Orbital Swelling as the Presenting Symptom of Gastric Adenocarcinoma

Abstract

Gastric cancer is one of the most common malignancies in the world, with liver, peritoneum, lung, and bone being the most common sites of metastasis. Orbital metastasis from gastric adenocarcinoma is uncommon and can be easily misdiagnosed as a cellulitis or other infiltrative disorder. A 57-year-old male with history of cognitive delay presented with blurry vision, pain, and swelling around the right eye for one week. Review of systems was pertinent for epigastric pain, nausea, and weight loss. Physical examination was significant for right eye proptosis, periorbital soft tissue swelling, scleral icterus, jaundice, and cervical lymphadenopathy. Computed tomography of the orbits demonstrated bilateral coronal and intra-conal masses inseparable from the optic nerves. Biopsy of the right orbital lesion demonstrated mucinous tumor cells positive for CAM 5.2, CDX 2, and CEA-p. Computed tomography of the abdomen and pelvis demonstrated irregular thickening and hyper-enhancement of the distal gastric body and antrum with bulky lymphadenopathy of the retroperitoneum. ERCP and EGD were attempted; EGD demonstrated a large, deep, necrotic and ulcerated area of the lesser curvature extending into the proximal duodenum, causing deformity and narrowing of the antrum. ERCP was terminated as the endoscope could not be advanced past the gastric mass. Biopsy of the ulcer demonstrated poorly differentiated adenocarcinoma with signet ring cell features and Helicobacter pylori-associated gastritis. A final diagnosis of stage IV mucinous gastric adenocarcinoma was made. Due to his functional level and stage of disease the patient opted to be discharged home with hospice care. Orbital metastasis is a very rare complication of gastric adenocarcinoma, usually occurring late in the course. The most common presenting symptoms include diplopia, pain, and visual loss, while proptosis, strabismus, and vision impairment are the most frequent clinical signs. This case represents a variable presentation of gastric adenocarcinoma that should be kept in the differential of a patient presenting with orbital swelling and alarm symptoms, such as unexplained weight loss, abdominal pain, bloating, or jaundice. Physicians should be aware of the metastatic potential of gastrointestinal malignancy to the eye as these lesions can precede systemic manifestations. A complete ocular examination and comprehensive systemic survey are essential to the work-up of orbital swelling.2613_A Figure 1. Computed tomography of orbits demonstrating intraconal medial rectus muscle mass.2613_B Figure 2. Gastric adenocarcinoma as seen through endoscopy.2613_C Figure 3. Gastric adenocarcinoma as seen through endoscopy.