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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 1  |  Page : 33-35

Metastatic lung adenocarcinoma presenting with isolated abducens palsy: Case report and literature review


1 Department of Medicine; Department of Neurology, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil
2 Department of Medicine, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil

Date of Submission01-Nov-2019
Date of Acceptance19-Feb-2020
Date of Web Publication07-Jul-2020

Correspondence Address:
Dr. Jamir Pitton Rissardo
Rua Roraima, Santa Maria, Rio Grande Do Sul
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_8_19

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  Abstract 


Almost half of the individuals with lung cancer will develop central nervous system metastases during the course of their disease. We report a case of an adult female presenting with progressive horizontal diplopia. Neurological examination showed horizontal diplopia in all directions of gaze. Eye movements were disconjugate when looking to the left; there was no abduction of the left eye. Bilateral vertical eye movements and right horizontal eye movements were intact. A cranial computed tomography (CT) scan revealed multiple lesions in both brain hemispheres suggestive of metastasis. An investigation to search suspected neoplasia of unknown origin was started. Chest CT scan with contrast revealed a large lesion, which was localized in the upper right lobe. An abdominal CT scan showed multiple lesions in the liver. A liver biopsy and the immunohistochemistry were diagnostic of adenocarcinoma of the lung. Three months after, the patient died due to septic shock following pneumonia.

Keywords: Abducens, adenocarcinoma, diplopia, lung


How to cite this article:
Rissardo JP, Fornari Caprara AL. Metastatic lung adenocarcinoma presenting with isolated abducens palsy: Case report and literature review. Amrita J Med 2020;16:33-5

How to cite this URL:
Rissardo JP, Fornari Caprara AL. Metastatic lung adenocarcinoma presenting with isolated abducens palsy: Case report and literature review. Amrita J Med [serial online] 2020 [cited 2020 Aug 5];16:33-5. Available from: http://www.ajmonline.org.in/text.asp?2020/16/1/33/289143




  Introduction Top


Adenocarcinoma of the lung is the most common type of non-small cell lung cancer (NSCLC). The clinical manifestations of this specific type of neoplasia are similar to other forms of lung cancer, and patients most commonly report persistent cough and dyspnea.[1] In this way, almost half of the individuals with lung cancer will develop central nervous system (CNS) metastases during the course of their disease.[2] However, the clinical presentation with isolated neurological symptoms is not frequent.

There are only a few cases of cancers presenting isolated abducens palsy that have been reported in the literature. More specifically, to the author's knowledge, there is one case report of an individual with metastatic small-cell lung cancer who developed the sixth cranial nerve paralysis.[3] Still, metastatic adenocarcinoma of the lung has not been reported until the present moment.

Here, we report a case of an elderly female who presented to our service with isolated left abduction palsy and after a systemic survey was diagnosed with adenocarcinoma.


  Case Report Top


A 65-year-old female presenting with double vision was admitted to our hospital. The patient reported that the horizontal diplopia started within 6 h and was progressively worsening. The individual denied other symptoms such as fever, headache, or eye pain. She was a previously healthy retired and her family history was negative for neurological diseases.

On neurological examination, she was right-handed and left abducens palsy was observed. Cranial nerve examination was remarkable for horizontal diplopia in all directions of gaze and was most prominent when focusing on distant objects especially and more so when looking toward the left. Eye movements were disconjugate when looking to the left; there was no abduction of the left eye. Bilateral vertical eye movements and right horizontal eye movements were intact. The patient was able to stand and walk a few steps with a wide-based gait, but not ataxic, with tendency to fall to the left due to diplopia. The pupils were symmetrical in both size and reaction to the light, and there was no ptosis, nystagmus, or skew deviation. The visual acuity was 20/20 in both sides. The fundoscopy showed normal color, deep excavations, blood vessels, and the optic discs with clear borders. Laboratory tests were within normal limits.

A cranial computed tomography (CT) scan revealed multiple lesions in both brain hemispheres, including a left posterior pontine lesion, which were suggestive of metastasis [Figure 1]. On neuroimaging, there were no signs of hemorrhage or intracranial hypertension.
Figure 1: Axial (a and b) cranial computed tomography showing a left pontine lesion

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An investigation to search suspected neoplasia of unknown origin was started. Cerebrospinal fluid analysis and opening pressure were normal. Chest CT scan with contrast revealed a large lesion of 10 cm, which was localized in the upper right lobe with an irregular thick wall. Mediastinal invasion and enlargement of lymph nodes were observed. Furthermore, an abdomen CT scan showed multiple lesions in the liver. A liver biopsy and the immunohistochemistry were diagnostic of adenocarcinoma of the lung. A brain magnetic resonance imaging revealed the previously reported findings with some enhancing lesions.

The patient was referred to an oncology center, and short courses of radiation therapy for symptom palliation were started. Three months after, the patient died due to septic shock following pneumonia.


  Discussion Top


The percentage of lung cancer individuals diagnosed with metastases in the CNS has increased throughout the last decades.[1] This probably has occurred due to the increased number of neuroimages in initial cancer staging, technical advances in radiological images, and better systemic control of the disease enabling the individual to live longer and to present more complications. In this context, while the incidence and mortality of lung adenocarcinoma have declined, it remains the most common primary lung cancer, leading cause of cancer death, and represents more than half of all NSCLC metastases.[1],[2] Moreover, one in every three individuals with NSCLC developed brain metastases alone with no evidence of lesions elsewhere. An interesting fact is that when the CNS is the only metastatic site, lung lesions are more likely located in the apical and peripheral regions.[2],[4]

To be more specific, studies with small-cell lung cancer and NSCLC reported that the incidence of symptomatic ocular metastases in lung cancer is <1%.[5] Furthermore, the most common clinical manifestations complained by the individuals were blurred vision, loss of vision, proptosis, ocular pain, redness, and tearing.[5] Thus, oculomotor symptoms alone are probably even rarer. However, the detailed ophthalmologic evaluation for ocular metastases routinely performed is able to avoid a misdiagnosis.

Another possible reason for the little percentage of oculomotor involvement in brain metastasis is that lung cancer and other cancers such as breast have hematogenous spread. Thereby, the uveal tissue (iris, ciliary body, and choroid) is probably the most common site of the visual system to be affected by metastases of lung cancer; also, this may justify the visual acuity be the main complaint. Furthermore, there could be an explanation for the fact that the choroid is generally a preferred site of metastasis.[5] The choroid architectural vascularity and other microenvironmental factors such as the interaction between adhesion molecules of malignant cells and the vessel walls could together increase the metastatic efficiency index to this specific uveal tissue.[6]

Only a few cases of lung cancer who presented with oculomotor deficit have been reported. We identified one case after a thorough review of the English-language literature, and we compared it with the present case [Table 1].[3] To the author's knowledge, the reported case was due to a paraneoplastic syndrome secondary to a small-cell lung cancer. In this way, the present case is the first to report the isolated abducens nerve palsy in lung adenocarcinoma. A literature search was performed in Embase, Google Scholar, Lilacs, Medline, Scielo, and ScienceDirect, on a set of terms that included abducens, lung, and adenocarcinoma.
Table 1: Case reports of patients with lung cancer who presented isolated abducens palsy

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In the cases of [Table 1], one interesting fact was that the prognosis of the patients was worse when compared with previous studies. The study of Su et al. showed that 62.5% of ocular metastases were early events, identified before or at the initial diagnosis of the lung cancer, and only 18% of ocular metastatic events presented as solitary distant metastases. Furthermore, Su et al. stated that the ocular symptoms in lung cancer are early events.[5] However, in our study, the patients had a poor outcome within death in months, and the primary lesion was large (more than 8 cm) in both cases. Therefore, probably, patients with ocular involvement usually developed CNS metastases in the setting of widely disseminated lung cancer and have a poor life expectancy as is already known for other neoplasias such as breast and renal.[2]

Isolated abducens paresis is the most frequent oculomotor palsy.[7] This cranial nerve has some special anatomic characteristic that predisposes it to be commonly affected. First, the sixth cranial nerve nucleus is localized in the pontine tegmentum and is looped by the axons of the facial nerve. Second, the abducens nerve emerges from the ventral surface of the brainstem. Third, it has a small subarachnoid portion and goes inside the Dorello's canal. After, the abducens nerve travel with the internal carotid artery, and anastomosis with sympathetic plexus passing through the cavernous sinus. Therefore, lesions leading to lateral rectus palsy can occur in the brain stem, subarachnoid space, petroclival region, cavernous sinus, or in the orbit.[7] In the present case, the area affected was the brainstem in the pontine tegmentum.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Myers DJ, Wallen JM. Cancer, Lung Adenocarcinoma. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519578/. [Last accessed on 2019 Jan 11].  Back to cited text no. 1
    
2.
Nayak L, Lee EQ, Wen PY. Epidemiology of brain metastases. Curr Oncol Rep 2012;14:48-54.  Back to cited text no. 2
    
3.
Chien KH, Chen JT, Chen PL. Acute isolated abducens paresis as an initial presentation of metastatic small cell lung cancer. Neuroophthalmology 2009;33:202-4.  Back to cited text no. 3
    
4.
Hendriks LE, Subramaniam DS, Dingemans AC. Editorial: Central nervous system metastases in lung cancer patients: From prevention to diagnosis and treatment. Front Oncol 2018;8:511.  Back to cited text no. 4
    
5.
Su HT, Chen YM, Perng RP. Symptomatic ocular metastases in lung cancer. Respirology 2008;13:303-5.  Back to cited text no. 5
    
6.
McCartney A. Intraocular metastasis. Br J Ophthalmol 1993;77:133.  Back to cited text no. 6
    
7.
Ayberk G, Ozveren MF, Yildirim T, Ercan K, Cay EK, Koçak A. Review of a series with abducens nerve palsy. Turk Neurosurg 2008;18:366-73.  Back to cited text no. 7
    


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