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Acute ptosis as the sole presenting symptom of a pulmonary adenocarcinoma
European Geriatric Medicine 5 (2014) 330–331
Available online at
ScienceDirect www.sciencedirect.com
EGM clinical case
Acute ptosis as the sole presenting symptom of a pulmonary adenocarcinoma K. Rohan Lee *, K. Chiang Ling, M. Reza Peyman, V. Subrayan Department of Ophthalmology, University Malaya, Jalan Lembah Pantai, 50603 Kuala Lumpur, Malaysia
A R T I C L E I N F O
Article history: Received 26 May 2014 Accepted 2 June 2014 Available online 5 September 2014
1. Introduction Although rare, secondary metastasis to the orbit is a wellrecognized clinical entity with a prevalence of 1–13% of all orbital tumours [1]. The most common aetiology of orbital metastasis among men are lung carcinomas and in women, breast carcinomas [2]. Presentations of orbital metastases are varied including eye pain, diplopia, visual impairment, proptosis, ocular motility disorders with possible palpable masses at the orbit [3]. It is rare for blepharoptosis to be the sole orbital metastatic presentation involving only the levator palpebrae superioris muscle [4].
2. Case report A 70-year-old gentleman, a heavy smoker of 60 pack-years, presented to the eye clinic with left droopy upper lid (Fig. 1A) of two days. There was no visual impairment, diplopia, eye pain or redness. Moreover, he complained of poor appetite and significant weight loss over the past three months. Examination revealed a cachexic man with a partial left eye ptosis. Pupils were equal and reactive to light. Extraocular movements were full with no muscle fatigability demonstrated. Systemic examination revealed a barrel chest with reduced air entry and crepitations in the lower zones of both lung fields. There were multiple matted cervical lymph nodes along the right side of the submandibular region. A computed tomography (CT) scan of the orbits and thorax revealed a solitary hyperdense nodule in the left levator * Corresponding author. Tel.: +60 379 492 060; fax: +60 379 494 635. E-mail address: [email protected] (K. Rohan Lee).
palpebrae superioris (Fig. 1B and C), with multiple hyperdense lesions of varying sizes in both lung fields with a right lower lobe collapse. A CT-guided biopsy confirmed the presence of pulmonary adenocarcinoma. A biopsy of the orbital lesion was deemed unnecessary as the clinical and radiological evidence of secondary metastasis was indisputable at this juncture. Unfortunately, our patient succumbed to his illness in the following 6 weeks. 3. Discussion Metastasis to the levator palpebrae superioris alone is a very rare phenomenon and to our knowledge has only been reported twice before in the literature [4,5]. Blepharoptosis can manifest as the sole presentation of other locally invasive tumours such as a meningioma [6], which directly damages the respective muscle or its nervous control. Secondary metastasis to the orbit may invariably lead to an ocular motility disorder and proptosis as a consequence of an increase in intra-orbital volume. The tumour seedlings spread by the haematogenous route (via ophthalmic or maxillary arteries) and gets deposited into the orbital fat or the extraocular muscles. Mean survival rates differ and it is found that metastasis arising from a carcinoid tumour has the longest mean survival of 60 months while that of a breast cancer is about 22 months [1]. Palliative treatment includes radiation and chemotherapy. However, surgical intervention is generally not recommended, unless it is performed for diagnostic purposes in patients (biopsy) or in cases of unmanageable local symptoms (tumour resection or enucleation) [7]. External-beam irradiation shows high rates (60– 80%) of clinical improvement (total dose of 20–40 Gy delivered in fractions over 1–2 weeks [1,7]). Stereotactic radiosurgery (SRS) is another modality that involves a complex combination of
http://dx.doi.org/10.1016/j.eurger.2014.06.005 1878-7649/ß 2014 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
K. Rohan Lee et al. / European Geriatric Medicine 5 (2014) 330–331
331
Fig. 1. A. Left blepharoptosis with frontalis overaction. B. A computed tomography scan of the brain and orbits revealing a solitary hyperdense nodule at the origin of the left levator palpebrae superioris muscle. C. A computed tomography scan of the mediastinum revealing enlarged left mediastinal lymph nodes with multiple hyperdense lesions at the left lower lobe parenchyma of the lung and collapsed right lower lobe.
image-guided radiation giving a shorter treatment course, thus contributing to a better quality of life [8]. Chemotherapy followed by hormone therapy are used in cases of hormone-sensitive tumours such as oat cell carcinomas of the lung or oestrogen-producing breast carcinomas. A new paradigm of treatment of orbital metastasis is the use of CyberKnife radiosurgery. Tumour stabilization or a decrease in size was achieved in 87% of orbital lesions demonstrated in a paper by Klingenstein et al. [9]. In conclusion, an acute unilateral ptosis presentation may herald a myriad of sinister causes and one should be vigilant of a metastatic foci. Disclosure of interest This study was supported by a UMRG grant (UMRG RP006F13HTM) from the University of Malaya.
References [1] Shields J, Shields C, Brotman H, Carvalho C, Perez N, Eagle R. Cancer metastasis to the orbit. Ophthal Plast Reconstr Surg 2001;17:346–54. [2] Su HT, Chen YM, Perng RP. Symptomatic ocular metastases in lung cancer. Respirology 2008;13:303–5. [3] Gonzalez F, Lopez-Couto C. Orbital metastases: a report of four cases and a review of the literature. Arch Soc Esp Oftalmol 2006;81:451–62. [4] Verhagen W, Venderink D. Ptosis due to metastasis in the levator palpebrae muscle as first symptom of an adenocarcinoma of the lung. Neuroophthalmol 2001;26:197–9. [5] Caliandro R, Souquet PJ, El Kouhry MT, Bohas C, Bernard JP. Ptosis re´ve´lateur d’une me´tastase orbitaire dans un ade´nocarcinome rectal. Presse Med 1994; 23:138. [6] Ng E, Ilsen PF. Orbital metastases. Optometry 2010;81(12):647–57. [7] Ahmad SM, Esmaeli B. Metastatic tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol 2007;18:405–13. [8] Bellmann C, Fuss M, Holz FG, et al. Stereotactic radiation therapy for malignant choroidal tumors. Ophthalmology 2000;107:358–65. [9] Klingenstein A, Kufeld M, Wowra B, Muacevic A, Fu¨rweger C, Schaller UC. Experimental study on pulmonary cryoablation in a porcine model of normal lungs. Technol Cancer Res Treat 2012;11:433–9.
Available online at
ScienceDirect www.sciencedirect.com
EGM clinical case
Acute ptosis as the sole presenting symptom of a pulmonary adenocarcinoma K. Rohan Lee *, K. Chiang Ling, M. Reza Peyman, V. Subrayan Department of Ophthalmology, University Malaya, Jalan Lembah Pantai, 50603 Kuala Lumpur, Malaysia
A R T I C L E I N F O
Article history: Received 26 May 2014 Accepted 2 June 2014 Available online 5 September 2014
1. Introduction Although rare, secondary metastasis to the orbit is a wellrecognized clinical entity with a prevalence of 1–13% of all orbital tumours [1]. The most common aetiology of orbital metastasis among men are lung carcinomas and in women, breast carcinomas [2]. Presentations of orbital metastases are varied including eye pain, diplopia, visual impairment, proptosis, ocular motility disorders with possible palpable masses at the orbit [3]. It is rare for blepharoptosis to be the sole orbital metastatic presentation involving only the levator palpebrae superioris muscle [4].
2. Case report A 70-year-old gentleman, a heavy smoker of 60 pack-years, presented to the eye clinic with left droopy upper lid (Fig. 1A) of two days. There was no visual impairment, diplopia, eye pain or redness. Moreover, he complained of poor appetite and significant weight loss over the past three months. Examination revealed a cachexic man with a partial left eye ptosis. Pupils were equal and reactive to light. Extraocular movements were full with no muscle fatigability demonstrated. Systemic examination revealed a barrel chest with reduced air entry and crepitations in the lower zones of both lung fields. There were multiple matted cervical lymph nodes along the right side of the submandibular region. A computed tomography (CT) scan of the orbits and thorax revealed a solitary hyperdense nodule in the left levator * Corresponding author. Tel.: +60 379 492 060; fax: +60 379 494 635. E-mail address: [email protected] (K. Rohan Lee).
palpebrae superioris (Fig. 1B and C), with multiple hyperdense lesions of varying sizes in both lung fields with a right lower lobe collapse. A CT-guided biopsy confirmed the presence of pulmonary adenocarcinoma. A biopsy of the orbital lesion was deemed unnecessary as the clinical and radiological evidence of secondary metastasis was indisputable at this juncture. Unfortunately, our patient succumbed to his illness in the following 6 weeks. 3. Discussion Metastasis to the levator palpebrae superioris alone is a very rare phenomenon and to our knowledge has only been reported twice before in the literature [4,5]. Blepharoptosis can manifest as the sole presentation of other locally invasive tumours such as a meningioma [6], which directly damages the respective muscle or its nervous control. Secondary metastasis to the orbit may invariably lead to an ocular motility disorder and proptosis as a consequence of an increase in intra-orbital volume. The tumour seedlings spread by the haematogenous route (via ophthalmic or maxillary arteries) and gets deposited into the orbital fat or the extraocular muscles. Mean survival rates differ and it is found that metastasis arising from a carcinoid tumour has the longest mean survival of 60 months while that of a breast cancer is about 22 months [1]. Palliative treatment includes radiation and chemotherapy. However, surgical intervention is generally not recommended, unless it is performed for diagnostic purposes in patients (biopsy) or in cases of unmanageable local symptoms (tumour resection or enucleation) [7]. External-beam irradiation shows high rates (60– 80%) of clinical improvement (total dose of 20–40 Gy delivered in fractions over 1–2 weeks [1,7]). Stereotactic radiosurgery (SRS) is another modality that involves a complex combination of
http://dx.doi.org/10.1016/j.eurger.2014.06.005 1878-7649/ß 2014 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
K. Rohan Lee et al. / European Geriatric Medicine 5 (2014) 330–331
331
Fig. 1. A. Left blepharoptosis with frontalis overaction. B. A computed tomography scan of the brain and orbits revealing a solitary hyperdense nodule at the origin of the left levator palpebrae superioris muscle. C. A computed tomography scan of the mediastinum revealing enlarged left mediastinal lymph nodes with multiple hyperdense lesions at the left lower lobe parenchyma of the lung and collapsed right lower lobe.
image-guided radiation giving a shorter treatment course, thus contributing to a better quality of life [8]. Chemotherapy followed by hormone therapy are used in cases of hormone-sensitive tumours such as oat cell carcinomas of the lung or oestrogen-producing breast carcinomas. A new paradigm of treatment of orbital metastasis is the use of CyberKnife radiosurgery. Tumour stabilization or a decrease in size was achieved in 87% of orbital lesions demonstrated in a paper by Klingenstein et al. [9]. In conclusion, an acute unilateral ptosis presentation may herald a myriad of sinister causes and one should be vigilant of a metastatic foci. Disclosure of interest This study was supported by a UMRG grant (UMRG RP006F13HTM) from the University of Malaya.
References [1] Shields J, Shields C, Brotman H, Carvalho C, Perez N, Eagle R. Cancer metastasis to the orbit. Ophthal Plast Reconstr Surg 2001;17:346–54. [2] Su HT, Chen YM, Perng RP. Symptomatic ocular metastases in lung cancer. Respirology 2008;13:303–5. [3] Gonzalez F, Lopez-Couto C. Orbital metastases: a report of four cases and a review of the literature. Arch Soc Esp Oftalmol 2006;81:451–62. [4] Verhagen W, Venderink D. Ptosis due to metastasis in the levator palpebrae muscle as first symptom of an adenocarcinoma of the lung. Neuroophthalmol 2001;26:197–9. [5] Caliandro R, Souquet PJ, El Kouhry MT, Bohas C, Bernard JP. Ptosis re´ve´lateur d’une me´tastase orbitaire dans un ade´nocarcinome rectal. Presse Med 1994; 23:138. [6] Ng E, Ilsen PF. Orbital metastases. Optometry 2010;81(12):647–57. [7] Ahmad SM, Esmaeli B. Metastatic tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol 2007;18:405–13. [8] Bellmann C, Fuss M, Holz FG, et al. Stereotactic radiation therapy for malignant choroidal tumors. Ophthalmology 2000;107:358–65. [9] Klingenstein A, Kufeld M, Wowra B, Muacevic A, Fu¨rweger C, Schaller UC. Experimental study on pulmonary cryoablation in a porcine model of normal lungs. Technol Cancer Res Treat 2012;11:433–9.