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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 275-276
 

A case of metastatic infiltrating ductal breast carcinoma with initial metastases to the optic nerve and subsequent extra ocular muscle involvement


Department of Ophthalmology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India

Date of Web Publication18-Feb-2016

Correspondence Address:
R Bhardwaj
Department of Ophthalmology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.176757

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How to cite this article:
Sharma V, Bhardwaj R, Chaudhary K P, Pandey M L, Sharma S. A case of metastatic infiltrating ductal breast carcinoma with initial metastases to the optic nerve and subsequent extra ocular muscle involvement. Indian J Cancer 2015;52:275-6

How to cite this URL:
Sharma V, Bhardwaj R, Chaudhary K P, Pandey M L, Sharma S. A case of metastatic infiltrating ductal breast carcinoma with initial metastases to the optic nerve and subsequent extra ocular muscle involvement. Indian J Cancer [serial online] 2015 [cited 2019 Jun 16];52:275-6. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/275/176757


Sir,

Metastatic tumors to the optic nerve are extremely rare. We describe a rare and unusual case of metastatic breast carcinoma initially presenting with optic nerve metastases with subsequent involvement of extra-ocular muscles.

A 43-year-old female was diagnosed with infiltrating ductal carcinoma breast (T2N1MO) in the year 2003 and lumpectomy along with level II lymph node dissection was performed. Chemotherapy (CAF, 6 cycles) and local radiotherapy (55 Gy/5 week/25 fractions) were administered and the patient was kept on regular follow-up. In 2010 there was evidence of multiple skeletal metastases. A new cycle (6 weeks) of taxane based chemotherapy was started. At the same time she reported to some eye care center with complaints of diminution of vision oculus dexter (OD). The visual acuity was recorded to be 20/120 at that time and a diagnosis of optic neuritis was made and patient was put on oral steroids, but there was no improvement. After 7 months, patient had evidence of lung metastasis along with an increase in the number of bone metastasis. Another round of chemotherapy was started (gemcitabine, epirubicin, latrozole 6 cycles). During this time, her visual acuity kept deteriorating (finger counting at 1 feet in October 2011). When she reported to our institute in December 2011 her visual acuity was hand motion (OD) and 20/20 (OS). There were no other ocular complaints. Relative afferent pupillary defect was present in OD. Ocular movements and anterior segment evaluation were normal. On fundus examination, a raised focus of intra-papillary and pre-papillary infiltration of optic disc along with vascularization at the periphery of the mass was seen. Fluorescein angiography revealed delayed filling, leaky collaterals and late hyper fluorescence of the mass. Bone scan revealed multiple skeletal metastases. On magnetic resonance imaging scan, there was evidence of intra-parenchymal, Dural and right optic nerve metastasis [Figure 1]. Radiotherapy was administered to the brain (30 Gy/2 week/10 fractions). Patient was on regular follow-up and was put on aromatase inhibitor based therapy. After 5 months, patient presented with pain, chemosis and restricted ocular movements OD. On contrast computed tomography, there was evidence of thickening and presence of enhancing lesions in the inferior and lateral recti [Figure 2]. External beam radiation therapy was administered and the patient improved.
Figure 1: Optic nerve metastasis in a patient with metastatic breast carcinoma. (a) Infiltrating optic disc mass involving the intra-papillary and pre-papillary regions. (b) Fluorescein angiogram in the AV phase showing delayed filling with evidence of collateral vessels. (c) T2 weighted magnetic resonance image showing diffuse enhancement of the right optic nerve. (d) Bone scans showing multiple areas of increased tracer uptake

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Figure 2: Contrast computed tomography orbit (coronal view) showing thickening and enhancement of the right sided optic nerve and its meninges. Also there is thickening and enhancement of the lateral rectus and inferior rectus muscles with stranding in the retro orbital fat

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Ocular metastases in case of carcinomas are a rare manifestation. The reported incidence varies from 1% for macro metastases to 12.6% for micro-metastases.[1] In their series, Ferry and Font reported only 3 cases (1.3%) with metastases to the optic nerve or sheath. They also concluded that misdiagnosis among metastatic carcinomas to the eye and orbit is quiet prevalent.[2] Metastases to the optic disc can appear either as a swollen disc without a distinct mass, which in our case was the presenting feature or as a discohesive cellular infiltration of the superficial aspects of the disc,[3] a late manifestation in our case. Initial involvement of optic disc with subsequent extra-ocular muscle involvement in the same eye, in patients of breast carcinoma is a rare occurrence and has not been reported in literature as per our knowledge. Such cases warrant a thorough medical history and complete physical examination along with close ophthalmologic monitoring. Visual disturbances are a warning clue to these ocular metastases and should be differentiated from other eye syndromes, which may clinically mimic such cases.

 
  References Top

1.
Eliassi-Rad B, Albert DM, Green WR. Frequency of ocular metastases in patients dying of cancer in eye bank populations. Br J Ophthalmol 1996;80:125-8.  Back to cited text no. 1
    
2.
Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit. I. A clinicopathologic study of 227 cases. Arch Ophthalmol 1974;92:276-86.  Back to cited text no. 2
    
3.
Augsburger JJ. Malignant tumors in the differential diagnosis of uveal melanoma. In: Podos SM, Yanoff M, editors. Textbook of Ophthalmology. 1st ed. London: Times Mirror; 1995. p. 13.2-13.9.  Back to cited text no. 3
    


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