Orbital metastasis: Unusual presentation of esophageal cancer

Sir, Metastatic orbital tumors account for around 3% of all orbital lesions.[1] About 2%–5% of all systemic cancers metastasize to the orbit through hematogenous pathways, of which breast carcinoma accounts for one-third of cases followed by lung cancer.[2,3] Herein, we report a very rare presentation of an esophageal primary malignancy with orbital mass and ptosis. A 52-year-old female presented with complaints of swelling over the left eye followed by drooping of left upper eyelid for three months without any blurred vision, diplopia, or watering. On clinical examination, supraorbital nontender swelling present with ptosis [Figure 1a] on the left side, with numbness over the left forehead and left cheek. The left eye was deviated in down and out direction, suggestive of third cranial nerve involvement [Figure 1b].Figure 1: Clinical picture showing ptosis (a) and deviation of eyeball (b)Magnetic resonance imaging (MRI) of orbit and brain revealed 3.3 × 3.2 cm T2/FLAIR heterogeneously hyperintense T1 hypointense mass in left orbit, compressing the eyeball [Figure 2a and b]. The mass was abutting left lacrimal gland with extension into supraorbital region, left frontal sinus, and extra-axial space of left frontal region with infiltration of underlying meninges. She underwent near-total excision of the supra-orbital mass, pathological examination of which showed metastatic squamous cell carcinoma [Figure 3]. A staging workup with FDG PET-CT showed low-grade FDG avid circumferential mural thickening of mid-thoracic esophagus of 6.5 cm length [Figure 2c], with multiple mediastinal, hilar, para-tracheal lymph nodes along with multiple lytic bone metastasis (cervico-dorso-lumbar vertebra, ribs, sacrum, both femur and humerus) and a residual supra-orbital mass. An upper gastrointestinal endoscopy showed an ulcero-proliferative growth at 28 cm from incisors, which came out to be poorly differentiated squamous cell carcinoma [Figure 3]. Post-operative MRI of brain revealed a residual 2 × 1.8 cm mass in left orbit, without any meningeal infiltration or parenchymal lesion.Figure 2: (a and b) MRI sequences showing left orbital mass, (c) FDG PET-CT showing esophageal thickeningFigure 3: (a) Esophageal biopsy showing an invasive malignancy with the features of squamous cell carcinoma (hematoxylin and eosin, 200×), (b) Nests of squamous cell carcinoma (top half) infiltrating the lacrimal gland (bottom left and right) (hematoxylin and eosin, 200×), (c) Nests and lobules of squamous cell carcinoma infiltrating the intertrabecular marrow spaces with thinning of the bony trabeculae (hematoxylin and eosin, 400×), (d) Immunohistochemistry for p40 showing diffuse strong nuclear positivity (400×)She received palliative radiotherapy 20 Gy in five fractions over a week to left supra-orbital and frontal area by two-dimensional antero-lateral 45° wedge pair and also to esophagus by antero-posterior field which yielded partial subjective response. She has now been started on palliative chemotherapy (paclitaxel-carboplatin) every three weeks along with zoledronate every 4 weeks. Here, we report a very rare case scenario where an esophageal primary presented with an ocular complaint. Orbital metastasis can thereby be the manifestation of any metastatic disease and should be evaluated without any delay to make a prompt diagnosis and initiate treatment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.