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Indian Journal of Cancer, Vol. 47, No. 1, January-March, 2010, pp. 74-76 Letter To Editor Proptosis due to "isolated" soft tissue orbital metastasis of prostate carcinoma Nayyar R, Singh P, Panda S, Kashyap S1, Gupta NP Departments of Urology, 1 Ocular Pathology, All India Institute of Medical Sciences, New Delhi - 110 029, India Code Number: cn10019 PMID: 20071798 DOI: 10.4103/0019-509X.58867 Sir, Despite the frequent occurrence of skeletal metastasis in advanced prostate cancer, visceral metastases are uncommon and oculo-orbital soft tissue metastasis is rare. Per se, prostate accounts for the third most common primary site to metastasize to the orbit.[1] Most such cases involve the bony orbit. Isolated soft tissue orbital metastasis as a presenting symptom for cancer prostate has not been reported earlier, though there are few case reports suggesting proptosis due to retro-orbital mass in conjunction with bony involvement. [2],[3],[4],[5],[6],[7] A 74-year-man presented to ophthalmologic clinic with right-sided proptosis of gradual onset, over the last 6 months. Physical examination demonstrated right exomphthalmos and lateral rectus palsy. On contrast-enhanced computed tomography (CECT) of orbit [Figure - 1], a right intraorbital soft tissue mass occupying the central and lateral portion of orbit was seen with normal adjacent fat and bone planes. The bony orbit was normal. Fine needle aspiration cytology (FNAC) from the mass revealed a metastatic adenocarcinoma [Figure - 2]. Efforts were then made to search for the primary lesion. Otolaryngologic examinations, CECT chest and abdomen showed normal results. Digital rectal examination revealed a grade I, hard, nodular prostate and serum prostate specific antigen (PSA) was markedly elevated at 211 ng/ml. A sextant prostate biopsy revealed adenocarcinoma, Gleason score 7(4+3) [Figure - 2]. Immunohistochemical staining for PSA and low-molecular-weight cytokeratin on FNAC slides from the orbital mass were also strongly positive, confirming the diagnosis of carcinoma prostate with orbital metastasis. Other metastatic evaluation in the form of bone scintigraphy, chest x-ray, CECT abdomen and pelvis showed normal results. The patient was offered hormonal therapy. He preferred surgical over medical castration. The ocular symptoms improved rapidly and antiandrogens, radiotherapy or steroids were not required given the excellent clinical response and resolution of metastatic mass. At 6 weeks, patient's PSA was 12 ng/ml and proptosis had completely subsided. By 6 months, PSA was 5.1 ng/ml and repeat CT orbit [Figure - 3] revealed complete resolution of the soft tissue mass. At 18-month follow-up patient is doing well with no evidence of disease progression and PSA of 0.4 ng/ml. Tumor metastasis to the orbit may occur through two routes.[2],[5],[8] First, through the carotid/ophthalmic artery, that is the general hematogenous route. Second path involves the Bateson's venous plexus, which may pick up the tumor emboli directly from the prostate to the vertebra. Through this plexus the emboli may reach the cranial venous sinuses/ophthalmic vein. We did a thorough Medline search and found that "isolated" deposition of such tumor emboli "in the soft tissue" of the orbit is a rare occurrence, reported for the first time in our case. Considering its rarity, the diagnosis was questioned even after obvious diagnosis of carcinoma prostate was made because as many as 50% males may harbor a histopathological focus of adenocarcinoma prostate by the age of 60 years.[9] In this case, it was even more questionable because of absence of any other focus of metastasis, not even in the adjacent/distant bones. Therefore, we confirmed the prostatic origin of the metastatic lesion by performing PSA staining of the FNAC slides from orbital mass. Resolution of proptosis after orchiectomy was further evidence for the metastatic origin of the mass from the prostate. In the end, proptosis as a presenting feature helped the patient to seek medical advice before generalized metastasis had occurred. Treatment options for such orbital metastasis include steroids to reduce orbital edema, radiotherapy, evisceration, chemotherapy or hormonal therapy, with all therapies aiming at the control of disease and palliation of symptoms.[1],[2],[3],[4],[5] Palliative radiotherapy has often been used in conjunction with hormonal treatment as it provides relief of pain, with regression of tumor size and restoration of vision. However, it also has side effects in the form of cataract and retinopathy. The choice of therapy should be individualized to the patient depending on the aggressiveness of disease, number of metastasis and emergency of the situation to prevent vision loss. This case reminds the clinicians to keep a high index of suspicion for prostate cancer, especially in elderly men presenting with orbital metastasis as this tumor has good treatment options available with good survival outcomes compared to some other sites of tumor origin. References
Copyright 2010 - Indian Journal of Cancer The following images related to this document are available:Photo images[cn10019f1.jpg] [cn10019f3.jpg] [cn10019f2.jpg] |
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