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Lateral rectus muscle biopsy as diagnosis of unknown metastatic breast cancer
Biopsia del músculo recto lateral orbitario como diagnóstico de cáncer de mama metastásico no conocido
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"apellidos" => "Mayol Belda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "E." "apellidos" => "Mengual Verdú" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital de San Juan de Alicante, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Oncología, Hospital de San Juan de Alicante, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital de San Juan de Alicante, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Biopsia del músculo recto lateral orbitario como diagnóstico de cáncer de mama metastásico no conocido" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 784 "Ancho" => 1400 "Tamanyo" => 171065 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Extrinsic ocular movement examination with left eye abduction limitation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Clinic case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">Female, 58, without relevant medical history, who visited due to binocular diplopia with one week evolution associated to rib pain, dyspnea, intense asthenia and loss of weight with 2 months evolution, together with disorientation episodes and ambulation impairment. The emergency analysis produced hypercalcemia, kidney insufficiency and bicytopenia, while chest X-ray revealed lytic bone lesions initially suggesting multiple myeloma with extra-osseous involvement. The patient was admitted for study, exhibiting dyspnea without association, tumor hypercalcemia associated to disorientation, corrected after administration of zoledronic acid (Zometa<span class="elsevierStyleSup">®</span>). In addition, the patient exhibited bicytopenia with anemia and thrombocytopenia grade <span class="elsevierStyleSmallCaps">iv</span> requiring repeated transfusions.</p><p id="par0010" class="elsevierStylePara elsevierViewall">At the ophthalmological level, the patient exhibited horizontal diplopia with limited abduction in the left eye (LE) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Visual acuity was preserved in both eyes, with 0.7 in the right eye and 0.6 in the left eye (measured with portable Snellen chart), without observing alterations in anterior pole or eye fundus. Examination was carried out at the bedside due to the poor general condition of the patient with a portable slit lamp.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient admission was indicated by the Internal Medicine Dept. which carried out cerebral CT and thoracoabdominal CT without contrast. In addition, bone marrow aspiration was performed, the analysis of which reported hypoplasia secondary to metastatic infiltration of unknown primary source, and proteingram in blood and urine with normal results, diminishing the probability of myeloma diagnostic.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Thoracoabdominal CT without contrast due to kidney insufficiency revealed multiple paratracheal and infrahilar mediastinic adenopathies, pre-vascular, supraclavicular and axillary bilateral ganglions, left pleural effusion, thin pericardium effusion and pathological rib fractures. The abdomen also exhibited retroperitoneal adenopathies and multiple vertebral diffuse lytic lesions with permeation pattern.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Cranial CT without contrast due to kidney insufficiency showed diffuse and lytic bone involvement in the calotte in permeating “salt and pepper” pattern with associated soft parts component. In addition, a lesion adjacent to the lateral wall of the left orbit was observed, exhibiting soft parts density measuring 3<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.2<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>1.6<span class="elsevierStyleHsp" style=""></span>cm, that includes the external rectus muscle exerting a mass effect on the optic nerve causing medial displacement (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Due to these findings, external rectus lesion biopsy was indicated.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">With prior transfusion of platelets, in the same day the CT-guided sacral bone biopsy and the lateral rectus muscle biopsy (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) were taken. Both biopsies produced the same result, i.e., the epithelial cells with positive CK 19 and 7 immunophenotype, hormonal receptors for positive diffuse estrogens and for progesterone positive (30%), with a Ki67 cell proliferation index (MIB1) of 12% and negative herceptest. These findings suggested carcinoma metastases compatible with mammary origin.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Subsequent physical examination confirmed the presence of a supra-areolar nodule through palpation of the left breast, although it was decided not to take a mammography or biopsy due to the clinic condition of the patient. Due to the persistence of thrombocytopenia and anemia secondary to bone marrow infiltration together with the clinic worsening of the patient despite medical treatment, together with visceral crisis due to metastatic breast cancer stage.</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSmallCaps">IV</span> luminal A, chemotherapy treatment was initiated on the basis of paclitaxel scheme (Taxol<span class="elsevierStyleSup">®</span>) 80<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span> at 80% of the dosage on days 1, 8 and 15 every 21 days, associating zolendronic acid (Zometa<span class="elsevierStyleSup">®</span>) with each cycle.</p><p id="par0045" class="elsevierStylePara elsevierViewall">After beginning chemotherapy treatment, the patient exhibited progressive clinic improvement with control of dyspnea, beginning ambulation with rehabilitation treatment, progressive improvement of thrombocytopenia and without treatment-derived toxicity. Ophthalmological clinic did not evidence anatomical or clinical improvement or worsening of the lesion in successive radiological controls. After 73 days in the hospital, the patient requested transfer to her country to continue recovery with rest and prescribed treatment.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0050" class="elsevierStylePara elsevierViewall">An atypical case of horizontal diplopia in the context of a patient with severe overall condition without established diagnostic is presented. Lateral rectus biopsy together with brain marrow biopsy were key to reach confirmation diagnostic.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Tumor orbital metastases is a rare disease with an incidence of 1–13% of all orbital tumors,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> accounting for a lower percentage than metastasis at the ocular level. In up to 25% of cases, orbital metastasis is the initial presentation of undiagnosed cancer.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Breast cancer is the tumor that most frequently produces metastases at the orbital level in adults, mainly compromising periorbital fat and extraocular muscles, with a preference for the lateral orbital quadrant.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Ophthalmological clinic generally debuts with diplopia, proptosis or ocular movement alterations.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> The latency period observed in breast cancer metastasis is longer compared to other types of primary cancer (mean 4.5–6.5 years).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Histological diagnostic through orbital biopsy should only be carried out if the primary tumor is not known as in this case, or when the orbit is the only likely metastasis location as this would involve a significant prognostic modification. The most widely accepted technique at present is open surgical biopsy, as PAAF has demonstrated to involve the risk of tumor dissemination.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> In the present case, presentation symptom was ocular (binocular diplopia) with the orbital lesion biopsy being decisive for diagnostic.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">No conflict of interests was declared by the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1173018" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1097152" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1173017" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1097151" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Clinic case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-13" "fechaAceptado" => "2018-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1097152" "palabras" => array:4 [ 0 => "Metastatic breast cancer" 1 => "Diplopia" 2 => "Ocular metastasis" 3 => "Orbital biopsy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1097151" "palabras" => array:4 [ 0 => "Metástasis de cáncer de mama" 1 => "Diplopía" 2 => "Metástasis ocular" 3 => "Biopsia orbitaria" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The case concerns a 58 year-old female with no medical history of interest who consulted due to binocular diplopia of one week onset. It was associated with costal pain, dyspnea, intense asthenia and weight loss of 2 months onset. In the blood analysis in the Emergency Department it showed hypercalcaemia, renal failure, and bicytopenia. The chest X-ray showed lytic bone lesions that initially lead to multiple myeloma with extra-osseous involvement.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In addition to the corresponding study, in case of horizontal diplopia, a cranial CT scan without contrast was performed where an adjacent lesion to the lateral wall of the left orbit is observed. This was of soft tissue density, and included the external rectus muscle that exerts a mass effect on the optic nerve by displacing it medially. Many lytic bone diffuse lesions with salt and pepper pattern were found in the calotte. A rectus lateral muscle and bone biopsy of the sacral wing was performed, resulting in metastasis of carcinoma compatible with mammary origin.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">An atypical case is presented of horizontal diplopia in the context of a patient with a severe constitutional picture with no established diagnosis, in which the biopsy of the lateral rectum was key to the confirmation diagnosis.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mujer de 58 años sin antecedentes médicos de interés que consulta por diplopía binocular de una semana de evolución, asociada a dolor costal, disnea, astenia intensa y pérdida de peso de 2 meses de evolución. En la analítica de urgencia presenta hipercalcemia, insuficiencia renal y bicitopenia, y en la radiografía de tórax de urgencias se observan múltiples imágenes osteoclásticas que orientan inicialmente a mieloma múltiple con afectación extraósea.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Además del estudio correspondiente, ante la diplopía horizontal se realiza TC craneal sin contraste, donde se observa una lesión adyacente a la pared lateral de la órbita izquierda, de densidad de partes blandas, que incluye el músculo recto externo y ejerce efecto masa sobre el nervio óptico desplazándolo medialmente. Además se observan múltiples lesiones líticas de distribución difusa en la calota, con patrón permeativo «en sal y pimienta». Se procede a la biopsia del músculo recto lateral y ósea de ala sacra, obteniendo como resultado metástasis de carcinoma compatible con origen mamario.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentamos un caso atípico de diplopía horizontal en el contexto de una paciente con un cuadro constitucional severo sin diagnóstico establecido, en el que la biopsia del recto lateral, junto con la biopsia de médula ósea, son claves a la hora del diagnóstico de confirmación.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Hernández Pardines F, Serra Verdú MC, Bernal Vidal A, Mayol Belda JM, Mengual Verdú E. Biopsia del músculo recto lateral orbitario como diagnóstico de cáncer de mama metastásico no conocido. Arch Soc Esp Oftalmol. 2019;94:192–195.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 784 "Ancho" => 1400 "Tamanyo" => 171065 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Extrinsic ocular movement examination with left eye abduction limitation.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 993 "Ancho" => 900 "Tamanyo" => 88886 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Lesion adjacent to lateral left orbit wall, with soft parts density including the external rectus muscle and exerting a mass effect on the optic nerve.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 520 "Ancho" => 1250 "Tamanyo" => 136750 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Pathological anatomy of lateral rectus biopsy (20× increase). 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