Metastatic Carcinoma with Associated Lymphoadenopathy and Acquired Horner’s Syndrome Portrayed in a Third Century CE Roman Bust

Over five centuries Roman portraiture developed through stylistic cycles. Physical elements of both politicians and wealthy individuals were alternatively represented as extremely veristic (realisitic) or classising (idealising) [1, 2]. In the third century CE, the portraits of wealthy freedmen (liberti) rather than the patrician élite were characterised by an unusual realism [1, 2], and great care was applied to reproduce the physiognomy of the sitters, defects and pathologies included [3]. In several cases, the Roman funerary art included the busts of the deceased [3] and some of them are so detailed to show suggestive evidence of neurological conditions [4].

Here we describe a potential case of metastatic carcinoma associated with lymphoadenopathy and acquired Horner Syndrome’s portrayed in a third century CE male bust housed in the collection of Count Franz I Erbach-Erbach (1754–1823) at Erbach Castle (Erbach, Hesse, Germany) (see Fig. 1a–d). The bust depicts an unknown bearded adult man known as “Single-eyed man”.

Fig. 1.

The third century CE Roman male bust named “Single-eyed man” housed at Erbach Castle: a In frontal view, the bust shows evidence of Horner’s triad. b The dorsal view. c The left lateral view; b and c show the presence of two lumps of different sizes corresponding to enlarged cervical lymph nodes. d. The right lateral view is normal. Reproduced with permission

When observed in the frontal view, the man displays some characteristics of the Horner’s syndrome in the left eye associated with left hemifacial atrophy [3]. The Horner’s Syndrome (HS), also called oculosympathetic paresis, manifests itself when lesions occur along one of the three neurons (central neuron, the preganglionic neuron or the postganglionic neuron) of the oculosympathetic pathway. This pathway innervates the sweat glands (ipsilateral body and face), the dilator muscle of the eye and, the retractor muscles of the upper and lower eyelids. Lesions may manifest anywhere along this pathway and can be either congenital or acquired [4, 5].

Previous research attributed the bust’s facial anomalies either to a case of congenital Horner’s [6] or acquired Horner’s syndrome [7]. Benendum [7] measured the left ptosis (distance from upper to lower eye lid: right 10 mm, left 5 mm), miosis (pupillary diameter: right 5/6 mm, left ¾ mm) and noted pseudo-enophthalmos. Hemifacial anhidrosis was not observable in the sculpture.

However, a detailed inspection of the bust, both in the left lateral (Fig. 1c) and dorsal (Fig. 1b) views shows the presence of two lumps of different dimensions. A smaller lump of 5.5 × 3.7 cm is located in the area of the left post-auricular lymph nodes whereas a major lump of 6.4 × 6.1 cm is present in the area of the posterior cervical lymph nodes. Given that both lumps correspond to the locations of lymph nodes, they may be attributed to lymphadenopathy.

The right lateral view does not show evidence of abnormality (Fig. 1d). All further “anomalies” can be attributed to preservation issues, e.g. the missing portion of the right pinna [8].

The pathological conditions leading to either HS or unilateral cervical lymphadenopathy alone are unlikely diagnoses. This holds particularly true for various infectious diseases, granulomatoses (e.g. sarcoidosis), vascular malformation (angioma) and lymphangioma, and acute blunt force to the neck. Similarly, diseases with typically bilateral lymphadenopathy, are also deemed extremely unlikely (Table 1).

Table 1.

List of differential diagnoses proposed

Disease	Horner’s syndrome	Cervical swelling	Hemifacial atrophy	Additional notes	References
Stroke	−	−	+	Usually in older age	[5, 13]
Arterial dissection	+	−	−		[5, 13]
Syringomyelia	+	−	+		[5, 13]
Lymphoma/Leukaemia	−	+	−		[5, 10, 11, 13]
Pulmonary pancoast tumour/oesophageal cancer	+	+	+		[5, 13]
Head and neck cancer	+	+	±		[5, 13]
Thyroid cancer	+	+	−	Thyroid gland tumour possible	[5, 13]
Viral infection	−	+	+		[5, 13]
Chiari malformation	+	−	+
Demyelinating disease	+	−	+		[5, 13]
Vascular malformation/lymphangioma	Rare	−	+	Associated lumps typically found in the anterior triangle of the neck	[5, 13]

Non-infectious unilateral cervical lymphadenopathy is often attributable to cancer. Moreover, posterior cervical lymphadenopathy, as observed in this bust, is more frequently attributed to malignancy than anterior lymphadenopathy [9]. The probability that the “Single-eyed man” suffered from a neoplastic disease is further increased by the presence of multiple ipsilateral lumps and a neurological disorder, indicating involvement of the nervous system. Based on the location of the affected lymph nodes and the associated Horner’s Syndrome, this case most likely represents a metastatic cancer with a primary tumour associated with HS e.g. head and neck cancer, pulmonary (Pancoast) tumour, or oesophageal carcinoma [5, 10, 11]. In the absence of further indirect sources on the individual sculpted, the diagnosis can be solely based on semeiotics [12].

Overall, this very realistic sculptural portrait of the ancient Roman permits a scientific ground-based retrospective diagnosis. This example confirms the potential for diagnostic evaluation of ancient portraiture/sculpture in some cases. Therefore, realistic art can be used to identify the presence of some soft tissue pathology in populations of the past where the availability of mummies is scant. This holds especially true for the Roman world apart from Egypt.

Funding

No funding obtained.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest to disclose.