대한안과학회지 2018 년제 59 권제 1 호 J Korean Ophthalmol Soc 2018;59(1):1-8 ISSN 0378-6471 (Print) ISSN 2092-9374 (Online) https://doi.org/10.3341/jkos.2018.59.1.1 Original Article 전이안와종양의임상양상 Clinical Characteristics of Orbital Tumors: Our Experience with 27 Cases 문예지 강선아 안찬주 사호석 Yeji Moon, MD, Sunah Kang, MD, Chan Joo Ahn, MD, Ho-Seok Sa, MD, PhD 울산대학교의과대학서울아산병원안과학교실 Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Purpose: To evaluate the clinical characteristics of metastatic orbital tumors. Methods: The medical records of patients who were diagnosed with metastatic orbital tumors at Asan Medical Center, Seoul, Republic of Korea, from May 2010 to May 2017, were retrospectively reviewed. Results: A total of 27 patients were studied, including 14 (51.9%) males. The mean age at diagnosis was 54.1 years and the mean follow-up period was 12.7 months. The most common primary tumor site was the breast (six patients, 46.2%) in females and the liver (five patients, 35.7%) in males. Proptosis (12 patients, 44.4%) was the most common complaint, with the other complaints including periorbital swelling, palpable masses and diplopia. Orbital imaging studies showed that the most common sites of orbital involvement were the orbital wall (nine patients, 33.3%) and the extraocular muscle (nine patients, 33.3%). Pathological diagnoses were performed in 10 patients (37.0%), 3 of these whom underwent a fine needle aspiration for intraconal lesions. Local and systemic therapies were conducted using a multidisciplinary approach, but the of orbital tumors increased in 12 (44.4%) of 27 patients. Eight (29.6%) patients died because of systemic metastasis, seven (25.9%) patients were referred to other institutions for palliative treatment, and five (18.5%) patients showed malignant progression despite treatment. Conclusions: Based on the varying clinical features of metastatic orbital tumors, it is important to fully diagnose patients, especially those with a history of cancer. Breast cancer is the most common primary cancer, and liver cancer is also common because of the high prevalence of hepatocellular in the Republic of Korea. Clinical diagnosis may be possible using patient history and/or imaging study data, but pathological confirmation may be necessary in some cases. The treatment options can be determined by the type of primary cancer and the general condition, but the overall prognosis is poor. J Korean Ophthalmol Soc 2018;59(1):1-8 Keywords: Metastasis, Orbital tumor 전이안와종양은안구와안와골사이의안와공간내로 Received: 2017. 8. 24. Revised: 2017. 10. 14. Accepted: 2017. 12. 20. Address reprint requests to Ho-Seok Sa, MD, PhD Department of Ophthalmology, Asan Medical Center, #88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: 82-2-3010-3680, Fax: 82-2-470-6440 E-mail: lineblue@hanmail.net * Conflicts of Interest: The authors have no conflicts to disclose. 전이된병변으로 1, 전체암환자의약 2-3% 에서발생하는드문질환이다. 2,3 전체안와종양의 1% 에서 13% 까지다양한빈도로보고되고있으며 4-7 최근암환자생존율이증가함에따라전이안와종양의빈도도증가하고있다. 8 안와로전이되는종양은대개혈관을통해전이된다. 다른보고들에서유방암과폐암의전이를높은빈도로보고한바있으며 5,6,9 원발병소발견전전이안와종양이발견된경우 10,11 혹은여러가지검사에도불구하고원발병소를찾지못한경우들도보고된바있다. 12 c2018 The Korean Ophthalmological Society This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1
- 대한안과학회지 2018 년제 59 권제 1 호 - 안와내로전이된종양은대개주위조직으로침윤하는양상으로안구돌출이나안구운동제한, 통증등을일으킬수있는데이러한증상들은다른염증성질환들과유사한양상으로나타날수있어진단및치료적접근에주의가필요하다. 11,13 전이안와종양의진단에는그가능성을의심하고염두에두는것이중요한데, 현재많은임상의들은전이안와종양에대한경험이많지않은실정이다. 국내에서전이성안구내종양 15예를보고한논문은있었으나 14, 전이안와종양에대해서는증례보고만있고전반적인임상양상을분석한연구는보고된바가없었다. 따라서저자들은최근수년간경험한전이안와종양환자들의임상양상을분석하고진단및치료방법과그예후를알아보고자하였다. 대상과방법 2010년 5월부터 2017년 5월까지서울아산병원안과에내원하여전이안와종양을진단받은환자를대상으로의무기록을이용하여후향적으로분석하였다. 총 27명의환자를대상으로기본적인인구학적자료와함께주증상및원발병소를포함한병력과초진시나안또는교정시력을확인하였다. 세극등현미경검사, 안저검사, 안구운동을포함한안과적평가를시행하였고전이안와종양의정확한위치와크기, 침범범위를확인하기위해모든환자에서안와전산화단층촬영 (computed tomography, CT) 또는안와자기공명영상검사 (magnetic resonance image, MRI) 를시행하였다. 악성종양의기왕력, 안과적진찰소견, 전신적인임상양상과영상검사소견등을바탕으로전 이안와종양을진단하였지만, 임상적으로전이안와종양의진단이어려울경우최종적확진을위해서병리학적조직검사를시행하였다. 전이안와종양에대한국소적치료와전신치료진행과정을확인하였으며전이안와종양의크기변화와함께전신적인치료예후에대해평가하였다. 본연구는서울아산병원생명윤리위원회 (Institutional review board, IRB) 의승인을받아진행되었다. 결과 전체 27명중남자는 14명 (51.9%) 이었고전이안와종양의진단당시평균나이는 54.1세 ( 범위, 19-84세 ) 였으며평균추적관찰기간은 12.7개월 ( 범위, 1-60개월 ) 이었다. 우측안와에전이된경우가 15명 (55.5%), 좌측안와에전이된경우가 10명 (40.7%) 이었고 2명 (7.4%) 에서는양측안와침범을보였는데두환자의원발암은모두유방암이었다. 전이안와종양의원발병소는성별에따라차이를나타냈는데여성의경우유방 (6명, 46.2%) 이가장흔하였다. 남성의경우간 (5명, 35.7%) 이가장흔한원발병소였고그외원발병소로전립선, 폐, 흉선, 위, 대장, 이자등이다양하게나타났다 (Table 1). 원발암진단전에전이안와종양이먼저진단된경우가 1예 (3.7%) 에서는최종적으로원발병소를확인하지못하였다. 환자의초진시주소는안구돌출 (12명, 44.4%), 안와주위부종 (6명, 22.2%), 촉지되는종괴 (5명, 18.5%), 복시 (4 명, 14.8%) 등이있었다 (Table 2). 시력저하를호소한환 Table 1. Primary sites of metastatic tumor to the orbit and sex of the patients Primary site Number of patients Male Female Breast 6 (22.2) 6 (46.2) Liver * 5 (18.5) 5 (35.7) Prostate 2 (7.4) 2 (14.3) Lung 2 (7.4) 1 (7.1) 1 (7.7) Thymus 2 (7.4) 1 (7.1) 1 (7.7) Stomach 1 (3.7) 1 (7.7) Thyroid 1 (3.7) 1 (7.7) Colon 1 (3.7) 1 (7.7) Endometrium 1 (3.7) 1 (7.7) Bone 1 (3.7) 1 (7.7) Pancreas 1 (3.7) 1 (7.1) Brain 1 (3.7) 1 (7.1) Penile shaft 1 (3.7) 1 (7.1) Bone marrow 1 (3.7) 1 (7.1) Unknown 1 (3.7) 1 (7.1) Total 27 14 13 Values are presented as n (%). * Four patients had hepatocellular, the other patient had cholangio; One patient had diffuse large B-cell lymphoma. 2
- 문예지외 : 전이안와종양의임상양상 - 자가 3명 (11.1%) 이었는데, 이중 1명은안와자기공명영상검사상안와첨부위의침윤소견을보였고, 나머지 2명은안와원뿔내를침범한전이안와종양에의한시신경압박소견을확인할수있었다. 전이안와종양의위치와크기, 침범범위등을확인하기위해모든환자에서안와전산화단층촬영 (computed tomography, CT) 또는안와자기공명영상검사 (magnetic resonance image, MRI) 가시행되었다. 27명중 9명 (33.3%) 에서안와벽침범이동반되었고, 외안근침범도 9명 (33.3%) 에서확인되었으며, 시신경초가침범된경우가 1 명 (3.7%) 있었다 (Table 3). 영상의학적검사상주로종괴 성병변을보인경우가 15예, 경계가불분명한침윤성병변을보인경우가 8예, 외안근의부피증가가주요병변인경우가 4예였다. 주병변이외안근의부피증가로나타난환자들 4명중 2명의원발암은유방암이었고한명은광범위큰B세포림프종 (diffuse large B-cell lymphoma), 다른한명은투명세포육종 (clear cell sarcoma) 이었다 (Fig. 1). 전체 27명환자중 10명 (37.0%) 에서안와병변에대한병리학적진단이이뤄졌다. 7명 (25.9%) 은수술적생검을, 3명 (11.1%) 은세침흡인생검 (fine needle aspiration ) 을시행받았으며, 세침흡인생검을받은환자들은모두안와원뿔내에위치한종괴성병변을보였다 (Fig. 2). Table 2. Initial presenting symptoms and signs of the patients Symptom & sign Number of patients Proptosis 12 (44.4) Periorbital swelling 6 (22.2) Palpable mass 5 (18.5) Diplopia 4 (14.8) Pain 4 (14.8) Decreased vision 3 (11.1) Epiphora 2 (7.4) Ptosis 1 (3.7) Values are presented as n (%). Table 3. Involving orbital structures of metastatic orbital tumors Involving orbital structure Number of patients Orbital wall 9 (33.3) Extraocular muscle 9 (33.3) Eyelid 4 (14.8) Optic nerve sheath 1 (3.7) Lacrimal gland 1 (3.7) Eyeball 1 (3.7) Values are presented as n (%). A D B E C Figure 1. Orbital metastasis from breast cancer. (A, B) Magnetic resonance images revealed thickened of left inferior rectus muscle and infiltrative lesion extending to left inferior oblique muscle and overlying lower eyelid. (C) Clinical photos showed supraduction limitation in the left eye. (D) HESS screen test also showed supraduction limitation in left eye and left hypotropia. (E) Pathologic study of left inferior rectus muscle demonstrated infiltration of metastatic cells with scant cytoplasm and hyperchromatic nuclei (H&E stain, original magnification 200). 3
- 대한안과학회지 2018 년제 59 권제 1 호 - 전이안와종양진단이후원발암의종류, 다른장기의전이여부를포함한환자의전신상태등을고려하여다학제적접근을통해이후치료방침을결정하였으며방사선치료, 항암치료, 호르몬치료, 감마나이프방사선수술 (Gamma-knife radiosurgery) 등이진행되었다 (Table 4). 안과적으로종양감량수술 (tumor debulking surgery) 을시행한경우가 1예있었고, 안구돌출과동반된노출각막염에대해눈꺼풀봉합술을시행한경우가 1예있었으며, 눈물길협착에대해코눈물관더듬자검사및실리콘관삽입술을시행한경우가 2예있었다. 전이안와종양진단후안과적추적관찰이가능했던환자 17명 ( 평균추적관찰기간 17.6개월, 범위 4-60개월 ) 중 12명에서는최종추적관찰시종양의크기가증가하는 A B C Figure 2. Magnetic resonance imaging of the metastatic orbital tumor from thymic origin neuroendocrine. (A) coronal view (B) axial view, which showed an enhancing mass with lobulating contour (2.6 1.9 cm) in the left retrobulbar area. (C) Smear from fine-needle aspiration showed numerous spindle cells with hyperchromatic nuclei (H&E stain, original magnification 400). 양상이었다. 4명에서는종양크기의감소를확인할수있었는데이중완전관해를보인환자는 1명으로원발암이광범위큰B 세포림프종이었던경우였고이환자는경과관찰기간동안전신적으로도완전관해를보였다. 전체 27 명중 8명 (29.6%) 이원발암의전신적전이에의해사망하였으며, 이 8명의환자들의전이안와종양진단후생존기간은평균 13.4개월 ( 범위, 4-31개월 ) 이었다. 또다른환자 7명 (18.2%) 은항암치료를중단하고완화치료 (supportive ) 를위해타의료기관으로전원되었다 (Fig. 3). 고찰 안와는드문전이병소이지만 2-7 최근진단기술의발전과암환자의생존율이증가함에따라전이안와종양의빈도도증가하고있다. 8 하지만많은문헌들에서보고하고있는유병률은실제빈도보다저평가되고있다고생각되는데, 안와내병변의크기가작은경우증상을일으키지않을수있고, 전신상태악화로인해안과적증상호소가어려운경우가있기때문이다. 뿐만아니라환자들이증상을호소하더라도다른염증성질환들과유사한양상으로나타날수있고, 원발암의진단이전에안와증상을호소할수있기때문에전이안와종양을진단하기위해서임상의들이그가능성을염두에두고의심하는것이중요하다. 10,11,13 지금까지발표된많은문헌에서유방을전이안와종양의가장흔한원발병소로보고하였다. 4,15-19 본연구에서도전체환자의 22.2% 에서유방암이원발암으로나타나이전논문들과마찬가지의결과를보였다. 하지만두번째로흔한원발병소에대해서는문헌마다다른결과를보였는데, 100명의환자를대상으로했던한보고에서는전립선을두번째로흔한원발병소로보고하였고호주에서진행된연구에따르면악성흑색종이두번째로흔한원발암이었다. 4,18 그외다른보고들에서는폐암을두번째로흔한원발암으로보고하기도하였다. 20,21 본연구에서는간이두번째로흔한원발병소로나타났으며이러한차이는연구대상의지리적, 인구학적특성에따른원발암의유병률차이에서기인한것으로생각되며, 본연구의대상이 27 명으로비교적적었던점도함께고려해야할것이다. 이전보고들을통해신경내분비암종의안와내전이는비교적드물다고알려져있고, 전체신경내분비암종중흉선에서기인하는경우는약 3% 로드문것으로보고된바있다. 18,22 그럼에도불구하고본연구에서는흉선에서기인한산경내분비암종이원발암이었던경우가 2예 (7.4%) 가있었는데, 이러한결과는본연구대상이수도권의 3차 4
- 문예지외 : 전이안와종양의임상양상 - Table 4. Pathologic study, treatment and prognosis of patients with metastatic orbital tumors Primary tumor orbital tumor Treatment for orbital Age Sex Site Pathology Biopsy Pathology lesion 72 F Breast Invasive ductal 71 F Breast Invasive ductal 62 F Breast Invasive ductal 39 F Breast Invasive ductal 58 F Breast Invasive mammary 51 F Breast Invasive lobular 57 M Liver Hepatocellular 50 M Liver Hepatocellular 48 M Liver Hepatocellular 44 M Liver Hepatocellular 51 M Liver Poorly differentiated CTx RTx Debulking surgery, CTx, Hormone therapy, RTx, CTx Orbital tumor Prognosis General condition Stationary Unknown Progression Progression CTx Decreased Stationary RTx, Hormone therapy Unknown Death RTx Unknown Death RTx Death RTx Stationary Death Supportive Unknown Transfer out for supportive Rtx Death 84 M Prostate Adeno Supportive Unknown Transfer out for supportive 19 M Prostate Diffuse large B cell lymphoma Diffuse large B cell lymphoma CTx Remission Remission 74 M Lung Adeno CTx Unknown Progression 71 F Lung Adeno Biologics Unknown Death 55 M Thymus Neuroendocrine RTx, CTx 44 F Thymus Neuroendocrine FNAB neuroendocrine neuroendocrine Transfer out for supportive RTx, CTx Unknown Progression 55 F Stomach Adeno Supportive Unknown Transfer out for supportive 62 F Thyroid Follicular RTx Death 39 F Colon Mucinous FNAB mucinous 59 F Endometrium Endometrial stromal sarcoma RTx, CTx Gamma-knife radiosurgey RTx, Biologics 20 F Bone Clear cell sarcoma RTx Decreased 60 M Pancreas Ductal adeno FNAB adeno RTx, CTx 48 M Brain Hemangiopericytoma Supportive 47 M Penile shaft 58 M Bone marrow Myeloid sarcoma RTx Decreased Diffuse large B cell lymphoma 64 M Unknown adeno Unknown Progression Transfer out for supportive Transfer out for supportive Transfer out for supportive Death CTx Unknown Stationary Follow-up loss Unknown Unknown F = female; M = male; CTx = chemotherapy; RTx = radiotherapy; FNAB = fine needle aspiration. 5
- 대한안과학회지 2018 년제 59 권제 1 호 - A B Figure 3. Clinical course of total patients. (A) Orbital lesion and (B) general conditions after treatment for metastatic orbital tumors ( * Loss to follow-up). 병원을내원한환자들이었다는점과관련있을것으로생각된다. 본연구에포함된총 27명의환자중 1명 (3.7%) 은원발암진단전에전이안와종양이먼저진단되었던환자로, 최종적으로원발암을찾지못하였다. 이는이전까지보고된국외여러연구들보다다소낮은빈도였다. 17,18,21,23 이러한결과는최근영상검사와핵의학검사의발달과의료적접근의용이성에따른차이때문이라고생각된다. 특히림프종과같이전신에서발견되는종양의경우원발병소를특정하기어려울수있는데, 본연구에포함된환자중림프종환자 2예에서는영상검사와핵의학검사를통하여원발병소를확인할수있었고, 원발암을찾지못했던환자는자의로추가적인검사를거부했던경우였던점을고려하면, 전이안와종양이진단되었을때원발병소를찾는것은과거에비해비교적어렵지않음을알수있었다. 전이안와종양의위치와크기, 침범범위를평가하기위해안와전산화단층촬영또는안와자기공명영상검사를시행하였는데, 원발병소에따라영상검사소견이유사한양상을보였다. 원발암이간세포암종이었던환자 4명은 모두종괴성병변을나타냈고, 폐암이원발암이었던 2명도종괴성병변을확인할수있었다. 흉선신경내분비암종이원발암이었던환자 2명도모두종괴성병변을보였고, 전립선암환자의경우안와골침범을함께동반하였는데이는이전문헌들에서와비슷한양상이었다. 8,24 다만, 가장흔한원발암인유방암의경우총 6명의환자중종괴성병변이 2명, 침윤성병변이 2명, 외안근부피증가가 2명으로다양한영상검사소견을보였다. 이중특히외안근부피증가가주병변으로나타나는경우다른염증성질환과의감별이어려워서진단에주의를기울여야하고확진을위한조직검사가필요할수있다. 13 악성종양의병력이있는환자에서안구돌출이나안와주위부종, 안와의만져지는종괴, 복시등의증상을보이는경우는전이안와종양의가능성을항상고려해야하며, 이전에알려진병력이없는환자에서도안와종양의조직검사에서안와에서흔히발견되지않는악성종양의소견이확인되는경우에는전이안와종양을염두에두고전신검사를고려해야한다. 안과적진찰소견과전신적인임상양상, 영상검사소견등을종합하여임상적으로전이안와종양을진단할수있는경우도있다. 본연구에서병리학적조직검사를시행하지않았던환자 17명은모두안와이외의전이병소를동반한악성종양의기왕력를가지고있었으며안과적이상소견과함께전이안와종양에합당한영상소견을나타내어임상적으로진단할수있었다. 하지만임상적으로전이안와종양의진단이어려울경우최종적확진을위해서생검을통한병리학적검사가필요하다. 본연구에서 10명은병리학적진단을위한조직검사를시행받았는데, 이중한명은악성종양의기왕력이없었고 4명은악성종양의기왕력이있으나안와종양이발견되기전까지전신전이병소없이원발암에대한치료종료후안정적인상태를유지하고있던환자였다. 다른 4명은전신전이를동반한악성종양이있었으나영상검사결과다른염증성질환이나기타암종과감별이필요한상태였고, 마지막한명은임상적소견과영상검사결과전이안와종양을강력히의심할수있었으나종괴가촉지되고접근이용이하여조직학적검사를쉽게시행할수있었던경우였다. 병리학적조직검사를시행한 10명중수술적접근이비교적용이한병변을가진 7명에대해서는정확한확진을위하여절개생검을시행하였으나, 나머지 3명에서는세침흡인생검을시행하였다. 이 3명은원발병소및원발암의종류가뚜렷하였고, 병변이안와원뿔내에위치하여수술적접근이쉽지않았던환자들이었으므로세침흡인생검을시행한경우였다. 세침흡인생검은안구와안와구조물 6
- 문예지외 : 전이안와종양의임상양상 - 의손상, 악성세포의파급에대한위험성을가지고있지만안와원뿔내공간과같이수술적접근이어려운병변에대해서외래에서도용이하게시행할수있는유용한진단도구이다. 25,26 다만혈관종처럼세침흡인생검이위험한경우, 해부학적으로세침의접근이어려운경우가있으며, 절개생검에비하여진단율이떨어진다는단점이있으므로시술전환자상태및영상의학적검토가충분히이뤄져야한다. 전이안와종양환자들의예후는전반적으로나쁜것으로나타났다. 전이안와종양에대해다학제적치료를진행하였으나절반이상의환자에서안와내병변이더욱진행하는양상을보였다. 전신적인예후역시좋지않았는데경과관찰기간내에 8명이사망하고 7명은완화치료를위해전원되었으며, 5명은전신적으로진행하는것으로분석되었고이는이전보고들과유사한양상이었다. 18 본연구는수도권에위치한 3차병원에내원한환자들을대상으로분석하였기때문에, 전이안와종양환자들의전반적인임상양상을대변하기어렵다는제한점을가지고있다. 그러나본연구에포함된환자들중타지역안과에서의뢰된경우가많다는점이이러한제한점을보완할수있을것으로생각된다. 지금까지국내에서발표된전이안와종양에대한보고들중대상환자수가가장많은연구이지만원발암에따른임상양상, 영상및조직학적검사결과의특성, 예후를비교하기에는원발암별환자수가많지않다는점이제한점으로생각된다. 또한본연구의대상이되었던환자들의전신상태에따라지속적으로안과적경과관찰이어렵거나완화치료를위해전원되는경우가많아전반적인예후분석에도다소한계가있을것으로생각된다. 결론적으로, 전이안와종양은다양한임상양상으로나타날수있으며임상의들이그가능성을염두에두고의심하는것이중요하다. 유방이가장흔한원발병소였으며간과같이국내에서비교적유병률이높은원발병소에대해서도전이안와종양의빈도가높은것으로나타났다. 환자의병력과임상양상, 영상검사소견들을종합하여임상적진단이가능한경우가많지만감별진단이어려울경우수술적접근을통한생검이나세침흡인생검을통한병리학적진단이필요하다. 원발암의종류와다른침범부위를포함한환자의전신적인상태등에따라치료방침을결정하게되지만전반적인예후는나쁜편으로평가된다. REFERENCES 1) Finger PT. Radiation therapy for orbital tumors: concepts, current use, and ophthalmic radiation side effects. Surv Ophthalmol 2009; 54:545-68. 2) Bloch RS, Gartner S. The incidence of ocular metastatic. Arch Ophthalmol 1971;85:673-5. 3) Albert DM, Rubenstein RA, Scheie HG. Tumor metastasis to the eye. I. Incidence in 213 adult patients with generalized malignancy. Am J Ophthalmol 1967;63:723-6. 4) Valenzuela AA, Archibald CW, Fleming B, et al. Orbital metastasis: clinical features, management and outcome. Orbit 2009;28: 153-9. 5) Civit T, Colnat-Coulbois S, Freppel S. Orbital metastasis. Neurochirurgie 2010;56:148-51. 6) Chong VF. The orbits in cancer imaging. Cancer Imaging 2006;6:S27-31. 7) Shields JA, Shields CL, Scartozzi R. Survey of 1264 patients with orbital tumors and simulating lesions: The 2002 Montgomery Lecture, part 1. Ophthalmology 2004;111:997-1008. 8) Ahmad SM, Esmaeli B. tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol 2007;18:405-13. 9) Shikishima K, Kawai K, Kitahara K. Pathological evaluation of orbital tumours in Japan: analysis of a large case series and 1379 cases reported in the Japanese literature. Clin Exp Ophthalmol 2006; 34:239-44. 10) Tomizawa Y, Ocque R, Ohori NP. Orbital metastasis as the initial presentation of invasive lobular of breast. Intern Med 2012;51:1635-8. 11) Gupta S, Bhatt VR, Varma S. Unilateral orbital pain and eyelid swelling in a 46-year-old woman: orbital metastasis of occult invasive lobular of breast masquerading orbital pseudotumour. BMJ Case Rep 2011;2011. pii: bcr1220103580. 12) Abbruzzese JL, Abbruzzese MC, Lenzi R, et al. Analysis of a diagnostic strategy for patients with suspected tumors of unknown origin. J Clin Oncol 1995;13:2094-103. 13) Papathanassiou M, Nikita E, Theodossiadis P, Vergados I. Orbital metastasis secondary to breast cancer mimicking thyroid-associated ophthalmopathy. Clin Exp Optom 2010;93:368-9. 14) Kong BD, Lee TW. Clinical analysis of metastatic intraocular malignancy. J Korean Ophthalmol Soc 1999;40:2928-34. 15) Shields CL, Shields JA, Peggs M. Tumors metastatic to the orbit. Ophthal Plast Reconstr Surg 1988;4:73-80. 16) Goldberg RA, Rootman J, Cline RA. Tumors metastatic to the orbit: a changing picture. Surv Ophthalmol 1990;35:1-24. 17) Tijl J, Koornneef L, Eijpe A, et al. tumors to the orbit--management and prognosis. Graefes Arch Clin Exp Ophthalmol 1992;230:527-30. 18) Shields JA, Shields CL, Brotman HK, et al. Cancer metastatic to the orbit: the 2000 Robert M. Curts Lecture. Ophthal Plast Reconstr Surg 2001;17:346-54. 19) Yan J, Gao S. orbital tumors in southern China during an 18-year period. Graefes Arch Clin Exp Ophthalmol 2011;249: 1387-93. 20) Günalp I, Gündüz K. orbital tumors. Jpn J Ophthalmol 1995;39:65-70. 21) Font RL, Ferry AP. Carcinoma metastatic to the eye and orbit III. A 7
- 대한안과학회지 2018 년제 59 권제 1 호 - clinicopathologic study of 28 cases metastatic to the orbit. Cancer 1976;38:1326-35. 22) Öberg K, Hellman P, Ferolla P, et al. Neuroendocrine bronchial and thymic tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23 Suppl 7:vii120-3. 23) Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97:620-4. 24) Green S, Som PM, Lavagnini PG. Bilateral orbital metastases from prostate : case presentation and CT findings. AJNR Am J Neuroradiol 1995;16:417-9. 25) Sa HS, Oh DE, Kim YD. Fine needle aspiration of posterior orbital tumors. J Korean Ophthalmol Soc 2005;46:1435-40. 26) Kennerdell JS, Dekker A, Johnson BL, Dubois PJ. Fine-needle aspiration. Its use in orbital tumors. Arch Ophthalmol 1979; 97:1315-7. = 국문초록 = 전이안와종양의임상양상 목적 : 저자들이경험한전이안와종양의임상적양상에대해알아보고자하였다. 대상과방법 : 2010 년 5 월부터 2017 년 5 월까지서울아산병원안과에내원하여전이안와종양으로진단받은환자 27 명의의무기록을후향적으로분석하였다. 결과 : 전체 27 명중남자는 14 명 (51.9%) 이었고진단당시평균나이는 54.1 세였으며평균추적관찰기간은 12.7 개월이었다. 전이안와종양의가장흔한원발병소는여성에서는유방 (6 명, 46.2%), 남성의경우간 (5 명, 35.7%) 이었다. 초진시주소로는안구돌출 (12 명, 44.4%) 이가장흔하였고, 안와주위부종, 촉지되는종괴, 복시등의증상을호소하였다. 영상검사를통해전이안와종양의침범범위를확인하였을때, 침범된안와구조물중안와벽과외안근이각각 9 명 (33.3%) 으로가장흔하였고시신경침범이 1 명 (3.7%) 있었다. 병리학적진단은총 10 명 (37.0%) 에서시행되었고, 그중 3 명은안와원뿔내에위치한병변에대해세침흡인생검을시행받았다. 전이안와종양진단후다학제적접근을통해치료가진행되었으나전체 27 명중 12 명 (44.4%) 은안와종양의크기가더욱커졌다. 전신적예후에서는 8 명 (29.6%) 이원발암의전신적전이에의해사망하였으며, 7 명 (25.9%) 은완화치료를위해타기관으로전원되었고, 5 명 (18.5%) 은치료에도불구하고진행하는경과를보였다. 결론 : 전이안와종양은다양한임상양상으로나타날수있으므로그가능성을염두에두고의심하는것이중요하다. 유방이가장흔한원발병소였고간암과같이국내에서비교적유병률이높은원발암에대해서도전이안와종양의빈도가높은것으로나타났다. 환자의병력과임상양상, 영상검사소견들을종합하여임상적진단이가능한경우가많지만감별진단이어려울경우병리학적진단이필요할수있다. 원발암의종류와다른침범부위를포함한전신적인상태등에따라치료방침을결정하게되지만전반적인예후는나쁜편으로평가된다. < 대한안과학회지 2018;59(1):1-8> 8