|Year : 2020 | Volume
| Issue : 2 | Page : 90-92
Breast cancer with orbital metastasis: An uncommon entity
Sneha Bothra1, Chaturbhuj Agrawal1, Pankaj Goyal1, Kahitij Domadia1, Abhishek Bansal2, Dinesh Chandra Doval1
1 Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, New Delhi110 085, India
2 Department of Radiology, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, New Delhi110 085, India
|Date of Submission||15-Jul-2020|
|Date of Acceptance||27-Oct-2020|
|Date of Web Publication||31-Dec-2020|
Dr. Chaturbhuj Agrawal
Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini Sector 5, New Delhi 110085.
Source of Support: None, Conflict of Interest: None
Orbital metastasis is rare in breast cancer. We present a case of a 45-year-old premenopausal lady with hormone positive locally advanced breast cancer managed with surgery, chemotherapy, radiation therapy and adjuvant hormone therapy, had systemic failure after 6 years of completion of definitive therapy, in the form of orbital and vertebral metastases. Patient was investigated for other causes, however was found to have 2.6 x 2.0 x 2.9 cm mass encasing the optic nerve, causing early vision loss in one eye, with minimal proptosis. She was not under any adjuvant hormone therapy during the relapse. She was treated with external beam radiotherapy followed by tamoxifen, which showed good partial response radiologically and gradual improvement in her vision and regression of the tumor.
Keywords: Breast cancer, orbital metastasis, proptosis
|How to cite this article:|
Bothra S, Agrawal C, Goyal P, Domadia K, Bansal A, Doval DC. Breast cancer with orbital metastasis: An uncommon entity. J Curr Oncol 2020;3:90-2
| Introduction|| |
Breast cancer incidence rate is rising slowly and is the most common cancer in Indian women. Metastasis from hormone-positive breast cancer commonly occurs in bones, visceral organs, and brain. Due to hematogenous spread, ocular metastasis is uncommon with breast cancer. However, with advancements in therapy for breast cancer and imaging techniques, more ocular metastasis is being diagnosed. However, any ocular symptoms in a diagnosed case of breast cancer should be investigated for ocular metastasis as in some studies ocular metastasis may be found in a significant number of patients.
| Case Presentation|| |
A 45-year-old premenopausal lady presented to our hospital with a history of progressively increasing lump in the left breast over the last 6 months. Clinical examination revealed a locally advanced breast cancer with a 5 × 6 cm lump in the left breast with peau d’orange appearance. There were few enlarged, palpable axillary nodes on clinical examination. Fine needle aspiration cytology from breast lump was suggestive of infiltrating ductal carcinoma and imaging with computed tomography (CT) chest and abdomen revealed locoregional disease with no evidence of any systemic spread. She underwent a modified radical mastectomy and the final histopathological diagnosis was infiltrating ductal carcinoma of grade III and pathological stage of pT3N2M0 and with estrogen receptor 80%, progesterone receptor 60%, Her 2 neu negative. She then received six cycles of anthracycline and taxane-based adjuvant chemotherapy followed by radiation to the breast, axilla, and supraclavicular region. She was advised for genetic testing, however, she refused. She also refused any adjuvant hormone therapy and was lost to follow-up for 6 months.
She reported after 6 months with a history of redness of the eye, with watering from the left eye of 1-month duration. On clinical examination, mild bulging of the left eyeball was also noted. She was diagnosed outside at the local place as conjunctivitis and was on treatment for the same with no relief. She was then evaluated for other causes of proptosis like hyperthyroidism; however, she was found to be euthyroid as per serum thyroid profile. On further enquiry, she also reported hemicranial headache, more on the left side which was not relieved with analgesics. On examination, eye movements were restricted on the left side. Her visual acuity was normal in the right eye while it was the only perception of light in the left eye. Magnetic resonance imaging (MRI) brain and orbit [Figure 1] showed heterogeneously enhancing hypermetabolic altered signal intensity mass in the left retro-bulbar area measuring 2.6 × 2.0 × 2.9 cm. The mass involved medial, superior, and inferior rectus muscle and encased the intra-orbital optic nerve. It also eroded the medial wall of the orbit and the roof of the maxillary sinus. Other brain parenchyma is normal. No intracranial metastasis was seen. Other sites of metastasis included the lumbar spine. There were no other sites of metastasis on imaging. The intra-orbital metastasis and the bony metastasis were treated with palliative radiotherapy and there was a significant response to therapy after completion. She was started on tamoxifen and bone-directed therapy after local therapy. Symptoms improved over the next few months and response evaluation after 12 weeks showed a significant reduction in size with good partial response to therapy [Figure 2]. The vision improved to finger counting at 2 m. Presently the patient is on Tab Tamoxifen 20 mg OD and monthly injection Zoledronic acid 4 mg IV with maintained ECOG performance status of 1 highlighting the importance of early diagnosis and management of oligometastatic hormone-positive recurrent breast cancer.
|Figure 1: (A) T1FS post-contrast MRI axial image and (B) fused FDG PET/CT axial image showing heterogeneously enhancing hypermetabolic altered signal intensity mass in the left retro-bulbar area measuring 2.6 × 2.9 cm.|
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|Figure 2: (A) T1FS post-contrast MRI axial image and (B) fused FDG PET/CT axial image showing good partial response to treatment with a reduction in size and metabolic activity of the mass in the left retro- bulbar area.|
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| Discussion|| |
We present a case of a hormone-positive recurrent breast cancer patient, who had initially received definitive therapy, had orbital and bony recurrence within 6 months of adjuvant chemotherapy., orbital metastasis usually arises from ranging from 28.5% to 58.8% of cases of orbital metastasis, followed by lung, prostate, gastrointestinal, kidney, and skin cancers.,,, Orbital metastasis is usually present in diagnosed metastatic disease with late presentations with metastasis to orbits. However, in this case, the patient presented with first distant failure after curative therapy with orbital metastasis. The usual presentation of orbital metastasis is a double vision or diplopia due to restricted mobility, exophthalmos, and redness of the eye with decreasing vision. This may easily be confused with hyperthyroid-associated opthalmopathy, orbital pseudotumor, and other inflammatory conditions. The main difference in these would be a rapid onset of symptoms with no response to steroids. Diagnosis of orbital metastasis may need an orbital biopsy, specifically in cases with undiagnosed cases. However, in this case, the patient had a recent treatment for breast cancer and positron emission tomography (PET)-MRI was strongly suggestive of fluorodeoxyglucose (FDG) avid metastatic deposit. These lesions are usually hypointense on T1-weighted images (T1WI) and hyperintense to fat on T2WI. This feature may help to differentiate it from an orbital pseudotumor, which is usually isointense to fat on T2WI. The need for any further biopsy confirmation was not there. The intent of treatment is inevitably palliative with the goal to prevent vision loss and to control local symptoms; hence, diagnosis at the earliest suspicion is must for providing salvage treatment at the earliest. The usual therapy is local external beam radiotherapy with the very little role of surgery. The usual dose used is 20–40 Gy delivered in 5–10 fractions over 7–14 days. Stereotactic radiation therapy is further evolving as a treatment option which will require validation in larger studies. Control of other systemic metastasis is also important. In this case, the patient was given 20 Gy in five fractions over 5 days, with local radiotherapy to the lumbar spine, and started on adjuvant hormone therapy. The patient had a good partial response to therapy with a reduction of the orbital metastasis and the bony lesion also regressed with a more sclerotic component. This case further highlights the importance of early intervention with radiotherapy to oligometastatic recurrent sites in breast cancer achieving a long-term disease control rate.
| Conclusion|| |
Though orbital metastasis is a rare site of distant failure in breast cancer, breast cancer is the most common cause of orbital metastasis in adults. It may be the initial site of systemic failure in a patient with breast cancer. It must be diagnosed at the earliest with institution early local therapy to prevent vision loss.
Dr. Sneha Bothra collected the necessary patient details and reviewed the literature. Dr. D.C. Doval, Dr. Pankaj Goyal, Dr. Kshitij Domadia, and Dr. Chaturbhuj Agrawal were involved actively in the management of the patient. Dr. Kshitij Domadia diagnosed the patient with orbital metastasis while others were involved in active management. Dr. Abhishek Bansal provided the radiological images for the article while Dr. Chaturbhuj Agrawal drafted the manuscript and all the others provided valuable inputs and guidance during the preparation of the manuscript. All authors read and approved the final manuscript.
Financial support and sponsorship
Conflicts of interest
The authors declare that they have no competing interests.
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