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Case Report

Case Report: Orbital metastasis as the presenting feature of lung cancer

[version 1; peer review: 2 approved, 1 approved with reservations]
PUBLISHED 05 Apr 2017
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This article is included in the Eye Health gateway.

Abstract

Orbital metastasis from lung cancer as an initial presenting symptom is a rare entity, which may paradoxically delay the diagnosis and initiation of correct management, due to the confusion of it being primary orbital pathology. Herein we report a case of a 58 year old woman, who presented with painful orbital swelling along with diminution in her vision. The patient was initially thought to have a primary eye lesion; however chest X-ray was suggestive of a lung mass, which was confirmed by chest computed topography followed by ultrasound guided fine needle aspiration cytology. The patient was then referred to a cancer centre for further management. This case report aims to increase the knowledge about this metastasis as a probable cause of orbital symptoms in certain subsets of patients, so that correct therapeutic decisions may be made in the future.

Keywords

orbit, metastasis, lung cancer

Introduction

Orbital metastatis as the initial presenting symptom from a metastatic lung lesion is a rare entity, occurring at an incidence of approximately 7%1,2. However, this should be kept as one of the differentials in any patients presenting with orbital symptoms, so as to frame an accurate and effective plan of management. Occasionally such rare presentations would invariably lead to a delay in the correct diagnosis, thereby increasing the risk of loss of vision, which decreases the quality of life of patients3. Poor management also increases the odds of progressing the tumor stage. Herein, we report one such case in a 58 year old woman, who presented with unilateral peri-orbital swelling and diminution of vision. Following detailed examination and investigations, the patient was found to harbor a malignant lung lesion.

Case report

A 58 year old woman from central Nepal presented to our outpatient clinic with a history of painful swelling around her right eye for two months. The patient also complained of diminishing vision in the same eye. The vision in the patient’s left eye had been previously lost following an injury during childhood. There was no other relevant family information or any significant past medical or surgical illnesses of the patient. Local examination revealed presence of peri-orbital swelling in the right eye with restricted eye movements (Figure 1). The patient’s visual acuity in the same eye was restricted to only perception to light. Funduscopy revealed the presence of papilledema. Remaining physical examinations were normal.

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure1.gif

Figure 1. Image showing right sided peri-orbital swelling.

Radio-imaging of the patient’s orbits revealed the presence of hyperostotic changes in theright orbit, with presence of enhancing lesions on the right globe with extension to the para-nasal sinuses and also invasion along the dural base in the anterior cranial fossa (Figure 2 and Figure 3). The initial differential diagnosis was an infective pathology. However, the patient was not immuno-compromised.

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure2.gif

Figure 2. Image showing abnormal hyperostotic changes within the right orbit in the computed tomography scan.

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure3.gif

Figure 3. Image showing enhancing lesion in the right globe (black arrow) with extension to para-nasal sinuses (brown arrow) and invasion to the dura of anterio cranial fossa (white arrow).

A chest X-ray was performed as a routine work up, which inadvertently revealed the presence of an elevated right hemi-diaphragm with presence of right para-hilar mass (Figure 4). Further evaluation through chest computed tomography confirmed the finding of a right para-hilar mass (Figure 5).

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure4.gif

Figure 4. Chest X-ray showing elevated right hemi-diaphragm (white arrow) and right para-hilar mass.

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure5.gif

Figure 5. Chest computed tomography revealing presence of right para-hilar lung mass (white arrows).

We discussed with the patient and her relatives the possibility of the eye findings to be related to the lung lesion and recommended approaches to obtain a definitive diagnosis. Ultrasound guided fine needle aspiration cytology (FNAC) from the lung lesion revealed findings suggestive of a malignant lung disease (Figure 6). Diagnostic biopsy from the nasal endoscope confirmed the metastatic nature of the disease from the lung (Figure 7). Therefore, a diagnosis of metastatic lung disease to the orbit was finally confirmed.

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure6.gif

Figure 6. Fine needle aspiration cytology from the lung mass revealing the presence of malignant cells.

c69b0cd2-ee6e-4edc-bb71-0f78a30ba6b3_figure7.gif

Figure 7. Computed tomography image revealing the presence of invasion of para-nasal sinuses by the lesion.

The patient was started on a steroid therapy (injection dexamethasone at 8mg stat followed by 4 mg every eight hours), which decreased the swelling on the patient’s eye and improved visual acuity to finger counting within a period of 1 week. This further hinted at compressive rather than infiltrative effect on the optic nerve by the lesion. The patient was counseled and then immediately referred to the National Cancer Centre, Kathmandu, Nepal for further management with systemic chemo-radiation therapy after evaluation. Since the patient had a single and minimally functioning eye left, the decision was taken not to surgically decompress the lesion from the orbit. The patients was initially started on chemotherapy with a further plan of management to be tailored as per the clinical response seen in the patient.

Initially, metastatic deposits causing eye swelling in the patient was not suspected. It was serendipity that the routine chest X-ray gave a clue to the presence of a lung mass. Even a small delay may have had a disastrous impact on the outcome of the vision in the patient.

Discussion

Metastatic disease to the orbit is a rare epiphenomenon occurring in only 7% of all cancers12. Of these, symptoms related to orbital metastasis presents earlier to that of the primary lesion in around 20% of patients2. Breast, prostate and lung carcinomas are the usual primaries in many cases of metastatic lesions to the orbit45. Lid swelling are a common presentation in such metastatic lesions5, which can paradoxically delay the actual diagnosisaccounting for the benign orbital lesions. Diplopia is the most common presenting symptom in metastatic lesions, while proptosis or visual loss is seen in patients with primary orbital neoplasms6. Loss of vision can be due to either direct infiltration to the optic nerve or subsequent to the mass effect. Rarely, is it subsequent to paraneoplastic phenomenon mainly from lung carcinoma. Pain resulting from perineural invasion is typical for metastatic orbital lesions6.

Diagnosis can be confirmed with FNAB, which has a diagnostic accuracy of more than 90%7. Further investigations need to be carried out to stage the tumor before embarking on the management option; PET scan is a rapid viable model for assessment tumor staging8.

Surgical debulking is the cornerstone of management in patients with diminished vision subsequent to optic nerve compression. This was not attempted in our case, since it was the only functioning eye in the patient and that was functionally impaired as well. Surgical removal of the lesion may be locally effective in few patients having symptoms, due to compression on the optic nerve following raised intra –orbital pressure6. However, chemo-radiation is usually preferred to surgery because it is non-invasive. Chemotherapy, especially platinum base regimes, is chosen for small cell lung cancer over radiation because of the risk of damage to the eye lens. For non-small cell cancers, either photon radiation of 30–40 Gy, or newer frontiers, such as tyrosine kinase inhibitors, are the mainstay of treatment. However, overall prognosis, despite systemic therapy, is poor with a median survival of little over 1 year, and only 27% of patients surviving for more than two years6,913. Compared to breast cancer, lung cancers metastasize early to the orbit and also have shorter median survival time14.

Conclusions

It is prudent to provide a strategy for management of cases presenting with eye symptoms, so that rare causes, such as metastatic lesions, are not omitted. Such a strategy would certainly help in providing an early and effective treatment plan in such patients with metastatic orbital lesions. This would increase the chance of improving vision, escalate quality of life and also initiate early cancer therapy following appropriate work up and staging.

Consent

Both written and verbal informed consent for publication of images and clinical data related to this case was sought and obtained from the patient.

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how to cite this article
Munakomi S, Chaudhary S, Chaudhary P et al. Case Report: Orbital metastasis as the presenting feature of lung cancer [version 1; peer review: 2 approved, 1 approved with reservations]. F1000Research 2017, 6:430 (https://doi.org/10.12688/f1000research.11247.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
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PUBLISHED 05 Apr 2017
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Reviewer Report 17 May 2017
Luis Rafael Moscote-Salazar, Department of Neurosurgery, RED LATINO (Latin American Trauma & Intensive Neurocare Organization), Bogotá, Colombia 
Guru Dutta Satyarthee, Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, Delhi, India 
Approved
VIEWS 8
An interesting case of orbital metastasis of lung adenocarcinoma is presented. Lung cancer is one of the leading causes of death globally. Adenocarcinoma occupies the first place in epidemiological frequency (50%) is also one of the most frequent types of ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Moscote-Salazar LR and Satyarthee GD. Reviewer Report For: Case Report: Orbital metastasis as the presenting feature of lung cancer [version 1; peer review: 2 approved, 1 approved with reservations]. F1000Research 2017, 6:430 (https://doi.org/10.5256/f1000research.12134.r22711)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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8
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Reviewer Report 04 May 2017
Trevor K. Rogers, Chest Clinic, Doncaster Royal Infirmary, Doncaster, UK 
Approved with Reservations
VIEWS 8
A major deficiency of the report is the lack of characterization of the tumour. Whilst the CT imaging is convincing for a lung primary it should at the very least be commented whether the tumour was non-small cell (and ideally ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Rogers TK. Reviewer Report For: Case Report: Orbital metastasis as the presenting feature of lung cancer [version 1; peer review: 2 approved, 1 approved with reservations]. F1000Research 2017, 6:430 (https://doi.org/10.5256/f1000research.12134.r22208)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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4
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Reviewer Report 02 May 2017
Matteo Giaj Levra, Thoracic Oncology Unit, Centre Hospitalier Universitaire de Grenoble, Grenoble, France 
Approved
VIEWS 4
This is an interesting case report, about an unusual site of metastasis in lung cancer patient. There are details about the symptoms, diagnosis and symptomatic treatment of the orbital metastasis. 

I would only add if there was ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Levra MG. Reviewer Report For: Case Report: Orbital metastasis as the presenting feature of lung cancer [version 1; peer review: 2 approved, 1 approved with reservations]. F1000Research 2017, 6:430 (https://doi.org/10.5256/f1000research.12134.r22210)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (0)

Version 1
VERSION 1 PUBLISHED 05 Apr 2017
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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