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which metastasize predominantly via the lymphatics, are muscles and fascial planes. In contrast, orbital metastasis
subsequently found mainly in draining lymph nodes. It has from carcinoid tumor, renal cell carcinoma, and melanoma
been proposed that entrapment and growth of tumors might tends to be more circumscribed, at least in early stages. [6]
be affected by qualitative or quantitative differences in tumor Diagnosis is usually established by tissue biopsy, open,
cells’ ability to adhere to the vascular endothelium of particular or fine needle aspiration to confirm a metastatic tumor
organs; organ-specific growth is thus a direct consequence lesion, and not simulating lesions, such as idiopathic
[11]
of the specific localization or entrapment of circulating tumor orbital inflammation (also known as orbital pseudotumor).
cells. While it is tempting to speculate an immunologic basis Special staining with mucicarmine and alcian blue may
[12]
for the propensity of breast cancer and malignant melanoma be helpful, not only to obtain a diagnosis but also to identify
to metastasize to the extra-orbital muscles; the nature of any the primary neoplasm. Histological diagnosis of metastasis
such site specificity remains unknown. [2] is typically straightforward and does not present a problem
to the pathologist. [7]
Although the patient did have skeletal symptoms due to
widespread bony metastasis which were largely dismissed Although we did not test for Ki-67 status, (also known
by her general practitioner as being part of her arthritis as MK 167) it has been used as prognostic parameter in
complex, the main presenting symptom in this case was breast cancer patients, [14] and its presence is associated
diplopia. However, a review of the literature indicates with lower disease free survival and lower overall survival.
that this not commonly the case. A previous study of 100 Currently neither St Gallen, nor ASCO recommendations
patients showed that diplopia constituted only 9% of nor the German Interdisciplinary S3 Guidelines for the
[6]
such patients. Frequency of their presenting symptoms and diagnosis, treatment, and follow-up of breast cancer have
signs were limited ocular mobility (54%), displacement proposed Ki-67 as a routine prognostic marker. Ki-67 has
of the globe with proptosis (50%), blepharoptosis(49%), been shown to have an inverse relationship with estrogen
a palpable mass (43%), blurred or decreased vision receptor status, but a possible direct relationship with
(23%), pain (17%), visible mass or swelling (17%), and HER2 status.
enophthalmos (11%). The latter sign interestingly and
paradoxically was found to be associated with scirrhous Treatment of histologically proven metastatic tumors to
breast cancer. [6,9,12] This may be explained by the presence the orbit is mainly palliative, [12] and is comprised of orbital
of desmoplasia and fibrosis associated with the tumor, irradiation with approximately 35-40 Gy to the affected
[6]
causing contracture of the orbital content, and paradoxical orbit in divided doses over 3-5 weeks. Slightly more or
enophthalmous. less radiation may be indicated depending on tumor type.
Radiation may improve and preserve vision for the
[7]
The diagnosis of metastatic tumor can be confirmed by remaining lifespan of the patient. Regression of ocular
CT scan [1,2] for more than 95% of orbital metastases and metastasis following sterilization, adrenalectomy, or
CT scan can provide considerable information regarding hypophysectomy has been reported in a number of cases of
size, location, relation to musculature and other structures, hormone dependent breast cancers, however, Aromatase
[2]
as a well as the nature of the lesion. High resolution CT inhibitors (Anastrozole, Letrozole, Exemestane) are now
imaging is also an excellent diagnostic tool for extra-ocular recognized as the agents of choice for the management
metastasis. Focal or nodular muscle enlargement without of post menopausal women with steroid hormone
focal bone destruction, fossa formation, orbital enlargement, positive metastatic breast cancer, in whom indications
or other evidence of neoplastic extension into contiguous for chemotherapy are not absolute. Enucleation of
[13]
structures is highly suggestive of metastasis. Diffuse the eye on the other hand should only be carried out in
enlargement with feathering of the muscle edge may occur cases of intractable pain, most often caused by secondary
or masquerade clinically as a myositic pseudotumor. glaucoma. [2]
[6]
Bilateral involvement can be present despite only unilateral
symptoms. MRI, on the other hand, did not add specificity Acknowledgments
[6]
to the radiographic information in our case. Any patient The author would like to thank Dr Mohammed Azazi,
with an undifferentiated malignancy first discovered in the Consultant Radiologist, King Fahad University Hospital,
orbit should undergo a full systemic evaluation to reveal Al Khobar, KSA, for his assistance in interpreting
the primary tumor. Although MRI may provide the best the images, and Dr I. T Saed, FRC path, Consultant
resolution of orbital metastasis, CT is more useful in cases Histopathologist, Queens Hospital, Romford UK, for her
[6]
of suspected prostate and breast cancer as metastatic bone contribution to the slides.
involvement is very common in breast cancer too.
Financial support and sponsorship
Metastatic lesions involved the horizontal rectus muscles Nil.
are more common than the vertical rectus or oblique
muscles. Orbital metastasis from breast cancer tends Conflicts of interest
[6]
to be diffuse and irregular, often growing along rectus There are no conflicts of interest.

Journal of Cancer Metastasis and Treatment ¦ Volume 2 ¦ March 28, 2016 ¦ 125