Discrete carcinomatous metastases in the extraocular muscles.

The orbit is a rare site for metastatic carcinoma (Duke-Elder, I952) and, although such orbital deposits may commonly involve muscle secondarily, discrete metastatic tumours in the extraocular muscles are extremely rare, as in muscle generally (Willis, I952, I953).A search of the literature has revealed four previous cases: two from carcinoma of the breast (Wintersteiner, I899; Bedford and Daniel, i960), one from carcinoma of the lung (Horner, I864), and one from malignant melanoma of the skin (Adelstein and Schmidt, I 968).This paper reports two further cases of extraocular muscle metastases from primary carcinoma of the breast, and outlines some of the diagnostic difficulties which arose. Case reportsCase i, a housewife aged 58 years, presented with a lump of 2 months' duration in the left upper lid towards the inner canthus.Apart from a sense of heaviness of the lid there was no pain or any other symptom.A biopsy was taken, but the histology proved puzzling; the biopsy was repeated and a malignant neoplasm of unknown origin was reported.A third biopsy was diagnosed bv the hospital pathologists as fibrosarcoma. SurgeryExploration of the orbit revealed a tumour mass discretely involving the extraocular muscles, and it was widely excised.Histopathologv (5957/59) Sections of all biopsies stained with haematoxylin and eosin showed identical histological features.The orbital muscle was infiltrated by an entirely anaplastic mass of polyhedral, spheroidal, and spindle cells having hyperchromatic nuclei with abundant pinkish cytoplasm and a tendency to arrange themselves in whorls or columns: mitotic figures were not seen (Figs I, 2, and 3).An interesting feature of this case was the great difficulty in reaching a conclusive diagnosis; there were several suggestions, most of which, when looked at in retrospect, were surprisingly wide of the mark.The lesion was at first thought to be a xanthomatous deposit, but fat stains of frozen sections were negative and at this early stage a malignant synovioma or secondary deposit were also queried.Sections were sent to a number of senior pathologists for second opinions and the replies received included meningioma, atypical fibrosarcoma, and renal carcinomatous metastasis, while a Consultant Histological Panel suggested myoblastoma, meibomian gland tumour, or meningioma.Subsequent clinical course Investigation in hospital failed to reveal a primary tumour.The orbital neoplasm was widely excised and the patient was discharged from hospital.One year after the onset of the lump in the