Acute proptosis as an initial presentation of bronchogenic carcinoma.

Sir, A 47 years non-smoker male presented with acute onset painless, rapidly progressive left ocular bulging for last seven to ten days. Patient also had diffi culty in left lateral gaze that caused double vision. He learnt to adapt to this by turning his head to the left. There was no other ocular symptom or symptoms pertaining to other body system. His past, personal and family history was non-contributory. On examination, the patient had moderate pallor and tender, fi rm hepatomegaly. Lymph nodes were not palpable. Most striking clinical sign was proptosis of the left eye. Detailed examination revealed lateral, superior and inferior rectus palsy along with conjunctival congestion. However, pupillary reaction was present and forced duction test was positiveexcluding both primary neurologic or muscular disease. Ophthalmoscopy showed no signifi cant abnormality. Examination of other systems was non-contributory. Investigations showed Hb= 8.6 gm%, ESR=106 mm at 1st hour, and alkaline phosphatase 482 U/L. All other routine investigations and thyroid function tests were normal including a negative anti-thyroperoxidase antibody. Ultrasound examination of the left eye revealed destruction of the lateral orbital wall by a heterogeneous mass with bony spicules. CT scan of orbit confi rmed the mass as an extraconal lesion. Chest X-ray revealed a 3 cm diameter mass in the right upper and mid zones with blunting of right costophrenic angle. CT scan of thorax, showed enlarged lymphnodes in pretracheal, precarinal, right paratracheal and subcarinal region. An inhomogeneously enhancing soft tissue density lesion was seen involving the right upper lobe extending to the pleural surface. Ultrasound of the abdomen revealed enlarged liver with multiple hypoechoic metastatic deposit. The lung mass on FNAC was diagnosed as large cell bronchogenic carcinoma. CT-guided FNAC from both the orbital mass and hepatic deposits corroborated with the diagnosis of metastatic large cell lung cancer. A whole body scintigram revealed multiple bony metastases involving left orbital wall, vault of the skull, lower cervical spine, and lumbosacral spine. The patient was given systemic chemotherapy (cisplatin and etoposide) and irradiation of left orbital tumor. A favourable response was achieved in ocular movements. Patient died one month later because of progression of the primary lesion. Metastatic orbital tumours represent 1.5% of all orbital tumours and tumour-like conditions1. The primary sites are breast (51-3%), prostate (12-17%), lungs (6-8%), gut (3-6%), kidney (3-5%), adrenal (1%), and unknown (10-11)1. The most common presenting signs and symptoms include diplopia with non-comitant strabismus (54%), proptosis (50%), and a palpable mass (43%).1 In 19-26% cases, the orbital metastasis may be the initial presentation.1 The average patient survival after the diagnosis is 13 months. Treatment includes chemotherapy, irradiation, hormone therapy, surgical excision, or observation depending on the clinical circumstances.1 Lung cancers tend to metastasize to the bone (25%), liver (20%), lymph nodes (20%), and brain (5-0%)2. Ocular and orbital involvement occurs in less than 1% of cases.2 The presence of distant metastasis at the time of initial diagnosis is signifi cantly higher in small cell lung cancer (84%), while brain and orbital metastases are more common with adenocarcinomas (56%).2 There are case reports of non-large cell bronchogenic carcinomas presenting as proptosis, often acutely.3 Extensive literature survey does not reveal any report of large cell bronchogenic carcinoma with orbital metastasis and that too as the initial presentation. This makes our case a unique one. In conclusion, physicians should consider the possibility of metastatic malignancy in patients presenting with acute onset proptosis particularly if it is unilateral. SK Bandyopadhyay*, Ranjana Bandyopadhyay+, Anita Dutta** *Assistant Professor, **Professor, Department of Medicine, Nil Ratan Sircar Medical College, 138, AJC Bose Road, Kolkata 14; +Consultant Pathologist, North City Hospital, Kolkata 54. Received : 5.5.2004; Revised : 17.8.2004; Re-Revised : 12.12.2005; Accepted : 10.4.2006