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Cases
Orbital Swelling and Pain in a Patient With Prostate Cancer
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Background
This 70-year-old man was found to have adenocarcinoma of the prostate in 1999. At that time, his prostate-specific antigen (PSA) value was 8 ng/dL, and his Gleason score was 8. He was treated with external beam radiation to the prostate.
One year after irradiation, the patient's PSA level started to rise. This biochemical recurrence was treated with complete androgen blockade with goserelin and bicalutamide. Despite treatment, his PSA level continued to rise, reaching 35 ng/dL. The patient was then referred to a urologist, who performed cryotherapy. His PSA value improved from 35 to 25 ng/dL.
The patient began to have severe fatigue and hot flashes due to goserelin. After a full discussion with the urologist, he consented to orchiectomy. Six months later, he began to have pain in his right eye and pain, swelling, and a headache in the right orbital area. The patient was evaluated by an otolaryngologist, who treated him for sinusitis and performed surgery to correct his deviated septum. These treatments provided some relief of his symptoms for a few weeks. However, the patient later felt fullness in his eye and went to an ophthalmologist, who found no retinal or choroids lesion. The patient's visual acuity was normal.
He then went to an oncologist, who ordered diagnostic tests, including orbital CT and bone scanning. What is the diagnosis?
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Scroll
down for Hint and Answer
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***** HINT *****
Could the problem be associated with the prostate cancer?
***** ANSWER *****
Orbital metastases from prostate cancer: In 85% of patients with metastatic prostate cancer, bone is involved. What is unusual (and clearly illustrated in this case) is that orbital and ocular metastases from prostate cancer are most often misdiagnosed as a primary eye, sinus, or neurologic condition. Ophthalmic manifestations of orbital metastases include diplopia, palsy of cranial nerves IV and VI, ptosis, exophthalmos, headache, and visual loss due to choroidal involvement or compression of the optic nerve. These findings can be mistaken for those of the other conditions.
This patient was seen by a radiation oncologist and an oncologist. He was treated with palliative irradiation to the orbit. Two weeks later, his headache resolved completely, but mild periorbital swelling persists. He may be enrolled in a chemotherapy trial for further palliation.
For more information about prostate cancer, please see the eMedicine articles Prostate Cancer: Metastatic and Advanced Disease, Prostate Cancer: Biology, Diagnosis, Pathology, Staging, and Natural History, and Prostate Carcinoma
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Author:
Mable W. Tan, MD, Assistant
Professor, Department of Geriatrics, University of Oklahoma City
Winston W. Tan, MD, FACP,
Assistant Professor, Department of Hematology Oncology, Mayo Clinic in Jacksonville
eMedicine Editor:
Sat Sharma, MD
Associate Professor, University of Manitoba, Department of Medicine, Division of Pulmonary Medicine
Source
http://emedicine.com
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