Figure 1. Clinical photographs showing the right brow deformity (A and B) that led the patient to seek medical attention.
Figure 2. Computed tomographic scans. Coronal (A) and axial (B) views show the bony destruction of the right orbit. L indicates left; R, right.
Whitman MC, Kazim M. Dent in the Forehead: A Rare Manifestation of Metastatic Cancer. Arch Ophthalmol. 2012;130(10):1349-1351. doi:10.1001/archophthalmol.2012.1490
Author Affiliations: Department of Ophthalmology, Edward Harkness Eye Institute, Columbia University, New York, New York.
A 67-year-old woman had a sunken deformity of her right brow associated with recurrent pain. Her medical history included herpes zoster, lymphoma, and breast cancer. Imaging revealed destruction of the right frontal bone and lateral wall of the right orbit. Despite the uniform lytic appearance on imaging, biopsy of the orbit revealed metastatic breast carcinoma. This case represents a remarkable level of unilateral bone destruction without significant symptoms, which is unusual for breast metastasis, and illustrates the importance of a tissue diagnosis of orbital masses.
A 67-year-old woman had a dent of her right brow associated with pain radiating to the temple for 2 to 3 weeks. She was otherwise asymptomatic. Her medical history included breast cancer in 2001 treated with modified radical mastectomy, chemotherapy, and radiation as well as follicular lymphoma in 2007 treated with rituximab and chemotherapy. She had right V1 shingles in 2009. Pain lasted only 6 weeks.
Ophthalmologic examination revealed visual acuity of 20/50 OU, normal pupils, full extraocular motion, no globe dystopia, normal levator function, a sunken deformity of the right brow (Figure 1), and Hertel measurements of 20 mm OD and 16 mm OS. There was no tenderness, edema, or inflammation of the region of the deformity, conjunctiva, or surrounding periorbital region.
Computed tomography of the orbits showed nearly complete destruction of the right frontal bone, including the frontal sinus and supraorbital ridge, destruction of the roof and lateral wall of the right orbit, the anterior portion of the zygoma, the anterior middle cranial fossa, the right olfactory groove, and the superior right lamina papyracea, with replacement by soft-tissue density. No mass effect or destruction of fat planes in the orbit or scalp was seen (Figure 2). This lesion was thought to be consistent with a neoplasm, recurrence of follicular lymphoma, or plasmacytoma.
Biopsy of the lateral orbital rim revealed a poorly differentiated metastatic carcinoma, consistent with breast origin, that was estrogen and progesterone receptor positive. Bone and positron emission tomographic scans revealed additional lesions in 2 ribs, 1 vertebral body, and the femur. She is currently being treated with fulvestrant, an estrogen receptor antagonist.
This case demonstrates several important points. The extensive unilateral (right-sided) bone loss surrounding the orbit, while producing few symptoms or signs, is highly atypical. The most common causes of destructive bone lesions in patients older than 40 years are bone metastasis, multiple myeloma, and lymphoma.1 Our patient had histories of breast cancer and lymphoma, both previously treated and in remission. Breast cancer frequently metastasizes to highly vascularized bones, producing lytic lesions of the long bones, ribs, vertebrae, sternum, pelvis, and ribs.2 Breast metastases to the skull base typically manifest with progressive cranial neuropathies in 1 of 5 syndromes: orbital, parasellar, middle fossa, jugular foramen, and occipital condyle.3,4 Despite the extensive cranial bone loss, our patient had no cranial neuropathies.
Myeloma and lymphoma are typically osteolytic, producing cortical and medullary bone destruction. Metastatic breast cancer can produce either osteoblastic lesions or a mixture of osteoblastic and osteoclastic lesions. In our patient, the nearly complete destruction of multiple skull bones is more typical of lymphoma or plasmacytoma than metastatic breast cancer. Of the 2 prior cancers, her lymphoma was treated more recently; her breast cancer was treated 10 years earlier and assumed to be cured. It is especially important to get a full history, including all previous cancers, as patients may not feel that a distant history of cancer in another body part is relevant to their ocular symptoms. This case illustrates the importance of obtaining a tissue diagnosis for appropriate treatment planning.
Correspondence: Dr Kazim, Department of Ophthalmology, Edward Harkness Eye Institute, Columbia University, 635 W 165th St, New York, NY 10032 (firstname.lastname@example.org).
Financial Disclosure: None reported.