Choroidal Metastasis as the Main Presentation of Lung Adenocarcinoma: A Case Report

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.

Choroid metastasis from primary lung cancer is rare and has a poor prognosis. It can be treated with an external beam of radiation or by laser photocoagulation. However, visual defects or blindness are possible complications related to radiotherapy. Chemotherapy for such a condition has not been widely reported. We report a 26-year-old patient who had stage IV lung adenocarcinoma and suffered from progressive blurred vision during a scheduled chemotherapy regimen. Fundoscopy, fluorescence angiography and optic coherence tomography indicated choroidal metastasis of both eyes. We prescribed a platinum double chemotherapy regimen with pemetrexed and cisplatin. A follow-up examination demonstrated complete remission of the choroid metastasis. Herein, we report the first case of lung cancer with choroid metastasis that underwent complete remission after pemetrexed administration. We share our experience and conduct a literature review. (Thorac Med 2012; 27: 159-166)

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.

Although metastasis to the eye is the most common ophthalmic malignancy, it is usually asymptomatic and rarely a presenting symptom that leads to the diagnosis of a primary. Here, we report a patient who was evaluated for visual symptoms and was eventually diagnosed to have disseminated adenocarcinoma of the lung. He was treated with external radiotherapy to the choroidal metastasis, attaining an excellent response that was sustained until his death. A brief review on the role of radiotherapy in the management of uveal metastases is also presented.

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.

Objective To investigate the clinical findings and diagnostic value of MRI,ultrasonography fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) in patients with choroidal neoplasms. Methods In this retrospective study,the clinical data of 22 patients with choroidal neoplasm treated in Zhongshan Ophthalmic Center,Sun Yat-sen University from January 2008 to December 2009 was collected and analyzed.All patients were examined by ultrasound type-B and color Doppler scan.Some of them received FFA,ICGA,CT and MRI examinations.The patients with primary malignant tumor were treated with enucleation.The patients with choroidal metastasis were referred to tumor hospital and usually had systemic chemotherapy and local radiotherapy.The patients with choroidal hemangiomas usually received retinal photocoagulation or photodynamic therapy except those with uncontrolled secondary glaucoma who often had enucleation. Results The imaging of 12 patients with choroidal malignant melanoma showed typical globular or mushroom-shaped intraocular mass with brown or black color.MR1 examination revealed high signal intensities on TlWI and low signal intensities on T2WI.Flat orange-red neoplasm in the posterior pole was the main clinical characteristics of choroidal hemangioma in 7 patients.In the early phase,hyperfluorescence was observed in choroidal hemangioma with FFA/ICGA.MRI revealed low or medium signal intensity on TlWI and high signal intensity on T2WI,with high enhancement.Three cases of choroidal metastasis usually demonstrated flat gray-yellow intraocular mass in posterior pole,all of them had the primary systemic tumor in our case series,and one patient was involved bilaterally. Conclusions The diagnosis of choroidal neoplasm often can be confirmed through detail routine fundus examination in eyes with refractive media transparency.FFA/ICGA is highly valuable in the diagnosis of choroidal hemangioma.MRI and ultrasound examination contributes well to the diagnosis of choroidal neoplasm in eyes with refractive media opacity. Key words: Choroidal neoplasm; MRI; Ultrasonography; Fundus fluorescein angiography; Indocyanine green angiography

Choroidal metastases from the lung are very rare accounting about 0.1%–7%. The most common site of ocular metastasis is choroid due to its abundant blood supply. Lung cancers commonly metastasize to the liver, bone, brain, and adrenals. Here, we present a very rare case of squamous cell carcinoma lung in a young nonsmoker patient with metastasis only to eye and no evidence of distant metastasis. This is a very rare case as metastasis to eyes itself is a very rare occurrence and has been mainly reported with adenocarcinoma and small-cell carcinoma. The other features which make this case rare are that squamous cell carcinoma is common in smokers and usual age of diagnosis is >50 years of age and this patient was only 38 years of age and nonsmoker. The aim of this case report is to emphasize the importance of thorough patient evaluation and effect of systemic chemotherapy on ocular metastatic lesions.

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

Objective To study the effect of Transpupillary thermotherapy (TTT) on choroidal metastases. Methods Nine cases were enrolled in the study, male 2 and female 7 cases. Bilateral eyes were affected in 3 cases. The age of cases was 37-60yrs with averaged at 44.6 yrs. The visual acuity was ≤0.05 in 1 eye,0.06-0.2 in 2 eyes, 0.3-1.0 in 9 eyes. The metastatic tumor showed as a yellow-white flat lesions with retinal detachment in different extent on their surfaces. The number of the lesions was single in 2 eyes, 2 in 3 eyes, ≥3 in 7 eyes. The location of the lesions was at the posterior pole in 4 eyes, at the macular and its surrounding in 6eyes, around the disc in 2 eyes. The primary tumor was located at the lung and bronchus in 5 cases, at the breast in 3 cases, at the large intestine in 1 case. Indirect ophthalmoscope, fundus fluorescein angiography (FFA), ultrasound (A, B) and optical coherence tomography (OCT) were used for exam. Treatment was delivered via slit lamp using an 810 nm diode laser (Iridex) with 250 to 1000 mw, with average 510 mw; the spot size was 2.0-3.0mm, duration ranged from 60 s to 120 s. The lesions just turned into pale-white appearance after treatment. The number of laser spot was 2-6 with average 3.7 spots. The session for management was 1-6 with average 2.9. The interval between 2 sessions was 1-3 months. The lesion just underlying the fovea was combined with photodynamic therapy (visudyne) in 1 case. Results The lesions turned into a flat scar with pigmentation and fluid absorption after treatment. The visual acuity was improved in 2 cases, unchanged in 4 cases, declined in 6 cases. The visual decline was caused by the lesion underneath the fovea and secondary macular lesions. The fellow-up was 1-32 months with average 9.6 months. Conclusions TTT is rational for choroidal metastatic lesions and has definite effect with low cost. It is worth doing in the future. Early discovering and managing the lesions helped to protect the visual acuity of the patients. Key words: Transpupillary thermotherapy; Choroidal metastasis; Photodynamic therapy

We report a case of lung cancer with an iris metastasis. The 80-year-old man had squamous cell carcinoma of lung with multiple bony metastases, and was treated with radiotherapy. Eight months after this treatment, brain metastases and increased intracranial pressure were diagnosed. Glycerol and corticosteroid were given to lower intracranial pressure. The condition of the patient improved. Systemic chemotherapy or brain radiotherapy was suggested, but rejected by the patient. Furthermore, he complained of blurred vision in both eyes. Best-corrected visual acuity was 20/50 in both eyes. By slit lamp examination, two whitish nodules (1×0.5 and 0.2×0.3 mm in size) without prominent blood vessels were identified at the inferior pupillary margin in the right eye. No secondary glaucoma, hyphema, or iritis was found. Metastasis to the iris from lung cancer without choroidal metastasis was impressed. We suggested a course of radiotherapy to the right eyeball, but the patient refused treatment. Metastatic iris tumors are not common. The characteristics, differential diagnosis, and management of iris metastasis will be reviewed in this report.

Breast cancer is the most common malignancy in women, with increasing incidence in Europe and North America. The frequency of involvement of the eye and visual pathways is reported to be as high as 30% in patients with known metastatic disease. In some cases, ophthalmic involvement can be the first sign of metastatic spread. Metastasis occurs via the haematogenous route and predominantly involves the choroid. Metastases to other ocular structures, the orbit and the visual pathways have also been described. Paraneoplastic effects are rare but significant. Different modalities are employed in the treatment of breast cancer and its metastases. These include chemotherapy and radiotherapy. The ocular adverse effects of these have been well described, but recently developed new treatment modalities, such as monoclonal antibodies, may have different side-effects. With the increasing incidence of breast cancer and the advent of new treatment strategies, the complications of the disease and the sequelae of therapy are highly relevant to both oncologists and ophthalmologists.

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.

Introduction: Metastatic colorectal cancer is highly fatal disease. While metastases are usually found in the thoracic cavity in colorectal cancer, the choroid has been shown to harbor metastases. The retrobuorbital pathway, although rarely, has also demonstrated colorectal metastases. Case report: A 54-year-old male with a one-year history of disseminated colon cancer presented with vision loss in his right eye in October 2013. A choroidal metastasis was found extending from the optic disc toward the fovea, Initial treatment consisted of systemic chemotherapy, supplemented by External Beam Radiation Therapy to the right eye one year after diagnosis. Thirteen months later, the left eye was found to have a choroidal tumor surrounding the disc. The cancer progressed through both local and systemic treatment. Discussion: While the disease progressed through multiple rounds of chemotherapy, external beam radiation therapy was shown to be effective in regressing the tumors. Managing refractory metastatic disease presents unique challenges in properly prioritizing therapeutic routes.

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.