An Orbital Metastasis of Prostate Adenocarcinoma: A Rare Case Report

Rogelio F Varela Jr MD 1, Joseph Ursua MD 1, Jaime C Balingit MD FPUA FPCS1 Lawrence Joseph S Valdez MD 2, Gloria Lim MD 2
1 2

Department of Urology, East Avenue Medical Center Department of Health, Eye Center, East Avenue Medical Center

Abstract A patient with known prostatic cancer presented with left supraorbital swelling with remarkable proptosis and restricted eye movements on left eye. Contrast enhanced computed tomography scan revealed dural and bone metastases with soft tissue component extending to the left orbit. Serum prostate specific antigen was markedly elevated at >100 ng/ml. Incision biopsy of the orbital tumor revealed only lymphocytic inflammatory cells within the fibrous stroma attributed mainly to the deeper location of the tumor or shallow locus of the biopsy. Incisional biopsy of the frontal bone revealed atypical looking cells in sheet cluster with nuclear enlargement, hyperchromatic in irregularity confirming the diagnosis of orbital metastasis of prostate carcinoma. Metastasis of prostate cancer to the orbit is rare. One should have a high index of suspicion of orbital metastasis when presented with an elderly patient with ocular symptoms and a history of prostate adenocarcinoma. A thorough clinical, radiological and histological evaluation is necessary to establish the diagnosis.

Keywords: Orbital metastasis, Ocular metastasis, Prostate Adenocarcinoma Introduction. Despite the aggressive struggle to fight the dreaded disease, prostate cancer remains to be one of the most common cancers among men. In fact, the American Urological Association recently stated that it is the second-leading cause of cancer deaths among men in the United States, and significant health-care problems due to its high incidence. 1 Prostate adenocarcinoma has recognizable metastases; with the axial skeleton and pelvic lymph nodes as common sites of spread. 2 Kattah in 1993 stated that although there are reports of prostate cancer involving the skull convexity, the skull base and orbits are less commonly affected. 3 Metastatic orbital lesions are relatively uncommon in prostate cancer. 4 Case Report. A 75-year-old male came in for swelling of the left eye (Fig 1). Nine years earlier, he was diagnosed with Prostate Adenocarcinoma Gleason 7 (4+3), after cystoscopy with transurethral resection of prostate. He underwent surgical castration through bilateral orchiectomy. After which, he did not follow-up with his urologists. The present condition is an 8-month history of gradual left supraorbital swelling with occasional fronto-temporal headache. During the last 2 weeks, the symptoms had been worsening. He denied any eye pain, diplopia, or change in visual acuity. Initial uncorrected visual acuity was 20/20-3 on right eye and 20/25 on the left. Ocular examination was remarkable for proptosis on left eye with some limitation of extraocular muscles (Fig 2). Physical examination revealed a firm, non-tender, non-movable bone-like lesion on the left fronto-temporal area compatible to a neoplastic process. A contrast enhanced

computer tomography scan of the cranium and orbit revealed dural and bone metastases as blastic changes in the left lateral frontal, left sphenoid and left occipital region with soft tissue component extending to the left orbit (Fig 3). Chest radiologic findings also revealed blastic lesions involving the visualized osseous structures probably due to a metastatic process. Fine needle aspiration cytology of the left orbit revealed positive for malignant cells showing atypical looking cell in sheet cluster. The individual cells display nuclear enlargement, hychromatic in irregularity surrounded by a hemorrhagic background (Fig 4). An incisional biopsy of the orbital tumor revealed only lymphocytic inflammatory cells within the fibrous stroma (Fig. 5). Incisional biopsy of the frontal bone revealed tumor cells within the fibrous stroma (Fig. 6). A serum prostate specific antigen was done revealing a markedly elevated result (>100 ng/ml; NV: 0-4 ng/ml). A transrectal ultrasound of the prostate revealed a small sized prostate gland with concretions and post-transurethral resection of prostate changes. Discussion. Orbital metastasis of the prostate adenocarcinoma is quite rare. In order to distinguish one from other orbital metastasis, Patel used the age of onset of symptoms and the histopathologic characteristic of the lesion as major differentiating features. It was noted that the mean age at onset of symptoms is greater among patients with prostate cancer versus that of other orbital metastasis (70.1 vs. 53.6 years). 4 Carrierre however reported that the age range of patients presenting with orbital metastases varies from 52 to 85, with the mean age of 70 years old. 5 Because of its rarity, there are only few published reports involving the prostate cancer metastasizing to the orbit.

In 1999, Long reviewed 508 Computed Tomographic studies of patients with prostate adenocarcinoma, and he reported that only 2.1% are noted with orbital or skull base metastasis. Proptosis, which was similarly found in our patient, was noted in 2 patients. He also observed that among the 508 patients, only 3.9% had highly elevated PSA (>100ng/dL) 2 A similar case was presented in 2005, when a 66-year-old gentleman presented with unilateral proptosis, eye pain with partial visual loss seven years after he was diagnosed with Prostate Adenocarcinoma, Gleason 6. Imaging studies of the orbits revealed a 2-cm lesion in the posterolateral right orbital wall near the optic foramen with compression of the optic nerve. After reinitiation of combined androgen blockade, the patients symptoms resolved. 4 Green in 1995 reported a similar case of prostate carcinoma that metastasized to the orbit. A 66-year old man presented with proptosis of the left eye, 2 years after being diagnosed with prostate adenocarcinoma gleason 9. The author noted that despite treatment with radical prostatectomy, bilateral orchiectomy, and a year later, radiotherapy, the patient still developed distant metastasis. 6 Baltogiannis noted that there are two (2) routes of metastasis: (1) Among patients with pulmonary metastasis, emboli can pass via the pulmonary circulation into the carotid arteries and subsequently into the ophthalmic artery. (2) In the absence of pulmonary lesions, prostatic or vertebral lesions may seed into Batsons plexus, and reach cranial venous sinuses traveling up to ophthalmic and vortex veins. 7 Clinical presentations of orbital metastases are, in order of frequency, decreased visual acuity, ocular pain, proptosis, retinal detachment, presence of a mass, uveitis (masquerade syndrome) and secondary glaucoma, as well as osteoblastic lesions of the orbital wall. 7

Computed tomography may guide the clinician to diagnose a prostate cancer metastasis to the orbit. Other orbital tumors may present as osteolytic lesions or softtissue masses, whereas prostate metastases to the orbit frequently present as osteoblastic lesions. 8 Osteolytic and mixed osteoblasticosteolytic lesions are also seen, but these are more common in the terminal stages of the disease, when the diagnosis of prostate cancer is more obvious. 9 The course of the disease for patients with prostatic orbital metastases is variable and depends on the time of onset of symptoms. The treatment of prostatic metastases to the orbit is palliative and does not alter the overall survival. Androgen ablation is the preferred treatment if the patient is hormone-nave. Local radiation therapy is also an effective alternative and has been used for palliation of symptoms in some cases. 4 References. 1. http://www.urologyhealth.org/urolo gy/index.cfm?article=146 2. Long MA, et. al. Review Article: Features of unusual metastases from prostate cancer. The British Journal of Radiology, 72 (1999) p.933-941 3. Kattah J, Chrousos G, Roberts J, Kolsky M, Zimmerman L and Manz H: Metastatic prostate cancer to the optic canal. Ophthalmology 100: 1711-1715, 1993. 4. Patel AR, et.al. Proptosis and

Decreased Vision Secondary to Prostate Cancer Orbital Wall Metastasis Anti-Cancer Research 25: 3521-3522 (2005) 5. Carrierre V, Karcioglu Z, Apple D and Insler M: A case of prostate carcinoma with bilateral orbital metastases and the review of the literature. Ophthalmology 89: 402406, 1982. 6. Green S, Bilateral Orbital Metastases from Prostate Carcinoma: Case Presentation and CT Findings American Society of Neuroradiology 16:417419, Feb 1995 7. Baltogiannis D, Kalogeropoulos C, Loachim E, Agnantis N, Pailas K and Giannakopoulos X: Orbital metastasis from prostatic carcinoma. Urologia Int 70: 219-222, 2003. 8. Boldt H and Nerad J: Orbital metastases from prostate carcinoma. Arch Ophthal 106: 1403-1408, 1988. 9. Plesnicar S: The course of metastatic disease originating from carcinoma of the prostate. Clin Exp Metastases 3: 103-110, 1985. 10. Nayyar R, et.al. Letter To Editor: Proptosis due to isolated soft tissue orbital metastasis of prostate carcinoma Indian Journal of Cancer, Vol. 47, No. 1, January-March, 2010, pp. 74-76

Figures and Images.

Fig. 1 75-year old man with swelling of the left eye.

Fig. 2 Ocular examination revealing some limited range of motion of the left extraocular muscles

Fig. 3 A contrast enhanced computer tomography scan of the cranium and orbit revealed dural
and bone metastases as blastic changes in the left lateral frontal, left sphenoid and left occipital region with soft tissue component extending to the left orbit (Red Arrow)

Fig 4

Fine needle aspiration cytology of the left orbit revealed positive for malignant cells showing atypical looking cell in sheet cluster. The individual cells display nuclear enlargement, hychromatic in irregularity surrounded by a hemorrhagic background

Fig 5 An incisional biopsy of the orbital tumor revealed only lymphocytic inflammatory cells
within the fibrous stroma (Fig. 5).

Fig. 6 Incisional biopsy of the frontal bone Fig. 7 High power field view of the tumour
revealed tumor cells within the fibrous cells within the fibrous stroma stroma