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

Abstract

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.

Keywords: Breast cancer; Chemotherapy; Head and neck cancer; Radiotherapy; Visual pathway.

Figure 1

Patient’s facial appearance showing right enophthalmos and pseudoptosis with inferior globe dystopia.

Figure 2

CT orbit, axial view (A) shows an aggressive infiltrative mass from an ethmoidal sinus (asterisk) infiltrating the right medial rectus and preorbital tissue. It also invades the left orbital apex and optic nerve (red arrow). Brain CT in bone window (B) demonstrates multiple lytic skull metastases (white arrow) and sclerotic skull metastasis (black arrow).

Figure 3

H&E staining (viewed at ×200 magnification) of the (A) endoscopic nasal biopsy and (B) wedge biopsy of the left breast specimens show a similar morphologic pattern of infiltrating ductal carcinoma. Tumour cells are arranged in clusters surrounded by fibrotic desmoplastic changes (black arrows). Immunohistochemistry for oestrogen and progesterone receptors (viewed at×200 magnification) (C and D) show 100% strong positivity of the tumour cells (red arrows).

Figure 4

CT scan after 1 year shows non-progression of the tumour, with an area of hypodensity within it—likely representing a necrotic component (red arrow).