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Thyroid Carcinoma Metastatic to the Orbit
Thyroid Carcinoma Metastatic to the Orbit ALBERT HORNBLASS, MD, FACS,*t LAWRENCE G. KASS MD * RAYMOND REICH, MDt ' ,
Abstract: Metastatic thyroid carcinoma rarely involves the orbit. A 35-year-old woman with a history of thyroid lobectomy for a "benign" goiter 6 years earlier presented with a right superotemporal mass causing bony erosion of the lateral orbital wall shown by clinical examination and computed tomographic (CT) scanning. Orbital exploration with biopsy showed metastatic thyroid carcinoma. This represents the youngest patient reported with this rare condition. [Key words: computed tomographic scan, goiter, metastases, orbit, orbital tumor, papillary carcinoma, thyroid, thyroid carcinoma.] Ophthalmology 94:10041007, 1987
Metastatic thyroid carcinoma rarely involves the orbit, and all cases reported previously have involved patients in their sixth and seventh decades of life_ We report the case of a young woman who presented with an orbital mass and was found to have metastatic thyroid carcinoma.
CASE REPORT On September 23, 1985, a 35-year-old woman presented because of gradual swelling along her right temple of 3 years' duration associated with tearing and painless progressive proptosis of the right eye (Fig 1). There was no history of visual disturbance, loss of appetite, or loss of weight. There was a history of cholecystectomy in 1982 and a right thyroid lobectomy for a "benign" goiter in 1979. Her visual acuity with correction was 20/20 in the right eye and 20/25 in the left. There was marked proptosis of the right eye; however, pupils and extraocular movements were normal. There was a fullness in the right superior orbit, associated with inferior displacement of the globe. A hard mass was palpable along the right orbital rim associated with marked excavation of the lateral orbital wall. Results of slit-lamp examination were normal and the fundus did not show choroidal folds or optic dis~ edema. The ocular tension was 14 mm in each eye. Schirmer's
From the Department of Ophthalmic, Orbital, Plastic and Reconstructive Surgery: Manhattan Eye, Ear and Throat Hospital, Lenox Hill Hospital, and The State University of New York,t Health Science Center, New York. Reprint requests to Albert Homblass, MD, FACS, 903 Lexington Avenue, New York, NY 10021.
1004
test with topical anesthesia was 5 mm in the right eye and 3 mm in the left after 5 minutes. Computed tomographic (CT) scan demonstrated a large destructive lesion involving the superolateral bony margin of the right orbit and extending to the outer cranial surface of the skull in the right temporal fossa (Fig 2). Only a thin amount of inner table separated the lesion from the right frontal lobe. Preoperatively, the differential diagnosis included atypical adenoid cystic carcinoma of the lacrimal gland, metastatic carcinoma, and eosinophilic granuloma. Results of a metastatic workup, including a complete blood count, chemistry profile (T3, T 4 , and thyroid-stimulating levels), urinalysis, total body bone scan, liver-spleen scan, and chest roentgenogram, were all normal (except for the bone scan, which demonstrated the known right orbital lesion). On November 19, 1985, an orbital exploration was done through an anterolateral incision. Firm, brown nodules were noted on the lateral orbital rim and in the temporal fossa where they extended full-thickness through the lateral orbital wall (Fig 3). Frozen sections from these nodules showed infiltrating adenocarcinoma. Avoiding the thin bony table separating the tumor from the frontal lobe, the more accessible tumor nodules were removed (Fig 4) and the incision was closed. Permanent histologic sectioning showed colloid adenocarcinoma of the thyroid gland (Fig 5). The patient was referred for endocrine and oncologic evaluation and treatment of the metastatic disease. Results of workup have been negative for evidence of additional metastatic sites, and the patient has been followed closely after ablative treatment with radioactive iodine. Review of the patient's records during the hospitalization in 1979 showed that, because of a goiter, a "cold" nodule of the right lobe of the thyroid gland was removed during an uneventful right thyroid lobectomy and partial isthmusectomy. The histologic diagnosis of adenomatous goiter with focal areas of hyperplasia was made. Review of the slides showed the presence of papillary thyroid adenocarcinoma.
HORNBLASS et al
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THYROID AND ORBITAL CARCINOMA
Fig 1. A 35-year-old woman with a 3-year history of slowly progressive
proptosis of the right eye.
Fig 2. Computed tomographic scan demonstrating the destructive lesion involving the superotemporal orbital wall and extending to the exocranial surface. Only a thin table of bone separates the lesion from the right frontal lobe.
Fig 3. Orbital tumor extending through the orbital wall into the tem-
poralis fossa and to the orbital rim.
Fig 4. Defect in orbital wall after tumor excision.
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OPHTHALMOLOGY
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AUGUST 1987
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VOLUME 94
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Fig 5. Colloid adenocarcinoma of thyroid origin.
DISCUSSION The orbit is only rarely affected by metastases from thyroid carcinoma. Two series studied the sites to which primary carcinomas of the thyroid metastasize. Heitz et all studied 573 primary malignant thyroid tumors and list none metastatic to the orbit. Albert et al 2 and Bloch and Gartner3 studied 213 and 230 patients with systemic carcinomas, respectively. By combining their data, there were nine cases of primary thyroid tumors among their 443 patients, of which 1 patient had an ocular metastasis. The age of the patient and the exact site of ocular metastasis was unspecified. Among studies of metastatic carcinoma to the orbit, the thyroid gland has only rarely been implicated as the site of the primary tumor. Font and Ferry4 reviewed 28 cases of metastatic carcinoma to the orbit, and none of these was found to be of thyroid origin. Henderson 5 found 43 of his 764 cases of orbital tumors to be due to metastatic carcinoma, of which two were from a primary thyroid carcinoma. There have been several isolated reports of orbital metastases from thyroid carcinoma. Knapp, 6 Appalanarsayya and Satyrendran, 7 Oberman et al, 8 Dhoine et al,9 and Vrabec and Zhan lO each described a single case of orbital metastasis from a primary thyroid tumor. In summary, a review of the literature shows seven cases of known primary thyroid carcinoma metastatic to the orbit. In one additional case, the exact site of ocular metastasis was unspecified. Considering the seven reported patients with known orbital metastases, they 1006
ranged in age from 49 to 66 years old (mean, 57.5 years). Five of the seven patients were women. Vrabec and Zahn 10 and Knapp6 each reported male patients aged 49 and 66, respectively. Our patient is unique among previously reported patients with this rare metastatic lesion because of the very young age at the time of presentation. That the true diagnosis was missed at the time of thyroidectomy may be because papillary carcinoma-the most common and most well-differentiated type of thyroid carcinoma -can vary widely in its histologic appearance in different sections of the same specimen. Establishing the correct diagnosis may require careful review of aJI sections. Also, as in our case, establishing the diagnosis may be difficult because metastases from papillary carcinoma may vary in its histologic appearance from the primary, assuming a more colloidal configuration. Although the orbital metastasis presented 6 years after the initial thyroid lesion in our patient, it is not unusual for this interval to be 10 years or greater. Henderson 5 reported a case in which the metastatic lesion presented 29 years after thyroidectomy for a "benign" tumor. In addition to the orbit, thyroid carcinoma has been known to metastasize to the uveal tract as well. Hart ll reviewed 133 cases of ocular metastases from the Armed Forces Institute of Pathology and found one case to be of thyroid origin with metastasis to the uvea. Ferry and Font l2 analyzed 227 cases from the Armed Forces Institute of Pathology and listed one case of thyroid carcinoma metastasizing to the uvea. Reese l3 published fundus photographs demonstrating metastatic thyroid carcinoma to the choroid of both eyes. Slamovits et al 14 reviewed the literature and reported a patient with two
HORNBLASS et al
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THYROID AND ORBITAL CARCINOMA
choroidal lesions in one eye, attributed to metastic thyroid carcinoma. Daicker and Gysin 15 reported two patients with metastases from medullary thyroid carcinoma to the anterior uvea of both eyes.
REFERENCES 1. Heitz P, Moser H, Staub JJ. Thyroid cancer: a study of 573 thyroid tumors and 161 autopsy cases observed over a thirty-year period. Cancer 1976; 37:2329-37. 2. Albert DM, Rubenstein RA, Scheie HG. Tumor metastasis to the eye. Part I. Incidence in 213 adult patients with generalized malignancy. Am J Ophthalmol1967; 63:723-32. 3. Bloch RS, Gartner S. The incidence of ocular metastatic carcinoma. Arch Ophthalmol1971; 85:673-75. 4. Font RL, Ferry AP. Carcinoma metastatic to the eye and orbit. III. A clinicopathologic study of 28 cases metastatic to the orbit. Cancer 1976; 38:1326-35. 5. Henderson JW. Orbital Tumors. 2nd ed. New York: Brian C. Decker; 1980; 467-9.
6. Knapp A. Metastatic thyroid tumor in the orbit. Arch Ophthalmol 1923; 52:68-74. 7. Appalanarsayya K, Satyrendran OM. Metastases in the lid and the orbit from thyroid carcinoma. Orient Arch Ophthal 1964; 2:183-4. 8. Oberman HA, Fayos JV, Lampe I. Pathology-radiation therapy conference: unusual orbital tumor. U Mich Med 1969; 35:36-8. 9. Dhoine G, Woillez M, Beal F. Metastase thyroidienne orbitaire. (Guerison apres 10 ans.) Bull Soc Ophtalmol Fr 1973; 73:1229-31. 10. Vrabec F, Zahn K. Thyroid carcinoma of the orbit. Ceskoslovenska Oftalmo 9:140-245. 11. Hart WM. Metastatic carcinoma of the eye and orbit. Int Ophthalmol Clin 1962; 2(2):465-82. 12. Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit: I. A clinicopathologic study of 227 cases. Arch Ophthalmol 1974; 92:276-86. 13. Reese AB. Tumors of the Eye. 3rd ed. Hagerstown: Harper & Row, 1976; 34. 14. Siamovits TL, Mondzelewski JP, Kennerdell JS. Thyroid carcinoma metastatic to the globe. Br J Ophthalmol 1979; 63:169-72. 15. Daicker B, Gysin P. Aderhaut-, Ziliarkorper- and Iris-metastasen Medullarer Schilddrusenkarzinoma. Klinische und pathologische Befunde von zwei Fallen. Klin Monatsbl Augenheilkd 1980; 177:193-9.
1007
Abstract: Metastatic thyroid carcinoma rarely involves the orbit. A 35-year-old woman with a history of thyroid lobectomy for a "benign" goiter 6 years earlier presented with a right superotemporal mass causing bony erosion of the lateral orbital wall shown by clinical examination and computed tomographic (CT) scanning. Orbital exploration with biopsy showed metastatic thyroid carcinoma. This represents the youngest patient reported with this rare condition. [Key words: computed tomographic scan, goiter, metastases, orbit, orbital tumor, papillary carcinoma, thyroid, thyroid carcinoma.] Ophthalmology 94:10041007, 1987
Metastatic thyroid carcinoma rarely involves the orbit, and all cases reported previously have involved patients in their sixth and seventh decades of life_ We report the case of a young woman who presented with an orbital mass and was found to have metastatic thyroid carcinoma.
CASE REPORT On September 23, 1985, a 35-year-old woman presented because of gradual swelling along her right temple of 3 years' duration associated with tearing and painless progressive proptosis of the right eye (Fig 1). There was no history of visual disturbance, loss of appetite, or loss of weight. There was a history of cholecystectomy in 1982 and a right thyroid lobectomy for a "benign" goiter in 1979. Her visual acuity with correction was 20/20 in the right eye and 20/25 in the left. There was marked proptosis of the right eye; however, pupils and extraocular movements were normal. There was a fullness in the right superior orbit, associated with inferior displacement of the globe. A hard mass was palpable along the right orbital rim associated with marked excavation of the lateral orbital wall. Results of slit-lamp examination were normal and the fundus did not show choroidal folds or optic dis~ edema. The ocular tension was 14 mm in each eye. Schirmer's
From the Department of Ophthalmic, Orbital, Plastic and Reconstructive Surgery: Manhattan Eye, Ear and Throat Hospital, Lenox Hill Hospital, and The State University of New York,t Health Science Center, New York. Reprint requests to Albert Homblass, MD, FACS, 903 Lexington Avenue, New York, NY 10021.
1004
test with topical anesthesia was 5 mm in the right eye and 3 mm in the left after 5 minutes. Computed tomographic (CT) scan demonstrated a large destructive lesion involving the superolateral bony margin of the right orbit and extending to the outer cranial surface of the skull in the right temporal fossa (Fig 2). Only a thin amount of inner table separated the lesion from the right frontal lobe. Preoperatively, the differential diagnosis included atypical adenoid cystic carcinoma of the lacrimal gland, metastatic carcinoma, and eosinophilic granuloma. Results of a metastatic workup, including a complete blood count, chemistry profile (T3, T 4 , and thyroid-stimulating levels), urinalysis, total body bone scan, liver-spleen scan, and chest roentgenogram, were all normal (except for the bone scan, which demonstrated the known right orbital lesion). On November 19, 1985, an orbital exploration was done through an anterolateral incision. Firm, brown nodules were noted on the lateral orbital rim and in the temporal fossa where they extended full-thickness through the lateral orbital wall (Fig 3). Frozen sections from these nodules showed infiltrating adenocarcinoma. Avoiding the thin bony table separating the tumor from the frontal lobe, the more accessible tumor nodules were removed (Fig 4) and the incision was closed. Permanent histologic sectioning showed colloid adenocarcinoma of the thyroid gland (Fig 5). The patient was referred for endocrine and oncologic evaluation and treatment of the metastatic disease. Results of workup have been negative for evidence of additional metastatic sites, and the patient has been followed closely after ablative treatment with radioactive iodine. Review of the patient's records during the hospitalization in 1979 showed that, because of a goiter, a "cold" nodule of the right lobe of the thyroid gland was removed during an uneventful right thyroid lobectomy and partial isthmusectomy. The histologic diagnosis of adenomatous goiter with focal areas of hyperplasia was made. Review of the slides showed the presence of papillary thyroid adenocarcinoma.
HORNBLASS et al
•
THYROID AND ORBITAL CARCINOMA
Fig 1. A 35-year-old woman with a 3-year history of slowly progressive
proptosis of the right eye.
Fig 2. Computed tomographic scan demonstrating the destructive lesion involving the superotemporal orbital wall and extending to the exocranial surface. Only a thin table of bone separates the lesion from the right frontal lobe.
Fig 3. Orbital tumor extending through the orbital wall into the tem-
poralis fossa and to the orbital rim.
Fig 4. Defect in orbital wall after tumor excision.
1005
OPHTHALMOLOGY
•
AUGUST 1987
•
VOLUME 94
•
NUMBER 8
Fig 5. Colloid adenocarcinoma of thyroid origin.
DISCUSSION The orbit is only rarely affected by metastases from thyroid carcinoma. Two series studied the sites to which primary carcinomas of the thyroid metastasize. Heitz et all studied 573 primary malignant thyroid tumors and list none metastatic to the orbit. Albert et al 2 and Bloch and Gartner3 studied 213 and 230 patients with systemic carcinomas, respectively. By combining their data, there were nine cases of primary thyroid tumors among their 443 patients, of which 1 patient had an ocular metastasis. The age of the patient and the exact site of ocular metastasis was unspecified. Among studies of metastatic carcinoma to the orbit, the thyroid gland has only rarely been implicated as the site of the primary tumor. Font and Ferry4 reviewed 28 cases of metastatic carcinoma to the orbit, and none of these was found to be of thyroid origin. Henderson 5 found 43 of his 764 cases of orbital tumors to be due to metastatic carcinoma, of which two were from a primary thyroid carcinoma. There have been several isolated reports of orbital metastases from thyroid carcinoma. Knapp, 6 Appalanarsayya and Satyrendran, 7 Oberman et al, 8 Dhoine et al,9 and Vrabec and Zhan lO each described a single case of orbital metastasis from a primary thyroid tumor. In summary, a review of the literature shows seven cases of known primary thyroid carcinoma metastatic to the orbit. In one additional case, the exact site of ocular metastasis was unspecified. Considering the seven reported patients with known orbital metastases, they 1006
ranged in age from 49 to 66 years old (mean, 57.5 years). Five of the seven patients were women. Vrabec and Zahn 10 and Knapp6 each reported male patients aged 49 and 66, respectively. Our patient is unique among previously reported patients with this rare metastatic lesion because of the very young age at the time of presentation. That the true diagnosis was missed at the time of thyroidectomy may be because papillary carcinoma-the most common and most well-differentiated type of thyroid carcinoma -can vary widely in its histologic appearance in different sections of the same specimen. Establishing the correct diagnosis may require careful review of aJI sections. Also, as in our case, establishing the diagnosis may be difficult because metastases from papillary carcinoma may vary in its histologic appearance from the primary, assuming a more colloidal configuration. Although the orbital metastasis presented 6 years after the initial thyroid lesion in our patient, it is not unusual for this interval to be 10 years or greater. Henderson 5 reported a case in which the metastatic lesion presented 29 years after thyroidectomy for a "benign" tumor. In addition to the orbit, thyroid carcinoma has been known to metastasize to the uveal tract as well. Hart ll reviewed 133 cases of ocular metastases from the Armed Forces Institute of Pathology and found one case to be of thyroid origin with metastasis to the uvea. Ferry and Font l2 analyzed 227 cases from the Armed Forces Institute of Pathology and listed one case of thyroid carcinoma metastasizing to the uvea. Reese l3 published fundus photographs demonstrating metastatic thyroid carcinoma to the choroid of both eyes. Slamovits et al 14 reviewed the literature and reported a patient with two
HORNBLASS et al
•
THYROID AND ORBITAL CARCINOMA
choroidal lesions in one eye, attributed to metastic thyroid carcinoma. Daicker and Gysin 15 reported two patients with metastases from medullary thyroid carcinoma to the anterior uvea of both eyes.
REFERENCES 1. Heitz P, Moser H, Staub JJ. Thyroid cancer: a study of 573 thyroid tumors and 161 autopsy cases observed over a thirty-year period. Cancer 1976; 37:2329-37. 2. Albert DM, Rubenstein RA, Scheie HG. Tumor metastasis to the eye. Part I. Incidence in 213 adult patients with generalized malignancy. Am J Ophthalmol1967; 63:723-32. 3. Bloch RS, Gartner S. The incidence of ocular metastatic carcinoma. Arch Ophthalmol1971; 85:673-75. 4. Font RL, Ferry AP. Carcinoma metastatic to the eye and orbit. III. A clinicopathologic study of 28 cases metastatic to the orbit. Cancer 1976; 38:1326-35. 5. Henderson JW. Orbital Tumors. 2nd ed. New York: Brian C. Decker; 1980; 467-9.
6. Knapp A. Metastatic thyroid tumor in the orbit. Arch Ophthalmol 1923; 52:68-74. 7. Appalanarsayya K, Satyrendran OM. Metastases in the lid and the orbit from thyroid carcinoma. Orient Arch Ophthal 1964; 2:183-4. 8. Oberman HA, Fayos JV, Lampe I. Pathology-radiation therapy conference: unusual orbital tumor. U Mich Med 1969; 35:36-8. 9. Dhoine G, Woillez M, Beal F. Metastase thyroidienne orbitaire. (Guerison apres 10 ans.) Bull Soc Ophtalmol Fr 1973; 73:1229-31. 10. Vrabec F, Zahn K. Thyroid carcinoma of the orbit. Ceskoslovenska Oftalmo 9:140-245. 11. Hart WM. Metastatic carcinoma of the eye and orbit. Int Ophthalmol Clin 1962; 2(2):465-82. 12. Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit: I. A clinicopathologic study of 227 cases. Arch Ophthalmol 1974; 92:276-86. 13. Reese AB. Tumors of the Eye. 3rd ed. Hagerstown: Harper & Row, 1976; 34. 14. Siamovits TL, Mondzelewski JP, Kennerdell JS. Thyroid carcinoma metastatic to the globe. Br J Ophthalmol 1979; 63:169-72. 15. Daicker B, Gysin P. Aderhaut-, Ziliarkorper- and Iris-metastasen Medullarer Schilddrusenkarzinoma. Klinische und pathologische Befunde von zwei Fallen. Klin Monatsbl Augenheilkd 1980; 177:193-9.
1007