Metastatic Breast Cancer Presenting as Progressive Ophthalmoplegia 30 Years After Initial Cancer Diagnosis

Abstract

:A 60 year-old woman presented with painless progressive ophthalmoplegia of the right eye. She had a history of left-sided breast carcinoma 30 years ago that was managed with mastectomy only, with appropriate serial follow-up investigations. On examination, her visual acuity was 20/400 in the right eye and 20/20 in the left. She had a right relative afferent pupillary defect. Ocular examination was significant for 2 mm of ptosis, complete ophthalmoplegia, and 2+ chemosis in the right eye. The left eye was normal. MRI of the brain and orbits showed bilateral retrobulbar infiltrative disease in the right eye greater than that in the left eye. Right orbitotomy and biopsy confirmed an infiltrative signet ring cell/histiocytoid carcinoma consistent with metastatic lobular breast carcinoma. Given that recurrence of breast cancer is most common during the second year after the initial disease and rarely reported beyond 20 years after the initial diagnosis, our patient's delayed recurrence 30 years after the treatment of initial disease is unusual and rare. However, it highlights the importance of including metastatic cancer in the differential diagnosis for ophthalmoplegia.

Successful management of bilateral orbital metastases from invasive lobular breast cancer with abemaciclib and letrozole: a case report and literature review

“…A review of cases involving bilateral orbital metastases from breast cancer, as reported in English-language literature, was conducted through PubMed, Medline, and Google Scholar databases using the appropriate controlled [MESH] keywords “breast cancer”, “bilateral”, “metastases”, “ocular” and “orbit” and acknowledging references list. The selected articles included case reports and case series that provided detailed clinical, histological, and treatment descriptions ( 30 , 42 , 47 , 48 , 50 – 77 ). The summarized findings are presented in Table 1 .…”

“…The mean age was 59 years (ranging from 36 to 83 years). The majority (64%) had known breast cancer ( 42 , 47 , 50 , 53 , 57 , 58 , 61 , 62 , 64 – 68 , 70 – 73 , 76 , 77 ), and orbital metastases were usually identified around 4.8 years after the first diagnosis. Due to the anatomical constraints of the compact orbit space, these metastases usually present as space-occupying lesions, leading to significant clinical symptoms ( 31 ).…”

“…Due to the anatomical constraints of the compact orbit space, these metastases usually present as space-occupying lesions, leading to significant clinical symptoms ( 31 ). Affected patients commonly exhibit limited ocular motility (55%) ( 30 , 48 , 50 , 51 , 54 – 58 , 60 , 61 , 64 , 65 , 67 – 71 , 73 – 77 ), vision loss (29%) ( 51 , 53 , 54 , 56 , 57 , 59 , 63 , 64 , 68 , 71 , 75 , 77 ), periorbital edema (24%) ( 30 , 52 , 53 , 59 , 62 , 65 , 66 , 68 , 69 , 76 ), diplopia (21%) ( 48 , 55 , 57 , 58 , 64 , 67 , 70 , 71 , 73 ), proptosis (14%) ( 47 , 51 – 53 , 56 , 59 ), ptosis (14%) ( 53 , 54 , 69 , 73 , 75 , 77 ), palpable mass (7%) ( 54 , 63 , 70 ), as well as dystopia ( 64 , 74 ), and upper lid retraction ( 53 , 67 ) (both 5%). A notable and intriguing occurrence is enophthalmos, observed in 2 cases (5%) ( 61 , 75 ).…”

“…This is likely due to the infiltration of neoplastic cells into the extraocular muscles and retro-bulbar stromal tissues, leading to desmoplasia, fibrosis, and the retraction of the eye globe ( 78 ). The majority of orbital metastases exhibit lobular histology (50%) ( 30 , 42 , 47 , 52 , 53 , 55 , 57 , 58 , 60 , 62 , 65 – 67 , 69 , 72 , 76 , 77 ) vs. ductal (14%) ( 56 , 59 , 64 , 71 , 72 , 75 ) ( 48 , 61 , 74 ) vs. mixed (5%) ( 72 ), a trend that is consistent throughout existing literature ( 42 ). The immunophenotype of these clinical cases is predominantly hormone receptor-positive in breast cancer, specifically belonging to the luminal subtype ( 42 , 47 , 56 , 62 , 64 – 66 , 69 , 72 , 76 ).…”