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CORRESPONDENCE
Year : 2018  |  Volume : 14  |  Issue : 6  |  Page : 1425-1427

Synchronous orbital and mandibular metastases from squamous cell carcinoma of lung as initial disease presentation in a young female: First report of a rare occurrence


1 Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Soumyajit Roy
Department of Radiation Oncology, 1st Floor, Dr. B. R. Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.199429

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 > Abstract 


Metastatic tumor to orbit or mandible as initial presentation is rare. According to the available literature, majority of these described cases had its origin from lung and breast. Adenocarcinoma is the most commonly described histology. Concurrence of both of these metastases from a squamous cell carcinoma of the lung has not been reported in literature as initial presenting symptom. A young female patient with synchronous orbital and mandibular metastases as initial presentation of squamous cell carcinoma of the lung is being presented. The patient was treated with palliative radiation and chemotherapy but unfortunately died of progressive disease. To the best our knowledge, this is the first report describing such unusual presentation.

Keywords: Lung, metastasis, orbit and mandible, squamous cell carcinoma


How to cite this article:
Mondal D, Jana M, Julka PK, Roy S. Synchronous orbital and mandibular metastases from squamous cell carcinoma of lung as initial disease presentation in a young female: First report of a rare occurrence. J Can Res Ther 2018;14:1425-7

How to cite this URL:
Mondal D, Jana M, Julka PK, Roy S. Synchronous orbital and mandibular metastases from squamous cell carcinoma of lung as initial disease presentation in a young female: First report of a rare occurrence. J Can Res Ther [serial online] 2018 [cited 2019 Sep 20];14:1425-7. Available from: http://www.cancerjournal.net/text.asp?2018/14/6/1425/199429




 > Introduction Top


Metastatic deposits in orbit or mandible as initial presentation of any malignancy is extremely rare. According to the available literature, majority of these described cases had its origin from lung and breast. Adenocarcinoma is the most commonly described histology. Concurrence of both of these metastases from a squamous cell carcinoma of the lung has not been reported in literature as initial presenting symptom.


 > Case Report Top


A 30-year-old female without any known medical or surgical comorbidity presented to the outpatient department with complaints of weight loss of more than 10 kg in the last 3 months, proptosis of the left eye for 1 month, and difficulty in opening the mouth with mild pain around the left temporomandibular (TM) joint for 1 week. Contrast-enhanced computed tomography (CECT) scan of the head and neck showed an extraconal solid enhancing mass in the superotemporal quadrant of the left orbit with thickening of the adjacent bone [Figure 1]a and a mass in relation to the left ramus of mandible involving the left masseter muscle, with thickening of the outer cortex of left ramus [Figure 1]b. Subsequent evaluation was done with a CECT scan of the chest, abdomen, and pelvis. A heterogenous 4 cm × 3.5 cm enhancing mass was detected in apicoposterior segment of the left lung [Figure 2]a with ill-defined margin, ground glass haze with multiple significantly enlarged mediastinal lymph nodes. Fibreoptic bronchoscopy showed lobulated growth completely occluding the apicoposterior segment of the left upper lobe of lung associated with left vocal cord palsy. Cytopathology of bronchoscopic wash fluid from the left lung showed tight clusters of atypical cells suggestive of carcinoma. Biopsy showed squamous cell carcinoma [Figure 2]b with nests of polygonal cells with pink cytoplasm and distinct cell borders, hyperchromatic and angular nuclei, immunopositive for CK5, CK6 and negative for CK7, thyroid transcription factor-1. Whole-body bone scintigraphy with 99mTc-MDP showed multiple skeletal metastases involving multiple dorsolumbar vertebrae. A diagnosis of squamous cell carcinoma lung with orbital, mandibular, and multiple skeletal metastases was established. CECT brain showed no detectable lesion. She was treated with palliative radiation to skeletal metastases and left orbit. Palliative radiation (8 Gy in single fraction) to each of the skeletal metastatic sites was delivered using direct posterior spinal field in Co60 teletherapy machine (Theratron 780-C). Palliative radiation to orbit was delivered using anterolateral orbital fields with 45° wedge pair using Co60 teletherapy machine (Theratron 780-C). Total dose offered was 20 Gy delivered in 5 fractions over 5 consecutive days (Monday-Friday). After 6 weeks of completion of palliative radiation, palliative chemotherapy with combination of paclitaxel (200mg/m2 q 3 weeks) and carboplatin (area under curve 5 q 3 weeks) was offered. Unfortunately, the patient died of progressive disease after 7 months of treatment.
Figure 1: Axial contrast-enhanced computed tomography of orbit, brain, face, and neck shows an extraconal solid enhancing mass in the superotemporal quadrant of left orbit, with thickening of the adjacent bone (a). There is another mass in relation to the left ramus of mandible and involving the left masseter muscle, with thickening of the outer cortex of left ramus (b)

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Figure 2: Axial contrast-enhanced computed tomography chest lung window reveals a mass with speculated margins in the left upper lobe apicoposterior segment and abutting left major fissure (a). H and E stain of the same mass showing squamous cell carcinoma with nests of polygonal cells with pink cytoplasm and distinct cell borders, hyperchromatic, and angular nuclei (b)

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 > Discussion Top


Metastatic tumor of the eye and mandible is a relatively uncommon phenomenon. When it occurs in eye, it usually involves the highly vascular uveal structure, commonly posterior choroid. Metastatic tumor to orbit is even rarer, consisting of approximately 5% of all orbital malignancies and occurs in 2%–3% of all cancers.[1],[2] In about 20% of cases, the metastasis is the first sign of malignancy, especially if the primary site is the lung, gastrointestinal tract, thyroid, or kidney.[3] The metastases are typically unilateral and equally distributed between the right and left orbits; however, in 5% of cases, they are bilateral. The metastases may be either localized (lung, kidney, and melanoma) or diffuse (breast and prostate) and occasionally involve contiguous bone as well as soft tissue.[3] According to the European and American literature, the most common primaries metastasizing to orbit include breast, lung, and prostate carcinoma in the west which differs from the Chinese literature where most of the orbital metastases are from nasopharynx, endemic in that region.[4] In 10% of cases, the primary site remains obscure despite intensive systemic evaluation.

In their retrospective analysis, Char et al. found that most commonly patients present with diplopia (48%) and less frequently proptosis (26%) and decreased vision (16%) from orbital metastasis. Pain was also noted. Very few patients had a secondary complaint of ptosis.[5] Limited ocular mobility, blepharoptosis, and palpable mass are some of the other reported symptoms.[3] The possible common differential diagnoses include metastasis to orbit, orbital lymphoma, uveal melanoma, orbital hemangiomas, granulocytic sarcoma of orbit, and rhabdomyosarcoma of orbit. Necessary workup include CECT of face, neck, chest, abdomen and pelvis, histopathological sampling, fluorodeoxyglucose positron emission tomography of whole-body, and triple endoscopy. However, the identification of a primary site does not significantly alter either treatment or prognosis, with the exception of lymphoma and possibly breast and uterine carcinoma.

Prognosis is usually dismal for these patients. The median survival was a little over 1 year, and only 27% had 2-year survival. In a small series, patients with breast cancer had a slightly longer survival than did patients with other malignancies.[6] In a series reported by Ratanatharathorn et al., the survival with orbital compared with other intraocular metastases was poorer.[7] In some tumors, such as renal carcinoma, cases have been reported with long-term survival after the removal of a solitary orbital metastasis.[8]

Treatment of orbital metastasis is mostly palliative. External beam radiotherapy is the treatment modality of choice for orbital metastasis. It contributes toward improving quality of life; first, by decreasing the size of the tumor and the pain associated with it; second, by increasing the patient's visual functions. Other treatment options include surgical resection, transpupillary thermotherapy, and intravitreal chemotherapy. In addition, anti-vascular endothelial growth factor therapy can be used to slow the progress of maculopathy and neuropathy as well as spare vision after local radiotherapy.[9],[10]

Metastasis to mandible is extremely sparse, accounting for only 1–2% of all malignant neoplasms of these sites. In around one-third of patients, these may be the initial presentation of an occult primary malignancy anywhere in the body.[11] In men, the four most common tumor sites that metastasize to the jaws in descending order of frequency are lung, prostate, kidney, and liver; and in women, breast, adrenal, female genital organs (uterus, cervix, ovaries), and colorectal primaries.[3] They may present with swelling, pain, or difficulty in opening the mouth depending on the location of the lesion. Majority of mandibular metastases involve molar or premolar region. Condylar involvement is rare. Palliative treatment is mainstay of the therapy to maintain quality of life. Unfortunately, majority of these patients harbor an aggressive primary and most of them succumb to death owing to progression of their primary disease.[12]

Role of systemic therapy in management of such cases is of pivotal importance. In patients with widespread metastases and chemosensitive primary tumor, systemic chemotherapy is the treatment of choice. However, chemotherapy has its own side effects. A few patients with either asymptomatic orbital metastases or with minor symptoms and those reeling under the burden of highly advanced disease can be managed by serial observation alone.[5]

Concurrence of orbital and mandibular metastasis from squamous cell lung cancer before diagnosing the primary tumor has not been reported till date, and to the best of our knowledge, this is the first such case being reported. In this patient, she was harboring both these even before the diagnosis of lung cancer was made and the histology was squamous cell carcinoma unlike adenocarcinoma or small cell lung carcinoma in other reported series.


 > Conclusion Top


This is one of the rarest occurrences where the patient presented with metastasis to both orbit and mandible even before the primary tumor produced any other symptom. This necessitates thorough evaluation of patients with such symptom and keeping in mind malignancy as one of the possible causes. Second, palliation should be the goal of treatment in patients with multiple metastases to provide optimal symptomatic relief and preserving a good quality of life with minimal treatment-related morbidity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Mena AM, Pardo J. Orbital metastasis as the initial manifestation of small cell lung cancer. Acta Ophthalmol Scand 2002;80:113-5.  Back to cited text no. 1
    
2.
Shields JA, Shields CL, Brotman HK, Carvalho C, Perez N, Eagle RC Jr. Cancer metastatic to the orbit: The 2000 Robert M. Curts lecture. Ophthal Plast Reconstr Surg 2001;17:346-54.  Back to cited text no. 2
    
3.
Barnes L. Metastases to the head and neck: An overview. Head Neck Pathol 2009;3:217-24.  Back to cited text no. 3
    
4.
Yan J, Gao S. Metastatic orbital tumors in Southern China during an 18-year period. Graefes Arch Clin Exp Ophthalmol 2011;249:1387-93.  Back to cited text no. 4
    
5.
Char DH, Miller T, Kroll S. Orbital metastases: Diagnosis and course. Br J Ophthalmol 1997;81:386-90.  Back to cited text no. 5
    
6.
Burmeister BH, Benjamin CS, Childs WJ. The management of metastases to eye and orbit from carcinoma of the breast. Aust N Z J Ophthalmol 1990;18:187-90.  Back to cited text no. 6
    
7.
Ratanatharathorn V, Powers WE, Grimm J, Steverson N, Han I, Ahmad K, et al. Eye metastasis from carcinoma of the breast: Diagnosis, radiation treatment and results. Cancer Treat Rev 1991;18:261-76.  Back to cited text no. 7
    
8.
Bersani TA, Costello JJ Jr., Mango CA, Streeten BW. Benign approach to a malignant orbital tumor: Metastatic renal cell carcinoma. Ophthal Plast Reconstr Surg 1994;10:42-4.  Back to cited text no. 8
    
9.
Wilson MW, Czechonska G, Finger PT, Rausen A, Hooper ME, Haik BG. Chemotherapy for eye cancer. Surv Ophthalmol 2001;45:416-44.  Back to cited text no. 9
    
10.
Finger PT. Radiation retinopathy is treatable with anti-vascular endothelial growth factor bevacizumab (avastin). Int J Radiat Oncol Biol Phys 2008;70:974-7.  Back to cited text no. 10
    
11.
Shen ML, Kang J, Wen YL, Ying WM, Yi J, Hua CG, et al. Metastatic tumors to the oral and maxillofacial region: A retrospective study of 19 cases in West China and review of the Chinese and English literature. J Oral Maxillofac Surg 2009;67:718-37.  Back to cited text no. 11
    
12.
Pereira-Filho VA, Chaves MD, Haddad J, Gabrielli MF, Gabrielli MA, Hochulli-Vieira E, et al. Mandible metastasis as the first sign from primary adenocarcinoma of the lung. Gen Dent 2007;55:224-7.  Back to cited text no. 12
    


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