Choroidal metastasis as a presenting manifestation of a lung adenocarcinoma with response to afatinib

Metástasis coroidea como signo de presentación de un adenocarcinoma de pulmón con respuesta a afatinib

To determine the clinical incidence and characteristics of symptomatic choroidal metastasis (CM) in breast cancer. Forty-six consecutive patients with CM from breast cancer were retrospectively reviewed in respect of ocular findings, medical history and systemic disease. Clinical incidence of CM was determined and compared with the incidence predicted from prevalence data obtained in ocular screening studies. Choroidal metastasis occurred with a median interval of 42.4 months after diagnosis of breast cancer and was predominantly unilateral (63% patients) and solitary (57% affected eyes). A total of 32% of patients had no history of metastatic tumour disease, but systemic screening with CT and scintigraphy revealed metastatic disease in 100% of patients. A median number of three other organs were affected by metastasis. Median survival from diagnosis of CM was 13.1 months. The mean number of local patients diagnosed with CM was 2.9 per year, which was one order of magnitude less than predicted from clinical screening studies. Choroidal metastasis occurs in advanced metastatic breast cancer, indicating a grave vital prognosis. In a minority of patients (32%) it is the first sign of metastatic disease. The clinical incidence of CM is far smaller than predicted from prevalence data obtained from ocular screening studies.

Lung cancer is 1 of the major health problems in the world and the leading cause of cancer death in Taiwan. Well-known metastatic sites of lung cancer include the lung, lymph nodes, brain, bone, liver, etc. Choroid metastasis is rare and the diagnosis is based primarily on clinical findings supplemented by imaging studies. However, clinicians do not routinely evaluate the possibility of intraocular metastasis, mainly because of the low incidence of asymptomatic choroid metastasis. The most commonly used treatment in patients with symptomatic intraocular metastasis is radiotherapy. Herein, we report the cases of 2 patients who had blurred vision as the initial presentation, and were diagnosed with adenocarcinoma of the lung with brain and choroid metastasis. They refused radiotherapy of the eye, and commenced systemic chemotherapy and brain radiation therapy. One received plaxitaxel and the other received vinorelbine. Throughout serial follow-ups, their visual acuity subjectively improved, along with a reduction in the size of the intraocular tumor, as seen by ophthalmoscopic examination in 1 case.

Purpose: To report a case of choroidal metastasis as the main presentation in a patient with lung carcinoma. Method: Case report. Results: A 69-year-old woman complained of blurred vision in her right eye for 2 months. The best-corrected visual acuity was counting finger in right eye. Fundoscopy demonstrated a large choroidal mass located inferiotemporally associated with exudative retinal detachment in her right eye. B-scan ultrasound revealed the tumor had a high internal reflectivity. Magnetic resonance imaging of the orbit showed an intraocular mass that was approximately 5 mm in thickness. After enucleation, pathologic study of the enucleated eye demonstrated a choroidal metastasis. Complete systemic survey disclosed that a primary lung adeno-carcinoma with bone and choroidal metastasis count for the ocular lesion. Conclusions: Choroidal metastasis can be the first clinical manifestation of lung adenocarcinoma. Ophthalmologists should be aware of systemic malignancy in choroidal metastasis and initiate a thorough systemic evaluation for early detection of life-threatening malignancies.

Purpose: We present a case of choroidal metastatic tumors achieving a best corrected visual acuity of 20/20 after intravitreal injection of bevacizumab (Avastin) and focal laser photocoagulation.Method: Interventional case report.Results: A 68 y/o male has been diagnosed with pulmonary adenocarcinoma (T4N1M0) in December 2006, and had received surgical intervention, radiotherapy and chemotherapy. He visited our outpatient department in December 2009 and presented with blurred vision in his right eye. His best corrected visual acuity was 20/40. Fundus examination revealed multiple subretinal masses, light orange in color, superotemporal and inferonasal to the fovea, in the right eye. Optical coherence tomography scan showed marked subretinal fluid of the macula. A diagnosis of choroidal metastasis secondary to lung cancer was made. After discovering choroidal metastatic lesions, two sessions of intravitreal injection of bevacizumab and three sessions of focal laser photocoagulation were performed. After three months follow-up, his best corrected visual acuity regained 20/20. Scarring and flattening of choroidal lesions were noted on color fundus photography. Multiple hyperfluorescent spots without leakage were showed on fluorescein angiography. Regression of macular edema and serous detachment were evident on optical coherence tomography scan.Conclusion: For the patient with choroidal metastases who wants to preserve good visual acuity and better quality of remained life, intravitreal injection of bevacizumab plus focal laser photocoagulation may be considered. Longer follow-up period is needed for evaluation of efficacy and effectiveness of such treatment.

Choroidal metastasis originating from renal cell carcinomas (RCCs) is rare. To the best of our knowledge, 31 cases of choroidal metastasis from RCC have been reported in the English literature as of January 31, 2024.Nevertheless, physicians need to be vigilant in recognizing this condition, as its progression impacts the quality of life (QOL) of affected patients. In Case 1, a 60-year-old male with a medical history of papillary RCC experienced a deterioration in visual acuity (VA) and was diagnosed with solitary choroidal metastasis. Subsequently, multiple metastases were identified, prompting the initiation of a combination therapy regimen consisting of pembrolizumab plus axitinib. Despite treatment, progression of choroidal metastasis and a further decline in VA were observed. The patient underwent stereotactic radiotherapy and experienced complete resolution of the choroidal metastasis, accompanied by a slight improvement in VA. In Case 2, a 76-year-old man presented with a renal tumor accompanied by lung metastases. He underwent nephrectomy, and the histological diagnosis was papillary RCC. We initiated combination therapy consisting of nivolumab plus cabozantinib. The patient experienced a decrease in VA during treatment. We identified extensive fine metastases scattered throughout the bilateral choroid. We administered axitinib, but the patient experienced bilateral blindness. Given the absence of established therapy for choroidal metastasis, it is crucial to maintain flexibility in treatment selection. Local or systemic approaches should be used as deemed appropriate for each individual case.

Bilateral Choroidal Metastases Revealing an Advanced Non-Small Cell Lung Cancer

A 68-year-old man was referred because of an abnormal shadow in the right upper lung field on a chest X-ray film. After the diagnosis of adenocarcinoma of the lung, left upper lobectomy was done. Histologically, adenocarcinoma with foci of squamous cell carcinoma was seen. About 11 months after that operation, he suddenly noticed a decrease in visual acuity on the left side. The fundus of the eye was tested and metastatic choroidal cancer was suspected. To prevent rupture, the eyeball was enucleated. The choroidal tumor appeared to have components of squamous cell carcinoma from primary lung cancer. About 7 months after enucleation of his eyeball, the patient was disease-free with no decrease in his quality of life. As a result of a recent increase in the incidence of lung cancer, it is important to pay attention to ophthalmological tests in patients with primary lung cancer.

Photodynamic therapy for choroidal metastasis from lung adenocarcinoma

Rationale:Breast carcinoma is the most common primary source of choroidal metastasis (CM). In the present case, esophageal cancer was the primary tumour, brain metastasis occurred, and CM occurred later in the left eye with 2 retinal detachments, which is very rare.Patient concerns:A 62-year-old man complained of a sudden decrease in visual acuity consisting of a small shadow in front of his left eye with a sensation of covered vision after 1 cycle of systemic chemotherapy and radiotherapy for resected esophageal cancer with brain metastasis. Fundus examination revealed exudative retinal detachment without retinal tears. CM with exudative retinal detachment was also considered. The patient refused further treatment. After the second cycle of chemotherapy, there were no significant changes in the retina and visual acuity improved. However, after craniocerebral surgery for brain metastasis, the visual acuity decreased again and showed 3 choroidal masses with macular involvement and retinal detachment but without retinal tears.Diagnosis:The final diagnosis was CM with retinal detachment.Interventions:The patient was advised to undergo enucleation of the left eye during the second retinal detachment, but he refused.Outcomes:Two months after the second retinal detachment, the patient died of systemic metastases.Lessons:It is important to consider CM when the first retinal detachment and known cancer are diagnosed. At present, it is necessary to develop a standardised treatment plan as well as a multidisciplinary approach to early diagnosis, combined treatment, and timely intervention for such cases.

So far as we know, the most metastatic site in lung cancer is brain and bone. Choroid metastases rarely occur in clinical diagnosis. We report a case of 57 yearold woman presenting as right blurred vision initially. She came to our hospital for further management due to deteriorating vision. Magnetic resonance (MR) revealed a homogeneous enhancing soft tissues mass occupied in the posterior surface of right eye. Under the impression of primary melanoma, enucleation was performed in June fifth, 2006. Pathologic report proved metastatic adenocarcinoma later. Chest computerized tomography (CT) displayed a spiculated mass at RUL and multiple mediastinal lymphadenopathies. Primary adenocarcinoma of lung with choroid metastases was final diagnosed. We also reviewed related literature and emphasized the importance of differentiating diagnosis in choroidal tumor, especially in cancer patients.

To determine the clinical characteristics of symptomatic choroidal metastasis (CM) resulting from metastatic lung cancer. Twenty-two consecutive patients with symptomatic CM resulting from lung cancer were retrospectively reviewed for ocular findings, medical history and systemic disease. All patients underwent a complete screening for further organ metastasis by computed tomography (CT) and bone scintigraphy. Annual frequency of CM was determined and compared with the incidence predicted from ocular screening studies. In eight of 22 (36%; 95% confidence interval [CI] 17-59) patients, lung cancer had been diagnosed before occurrence of CM, with a median interval of 13 months. In 14 patients lung cancer was detected after diagnosis of CM, with a median interval of 1 month. Choroidal metastasis was unilateral, solitary and located close to or at the posterior pole in the majority of patients. Further organ metastasis with a median number of three affected organ systems was present in 19 (86%; 95% CI 65-97) patients. Median survival after diagnosis of symptomatic CM was 13 months, by contrast with 2 months in lung cancer patients with CM identified in an ocular screening study. The mean number of patients in Berlin diagnosed with symptomatic CM was 1.4 per year, which was two orders of magnitude less than predicted from screening studies. Symptomatic choroidal lung cancer metastasis in the majority of patients presents as a solitary tumour before diagnosis of lung cancer in patients with multiple organ systems affected by metastatic disease. Contrary to predictions from ocular screening studies, it is a rare clinical entity.

Acute angle-closure is a rare manifestation of choroidal metastasis. We reported a case of choroidal metastasis from lung adenocarcinoma presenting with unilateral acute angle-closure attacks relieved with radiotherapy after failed conventional medical and laser treatments. This represented the first detailed report of treatments of secondary acute angle-closure attacks in patients with choroidal metastasis. A 69-year-old female without ocular history was diagnosed with metastatic lung adenocarcinoma. One month later, she complained of blurred vision and pain in the right eye that lasted 2 days. IOP was 58 mmHg and best-corrected visual acuity (BCVA) was counting finger in the right eye. Slit-lamp examination revealed corneal edema with ciliary congestion, extremely shallow anterior chamber both centrally and peripherally, mid-dilated pupil and moderate cataract in the right eye. While the left eye was normal. B-scan ultrasound and orbital computed tomography showed an appositional choroidal detachment with an underlying choroidal thickening suggesting choroidal metastasis in the right eye. There was limited effect of medical and laser therapy. IOP was 9 mmHg in the right eye after two months of palliative external beam radiotherapy in the right orbit. BCVA was hand motion in the right eye. Slit lamp examination revealed clear cornea, deep anterior chamber in the right eye. Regression of choroidal detachment and choroidal metastasis in the right eye were observed in B-scan ultrasound. This case demonstrated that patient with secondary acute angle-closure attacks from large bullous choroidal detachment related to choroidal metastasis could only be successfully treated with radiotherapy as both medical and laser therapy might not be capable of breaking angle-closure attacks.

Circumscribed choroidal hemangioma: Clinical manifestations and factors predictive of visual outcome in 200 consecutive cases

To report the authors experience in the use of infrared diode laser transpupillary thermotherapy in the management of selected posterior choroidal metastatic tumors. Seven eyes of seven patients were treated using 810 nm infrared diode laser. Spot sizes of 0.5 to 3 mm were selected, each lasting 1 minute. When necessary, the treatment was repeated at 8- to 10-week intervals. Disappearance of the tumor was the main outcome measure. The primary sites of carcinomas were breast, prostate, and lungs. The largest basal diameters of ocular tumors varied between 5 mm and 10 mm and the thickness ranged between 2 mm and 4.5 mm. A mean power of 612 mW was used in one to four treatment sessions. In six eyes the tumors were reduced into flat scars whereas in one case the tumor continued to grow necessitating external beam radiotherapy. In three eyes the visual acuity decreased and in three eyes the vision became better. In one eye the vision was restored after external beam radiotherapy with the disappearance of extensive subretinal fluid. There were no immediate postoperative complications. Transpupillary thermotherapy can be a reliable, convenient, and cost-cutting option in the management of small, solitary choroidal metastatic tumors with a thickness of less than 3.5 mm and which have minimal subretinal fluid. Although successful in terms of tumor control, treatment close to the fovea or optic nerve head may cause a permanent decrease in visual acuity. (Eur J Ophthalmol 2004; 14: #-9).