|Year : 2022 | Volume
| Issue : 1 | Page : 85-88
Orbital metastases as the initial clinical manifestation of thyroid carcinoma: A case series
Mutmainah Mahyuddin1, Kania Theresia1, Neni Anggraini1, H Imam Subekti2
1 Department of Ophthalmology, Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo Kirana Eye Hospital, Jakarta, Indonesia
2 Department Internal Medicine, Faculty of Medicine, Universitas Indonesia – Cipto Mangunkusumo Hospital, Jakarta, Indonesia
|Date of Submission||11-Mar-2021|
|Date of Decision||21-Jul-2021|
|Date of Acceptance||11-Oct-2021|
|Date of Web Publication||02-Mar-2022|
Dr. Mutmainah Mahyuddin
Jl. Kimia No. 8, Jakarta 10320
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Thyroid carcinoma rarely metastasizes to the orbit. Approximately only 2%–7% of orbital metastatic lesion were found originally from thyroid carcinoma. We present three cases to increase the awareness of orbital metastases as the initial manifestation of thyroid carcinoma. Three female patients aged 28–65 years old presented with initial complaint of orbital mass. Further examination discovered an asymptomatic lump on every patient's neck. However, one patient was unaware of her lump. Examination revealed that all lesions were metastases from papillary thyroid carcinoma. These cases conclude several similarities. First, prominent unilateral proptosis, orbital mass in the superior quadrant, limited eyeball movement, and orbital bone destruction were found in every patient. Second, all the orbital computed tomography scan showed extraconal solid masses involving adjacent structures and expanding intra-cranially or intrasinusly. These findings should raise one's suspicion of a metastatic lesion primarily caused by thyroid carcinoma. Despite the rarity of orbital metastases, thyroid carcinoma must be considered as a potential primary tumor in patients with initial presentation of orbital mass. Thorough physical examination is important to determine the origin of metastases.
Keywords: Orbital metastases, orbital tumor, thyroid carcinoma
|How to cite this article:|
Mahyuddin M, Theresia K, Anggraini N, Subekti H I. Orbital metastases as the initial clinical manifestation of thyroid carcinoma: A case series. Oman J Ophthalmol 2022;15:85-8
|How to cite this URL:|
Mahyuddin M, Theresia K, Anggraini N, Subekti H I. Orbital metastases as the initial clinical manifestation of thyroid carcinoma: A case series. Oman J Ophthalmol [serial online] 2022 [cited 2022 Nov 29];15:85-8. Available from: https://www.ojoonline.org/text.asp?2022/15/1/85/338894
| Introduction|| |
Orbital tumors is classified into primary tumors, secondary tumors (extending from neighboring structures), and metastatic tumors which could be challenging to distinguish at initial stage. Studies revealed that metastatic orbital lesions account for 1%–13% of all orbital tumors., Orbital tumor metastases primarily originated from breast carcinoma (48%–53%), lung carcinoma (8%–12%), prostate carcinoma (3%–10%), and thyroid carcinoma (3%) that predominantly manifested by papillary thyroid carcinoma (PTC).,,,
It is difficult to confirm a metastatic lesion without known history of primary malignancy. We reported three cases of thyroid carcinoma with orbital mass as the initial presentation that were found within <1.5 year in our hospital.
| Case Reports|| |
A 65-year-old female complained of painful mass of left eye (LE) for 3 months [Figure 1]a. The patient had a lump on her right neck 10 years ago which revealed to be an adenomatous goiter from isthmusectomy. Visual acuity of the LE was 20/40, with a notable downward proptosis and limitation on upward gaze. The orbital mass was 4 cm × 5 cm × 3 cm in size. Anterior and posterior segments of the eye were unremarkable. Orbital computed tomography (CT) scan showed an extraconal solid contrast-enhancing mass at the superior left orbit extending intracranially [Figure 2]. Orbital mass incisional biopsy through frontorbital approached showed a well-differentiated thyroid carcinoma.
|Figure 1: Patient 1. (a) Initial clinical presentation. Smooth surface and non-tender mass was noted along the superior orbital rim. (b) Posttumor removal surgery and craniotomy. (Fronto-temporal approach)|
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|Figure 2: Orbital computed tomography scan of Patient 1. Tumor on the left orbit extended to the orbital roof, left lateral wall of anterior ethmoid sinus, and left inferoposterior wall of frontal sinus with noticeable bone destruction (a) Axial view. (b) Coronal view|
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Further examination discovered a mobile, solid, smooth-surfaced, nontender mass on the left neck, measuring 2 cm × 2 cm × 1 cm. Thyroid histopathological examination showed adenomatous goiter with follicular variant of PTC. Thorax and abdominal CT scan discovered multiple metastatic thyroid tissues in the left orbital, lung, liver, vertebrae, humerus, and iliac.
A total dose of 150 mCi of radioactive iodine-131 (RAI) therapy was given. Total tumor removal was done through craniotomy with preoperative digital subtraction angiography embolization to coagulate the tumor blush remnants [Figure 1]b. The patient was maintained with levothyroxine and calcium supplements during 8 months of follow-up.
A 28-year-old female presented with 4 years history of enlarging mass on the right upper eyelid [Figure 3]a. The visual acuity of the right eye (RE) was 20/40 with a palpable, nontender, fixated solid mass on the upper eyelid, measuring 2 cm × 3 cm × 4 cm. RE was heavily protruded, but the eye movement was good. Anterior and posterior segment of the eye were unremarkable. Orbital CT scan showed an aggressive solid contrast-enhancing mass expanded intracranially and attached to the right frontal dura mater [Figure 4]. Orbital mass incisional biopsy through frontorbital approached showed a well-differentiated thyroid carcinoma.
|Figure 3: Initial clinical presentation. (a) Patient 2. A palpable mass with unilateral non-axial proptosis toward the inferior of the right eye. (b) Patient 3. A palpable mass, measuring 10 cm × 7 cm × 3 cm, with non-axial proptosis toward the inferolateral, 15-mm lagophthalmos, and full corneal exposure|
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|Figure 4: Orbital computed tomography scan of Patient 2. Aggressive solid mass, measuring 2.3 cm × 3.5 cm × 4.1 cm, on the right frontal bone expanded to intracranial and pushed the right bulbus oculi and right superior rectus muscle toward the inferolateral. (a) Axial view. (b) Coronal view|
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Further examination revealed a mobile 1 cm × 1 cm × 1 cm solid mass on the right thyroid that was unnoticed by the patient before. Biopsy showed follicular and solid variant of PTC. No other metastases were found. RAI therapy was performed followed by tumor removal through craniotomy. The patient was maintained with 1 × 150 mg propylthiouracil during 8 months of follow-up.
A 62-year-old female presented with an enlarged mass on the LE pushing the eyeball downward for 18 months. LE had progressive blurry vision and white lesion on pupil since 1 year [Figure 3]b. She had no light perception on the LE with well-defined margin, fixated, and lobulated solid mass expanding from frontal to superior orbital rim, measuring 10 cm × 7 cm × 3 cm. Eye movement was restricted to all directions. Cicatrix and neovascularization were found on the central cornea. Anterior chamber was deep, but cell and flare were hard to be evaluated. Other slit-lamp examination of the LE was hard to be performed due to the corneal haziness. There was no abnormality on the right eye. Orbital CT scan showed an irregular lobulated extraconal solid contrast-enhancing mass in the superomedial quadrant of the LE. The mass was attached to the left superior rectus muscle and destructed the left medial-superior wall of the orbital rim and the left frontal bone. It expanded toward the sinus and brain. Infiltration toward the left intraocular was unclear [Figure 5]. Orbital mass incisional biopsy through frontorbital approached showed a well-differentiated thyroid carcinoma.
|Figure 5: Orbital computed tomography scan of Patient 3. Computed tomography scan showed an irregular lobulated extraconal solid mass of 5.5 cm × 5.3 cm × 5.6 cm with distinct margin and necrotic components on the medial of left orbit. (a) Axial view. (b) Coronal view|
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The patient had an 11 cm × 8 cm × 6 cm nonprogressing mass on her right thyroid for 20 years. Biopsy revealed follicular and solid variants of PTC. Metastatic tissues were discovered in the lung through thorax CT. RAI therapy was performed. Doxorubicin was prescribed and the patient was maintained with levothyroxine during 6 months of follow-up.
| Discussion|| |
Thyroid carcinoma rarely metastasizes to the orbit and occurs less frequently than intraocular metastases. In studies of 134 cases of orbital metastases, only 3% were found originally from thyroid carcinoma.
We reported three cases of orbital metastases derived from thyroid carcinoma with wide range of age difference (28–65 years old), which is in line with previous study (16–75 years old). In addition, patients over 45 years old showed progressive manifestation with distant metastatic diseases.
Besic and Luznik reported that unilateral proptosis and diplopia are the primary symptoms of thyroid carcinoma with orbital metastases. Other symptoms were a firm nontender mass on the supraorbital region, pain, deteriorating vision, and ptosis., Our study outlined that all patients experienced prominent unilateral proptosis, orbital mass in the superior quadrant, and limited eyeball movement
The onset of progressivity in this case series varies between 3 months and 4 years. There is not yet a conclusive descriptive study on the onset of progressivity of orbital metastasis due to thyroid carcinoma. However, 3 months was quite rapid compared to the previous cases that had shown the onset varies from 1 to 2 years., Some metastases grow at a relatively slow rate and may mimic a benign lesion as shown in case 2. The mass enlarged only 2 cm × 3 cm × 4 cm in 4 years, contrast with case 1 which enlarged to 4 cm × 5 cm × 3 cm in 3 months or case 3 which enlarged to 10 cm × 7 cm × 3 cm in 18 months. Therefore, it is very important to make an accurate diagnosis because a delayed diagnosis would result in increased morbidity or mortality.
Pagsisihan et al. suggested that ten out of thirteen cases of thyroid carcinoma with orbital metastases were initially presented with orbital metastases. Our patients came with initial complaint on their eyes although they had persisting mass on the neck, except one patient who was unaware her lump before. Occasionally, occurrence of distant metastases of thyroid malignancy as the initial manifestation may present without clinically apparent disorder in the thyroid region.
There are some other options to investigate the orbital mass, including CT scan and magnetic resonance imaging (MRI). We did not assess the MRI due to policy national health insurance limitation and long queues for MRI. Metastatic orbital lesions predominantly emerge in the anterior orbit. Appearances of extraconal lesion with involvement of the extraocular muscles and bone are more likely to be metastases., CT scan in this study revealed extraconal solid masses, involving adjacent structures, expanded intracranially and/or intrasinusly, and located in the superior orbit. Thus, it supports our presumption that these lesions are metastatic which was proven in the biopsy result.,
There was destruction of the orbital bone in all three cases, that was on orbital roof, lateral wall of anterior ethmoid sinus, inferoposterior wall of frontal sinus [Figure 2], medial-superior wall of the orbital rim, and frontal bone [Figure 5]. Thyroid carcinoma with orbital metastasis may have adverse effect on the bone, extraocular muscle, and lacrimal gland. Paranasal sinus involvement in thyroid malignancy commonly occurred in maxillary sinus followed by the sphenoid sinus, ethmoid, and frontal sinus.
Histopathological analysis showed that all orbital lesions in these cases were follicular variant of PTC (FVPTC), one of the PTC variants. FVPTC is clinically indolent and slow-growing tumor, but it may become aggressive, spreading locally, and causing distant metastases in some cases. It forms multiple tumor foci in the gland, spread through lymphatic system, or hematogenously.,
There was no complication in these cases. Patient 1 and 2 are doing well during 8 months of follow-up after tumor removal, whereas patient 3 is suffering in cancer pain during 6 months of follow-up after chemotherapy. Regardless of the type of thyroid carcinoma, poor prognosis is often derived from older age (≥55 years old) at diagnosis and widespread metastatic diseases. Based on the American Joint Committee of Cancer 8 thyroid carcinoma staging, distant metastasis case with age at diagnosis <55 years was categorized as stage II with expected 10-year survival 85%–95%, while distant metastasis in age ≥55 years was categorized as stage IVB with 10-year survival <50%. Therefore, case 2 (29 years old) seemed to have better prognosis than the other. Surgical excision may provide benefit in enhancing disease control for metastases of thyroid carcinoma to the eye., Case 3 had the larger mass that not possible for debulking and had intracranial expansion. This was an advanced stage of orbital metastases and life-threatening condition, that rarely occurred in literature. Chemotherapy was expected to improve the patient's condition, such as reduction of the mass, so that surgical therapy may be performed more easily.
Orbital metastases of thyroid carcinoma are considered uncommon; however, in elderly women with orbital metastases, thyroid carcinoma should not be ruled out as the potential primary tumor. Ophthalmologists should take a comprehensive history and physical examination as orbital metastatic mass may be found without clear organ disorder of metastasis origin. Furthermore, when imaging shows a tumor located in the superior orbital expanding to the intracranial region, one has to consider about the possibilities of orbital metastases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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
Conflicts of interest
There are no conflicts of interest.
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