Incidence and clinical characteristics of symptomatic choroidal metastasis from lung cancer

Purpose: To determine the clinical characteristics of symptomatic choroidal metastasis (CM) resulting from metastatic lung cancer. Methods: 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. Results: 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. Conclusions: 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.     

Clinical characteristics of choroidal metastasis

ZusammenfassungHintergrund Die Aderhautmetastase ist der häufigste maligne intraokulare Tumor. Ziel dieser Untersuchung ist die Charakterisierung des klinischen Erscheinungsbildes, der zugrunde liegenden Tumorerkrankung sowie des differenzialdiagnostischen Vorgehens bei Aderhautmetastasierung (AM).Patienten und Methode Es wurden 71 konsekutive Patienten mit AM ausgewertet. Besondere Beachtung fanden die okulären Symptome, das ophthalmoskopische und sonographische Erscheinungsbild der AM sowie die Charakterisierung der zugrunde liegenden Tumorerkrankung. Bei allen Patienten erfolgte ein vollständiges Screening (CT Kopf, Thorax und Abdomen; Knochenszintigraphie) zur Primärtumorsuche bzw. bei bereits bekanntem Primärtumor zur Suche nach weiteren Organmetastasen.Ergebnisse Eine symptomatische AM zeigten 95% der Patienten, bei 5% handelte es sich um einen Zufallsbefund. Bei 60% der Patienten bestand eine solitäre AM, bei 40% multiple AM (2–14). Bei Erstvorstellung war bei 18% der Patienten (n=13) keine Tumorerkrankung bekannt. Bei 12 dieser Patienten konnte ein Bronchialkarzinom diagnostiziert werden. Insgesamt bestand bei 53% der Patienten ein Mammakarzinom, bei 26% ein Bronchialkarzinom, bei je 3% ein Nieren- oder Darmkarzinom, ein Aderhautmelanom oder ein kutanes Melanom, sowie bei einzelnen Patienten ein Zervix-, Ovarial-, Thymus- oder Prostatakarzinom sowie in einem Fall ein unbekannter Primärtumor. Weitere Fernmetastasen zeigten 96% der Patienten. Beim Bronchialkarzinom trat die AM im Mittel 9 Monate, beim Mammakarzinom 68 Monate nach Diagnose der Tumorerkrankung auf. Bei 58% der Patienten mit Bronchialkarzinom war die AM die Erstmanifestation der Grunderkrankung, beim Mammakarzinom bei 28% das erste Zeichen der Metastasierung.Schlussfolgerung Aderhautmetastasen finden sich fast nur bei einer generalisierten Tumorerkrankung. Beim Mammakarzinom treten sie typischerweise Jahre nach Diagnose auf und können das erste Zeichen einer Generalisierung sein. Beim Bronchialkarzinom kann die Aderhautmetastase das erste klinische Zeichen der Erkrankung sein.Teile des Beitrags wurden auf der 98. Tagung der Deutschen Opthalmologischen Gesellschaft präsentiert.     

脉络膜转移癌临床特征的分析

目的 研究脉络膜转移癌的临床特征,以便早期诊断及与其他脉络膜肿瘤进行鉴别诊断.方法 本研究为回顾性系列病例研究.通过病历,收集患者视力检查、裂隙灯显微镜眼前节检查、问接检眼镜眼底检查、荧光素眼底血管造影(FFA)、吲哚氰绿血管造影(ICGA)、相干光断层扫描(OCT)及A超和B超扫描、磁共振(URI)以及胸部CT检查等资料.结果 共5例(9只眼)脉络膜转移癌,单眼1例,双眼4例.男性1例,女性4例;年龄31～56岁,中位数年龄45岁.症状:视力减退4例,视物变形1例.眼部检查:视力≤0.05且<0.3者4只眼;≤0.3且<0.7者2只眼;≥0.7者3只眼.原发癌来自肺癌者3例,乳腺癌1例,胃癌1例.肿瘤转移至眼的时间:2例为眼科首诊发现,3例分别为1年半、4年及5年.眼底特征:脉络膜转移癌表现为黄白色扁平形隆起者比球形隆起更多见,或伴斑驳样色素沉着及视网膜下液体或视网膜脱离.转移癌位于黄斑部和近视乳头者共6只眼,黄斑和赤道部之间3只眼.孤立转移灶5只眼,多个转移灶4只眼.FFA表现为瘤体呈现斑驳样强荧光,晚期有荧光素渗漏.ICGA表现为遮蔽荧光和弱荧光.A超扫描显示转移灶呈现中等不规则内反射.B超扫描显示扁平实质性隆起.眼部MRI显示肿瘤处表现为中等短T1W和短T2W信号.血清肿瘤标志物增高:3例癌抗原分别为16.28 μg/L、4.95μ/L、癌抗原125增高为160.50 kU/L.结论 脉络膜是最常发生转移癌的部位.脉络膜转移癌可发生在原发癌诊断之前,当患者眼底有黄白色扁平形隆起病灶时,尤其是双眼有病灶者,眼A、B超扫描、胸部CT及癌抗原检查以排除来自肺和乳腺的原发癌是很重要的.     

Regression of choroidal metastasis from breast carcinoma following Letrozole therapy

Metastasis to the choroid from primary tumours elsewhere in the body is not an infrequent occurrence. Management of such metastasis may involve modalities such as radiotherapy, chemotherapy, photocoagulation and surgical resection. The role of hormonal therapy is poorly defined in the management of these tumours. Herein regression of choroidal metastasis from primary breast carcinoma following antihormonal therapy with the antioestrogen drug Letrozole is reported.     

Radiation therapy of choroidal metastases from breast cancer

Summary Radiation therapy of 26 patients with choroidal metastases from breast cancer has been reviewed. At the time of initial diagnosis of choroidal metastases 13 patients had bilateral choroidal metastases. The median age of the patients was 54 years and the survival from the first symptom of choroidal metastases varied from 2 to 45 months with a median survival of 9.5 months.End results of radiation therapy had been recorded in 22 patients. Local radiation therapy improved vision permanently in 16 patients.     

Regression of late onset choroidal metastasis from a breast carcinoma with letrozole

We report the case of a 50-year-old woman with a history of diabetes mellitus who underwent left breast lumpectomy and ipsilateral lymphadenectomy in 1994 because of an infiltrating ductal carcinoma. Chemotherapy followed by radiotherapy to the breast and nodal areas were performed. In 2010, in a routine screening for diabetic retinopathy, two choroidal elevated masses above and below the optic nerve associated to serous retinal detachment of her right eye were noted. The patient was asymptomatic. Carcinoma was positive for hormone receptor. Hormone treatment with letrozole was established. Complete regression of the choroidal metastasis was observed 3 months later. Ophthalmologic screening in asymptomatic patients with breast cancer has the advantage of being a noninvasive procedure and enables an early treatment in isolated cases. However, some studies are an argument against the usefulness of eye screening due to the low incidence of asymptomatic choroidal metastasis and the cost that involves performing it routinely in a large number of patients. Aromatase inhibitors are well-tolerated drugs that may be a powerful tool in the management of metastatic breast cancer that express hormone receptors.     

Unsual ocular metastasis from breast cancer

Herein a clinical case of an unusual metastasis from breast cancer to the retina and vitreous confirmed by diagnostic vitrectomy is described. Further investigation also demonstrated the central nervous system metastasis.     

Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: argument against screening

AIM: To determine the frequency of visually asymptomatic choroidal metastases in patients with disseminated breast and lung carcinomas in order to establish optimal patient management policies. METHODS: All patients with confirmed metastatic disease treated in our institution between January 2002 and December 2003 were invited to undergo a funduscopic examination and a B-scan ultrasound evaluation. RESULTS: Of the 169 study participants, 77 had breast cancer (64 with metastases in one organ and 13 with multiple-organ involvement) and 92 had lung cancer (85 with metastases in one organ and 7 with multiple-organ involvement). No patient with metastatic breast cancer and two patients with metastatic lung disease (each with multiple-organ involvement) were found to have choroidal metastases. The choroidal metastases were detected by both the funduscopic and ultrasound examinations. CONCLUSIONS: The 2.17% incidence of choroidal metastasis in disseminated lung cancer and the 0% incidence in disseminated breast cancer speaks against the practicality of screening for early detection of choroidal metastasis among these patients, even though it would lead to early implementation of appropriate, often vision saving, therapeutic management. Its low incidence probably testifies to progress achieved by enhanced systemic oncological treatment policies that have been introduced into routine patient management over the past few years.     

Photodynamic therapy with verteporfin of choroidal malignancy from breast cancer

PURPOSE: To evaluate the effectiveness of photodynamic therapy (PDT) with verteporfin for treating a submacular choroidal metastasis from breast cancer. DESIGN: Interventional case report. METHODS: Multispot PDT irradiation of tumor surface was performed in a 45-year-old woman who had a choroidal metastasis from breast cancer in the right eye. The response of uveal metastasis to photodynamic action was investigated with the use of fluorescein angiography and optical coherence tomography (OCT). RESULTS: Within four months after photosensitization, the exudative detachment of the macula was resolved, with improvement in the visual acuity following decrease in the tumor vascular permeability and absorption of subretinal fluid. CONCLUSIONS: PDT can effectively destroy a malignant tissue and induce an antitumor activity. PDT as an adjunct to chemotherapy is a possible treatment and might be appropriate for patients who require ocular treatment only.     

累及视神经的脉络膜转移癌临床及影像学特征

目的探讨累及视神经的脉络膜转移癌的临床特征及影像学特点。方法收集我院所诊治的侵犯视神经的脉络膜转移癌患者5例(5眼)的临床资料,分析其眼底表现、眼部B超、彩色超声多普勒、眼底荧光血管造影、MRI等影像学检查特征。结果 5眼均可见眼底后极部累及视神经及其周围脉络膜组织的扁平实质性占位病变,视盘隆起、水肿,表面小血管扩张,动脉期即出现荧光素渗漏。B超表现为视神经附近沿眼球壁扁平隆起的病灶,视盘隆起且回声增强。眼部彩色超声多普勒可见肿块内血流信号。眼部MRI:眼球后壁视盘区局限性增厚,T1WI呈高于玻璃体的中等信号,T2WI瘤体呈低信号,累及视神经球内段及眶内段起始部,视神经增粗。结论累及视神经的脉络膜转移癌诊断需结合详细的病史、综合的影像学检查,并重视与相关视神经疾病的鉴别诊断,该类患者的视力预后及生命预后均不佳。     

Uveal metastasis from breast cancer in 264 patients

PURPOSE: Breast cancer is an increasingly important health problem in women and is the most common tumor to metastasize to the uvea. This study was designed to evaluate the clinical features, management, and prognosis of patients with uveal metastasis from breast cancer. DESIGN: Retrospective interventional case series. METHODS: We retrospectively reviewed 264 consecutive patients with uveal metastasis from breast cancer. We assessed the clinical features of the patient and tumor at the time of presentation, management, and prognosis. Kaplan-Meier survival estimates were used to analyze the probability of death as a function of time. RESULTS: Uveal metastasis was the initial manifestation of breast cancer in seven patients (3%) and the first systemic metastatic site of previously diagnosed breast cancer in 43 (16%). Associated with uveal metastasis, optic disk metastasis was found in 13 patients (5%), eyelid metastasis in one patient (1%), and conjunctival and orbital in one patient (<1%). Of 264 patients with uveal metastasis, 225 (85%) had choroidal metastasis, eight (3%) iris metastasis, two (<1%) ciliary body metastasis, and 29 (11%) had metastasis in multiple uveal sites. In the 264 patients with uveal metastasis, the most common symptom was blurred vision in 197 patients (88%), floaters in 15 (5%), photopsia in 12 (5%), and 19 (7%) were asymptomatic. The uveal metastases were bilateral in 99 patients (38%) and unilateral in 165 (62%). In 55 (56%) of the 99 bilateral cases, a uveal metastasis was found in the asymptomatic fellow eye during follow-up examination. External beam radiotherapy was used in 137 patients with uveal metastasis (52%), providing tumor control in 116 patients (85%) at a mean follow-up of 21 months. Using Kaplan-Meier estimates, survival rates of all patients with uveal metastasis from breast cancer was 65% at 1-year, 34% at 3-year, and 24% at 5-year follow-up. CONCLUSIONS: Patients with uveal metastasis from breast cancer presented to ophthalmologists with visual symptoms in 93% of cases. However, asymptomatic metastases were commonly detected in the fellow eye. Local ocular tumor control was excellent with current therapies. However, systemic prognosis for all patients, including those who had been treated with different management options, was poor with survival rates of 65% at 1-year and 24% at 5-year follow-up.     

Incidence and clinical patterns of polypoidal choroidal vasculopathy in Korean patients

Purpose To determine the incidence, demographic features, and clinical characteristics of polypoidal choroidal vasculopathy (PCV) in Korean patients. Methods A retrospective review was undertaken of 392 eyes of 321 symptomatic patients suspected of having exudative age-related macular degeneration (AMD) after their first visit to a tertiary hospital between February 2002 and May 2006. All patients underwent a complete ophthalmic examination, including fluorescein and indocyanine green angiography (ICGA). Results Of the 321 patients (392 eyes), 79 (98 eyes, 24.6%) were diagnosed with PCV. The mean PCV patient age was 64.6 ± 7.6 years. PCV was more common in men (78.5%), and was usually unilateral (75.9%). In terms of PCV clinical manifestation, 52% of patients showed an exudative pattern, 34.7%, a hemorrhagic pattern, and 13.3%, an extensive hemorrhagic pattern. The mean visual acuity at presentation was 0.231 ± 0.256. Classification was based on ICGA findings; 52% of patients showed relatively large aneurismal dilations, 25.5% showed atypical vessel deformations, and 22.5% showed dense clusters of numerous small hyperfluorescent dots. Conclusions The incidence of PCV in Korean exudative AMD patients was relatively high compared with that in other ethnic groups. As in other Asian patient populations, PCV occurred more commonly in men and was predominantly unilateral.     

Systemic chemotherapy and tamoxifen induced regression of choroidal metastasis from a breast carcinoma in a male

We report a case of a 55-year-old male patient with breast carcinoma, who developed choroidal metastasis. The patient had undergone mastectomy for carcinoma of right breast, five years ago. The patient was advised close follow-up for the left eye, as he was already on tamoxifen therapy (started a month ago) for spinal metastasis. On last follow-up, a year later, the choroidal lesion had completely scarred, with no recurrences. Systemic hormonal therapy like tamoxifen given for the breast primary and other systemic metastases may cause regression of the choroidal metastasis, thereby avoiding ocular radiotherapy. Medline search revealed only one published case of regression of choroidal metastasis from a male breast primary, on tamoxifen therapy.     

脉络膜皱褶的临床特征分析

目的 观察脉络膜皱褶患者眼底、荧光素眼底血管造影（FFA）、吲哚青绿血管造影（ICGA）和光相干断层扫描（OCT）等临床特征。方法 回顾性分析34例脉络膜皱褶患者62只眼的临床资料。其中伏格特-小柳-原田综合征10例20只眼，Behccet病1例2只眼，其他类型葡萄膜炎11例21眼，视盘水肿5例9只眼，脉络膜肿瘤2例2只眼，低眼压性黄斑病变2例4只眼，Graves眼病1例2只眼，眼钝挫伤1例1只眼，脉络膜渗漏综合征1例1只眼。所有患者均行直接检眼镜、眼底彩色照相、FFA检查，9例17只眼同时行ICGA检查，9例18只眼同时行OCT检查。结果 脉络膜皱褶眼底表现为明暗相间的条纹，其数量多少不限，在后极部呈放射状、水平状、斜行或以黄斑为中心同心圆样排列，也可表现为围绕视盘呈放射样排列，但很少超过赤道部。FFA观察到的皱褶数量比眼底表现多，主要是细小皱纹和粗大皱褶。条状弱荧光在动静期明显，晚期无荧光渗漏。ICGA检查显示，早期表现为条状弱荧光或正常荧光，晚期为强荧光或弱荧光，与FFA的弱荧光条带相对应，但没有FFA表现明显。OCT检查显示皱褶累及脉络膜和视网膜色素上皮层。结论脉络膜皱褶为累及脉络膜和视网膜色素上皮层的明暗相间的眼底条纹，造影表现为无荧光素渗漏的条状弱荧光。熟悉脉络膜皱褶的影像学特征有助于临床上发现脉络膜皱褶及原发疾病。     

Solitary choroidal metastasis from bronchial carcinoid.

This report describes the clinical, light microscopical, and electron microscopical features of a metastasis from a bronchial carcinoid tumour occurring in a 29-year-old white woman. The eye lesions was diagnosed 30months after resection of the primary pulmonary tumour. Ophthalmoscopically the patient was observed to have a solid choroidal mass. Enucleation was carried out because of the possibility that the tumour was a primary choroidal melanoma. Enucleation was also indicated because of the relatively good prognosis for long-term survival in patients following excision of metastases from a bronchial carcinoid tumour. By light microscopy the metastasis was seen to be composed of cords; and ribbons of cells which showed positive staining characteristics for argentophilia. On electron microscopical study, neurosecretory vesicles, numerous microvilli, mitochondria, and light and dark cells, characteristic of endocrine tissue in different states of activity were noted.