Regression of a choroidal metastasis from prostate adenocarcinoma after hormonal therapy

CASE REPORT: We report a case of a patient diagnosed with prostatic adenocarcinoma with multiple bone metastases and a choroidal metastasis in his left eye. Hormonal therapy with an anti-androgen and a LH-RH agonist was followed by regression of the choroidal mass over a period of 2 months. No metastatic recurrence has been demonstrated after a follow-up period of 14 months. DISCUSSION: Complete resolution of choroidal metastases of prostatic adenocarcinoma with hormonal therapy is exceptional, but the effect of this treatment on such metastases should be observed before recommending radiation therapy.     

Red lesions of the iris, choroid, and skin secondary to metastatic carcinoma of the thyroid: a review

An 83-year-old man was seen with a history of bilateral progressive loss of vision of 1 month's duration. On examination, there was a reddish, nodular lesion adjacent to the right side of the nose. Slit-lamp examination revealed a reddish iris mass in the left eye. Ophthalmoscopic examination revealed two orange choroidal lesions in the right eye and a large subretinal hemorrhage in the posterior pole with a central reddish vascular lesion in the left eye. An excisional biopsy of the skin lesion was performed. A diagnosis of metastatic follicular thyroid carcinoma was made according to the histopathologic findings and immunohistochemistry. The patient had no known history of thyroid malignancy and a metastatic survey revealed widespread metastasis. The patient had a total thyroidectomy followed by two series of radioactive iodine ablation. The iris lesion completely resolved and the choroidal lesions in the right eye showed partial regression during the follow-up period. Ocular and skin metastasis secondary to thyroid carcinoma is uncommon. In a review of English literature we found reports of 12 clinically well-documented cases of choroidal metastasis and two cases of iris metastasis. Our case and review of the previous cases reveal that reddish/orange color is a commonly observed feature of the uveal metastasis of thyroid carcinoma. Although ocular and skin metastases from thyroid carcinoma are rare, this possibility should be considered in the differential diagnosis of reddish-colored iris and choroidal masses as well as reddish nodular lesions of the scalp, face, and neck.     

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.     

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.     

A case of diode laser photocoagulation in the treatment of choroidal metastasis of breast carcinoma

To report a single case of improvement on choroidal metastasis of breast cancer after laser photocoagulation. A 52-year-old female patient who complained of visual disturbance of the right eye with multiple states of metastasis of breast carcinoma. On initial examination, the right best-corrected visual acuity was 0.63. Right fundoscopy revealed an elevated mass-like lesion temporal to the macule with serous retinal detachment. The mass had a 3.5-disc diameter. A right fluorescein angiogram revealed hypofluorescence during the prearterial and arteriovenous phase and hyperfluorescence during the venous phase. The venous phase showed almost total masking of background choroidal fluorescence at the elevated lesion because of leakage and neovascularization. The patient was treated 4 times by diode laser photocoagulation in addition to chemotherapy. Fifty days after the diode laser treatments, the funduscopy examination and fluorescein angiogram revealed that the serous retinal detachment had been absorbed, the choroid had become flat, the lesion had been reduced in size and hyperfluorescence. The right best-corrected visual acuity was improved to 0.8. Laser photocoagulation appears not to cause any problems for the patient and may be an efficient treatment for patients with choroidal breast carcinoma.     

Management of choroidal metastases from breast carcinomas using aromatase inhibitors

PURPOSE OF REVIEW: The outcome of patients diagnosed with uveal metastases from breast carcinoma, all of whom were treated with one of the new generation of hormone therapies named aromatase inhibitors, is reported. RECENT FINDINGS: Charts of all patients with uveal metastases from breast cancer seen at Wills Eye Hospital between 1995 and 2005 are reviewed. Seventeen patients were diagnosed with uveal metastases from estrogen-receptor-positive breast cancer and subsequently treated with one of the aromatase inhibitors (anastrozole, letrozole, exemestane). SUMMARY: The interval between initial diagnosis of breast cancer and choroidal metastases ranged from 1 month to 17 years. Thirteen patients had received tamoxifen either at the time of breast surgery or as part of the metastases treatment. In 10 cases, both the systemic and choroidal metastases remained regressed over a mean of 20 months follow-up (4-50 months). There was no toxicity or intolerance to the medication. Aromatase inhibitors represent a new generation of hormone therapy for metastatic breast cancer. They were effective in 59% of the patients with estrogen-receptor-positive breast cancer, many of them nonresponding to prior treatment with tamoxifen. Aromatase inhibitors avoid the need for external beam radiation therapy as a treatment for the ocular metastases.     

Choroidal metastases from breast cancer--clinical observations of 18 cases

PURPOSE: To present clinical picture and results of treatment of breast carcinoma metastases to choroid. MATERIAL AND METHODS: Eighteen females (26 eyes), age: 31-70 years old; mean age: 50.5 +/-14.5 years with breast carcinoma choroidal metastases were enrolled in this study. Choroidal metastases occurred 1 month to 288 months, mean: 64 +/- 33 months, after primary tumors had been diagnosed. In all cases basic eye examination with ultrasonography as well as fluorescein and indocyanine green angiography in some patients, were performed. Method of treatment was applied according to tumor size and its localization; 106Ru plaque therapy was used in 8 cases, I25I in 2, transpupillary therapy (TTT) in 8, 106Ru + TTT ("sandwich method") in 4, teleradiotherapy in 3 and enucleation was performed in one case. The follow-up period ranged from 6 months to 5 years, mean 15.3 +/- 7.7 months. RESULTS: Unilateral choroidal metastases were present in 10 patients and bilateral in 8. Single metastatic lesions were detected in 15 patients and multiple in 3. Tumors thickness measured by ultrasonography ranged from 1.2 to 16.2 mm. After therapy regression of tumors was noted in 7 eyes (10 tumors), among which in four eyes (7 tumors) total regression was observed. Stabilization was found in 4 eyes (4 tumors) and progression in other 4 eyes (4 lesions). CONCLUSIONS: Tumor size, its localization and general patient condition are the main factors deciding about the method in treatment of choroidal metastases. Plaque therapy and transpupillary thermotherapy are effective methods of treatment in majority of metastatic tumors. They induce tumor regression and in some cases they may provide improvement in visual acuity.     

Bilateral Macular Edema in a Patient Treated with Tamoxifen: A Case Report and Review of the Literature

We present a case of a 41-year-old female patient with progressive bilateral visual loss. On examination, her best corrected visual acuity (BCVA) in her right eye was 3/10 and her BCVA in her left eye was 2/10. Fundus and optical coherence tomography examination revealed severe bilateral macular edema. She had been diagnosed with breast cancer 6 years ago and was receiving tamoxifen at a dosage of 20 mg/day ever since. Tamoxifen therapy was discontinued, and the patient received 250 mg of acetazolamide three times a day for a period of 1 month. Both foveae regained their normal contour within 2 months, and her vision was restored to 10/10 BCVA 3 months later. To our knowledge, this is the first case reported where bilateral intraretinal macular edema is the only retinal manifestation in a patient on oral tamoxifen.Key words: Tamoxifen retinopathy, Tamoxifen therapy, Macular edema     

Primary intraocular lymphoma: another great masquerader

PURPOSE: To describe diverse and atypical presentations of the most common masquerader in neoplastic masquerade syndromes. METHODS: Retrospective interventional case series. The authors identified three patients who presented with atypical and diagnostically challenging masquerading manifestations. These patients were eventually found to have primary intraocular lymphoma (PIOL). Their case histories, presenting signs and symptoms, diagnostic tests, and treatments are described. RESULTS: Patient 1 masqueraded as viral retinitis and branch retinal vein occlusion but was resistant to 5 weeks of oral and intravenous acyclovir. Patient 2 presented with choroidal infiltrates and vision loss. This patient had had breast carcinoma for the last 25 years and secondary metastasis was suspected. Patient 3 had chronic uveo-retinitis and a chronic Propionibacterium acnes infection was suspected. All three patients were diagnosed with PIOL. CONCLUSIONS: PIOL is an aggressive masquerader and not only presents clinical diagnostic difficulties but also requires expert tissue handling and analysis, so that early diagnosis can be made and therapy can be instituted.     

Spontaneous regression of choroidal metastasis from renal cell carcinoma

PURPOSE: To describe a patient with choroidal metastasis from renal cell carcinoma that spontaneously regressed after nephrectomy. DESIGN: Interventional case report. METHOD: A 48-year-old Hispanic woman presented with reduced vision in the left eye attributable to an elevated choroidal lesion and associated exudative retinal detachment. Oncology workup revealed a left kidney renal cell carcinoma with pulmonary metastases. The patient underwent primary nephrectomy, without specific treatment of choroidal or pulmonary metastases. RESULTS: The metastatic choroidal lesion regressed and the retinal detachment completely resolved, as evidenced by fundus photographs and ultrasonography. CONCLUSIONS: Choroidal metastasis from renal cell carcinoma may spontaneously regress after removal of the primary tumor.     

Stereotactic radiation therapy for malignant choroidal tumors: preliminary, short-term results

PURPOSE: To evaluate the role of stereotactic radiation therapy (SRT) in the treatment of malignant choroidal tumors. DESIGN: Prospective, noncomparative case series. PARTICIPANTS: Ten patients with unifocal choroidal metastasis (three lung carcinoma, three breast carcinoma, three colon carcinoma, one cutaneous melanoma) and five patients with primary choroidal melanoma underwent single-dose or fractionated SRT. METHODS: Before treatment, computed tomography (CT) scans of the orbit were obtained with the patient wearing an individualized immobilization mask. An integrated macro-CCD-camera system viewed the eye for detection of movements. Three-dimensional computer-based treatment planning was carried out. Dose distribution was calculated and displayed in isodose lines on the CT data set. For SRT, a dedicated stereotactic linear accelerator (6 MV) was used. Total doses for choroidal metastases were 12 to 20 Gy in a single dose or 30 Gy over 10 days (3 Gy each session), and total doses for choroidal melanoma were 50 Gy over 5 or 10 days (10 or 5 Gy each session). MAIN OUTCOME MEASURES: Best corrected visual acuity (ETDRS-chart), biomicroscopy, ultrasound examination, fluorescein angiography, and magnetic resonance imaging (MRI) were performed before treatment and at regular intervals after completion of SRT. RESULTS: During a follow-up period from 1 to 34 months (median, 6.5 months), local tumor control was achieved in all eyes. A decrease in tumor size on ultrasonography or MRI was noted in eight patients. No persistent side effects were observed during follow-up. CONCLUSIONS: Stereotactic radiation therapy allows steep dose gradients outside the target volume by minimizing the field of exposure. Thus only low radiation doses affect surrounding radiosensitive ocular structures. Our initial findings suggest that this technique may be effective in controlling tumor growth. Further studies are needed to compare treatment efficacy and safety with conventional treatment methods.     

Bronchial carcinoid--a rare neoplasm metastasis to choroid

PURPOSE: To present a clinical picture and results of treatment in two patients with bronchial carcinoid metastases to choroid. MATERIAL AND METHODS: Two females aged 47 and 56 with bilateral and multiple metastases of bronchial carcinoid were enrolled in this study. Choroidal metastases occurred 6-7 years after primary tumors had been diagnosed. The follow-up period ranged from 2.5 to 5 years. In one patient teleradiotherapy of choroidal metastases was performed, while in a second case plaque therapy with 106 Ru and 125 I and a diode laser therapy were used. RESULTS: After therapy, one patient demonstrated partial regression of two choroidal metastases and total regression of one tumor, while the second one, showed total regression of all intraocular tumors. One patient developed irradiation neuropathy and retinopathy as a result of teleradiotherapy, which were the main cause of decreased visual acuity in her one eye. CONCLUSIONS: Regarding the good prognosis and potentially long survival of patients with bronchial carcinoid, prompt treatment of choroidal metastases is recommended. Applied method of therapy depends on tumor size, its localization and patient's general condition.     

Choroidal metastasis from medullary thyroid carcinoma in multiple endocrine neoplasia

PURPOSE: To report choroidal metastasis from medullary thyroid carcinoma in a patient with multiple endocrine neoplasia (MEN) type 2b.DESIGN: Interventional case report.METHODS: Medullary thyroid carcinoma developed in a 20-year-old woman and led to the diagnosis of MEN 2b. She had mucosal neuromas on the lips and tongue and prominent corneal nerves in both eyes. Right choroidal metastasis developed when she was 36 years of age.RESULTS: The eye was treated with irradiation, but 9 months later the patient died of widespread metastases.CONCLUSIONS: In patients with MEN type 2b, choroidal metastasis can develop from medullary thyroid carcinoma. Although fundus abnormalities typically do not occur with MEN 2b, choroidal metastasis from medullary thyroid carcinoma is a potential fundus finding.     

Presumed choroidal metastasis of Merkel cell carcinoma

Merkel cell carcinoma is a rare skin tumor of neural crest origin and is part of the amine precursor uptake and decarboxylase system. It typically occurs on the face of elderly people. Distant metastasis is almost uniformly fatal. Choroidal metastasis, to our knowledge, has not been described. We report a patient with Merkel cell carcinoma who had a synchronous solid choroidal tumor and a biopsy-proven brain metastasis. Our 56-year-old patient presented with a rapidly growing, violaceous preauricular skin tumor. Computed tomography of the head disclosed incidental brain and choroidal tumors. Light and electron microscopy of biopsy specimens of both the skin and the brain lesions showed Merkel cell carcinoma. Ophthalmoscopy, fluorescein angiography, and A and B echography revealed a solid choroidal mass. The brain and skin tumors responded well to irradiation. A radioactive episcleral plaque was applied subsequently to the choroidal tumor. All tumors regressed, and the patient was doing well 28 months later. To our knowledge this is the first case of presumed choroidal metastasis of Merkel cell carcinoma.     

Late choroidal metastasis secondary to papillary thyroid carcinoma.

PURPOSE: To report a case of late choroidal metastasis from papillary thyroid carcinoma. METHODS: Interventional case report. A 43-year-old woman who had been treated for papillary thyroid carcinoma 30 years earlier presented for evaluation of vision loss in the left eye. Eight weeks before this presentation, an ophthalmologist had diagnosed a metastatic uveal mass in the left eye of the patient. The clinical record was retrospectively reviewed. Ocular sonography was performed to confirm the diagnosis of choroidal metastasis. RESULTS: The choroidal mass had the typical characteristics of a metastatic lesion. The patient was treated with a combination of brachytherapy and chemotherapy. CONCLUSION: Papillary thyroid carcinoma can metastasize to the choroid many years after the initial diagnosis.     

Laser therapy in the management of choroidal breast tumor metastases

PURPOSE: To evaluate the potential of laser photocoagulation as a method of treating small metastatic lesions of breast carcinoma in the choroid. METHODS: The 10 eyes of 7 patients were treated by Krypton red or argon green laser applications for small choroidal breast carcinoma metastasis with serous detachment of the retina. Before treatment 5 eyes had visual acuity of finger counting and 5 eyes had visual acuity of 6/15 or better. The treatment was repeated once in all eyes, except 1 eye in which it was repeated 3 times. RESULTS: In all eyes, one to two weeks after the treatment the tumor shrunk, the subretinal serous detachment absorbed, the retina flattened, and the visual acuity improved to 6/6-6/21. No reduction in vision was seen after the second treatment until the end of the follow-up period. In 1 eye, new tumors located elsewhere were again twice successfully treated. Patients reported a significant improvement of their quality of vision, as judged subjectively. CONCLUSIONS: Laser treatment is a feasible, easy, rapid, and effective therapy for small choroidal breast carcinoma.     

Presumed eccrine carcinoma metastatic to the choroid

The purpose of this article is to describe a patient with presumed choroidal metastasis from an eccrine adenocarcinoma of the scalp. A 45-year-old Caucasian woman presented with decreased visual acuity. Ophthalmologic examination was unremarkable. Her past medical history was significant for eccrine carcinoma of the scalp. The patient developed bilateral cervical lymph node metastases, and received chemotherapy and radiotherapy. She had recurrence of the scalp lesion and developed bone metastasis. The patient was again referred to an ophthalmologist owing to reduced visual acuity. Multiple choroidal metastases were detected in right eye, and one metastatic lesion in left eye. The patient passed away 2 months after choroidal metastases. This is the first report of choroidal metastases from an eccrine carcinoma. This is a rare aggressive neoplasm with poor outcome in most cases of metastatic disease, and in this case report, uveal metastasis was indicative of poor prognosis.     

Clinical Course of a Presumed Metastatic Uveal Melanoma to the Contralateral Choroid

Abstract

We present the ultrasound and optic coherence tomography follow-up of a presumed choroidal metastasis from a contralateral melanoma. A 53-year-old male was diagnosed with uveal melanoma with extraescleral extension in his left eye. A year later, the fundus examination revealed a flat, gray-green, pigmented choroidal lesion in the right eye. The ultrasonography showed a mass, almost flat, and all these findings were compatible with a choroidal melanocytic lesion with risk factors for growth. One month later, melanocytic skin lesions appeared on the scalp, as well as small tumors. Three months later, an ultrasonography on B scan showed a growth of the tumor size. The patient developed a progressive deterioration and died. Three possibilities can explain the occurrence of a choroidal pigmented tumor in the contralateral eye: first, bilateral primary choroidal melanomas; second, both choroidal tumors are metastatic in origin from an unknown primary melanoma; and third, the contralateral tumor is a metastatic tumor from the primary choroidal melanoma.     

Transpupillary thermotherapy for choroidal metastases

INTRODUCTION: We report on a case with bilateral choroidal metastases derived from a renal cell carcinoma 13 years after nephrectomy. The treatment modality is discussed. METHODS: A male patient (58 years of age) presented with asymptomatic bilateral choroidal metastases deriving from renal cell carcinoma. The right kidney had been removed because of renal cell carcinoma 13 years before the appearance of the choroidal metastases. He had full visual acuity (20/20) and normal intraocular pressure in both eyes. Fundus examination showed a small tumor in the peripheral choroidea of his right eye and an intermediate-sized solid tumor in the periphery of his left eye. RESULTS: The tumor of the right eye was treated by TTT and the tumor of the left eye by (106)Ru plaque radiotherapy. The tumors showed total regression into flat chorioretinal atrophies in both eyes and no tumor could be found 13 moths after treatment maintaining full visual acuity (20/20). CONCLUSION: Asymptomatic ocular metastases can develop even many years after removal of the primary tumor. TTT and (106)Ru brachytherapy are useful treatment modalities in cases of small and intermediate-sized choroidal metastases.     

Tamoxifen retinopathy in a male patient

PURPOSE: To report a case of tamoxifen retinopathy in a male patient. METHODS: Case report. A 68-year-old man, who had received a cumulative tamoxifen dose of 60 g over 33 months for unresectable hepatocellular carcinoma, was evaluated. RESULTS: A peculiar, bilateral, symmetric, inner retinal crystalline deposition associated with mild macular edema was discovered. No other ocular toxicity of tamoxifen was observed. CONCLUSION: To our knowledge, this is the first report of tamoxifen retinopathy in a male.