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CORRESPONDENCE
Year : 2012  |  Volume : 8  |  Issue : 4  |  Page : 639-640

Choroid as the first recurrence site: 13 years after breast carcinoma


State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China

Date of Web Publication29-Jan-2013

Correspondence Address:
Bin Yu
State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.106585

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 > Abstract 

Breast carcinoma is one of the most common primary tumors of metastatic choroidal tumors. The average time from the breast cancer diagnosis to metastasis to the eye and orbit has been reported to be approximately 4 years. We report an unusual case of the choroid as the first recurrence site in a 48-year-old woman with a history of breast cancer. In our reported case, the patient had a 13-year interval between the breast cancer surgery and the identification of the first and sole metastasis to the choroid. We present this unusual case, and to analyze the clinical, histopathological and immunohistochemical findings, so as to differential diagnosis from other choroidal tumors.

Keywords: Breast carcinoma, choroid, metastases


How to cite this article:
Liu T, Xu Y, Wan L, Yu B. Choroid as the first recurrence site: 13 years after breast carcinoma. J Can Res Ther 2012;8:639-40

How to cite this URL:
Liu T, Xu Y, Wan L, Yu B. Choroid as the first recurrence site: 13 years after breast carcinoma. J Can Res Ther [serial online] 2012 [cited 2019 Sep 15];8:639-40. Available from: http://www.cancerjournal.net/text.asp?2012/8/4/639/106585


 > Introduction Top


Breast carcinoma is one of the most common primary tumors of metastatic choroidal tumors, followed by carcinomas of the lung and gastrointestinal tract. The kidneys, uterus, prostate, and thyroid are less frequent primary sites of choroidal metastases. [1],[2] If a patient has a malignant tumor history, metastatic tumors will unquestionably be considered. However, the time at which choroidal metastases can be excluded is unknown. We report what we believe to be the longest term case of breast carcinoma as the first recurrence site.


 > Case Report Top


In March 2011, a 48-year-old woman noticed blurred vision in her right eye and persistent vision decline approximately 1 month before presentation. She denied eyeball pain or discomfort. Her past medical history was remarkable for breast carcinoma 13 years prior to her presentation. At the time of her original diagnosis in 1998, the patient underwent a modified radical mastectomy, and the primary breast tumor was judged to be a grade 2 invasive ductal carcinoma of the breast. She was initially treated with three courses of chemotherapy with carboplatin and taxol and was not found to have any metastatic tumors based on a systemic examination and CT. The initial examination at our clinic demonstrated that the patient's visual acuity was hand motion in the right eye and 16/20 in the left eye. Her palpebral fissures were symmetrical at 10 mm. No palpable orbital or ocular adnexal masses were appreciated. A slit-lamp examination showed normal anterior segments. Her intraocular pressure was 18 mmHg on the right and 19 mmHg on the left by applanation tonometry. Her right pupil reacted slowly, and an afferent pupillary defect was noted. With indirect ophthalmoscopy, a dilated fundus examination of the right eye revealed a dome-shaped, darkly pigmented mass under the nerve layer at the macula [Figure 1]a. Neurosensory detachment could be observed at the post pole and the temporal side of the right eye around the macula. Fundus fluorescein angiography of the retina showed hypofluorescence during the arterial phase and progressive hyperfluorescence during the subsequent phases. The lesion borders revealed retinal capillary dilation during the arteriovenous phase and persistent pinpoint leakage throughout the angiogram [Figure 1]b. B-scan ultrasonography showed apposition of the temporal choroidal mass, which obliterated the vitreous cavity and caused neurosensory detachment [Figure 1]c. B-scan ultrasound demonstrated that the left eye was normal. The clinical findings were consistent with a metastatic tumor of the right eye in the setting of a posterior segment mass. The differential diagnosis at this point included a choroidal malignant melanoma or a choroidal hemorrhage. The decision was made to proceed with surgical enucleation and was discussed at length with the patient. She chose a therapeutic and diagnostic enucleation. The patient tolerated the procedure well. The surgery was successful, and the eyeball was resected with 1.0 cm of the optic nerve. A gross examination found no evidence of outgrowth or nerve infusion [Figure 2]a. The breast carcinoma histopathology was marked by a solid group of cells on a fibrovascular framework. The cells were cuboidal in shape with granular cytoplasms. The tumor cells were atypical, and nuclear pleomorphism, hyperchromasia, and macronuclei were prominent cell features [Figure 2]b. The histopathology of the enucleated specimen and CA15-3 immunostaining were consistent with choroidal metastases from a breast invasive ductal carcinoma [Figure 2]c. S100 and HMB45 immunostaining was performed and was negative, excluding a choroidal malignant melanoma.
Figure 1: A representative fundus photograph, fl uorescence imaging and ultrasonography, (a) Choroidal metastasis associated with perifoveal serous retinal detachment and alterations in the retinal pigment epithelium in the right eye, (b) Fluorescein angiography revealed late hyperfl uorescence with areas of hypofl uorescence in the right eye, (c) Ultrasonography showed a choroidal mass pattern with moderate internal refl ectivity in the right eye (arrow)

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Figure 2: The histological changes evident in the choroidal breast carcinoma, (a) The resected specimen showed a white choroidal mass at the post pole of the retina near the optic disc (arrow) and multiple retinal detachments, (b) and atypical cells grouped under the retinal pigment epithelium, (c) The tumor cells were positive for CA15-3. Scale bar 50 μm

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 > Discussion Top


As reported, unilateral or even bilateral choroidal metastasis has been shown to have a poor visual prognosis. [3] The clinical presentation of choroidal metastases is usually blurred vision or decreased visual acuity, [4] and our patient complained of both. Metastatic tumors usually reveal an initial choroidal blockage, and the late angiogram phases often show a combination of diffuse leaks and pinpoint leaks. Choroidal metastases are yellow in color, plateau shaped, and associated with the subretinal fluid. With the assistance of fluorescein angiography and echography, metastatic tumors can be distinguished from other diseases that might also be included in a differential diagnosis. Choroidal metastases consistently demonstrated medium to high reflectivity and an irregular internal structure using echography, often accompanied with neurosensory detachment. [5] In a histological differential diagnosis, we also need to exclude malignant melanoma, which is HMB45 and S100 positive. CA15-3 is a breast cancer-related antigen and is considered to be a sensitive marker for evaluating and monitoring breast cancer patients. Positive CA15-3 tissue staining is thought to be specific to breast cancer. [6] In a review of 264 breast cancer patients, the uvea was the first systemic metastatic site of previously diagnosed breast cancer in 43 (16%) patients. [7] Freedman et al. [8] reviewed the charts of 112 patients (141 eyes) presenting with a metastasis to the eye or orbit and revealed that the average time from the breast cancer diagnosis to metastasis to the eye and orbit was approximately 4 years (1266 days). In our reported case, the patient had a much longer time between the breast cancer surgery and the identification of the first and sole metastasis to the choroid. It is also possible that the metastasis occurred earlier but remained asymptomatic for a period of time; asymptomatic patients with metastatic breast carcinoma have been previously reported. In these reports, the incidence of asymptomatic choroidal breast cancer metastases was 0%-5%, [9],[10] indicating that the primary tumor can remain inactive for a long period of time before it metastasizes or reactivates.

In this case study, we present a patient with a choroidal metastasis 13 years after the original diagnosis and breast cancer lumpectomy. To the best of our knowledge, our report is the first to document such a prolonged period between the initial surgery and the appearance of a breast invasive ductal carcinoma metastasis in the choroid as the first recurrence site. Ophthalmologists need to be aware of the potential for a choroidal metastasis when diagnosing a patient with a past history of breast cancer, even if it occurred more than 13 years prior to the current clinical presentation.

 
 > References Top

1.Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265-76.  Back to cited text no. 1
    
2.Sharma SG, Gokden M, McKenney JK, Phan DC, Cox RM, Kelly T, et al. Uterine papillary serous carcinoma metastatic to the choroid. Retin Cases Brief Rep 2010;4:62-4.  Back to cited text no. 2
    
3.Biswas J, Ho TC, Bhavsar K. Bilateral metastasis to the retina, choroids and optic nerve from breast cancer: A clinicopathological case. Indian J Ophthalmol 2007;55:71-2.  Back to cited text no. 3
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4.Soysal HG. Metastatic tumors of the uvea in 38 eyes. Can J Ophthalmol 2007;42:832-5.  Back to cited text no. 4
    
5.Arevalo JF, Fernandez CF, Garcia RA. Optical coherence tomography characteristics of choroidal metastasis. Ophthalmology 2005; 112:1612-9.  Back to cited text no. 5
    
6.Tohnosu N, Narushima K, Sunouchi K, Saito T, Shimizu T, Tanaka H, et al. A case of breast cancer metastatic to the tail of the pancreas. Breast Cancer 2006;13:225-9.  Back to cited text no. 6
    
7.Demirci H, Shields CL, Chao AN, Shields JA. Uveal metastasis from breast cancer in 264 patients. Am J Ophthalmol 2003;136:264-71.  Back to cited text no. 7
    
8.Freedman MI, Folk JC. Metastatic tumors to the eye and orbit. Patient survival and clinical characteristics. Arch Ophthalmol 1987;105:1215-9.  Back to cited text no. 8
    
9.Fenton S, Kemp EG, Harnett AN. Screening for ophthalmic involvement in asymptomatic patients with metastatic breast carcinoma. Eye (Lond) 2004;18:38-40.  Back to cited text no. 9
    
10.Wiegel T, Kreusel KM, Bornfeld N, Bottke D, Stange M, Foerster MH, et al. Frequency of asymptomatic choroidal metastasis in patients with disseminated breast cancer: Results of a prospective screening programme. Br J Ophthalmol 1998;82:1159-61.  Back to cited text no. 10
    


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