pancreatic head previously treated with surgery and chemotherapy presenting a skeletal metastasis in the left cheekbone 5 years after primary treatment. No other similar cases have been previously described. The therapeutic decision was not simple because of the uncommon site of pancreatic metastasis. Surgical resection was the only possibility after the radiotherapy failure.

KEY WORDS

Cheekbone mass, Cheekbone metastasis, Pancreatic adenocarcinoma, Pancreatic adenocarcinoma metastasis.

Adenocarcinoma of Unknown Primary Site with Bone Marrow and Orbital Metastases Suggestive of a Prostatic Origin

Prostate cancer may occasionally present as an adenocarcinoma with an undetermined primary site. We report a case in which bone marrow invasion and orbital metastasis were the first evidence of malignancy. Recognition of metastatic prostate cancer is important since it can be managed safely and effectively with hormonal therapy.

Retrobulbar Metastasis from Gallbladder Carcinoma after Laparoscopic Cholecystectomy. A Case Report

Extra-abdominal metastases from gallbladder cancer are very rare; the sites outside the abdomen most frequently affected are the skin, bone and central nervous system. In the literature, only one case of orbital metastasis from gallbladder cancer has been reported, in a patient previously treated by open cholecystectomy. We report the case of a 53-year-old woman who underwent a laparoscopic cholecystectomy for symptomatic gallbladder stones. Postoperative histological examination revealed an unsuspected gallbladder adenocarcinoma. One month later she came to our observation after having developed diplopia and ophthalmic pain due to an orbital metastasis. We decided not to perform a surgical second look because of the already rapid dissemination of the malignant tumor.

The few cases of uncommon gallbladder cancer metastases after laparoscopic cholecystectomy described in the literature are discussed, as well as the possible role of laparoscopy in the dissemination and localized seeding of malignant cells.

Sinonasal Undifferentiated Carcinoma Invading the Orbit

Sinonasal undifferentiated carcinoma (SNUC) is an infrequent tumor described by Frierson et al. in 1986. Since its initial description, fewer than 100 patients have been reported. We present a case of a SNUC invading the orbit in a 57-year-old woman, for which the findings are documented by CT scan, light and electron microscopy.

Orbital Metastasis of Renal Cell Carcinoma Masquerading as Amaurosis Fugax

Renal cell carcinoma (RCC) is the most common malignancy involving the kidney. Only rarely does it metastasize to the eye and orbit, sometimes mimicking other lesions. A 70-year-old woman was referred from neurology because of a right orbital lesion, six months after the start of a neurological investigation because of amaurosis fugax. Six months earlier she had complained of transient visual disturbances in her right eye. After excluding cardiovascular abnormalities and coagulopathies as the source of her complaints, she was diagnosed as having a right senile ptosis. A computed tomography scan, done to complete the workout, detected a right orbital mass. The patient was referred to the oculoplastic unit. A biopsy and then a lateral orbitotomy were performed. Histopathological examination proved it to be a metastatic renal cell carcinoma, seven years after the primary tumor had been diagnosed and treated by nephrectomy.

The characteristics of metastatic renal cell carcinoma are discussed, in view of the rarity of metastasis to the eye and, in particular, to the orbit, and its tendency to masquerade as other lesions or symptoms. In this case it presented as amaurosis fugax before other signs appeared.

Esthesioneuroblastoma: An Atypical Form of Manifestation

Esthesioneuroblastoma is a rare tumor that originates in the olfactory epithelium and can invade the orbit. We report a case in which the first symptom was a post-traumatic paralysis of the IV cranial nerve. Whether the tumor itself or the trauma or a combination of the two factors caused the paralysis is discussed.

Periorbita: Computed Tomography and Magnetic Resonance Imaging Findings

Purpose

The periorbita has been regarded as the critical structure in decision of exenteration in the patients with paranasal (PNS) malignancies. The purpose of this study is to present the CT and MRI findings of the periorbita with PNS malignancies.

Materials and Methods

Ten patients with PNS cancers were chosen for this study. PNS CT and MRI scans were performed on all patients. The imaging findings were reviewed retrospectively by consensus of two neuroradiologists. Assessment of the defect of the orbital bone and invasion of the orbital fat was made by CT and MRI. The signal intensity (SI), thickness, enhancement, and correlation with the orbital bone of the periorbita were analyzed on MRI. The intraoperative and pathologic reports were used as the gold standard for orbital invasion.

Results

In patients with bone defects, it was impossible to differentiate the periorbita from the mass on CT. The periorbita showed hypointensity on T2-weighted images compared with the SI of mass. On Gd-enhanced T1-weighted images, the periorbita showed less enhancement than the mass in nine patients. Six patients showed two hypointense layers (the outer bony wall and the inner periorbita) between the mass and orbital fat on T2-weighted images. The thickness of the periorbita was 0.79–1.4 millimeter. Orbital invasion was more conspicuous on T2-weighted coronal images than on the CT images.

Conclusions

MRI was more conspicuous for detecting orbital invasion than CT. The mass beyond the thickened periorbita on T2-weighted images was considered to be a positive finding of orbital invasion.

Orbital and conjunctival metastasis from lobular breast carcinoma

This article examines the clinical presentation of ocular metastasis from an infiltrating lobular breast carcinoma. We examined a conjunctival biopsy from a 69-year-old woman who developed unilateral conjunctival inflammation together with a neurotrophic corneal ulcer and proptosis. Infiltrating lobular breast carcinoma (ILBC) was diagnosed using routine histology and immunohistochemistry. She had a past history of a hormone receptor-positive infiltrating ILBC 11 years ago with cutaneous and diffuse osteoblastic metastases, and she was kept under treatment with lezotrol. Treatment was initiated with systemic corticosteroids but an annular conjunctival perilimbal infiltration was found to have spread, which did not respond either to local radiotherapy (total dose 60 Gy, 2 Gy per day). A new extensive corneal epithelial defect recurred, and because it had not responded to matrix therapy agent (RGTA, Cacicol®) eye drops, autologous serum eye drops and a therapeutic contact lens, a permanent total tarsorrhaphy was performed. Progression of the diffuse bone metastases was detected and the treatment with lezotrol was replaced by fulvestrant.Infiltrating lobular breast carcinoma is a rare cause of conjunctival metastasis. This aggressive malignancy did not respond to external beam radiotherapy.

Rare metastasis of renal carcinoma in the frontoethmoid-orbital region - case report and review of the literature

A tumor located in the region of the paranasal sinuses and the orbit is not usually a metastasis, but a primary tumor. Even more, renal cell carcinoma (RCC) is very rarely the cause of metastasis in the paranasal sinuses or the orbit. Up to the present moment, few cases have been reported in the literature of such an association. The aim of the authors is to highlight the rare case of a male patient presented with ptosis, frontal swelling, minor headaches and epistaxis, as the only symptoms, but in which the mass located in the left frontoethmoidal region with extension to the orbit proved to be a RCC metastasis, thus leading to the diagnosis of the primary renal tumor. We must underline the need for clinical suspicion and the importance of accurate histopathological and immunohistochemical investigations, in such rare cases, where they are crucial in obtaining the right diagnosis.

[Carcinoid of the Appendix Goblet Cells Metastasize to the Orbit - a Clinical Case Report and Review of the Literature]

Goblet cell carcinoid (GCC) of the appendix is extremely rare, representing approximately 5% of all primary appendiceal neoplasms. Histologically there are three groups of GCC: group A (typical GCC), adenocarcinoma ex GCC signet ring cell type (group B), and adenocarcinoma ex GCC poorly differentiated carcinoma type (group C), which is the most aggressive. GCC metastasizes in 15-60% of cases, mainly to the ovaries, pelvis, abdominal cavity, ribs, vertebrae, and lymph nodes. Hematogenous metastasis to the liver or other parenchymal organs can occur, but this is very rare. The different organs metastases havent been described yet. The primary mode of treatment is radical surgical resection or debulking, followed by chemotherapy; however, patients with unresectable or recurrent GCC are candidates for systemic therapy. Here, we report a case of very aggressive GCC of the appendix, which had metastazed to the liver at the time of diagnosis and subsequently metastasized to the orbit.

Secondary Bilateral Orbital Involvement from Primary Non-Hodgkin Lymphoma of the Cheek

We describe a patient with oculomotor nerve palsy due to secondary orbital infiltration from the primary malignant lymphoma of the cheek. The patient was a 78-year-old female who had non-Hodgkin lymphoma (diffuse large B cell lymphoma [DLBCL]) of the cheek. The patient received chemotherapy and local radiation therapy. The combined treatment brought about complete remission. About 6 months after the last treatment the patient began to have left blepharoptosis and impaired vision. Findings from ophthalmological and neurosurgical examinations suggested no intraorbital or intracranial lesions. Repeated MRI and CT scans also showed no such lesions. One month later, the patient suddenly had a left oculomotor disturbance, diplopia and exophthalmus, followed by right oculomotor nerve palsy. An MRI revealed bilateral intraorbital tumors. Recurrence at the orbital tissue of malignant lymphoma originated from the left cheek appeared to cause the ophthalmological symptoms. Salvage chemotherapy was performed and her ocular symptoms were recovered. However, the patient died approximately 10 months after recurrent orbital tumor onset.

Orbital Metastasis Is Associated With Decreased Survival in Stage M Neuroblastoma

BACKGROUND

Approximately 30% of patients with metastatic (stage M) neuroblastoma present with periorbital ecchymosis from orbital osseous disease. Though locoregional disease is staged by imaging, the prognostic significance of metastatic site in stage M disease is unknown. We hypothesize that, compared to nonorbital metastasis, orbital metastasis is associated with decreased survival in patients with stage M neuroblastoma, and that periorbital ecchymosis reflects location and extent of orbital disease.

PROCEDURE

Medical records and imaging from 222 patients with stage M neuroblastoma seen at St. Jude Children's Research Hospital between January 1995 and May 2009 were reviewed. Thirty-seven patients were <18 months of age at diagnosis and 185 were ≥18 months of age. Overall survival (OS) and 5-year survival (5YS) were compared for patients with and without orbital, calvarial and nonorbital osseous metastasis, and with and without periorbital ecchymosis (log-rank test). Associations of periorbital ecchymosis with orbital metastasis location/extent were explored (Fisher's exact test, t-test).

RESULTS

In patients ≥18 months of age, only orbital metastasis was associated with decreased 5YS (P = 0.0323) and OS (P = 0.0288). In patients <18 months of age, neither orbital, calvarial, or nonorbital bone metastasis was associated with OS or 5YS. Periorbital ecchymosis was associated with higher number of involved orbital bones (P = 0.0135), but not location or survival.

CONCLUSIONS

In patients ≥ 18 months of age with stage M neuroblastoma, orbital metastatic disease is associated with decreased 5YS and OS. In future clinical trials, orbital disease may be useful as an imaging-based risk factor for substratification of stage M neuroblastoma.

Orbital metastasis revealing an undifferenciated Carcinoma of nasopharyngeal type: a case report

The evolution of the undifferentiated carcinoma of the nasopharynx (NPC) is marked by the occurrence of regional or distant metastasis. We report a rare observation of bilateral orbital metastasis of NPC. Clinical symptoms were ocular proptosis, blurred vision and eye redness. Imaging permitted to precise the extensions of the tumor which was classified T4N1M1 after clinical and paraclinical exams. The treatment consisted of concomitant radiochemotherapy. The evolution didn't revealed recurrence of the disease after 18 months.

[Orbital Exenteration in Patient with Metastatic Choroidal Melanoma - a Case Report]

INTRODUCTION

Uveal melanoma is the most common primary intraocular tumour in adults in Caucasians and in 75% is arising from choroid. It threatens not only the patients loss of vision and eye, but also 50% of patients after 5-year interval after therapy die due to distant metastases. The treatment of small and medium-sized melanoma are methods preserving eye globe. Almost half of the total number of patients is still unavoidable enucleation. Considerably rarer is indicated exenteration of an orbit. These tumors metastasize only hematogenous, while the most frequent place of localization of distant metastases is the liver. Generalized disease prognosis is poor, and our current treatment options in this stage are ineffective.

MATERIAL AND METHODS

Case report of 59 years old patient with choroidal melanoma stage T4 N1 M1 massively infiltrating the orbit. At the time of diagnosis of the primary tumor distant metastases were present. The patient underwent exenteration of the orbit and systemic chemotherapy.

DISCUSSION

Although choroidal melanomas with extrascleral extension and infiltration into the orbit have no better prognosis after exenteration of the orbit, surgery is providing us local tumour control. Good cosmetic effect after this mutilating procedure is offered by individually made prosthesis (epithesis). All patients with uveal melanoma require lifelong dispensation, distant metastases may occur even after many years. In the treatment of generalized disease is available systemic chemotherapy and immunotherapy only palliative. The best effect on survival has complete surgical resection of single metastasis. Uveal melanoma has a different genetic profile as cutaneous melanoma. The biological nature of uveal melanoma seems to be the key to determining risk patients, as well as the development of targeted systemic therapy.

CONCLUSION

Treatment of patients with generalized large uveal melanoma with extrascleral extension is difficult. A better understanding of biological interest may be the key to the detection of patients at higher risk of distant metastases formation, and to an effective systemic treatment.

KEY WORDS

large uveal melanoma, extrascleral extension, orbital exenteration, the treatment of generalized disease.

Orbital Decompression for Compressive Optic Neuropathy in Patients with a Metastatic Orbital Tumor from Breast Carcinoma

We report two patients who underwent orbital decompression for compressive optic neuropathy due to a metastatic orbital tumor from breast cancer. One patient was a 47-year-old woman with right compressive optic neuropathy. Balanced orbital decompression was performed 11 days after her first visit. At postoperative week 1, her right visual acuity and critical flicker frequency value had improved from 0.1 and 20 Hz to 1.0 and 35 Hz, respectively, and good vision was maintained at 6 months postoperatively. The other patient was a 61-year-old woman with right compressive optic neuropathy. Medial orbital wall decompression was performed 5 days after her first visit. Her right visual acuity and critical flicker frequency values improved until 38 days after the surgery, from 0.5 and 19 Hz to 1.2 and 31 Hz, respectively, with stable good vision for the following 6 months.

Metastases to oro-maxillo-facial region from distant sites: are they so rare? A single centre 8-years experience

AIM

The goal of our study is investigate the frequency of metastasis to oro-maxillo-facial region to understand if they are really so rare.

MATERIAL OF STUDY

In this eight year's retrospective study (2004-2012) we collected 15 cases of metastasis localized in the maxilla-facial region from distant primary tumor.

RESULTS

Our results show breast and kidney as the most frequent primary site (40% and 20% respectively), adenocarcinoma as most common histological type (60%). Bone involvement has found to be much frequent than the soft tissue one (53.3%). The mandible (5/15 cases) is more affected than the maxilla, and most common interested subsites are molar and retromolar region. In our study we found only one case of unknown primary tumor, it was a mandibular bone metastasis from a renal clear cell carcinoma.

CONCLUSION

Finally, according to our results and considering the increase of survival in cancer disease, even if metastases to oro- maxilla- facial region from distant sites are not frequent, it is important to suspect secondary lesions both in patients that was referred a tumor in their medical history and in those that present a head and neck lesion.

Adult rhabdomyosarcoma of the maxillary sinus with orbital extension

A 40-year-old male presented with 2 weeks of left facial pain, nasal congestion, dysphonia, and epistaxis along with left-sided epiphora. CT showed a large infiltrative mass centered in the left maxillary sinus with extension into the left orbit, bilateral paranasal sinuses, nasal cavity, and bilateral enlarged cervical lymph nodes. Biopsy results confirmed adult alveolar rhabdomyosarcoma (RMS). Systemic workup confirmed bilateral cervical lymph node metastasis. Currently the patient is undergoing chemotherapy. We describe a rare case of adult paranasal sinus RMS with orbital invasion.

An unusual orbital metastasis of breast cancer

In this paper we report the clinical case of a 84 year old female patient with a history of breast cancer diagnosed 14 years before, treated only with hormone therapy for 10 years and with subsequent follow-up oncology which always demonstrated negative results. 14 years after the first diagnosis, the patient presented with an increase in mass markers (CEA), and progressive symptoms of the right eye (diplopia). A CT scan and an MRI of the orbits confirmed the presence of an expansive neoplastic formation of the right orbit of 16 × 9 mm. The orbital metastases are rare locations of metastatic breast cancer which pose problems of differential diagnosis and require prompt and multimodal treatment (chemotherapy, hormone therapy, radiation therapy) aimed at improving the quality of life of the patient.

Simultaneous pectoralis major muscle and orbital metastasis as the primary presentation of pulmonary adenocarcinoma

A 63-year old male with chronic shoulder pain and painful left eye with binocular diplopia of sudden onset was seen independently by Ophthalmologists and his family Doctor and investigated first non-invasively where masses were found both in the orbit and pectoralis muscle. Further investigations including biopsy confirmed non-small cell lung carcinoma with metastasis to these sites; unusual sites of tumour metastasis and the first reporting of such tumour behaviour.

Head and neck cutaneous squamous cell carcinoma metastatic to cervical sublevel IIb lymph nodes occurred from primary sites involving the auricle and adjacent neck

PURPOSE

Neck dissections that include sublevel IIb increase the risk of postoperative shoulder dysfunction. The purpose of this investigation was to document the incidence of level IIb metastatic lymphatic spread in a group of patients undergoing neck dissection as part of the surgical management of cutaneous squamous cell carcinoma of the head and neck.

MATERIALS AND METHODS

A retrospective review of the pathology records taken from 1 surgeon from June 2006 through June 2013 was carried out. The predictor variable was the primary tumor site. The outcome variable was the metastatic nodal involvement according to neck level and sublevel. Secondary variables included T stage, pathologist, tumor depth, and the presence of perineural, perilymphatic, and perivascular invasion. Data analyses were by descriptive statistics.

RESULTS

Thirty-six patients with a total of 40 neck dissections met the inclusion criteria. The average primary site tumor depth was 14.7 mm, and there were 16 cases of poorly differentiated squamous cell carcinoma. Sublevel IIb was involved in 7.5% of cases, all of which occurred from lateralized primary sites of the head and neck.

CONCLUSIONS

Cutaneous squamous cell carcinoma arising from the auricle and neck sites adjacent to sublevel IIb may have increased risk of metastatic involvement of sublevel IIb nodes. Further studies with larger numbers are required to determine the risk of metastasis to sublevel IIb from midline sites of the face.