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Editor,—The sites of primary tumour metastatic to the orbit have been well documented by several major surveys. Metastatic breast, lung, and prostate carcinoma account for most of the orbital metastases.1-7 To our knowledge, orbital metastasis from carcinoma of the cervix has not been described before. We report a 46-year-old Chinese woman in whom orbital metastasis developed 4 months after she was diagnosed to have squamous carcinoma of the cervix.
A 46-year-old Chinese woman was diagnosed to have squamous cell carcinoma of the cervix FIGO stage IIB in February 1993. She received radiation therapy to the pelvis from 16 March to 22 April 1993. She started to develop a right proptosis in June and presented to us in late October 1993 (Fig 1). Ocular examination showed a visual acuity of 6/24 right and 6/9 left with normal colour vision. Hertel’s exophthalmometer confirmed the right proptosis (23 mm right, 15 mm left). Ocular movement was limited in all directions of gaze. Intraocular pressures were 25 mm Hg right and 18 mm Hg left. The pupillary reactions were normal. Fundus examination did not reveal any disc swelling. Computer tomography of the orbit revealed a mass with its epicentre in the lateral orbital wall, within the greater wing of the right sphenoid bone; the mass had extended into the orbit, deviating the lateral rectus muscle and compressing the optic nerve at the orbital apex. It also extended into the anterior aspect of middle cranial fossa and the right frontal sinus (Fig 2). One week later, she presented with severe right proptosis and sudden loss of vision in the right eye. Ocular examination showed a vision of no light perception in the right and 6/9 in the left. Right relative afferent pupillary defect was present. Emergency lateral cathotomy and inferior cantholysis followed by tarsorrhaphy were performed for the right proptosis. Fine needle biopsy of the right orbital tissue showed scattered sheets of malignant epithelial cells with hyperchromatic, pleomorphic nuclei and abundant but non-keratinising cytoplasm, consistent with the diagnosis of a large cell non-keratinising carcinoma from the cervix (Fig 3). The patient subsequently received a low dose radiation therapy to the orbit from 22 November to 3 December 1993. Her proptosis improved, but her right vision remained at that of no light perception. She died in February 1994.
Malignant neoplasm from a distant primary site generally metastasises by haematogenous route to the orbit in which lymphatic channels are absent.1 Several major surveys have shown that breast, lung, and prostate carcinoma comprise the largest groups of metastatic cancer to the orbit with occult primary tumour also forming a significant proportion.1-7 To our knowledge, orbital metastasis from carcinoma of the cervix has not been reported before even though carcinoma of the cervix is one of the commonest tumours in women.8-10
Proptosis and motility disturbance are the commonest presenting symptoms and signs of orbital metastasis.1-7 The onset of symptoms is typically rapid, unrelenting, and progressive over a few days or months,7 as demonstrated in our case in which the patient became blind within 4 months of onset of symptoms.
Most patients die within a year of diagnosis of orbital metastasis1 and our patient is no exception. This case also illustrates the importance of fine needle aspiration biopsy as an adjunctive tool in the diagnosis of orbital metastasis as it is less invasive than open biopsy. Several studies have shown that about a quarter of patients with orbital metastases develop ocular symptoms before the diagnosis of primary neoplasm.1 Hence a high index of suspicion and good clinical judgment on the part of ophthalmologists are important in leading to an earlier diagnosis of systemic cancer which will have a profound impact on the patient’s prognosis. This case suggests that screening for malignancy of the cervix might be useful as part of the systemic examination for cases of orbital metastases without known primary tumour sites.
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