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A 64 year old man was referred to the Department of Ophthalmology (Southern General Hospital) with 4 month history of painless swelling of the left side of the left orbit. There was no diplopia. His general health appeared reasonably good. Examination showed fullness in the region of the lacrimal gland associated with ecchymosis (fig 1). Visual acuity was 20/20 in each eye. Direct coronal computerised tomography scan of the orbits (fig 2) showed the presence of an extensive ill defined mass lying in the anterior third of the orbit and displacing the globe medially and slightly downwards. The superior and lateral rectus muscles could not be seen separate from the mass anteriorly although they were defined posteriorly. There was no evidence of perineural spread. The radiologist concluded that the appearance is consistent with perilacrimal gland tumour but lymphoma and a secondary tumour should also be considered.
Biopsy of the orbital mass was initially considered to be a poorly differentiated adenocarcinoma of the lacrimal gland (reported by Professor W R Lee, Western Infirmary, Glasgow).
On further questioning (systemic review) the patient subsequently volunteered a history of dysphagia. In view of this history, barium meal examination was performed and a 4 cm shouldered stricture with associated mucosal irregularity was identified (fig 3).
An endoscopic biopsy of the oesophageal tumour revealed an infiltrating poorly differentiated squamous cell carcinoma with a histological pattern almost identical to that of the orbital tumour (fig 4, reported by Dr Richard Morton, Southern General Hospital)
In light of this development, the tumour obtained from the orbital biopsy was reviewed and the diagnosis of secondary deposits of a poorly differentiated metastatic squamous cell carcinoma of the oesophagus was made (fig 5, reported by Professor W R Lee, Western Infirmary, Glasgow)
The oesophageal stenosis was dilated and a stent inserted. He was treated with palliative radiotherapy to the oesophagus and the left orbit, but he died 3 months later of generalised metastatic disease.
At the time of initial examination, there was very little to indicate that the patient had metastatic disease. The most likely diagnosis in this patient therefore was a primary malignant tumour of the lacrimal gland with orbital extension. He was admitted for investigations and treatment
After the findings of the CT scan, it was deemed unlikely that the tumour could be excised. Accordingly the appropriate management was to perform a biopsy initially. This was done 2 weeks following his initial presentation. After the pathological report of a poorly differentiated tumour was made and the presence of metastasis suspected, the symptoms of dysphagia led to further investigation and demostration of an oesophageal primary carcinoma. (The oesophageal biopsy was done 10 days after the orbital biopsy).
The orbital tumours may be located anywhere in the orbit but presentation as a lacrimal gland tumour is unusual.
Only one report describes a metastatic oesophageal carcinoma to the intraconal orbit,4 but in this case, the clinicians were aware of the oesophageal disease before the occurrence of the orbital tumour.
As far as we know, our case is the first report of a silent carcinoma of the middle third of the oesophagus presenting as a lacrimal gland neoplasm and the case reiterates the importance of careful history taking and thorough preoperative assessment.