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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 770-771

Periorbital metastasis from breast cancer: Two rare cases with successful treatment and outcome


Second Department of Medical Oncology, General Oncology Hospital of Kifissia “Agioi Anargiroi”, Athens, Nea Kifissia, Greece

Date of Submission22-Jan-2022
Date of Acceptance24-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Evangelia Pliakou
Medical Oncology Resident, Second Department of Medical Oncology, General Oncology Hospital of Kifissia “Agioi Anargiroi”, Athens, Nea Kifissia, 14564
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_212_22

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  Abstract 


Breast cancer (BC) is a heterogeneous disease, both molecularly and histologically. The most common histological subtype of BC is that of no special type, followed by lobular carcinoma. Metastatic tumors of the orbit are relatively infrequent, and their primary sites can be the prostate, the gastrointestinal tract, and for women, the breast. The diagnosis and management of such rare cases are very challenging due to the limited data. We present two interesting cases of women initially diagnosed with BC characterized by different histological features who developed periorbital metastases. Orbital radiotherapy was the treatment of choice, and the outcome was successful.

Keywords: Ductal breast carcinoma, invasive breast cancer, lobular breast carcinoma, orbital and periorbital metastases


How to cite this article:
Pliakou E, Poulli T, Lampropoulou DI, Soupos N, Aravantinos G. Periorbital metastasis from breast cancer: Two rare cases with successful treatment and outcome. Indian J Ophthalmol Case Rep 2022;2:770-1

How to cite this URL:
Pliakou E, Poulli T, Lampropoulou DI, Soupos N, Aravantinos G. Periorbital metastasis from breast cancer: Two rare cases with successful treatment and outcome. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 13];2:770-1. Available from: https://www.ijoreports.in/text.asp?2022/2/3/770/351135



Breast cancer (BC) is the most common diagnosed malignancy in women worldwide.[1] It is a heterogeneous disease, both molecularly and histologically. The most common histological subtype is that of no special type (NST, former ductal BC), followed by lobular BC (ILC, 10%–15% of cases). The incidence of ILC is continuously increasing, and compared to NST, it is characterized by unique features, such as loss of E-cadherin expression and special metastatic patterns.[2]

Metastatic tumors of the orbit are relatively infrequent. Clinical manifestations include exophthalmos, ptosis, eyelid swelling, and diplopia. Primary sites include prostate gland, lung, gastrointestinal tract malignancies, and BC, with a predominant origin of the lobular variant.[3],[4]

In this article, we describe the interesting cases of two female patients who developed orbital metastases (OM) from BC. As the existing data is limited and literature consists mainly of case reports or small series, we aim to provide further valuable information for management and treatment strategies.


  Case Report Top


A 67-year-old woman initially presented in March 2016 with weight loss and fatigue. A chest CT revealed enlarged axillary and supraclavicular lymph nodes (LNs). An axillary LN biopsy confirmed a de novo, grade 3 metastatic lobular BC [ER + 100%, PR−, HER2−, ki67: 20%]. The mammogram was not diagnostic, whereas the breast MRI revealed a lesion on the right breast. The PET/CT confirmed the presence of hypermetabolic right axillary and hepatoduodenal LNs. Moreover, abnormal uptake was detected in the fourth thoracic vertebra and the sixth right rib. She received first-line chemotherapy followed by bevacizumab maintenance until August 2017. Subsequently, the patient refused to have hormonal therapy as suggested and was on a stable condition and follow-up every 4–6 months. However, in January 2018, a CT demonstrated enlargement of axillary LNs and a new lesion in the 5th thoracic vertebra. The patient initiated treatment with ribociclib plus letrozole due to relapse. The disease was stable for about 2 years, when the patient presented with a small but persistent lesion in the lower right eyelid and mild edema [Figure 1]. For diagnostic purposes, it was biopsied and a solitary metastasis of the known BC, [ER+ >95%, PR+ >90%, HER2−, ki67: 15%–20%] was diagnosed. The patient was subjected to 25 sessions of fractionated stereotactic body radiotherapy (50Gy) locally with an excellent response and remission of disease. Because the disease was otherwise stable, we switched to fulvestrant plus ribociclib. The patient remained stable for 17 months after the diagnosis of an OM and then suffered from BC progression and died in October 2021.
Figure 1: The first patient with a persistent lesion in the lower right eyelid and mild edema was biopsied about 2 months after the onset of the symptoms. She was diagnosed with orbital metastasis about 4 years after the initial diagnosis of lobular breast cancer

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The second patient is a 67-year-old woman who was diagnosed in 1993 with de novo, grade 1 ductal cancer in the left breast [ER−, PR + 80%, HER2−, ki67: 20%]. She underwent a modified radical left mastectomy with 6+/18 LNs, and she was treated with chemoradiotherapy. Then, she was under tamoxifen until 2001. In 2012, she was diagnosed with bone metastases and received multiple lines of chemotherapy. Her tolerance was good, and her performance status was 0. In September 2020, she complained about diplopia, mild pain, and edema of the right eyelid with a sudden onset [Figure 2]. An MRI revealed a lesion in the right superior rectus muscle not infiltrating the optical nerve. The lesion was biopsied and metastasis from ductal BC [ER+ 15%+, PR+ 80%+, HER2−, ki67: 30%] was confirmed. The patient was subjected to five sessions of stereotactic radiotherapy (SRT, cyberknife®) with a total dose of 30 Gy locally (November 2020). An MRI in December 2020 revealed two new lesions in the contralateral eye (apart from the known lesion): one in the left superior rectus muscle and another in the left lateral rectus muscle. Furthermore, the patient developed liver and skin (three small subcutaneous lesions in the head, confirmed by biopsy) metastases while being under capecitabine. Six months after SRT, the patient had no symptoms from the orbit and good vision, whereas an MRI demonstrated a decrease in the size of the right lesion. However, some new lesions were developed (one in the right superior oblique, one in the left inferior rectus) that infiltrated the optical nerve. The latest MRI in July 2021 revealed a further decrease in all known lesions. The patient is still alive, about 16 months after the initial diagnosis of the OM; however, her performance status has dropped to 4 due to progressive disease.
Figure 2: The patient presented with diplopia, mild pain, and edema of the right eye. The periorbital metastases developed about 17 years after the initial diagnosis and about 8 years after the first remission of the disease

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  Discussion Top


Orbital metastases most frequently occur in extraocular muscles, orbital fat, conjunctiva, and eyelids. The possible pathogenetic mechanisms for developing OM from BC remain unknown. The contribution of the microenvironment has been implicated due to the production of steroid hormones. The presence of such metastases suggests hematogenous spread of the disease and poor prognosis, with an estimated survival time of less than 2 years.[2]

Increasing data demonstrate that ILC is associated with overpresentation of OM.[2],[3],[4],[5] Moreover, the predominance of ILC was verified in a meta-analysis of 72 patients with OM; non-small cell lung cancer was the second primary tumor associated with OM.[5] Interestingly, in our case, only the first patient was in accordance to these, while the second patient was diagnosed with ductal BC.

The diagnosis of OM from BC can be challenging and presupposes increased suspicion and a multidisciplinary approach. CT or MRI scans are the preferred imaging techniques, followed by histopathologic confirmation. The treatment options include surgical removal, radiotherapy, chemotherapy, targeted or hormonal therapy; in most cases, the treatment remains mainly palliative. However, it seems that orbital radiotherapy, if applicable, should be performed on these patients because it is associated with successful outcomes and local control of the disease.


  Conclusion Top


The presence of a persistent, ocular lesion or the sudden onset of diplopia in a patient with BC should always raise suspicion for periorbital metastases. Prompt biopsy, diagnosis and multidisciplinary approach are required and might result in successful outcomes.

Author's contributions

Conceptualization: Evangelia Pliakou; Data curation: Evangelia Pliakou, Tsielestina Poulli, Dimitra Ioanna Lampropoulou; Project administration: Evangelia Pliakou, Dimitra Ioanna Lampropoulou; Supervision: Gerasimos Aravantinos; Roles/Writing - original draft: Evangelia Pliakou, Tsielestina Poulli; Writing - review and editing Evangelia Pliakou, Nikolaos Soupos, Gerasimos Aravantinos.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209-49.  Back to cited text no. 1
    
2.
Tsagkaraki IM, Kourouniotis CD, Gomatou GL, Syrigos NK, Kotteas EA. Orbital metastases of invasive lobular breast carcinoma. Breast Dis 2019;38:85-91.  Back to cited text no. 2
    
3.
Blohmer M, Zhu L, Atkinson JM, Beriwal S, Rodríguez-López JL, Rosenzweig M, et al. Patient treatment and outcome after breast cancer orbital and periorbital metastases: A comprehensive case series including analysis of lobular versus ductal tumor histology. Breast Cancer Res 2020;22:70.  Back to cited text no. 3
    
4.
Framarino-Dei-Malatesta M, Chiarito A, Bianciardi F, Fiorelli M, Ligato A, Naso G, et al. Metastases to extraocular muscles from breast cancer: Case report and up-to-date review of the literature. BMC Cancer 2019;19:36.  Back to cited text no. 4
    
5.
Raap M, Antonopoulos W, Dämmrich M, Christgen H, Steinmann D, Länger F, et al. High frequency of lobular breast cancer in distant metastases to the orbit. Cancer Med 2015;4:104–11.  Back to cited text no. 5
    


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