Unilateral Orbital Metastasis as the Unique Symptom in the Onset of Breast Cancer in a Postmenopausal Woman: Case Report and Review of the Literature

Abstract

The orbit represents an unusual metastases site for patients diagnosed with cancer, however, breast cancer is the main cause of metastases at this level. These orbital metastases were discovered in patients with a history of breast cancer as unique or synchronous lesions. We present a rare case of a unique retroocular metastasis as the first initial symptom of a tubulo-lobular mammary carcinoma in a postmenopausal woman. A 57-year-old patient complains of diplopia, diminishing visual acuity, orbital tenderness, slight exophthalmia and ptosis of the left eyelid, with insidious onset. Clinical examination and subsequent investigations revealed a left breast cancer cT2 cN1 pM1 stage IV. Breast conserving surgery was performed on the left breast. Pathological examination with immunohistochemistry staining established the complete diagnostic: pT2pN3aM1 Stage IV breast cancer, luminal B subtype. After two years from the initial breast cancer diagnosis, the patient was diagnosed by the psychiatrist with a depressive disorder and was treated accordingly. Orbital metastases are usually discovered in known breast cancer patients and they are found in the context of a multi-system end-stage disease. Most reports cite that up to 25% of the total orbital metastases cases are discovered before the diagnosis of the primary tumor, as our case did. MRI is the gold standard for evaluating orbital tumors. The ILC histological subtype metastasizes in the orbitals more frequently than invasive ductal carcinoma. The prognosis of patients with orbital metastases is poor. The median survival after diagnosis of orbital metastases from a breast cancer primary is ranging from 22 to 31 months. Overall survival of our patient was 56 months, longer than the median survival reported in literature. Orbital metastases must be taken into account when patients accuse ophthalmologic symptoms even in the absence of a personal history of cancer. Objective examination of every patient that incriminates these types of symptoms is essential, and breast palpation must be made in every clinical setting. Orbital biopsy is necessary for the confirmation of the diagnosis and for an adequate treatment. Although recommendations for management of orbital metastases are controversial, it appears that multidisciplinary treatment of both metastases and primary cancer improves overall survival.

Keywords: breast cancer; orbital metastasis; postmenopausal; tubulo-lobular carcinoma.

Figure 1

Brain CT scan showing an inhomogeneous mass with contrast agent capture in the retroocular space of the left orbit, cuffing the left optic nerve.

Figure 2

Brain MRI exhibiting a left retroocular intraorbital tumor, which infiltrated the ocular muscles in three out of quarter quadrants.

Figure 3

Bilateral mammography shows in the upper external quadrant of the left breast a density asymmetry, with multiple microcalcifications and associate multiple axillary adenopathies without the visualization of the fatty hilum.

Figure 4

Mammography also revealed in the upper internal quadrant of the right breast, an oval shaped image, well circumscribed, with benign characteristics suggestive for a fibroadenoma.

Figure 5

(a) Invasive lobular carcinoma: isolated tumor cells and “indian file” arrangement (arrows) (H and E staining 20×). (b) Some invasive tumor cells have signet-ring cell morphology (arrow) (H and E staining 20×). (c) High expression of estrogen receptor (ER) in the nuclei of tumor cells. 20×. (d) Absence of progesterone receptor (PR) in the tumor cells (internal positive control−benign glands−arrow) × 20. Anti-PR 20×. (e) Low proliferative activity. Anti-Ki-67 20×.