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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 977-979

Orbital metastasis from breast carcinoma presenting as an osteoblastic lesion


1 Department of Ophthalmology, Royal Adelaide Hospital, Port Road; Discipline of Ophthalmology and Visual Sciences, University of Adelaide, North Terrace, South Australia
2 Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia

Date of Submission20-Apr-2022
Date of Acceptance15-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Raghav Goel
Department of Ophthalmology, Royal Adelaide Hospital, Port Road, Adelaide
South Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_463_22

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  Abstract 


A 66-year-old female presented with a swollen and itchy eyelid for 4 weeks. A computed tomography (CT) scan revealed a lesion epicentered in the greater wing of the sphenoid and anterior lateral and superior orbital walls, predominantly showing osteoblastic features. Magnetic resonance imaging (MRI) demonstrated further calvarial and pachymeningeal involvement. Biopsy of the lesion demonstrated a poorly differentiated carcinoma. A distant history of breast cancer (20 years) prompted specific immunochemistry that confirmed breast carcinoma metastases. Staging positron emission tomography-computed tomography (PET) revealed multisystem spread. This report highlights the fact that breast carcinoma metastasis may rarely present with a predominantly osteoblastic lesion in the orbit.

Keywords: Breast cancer, orbital metastasis, orbital tumors, osteoblastic lesion


How to cite this article:
Goel R, Shapira Y, Patel S, Selva D. Orbital metastasis from breast carcinoma presenting as an osteoblastic lesion. Indian J Ophthalmol Case Rep 2022;2:977-9

How to cite this URL:
Goel R, Shapira Y, Patel S, Selva D. Orbital metastasis from breast carcinoma presenting as an osteoblastic lesion. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:977-9. Available from: https://www.ijoreports.in/text.asp?2022/2/4/977/358172



Orbital bone metastases are infrequent and usually present in patients with advanced metastatic disease.[1] Breast carcinoma metastases to the orbit most frequently in females where it compromises 29%–53% of all orbital metastatic lesions. Breast carcinoma orbital bone metastases have been reported to have infiltrative and osteolytic features while prostate cancer is primarily osteoblastic.[2],[3] We report a case of metastatic breast carcinoma presenting as an osteoblastic (bone-forming) lesion in the orbit.


  Case Report Top


A 66-year-old female presented with symptoms of a painless itchy and swollen left upper lid for 4 weeks. She had no systemic symptoms. Her medical history was notable for grade two (ductal) breast cancer with axillary lymph node involvement (T2N1M0), which was managed with a unilateral mastectomy and axillary lymph node resection 20 years ago. She had no known recurrence since and was not receiving treatment. Her best-corrected visual acuity was 6/9 in both eyes. Optic nerve functions were preserved. There was 3 mm proptosis, inferior dystopia, and limitation of abduction in the left eye [Figure 1].
Figure 1: Clinical photos displaying left eye inferomedial dystopia, mild eyelid edema, and erythema (a) and 3 mm left proptosis (b)

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A computed tomography (CT) conducted by her general ophthalmologist revealed a left extraconal mass that seemed epicentred in the greater wing of the sphenoid and anteriorly along the lateral orbital wall, displacing the lacrimal gland medially and posteriorly. It had predominantly osteoblastic features with a possible minor osteolytic component [Figure 2]. The patient was subsequently referred to our orbital clinic for further investigation. Magnetic resonance imaging (MRI) was conducted urgently, demonstrating a T1 enhancing, T2 heterogeneous osteoblastic lesion involving the entire lateral wall of the left orbit and the frontal and parietal calvaria. There was anterior cranial fossa pachymeningeal enhancement [Figure 3]. The patient underwent an incisional biopsy of the orbital tissue and the bony mass through an upper eyelid crease approach.
Figure 2: CT head and orbits bone windows (a) coronal and (b) axial showing a left orbital predominantly osteoblastic bone lesion (green arrow depicting bone growth) epicentered in the (greater) sphenoid wing and anteriorly along the lateral orbital wall. The red arrow demonstrates some permeative bone morphology of the lesion in T1 coronal

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Figure 3: MRI orbits. (a) Coronal T1-weighted image and (b) Coronal T1 fat suppressed precontrast image demonstrating a (predominantly isointense) osteoblastic lesion in the superolateral orbit, extending to the frontal and parietal calvarium. (c) axial T1 (fat suppressed) and (d) T2 coronal (fat suppressed) with gadolinium showing patchy enhancement of the lesion and adjacent dural thickening

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Histopathology initially showed a poorly differentiated carcinoma. Based on the history of breast carcinoma, targeted immunohistochemistry was positive for GATA3, A1/E3, estrogen receptor (ER), and progesterone receptor (PR) consistent with metastasis from breast carcinoma [Figure 4]a,[Figure 4]b,[Figure 4]c,[Figure 4]d,[Figure 4]e. The HER2 gene status was negative [Figure 4]f. A staging positron emission tomography-computed tomography (PET-CT) revealed widespread visceral, nodal, and skeletal fluorodeoxyglucose (FDG) avid abnormalities indicative of multisystem/multifocal involvement. There was no involvement of local submandibular or cervical lymph nodes, however, axillary and right hilar/perihilar lymph nodes demonstrated FDG activity. She was consequently referred to the oncology service for further management.
Figure 4: (a) HE staining shows dense fibrous tissue infiltrated by irregular nests of cells with large hyperchromatic nuclei, coarse chromatin, indistinct nucleoli, and moderate amounts of amphophilic cytoplasm. The features are consistent with a poorly differentiated carcinoma with immunohistochemistry reactivity for: (b) Estrogen receptor, (c) Progesterone receptor (d). GATA3, (e) Strong positive staining with AE1/3, consistent with carcinoma (f) HER2 receptor negative by silver in situ hybridization. Overall, features consistent with metastasis from breast carcinoma

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  Discussion Top


The largest series of orbital bony lesions (epicentered in the greater wing of the sphenoid) was reported by McNab et al.[3] Of 141 lesions described, the largest diagnostic group was metastases (48%). Of these, 20% were predominantly osteoblastic. Metastatic prostate carcinoma was most likely to present as an osteoblastic lesion (18/21, 86%). Other, primary orbital lesions showing an osteoblastic response, were intraosseous hemangioma and osteosarcoma. Lesions that had mixed osteoblastic and osteolytic features included prostate carcinoma, colonic carcinoma, plasmacytoma, ossifying fibroma, myxoma of bone, and epithelioid hemangioendothelioma. Almost all other (86%) metastatic lesions, including all six cases of breast carcinoma, were osteolytic.[3] Our case represents a breast carcinoma orbital bony metastasis with predominantly osteoblastic features. Osteoblastic features have been reported in up to 15%–20% of extraorbital breast cancer bone metastases (e.g., femoral head), however, presentation in the orbit is rare.[4]

Breast cancer metastases to the orbit are often unilateral and tend to localize to fat and muscle rather than bone.[5],[6] Previous studies have shown that metastatic orbital lesions commonly metastases to the lateral (39%) and superior (32%) orbital wall, similar to our case [Figure 2].[7] In the series of Akda et al., bone involvement was noted in only 13% of cases similar to the 10% of cases reported by Homer et al.[8],[9] Orbital bony metastatic lesions from breast cancer have been described to show T2-weighted homogeneous hyperintensity, leptomeningeal involvement, presence of a dural tail, and osteolytic lesion if bony involvement.[3] These findings are consistent with our case, aside from the osteoblastic lesion, which is an atypical feature.

The common presentation of orbital metastases from breast cancer (not epicentred on the bone) include decreased visual acuity, pain, proptosis, diplopia, eyelid swelling, palpebral ptosis, and globe dystopia. Enophthalmos is a less common but distinctive sign of orbital infiltration by scirrhous breast adenocarcinoma.[1],[10] In comparison, our patient's atypical osteoblastic lesion produced a painless mass effect (with nonaxial proptosis), extraocular motility disturbance, preserved visual acuity, and optic nerve function. The painless mass may be explained by the osteoblastic well-circumscribed lesion rather than a lytic infiltrative lesion.

Our patient has a distant history of breast cancer in remission for the past 20 years, which is significantly longer than the typical time frame of 4.5 to 6 years in breast cancer metastases.[5],[11] Orbital metastatic lesions are commonly found in patients with an established diagnosis of disseminated cancer, however, in up to 30% of cases, orbital metastases can be the first manifestation.[1],[10] Although no recurrence or metastasis was known, the clinical history allowed a high index of suspicion. Consequently, while the histological morphology was poorly differentiated and nondiagnostic, targeted immunohistochemistry yielded the diagnosis. Studies have suggested that lobular breast cancer metastasizes more often to the orbit as compared with the ductal variant.[8],[12] In our case, this was a ductal variant of breast cancer that metastasized to the superolateral left orbit.


  Conclusion Top


In summary, we present a case of an osteoblastic orbital lesion from breast cancer considered to be in remission for 20 years. This case highlights that metastatic breast carcinoma can initially present as an osteoblastic lesion in the orbit and it is important to be aware of these clinicoradiological features to help establish a prompt diagnosis.

Declaration of patient consent

The case report adhered to the ethical principles outlined in the Declaration of Helsinki (2013).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Vlachostergios PJ, Voutsadakis IA, Papandreou CN. Orbital metastasis of breast carcinoma. Breast Cancer (Auckl) 2009;3:91-7.  Back to cited text no. 1
    
2.
Valenzuela AA, Archibald CW, Fleming B, Ong L, O'Donnell B, Crompton JJ, et al. Orbital metastasis: Clinical features, management and outcome. Orbit 2009;28:153-9.  Back to cited text no. 2
    
3.
McNab AA, Jones RS, Hardy TG. Spheno-orbital lesions—A major review of nonmeningioma causes. Ophthalmic Plast Reconstr Surg 2021;37:522-33.  Back to cited text no. 3
    
4.
Gupta R. Osteoblastic metastasis from breast cancer. In: Gupta R, Matthews R, Bangiyev L, Franceschi D, Schweitzer M, editors. PET/MR Imaging: A Case-Based Approach. Cham: Springer International Publishing; 2018. p. 49-50.  Back to cited text no. 4
    
5.
Croxatto JO, Karcioglu ZA. Metastatic tumors. In: Karcioglu ZA, editor. Orbital Tumors: Diagnosis and Treatment. New York, NY: Springer New York; 2005. p. 279-89.  Back to cited text no. 5
    
6.
Tailor TD, Gupta D, Dalley RW, Keene CD, Anzai Y. Orbital neoplasms in adults: Clinical, radiologic, and pathologic review. Radiographics 2013;33:1739-58.  Back to cited text no. 6
    
7.
Ahmad SM, Esmaeli B. Metastatic tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol 2007;18:405-13.  Back to cited text no. 7
    
8.
Homer N, Jakobiec FA, Stagner A, Cunnane ME, Freitag SK, Fay A, et al. Periocular breast carcinoma metastases: Correlation of clinical, radiologic and histopathologic features. Clin Exp Ophthalmol 2017;45:606-12.  Back to cited text no. 8
    
9.
Akda F, Hafezi F, Heule-Dieleman H, van den Bosch W, Luyten G, Tanghe H, et al. Orbital metastases of breast cancer. Radiologic features. Ophthalmologe 2010;107:728-32.  Back to cited text no. 9
    
10.
Grajales-Alvarez R, Gutierrez-Mata A. Orbital metastases from breast cancer: A retrospective analysis of 28 cases. Cancer Treat Res Commun 2020;24:100184.  Back to cited text no. 10
    
11.
Reeves D, Levine MR, Lash R. Nonpalpable breast carcinoma presenting as orbital infiltration: Case presentation and literature review. Ophthalmic Plast Reconstr Surg 2002;18:84-8.  Back to cited text no. 11
    
12.
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. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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