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CORRESPONDENCE
Year : 2013  |  Volume : 9  |  Issue : 3  |  Page : 504-506

Carcinoma lung presenting with choroidal metastasis as initial presentation: A rarity


Department of Radiotherapy, Oncology, Ophthalmology, and Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication8-Oct-2013

Correspondence Address:
Rakesh Kapoor
Department of Radiotherapy and Oncology, Regional Cancer Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.119361

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 > Abstract 

Diminished vision due to choroidal metastasis as the primary symptom of lung cancer is very uncommon. Here, we report such a presentation in a 54-year-old male patient of small cell lung cancer. The outcome is usually dismal with this kind of presentation. The patient received systemic chemotherapy as well as intravitreal bevacizumab but with no improvement in vision. The patient had been given external beam radiotherapy and showed subjective improvement in his ocular symptoms.

Keywords: Bevacizumab, chemotherapy, choroidal metastasis, radiotherapy


How to cite this article:
Bhattacharyya T, Kapoor R, Bahl A, Yadav BS, Singh U, Joshi K, Rane S, Sharma S C. Carcinoma lung presenting with choroidal metastasis as initial presentation: A rarity. J Can Res Ther 2013;9:504-6

How to cite this URL:
Bhattacharyya T, Kapoor R, Bahl A, Yadav BS, Singh U, Joshi K, Rane S, Sharma S C. Carcinoma lung presenting with choroidal metastasis as initial presentation: A rarity. J Can Res Ther [serial online] 2013 [cited 2019 Nov 21];9:504-6. Available from: http://www.cancerjournal.net/text.asp?2013/9/3/504/119361


 > Introduction Top


Choroidal metastasis is the most common intra-ocular malignancy. Breast and lung cancers represent more than two-thirds of the primary cancer sites in such patients. Choroidal metastasis in lung cancer is usually present when multiple other organs are affected. Decrease in visual acuity as the initial manifestation of lung cancer is rare. To date, only 15 cases of choroidal metastasis as the first sign of lung carcinoma have been reported. We present a 54-year-old man with choroidal metastasis as the initial manifestation of a small cell lung cancer. Treatment involves combination of systemic chemotherapy and intraocular therapy in the form of intravitreal chemotherapy, external beam radiotherapy, and plaque radiotherapy. Despite the intravitreal bevacizumab and systemic chemotherapy, the patient did not show any improvement in his visual acuity. So he had been given external beam radiotherapy and showed reasonable improvement in his vision which offered him a better quality of life.


 > Case Report Top


A 54-year-old male presented with chief complaints of painless, progressive dimness of vision in the right eye for 3 months. He was a heavy smoker who used to smoke one pack of cigarette a day for last 20 years. His medical history was unremarkable. His visual acuity was 6/60 in the right eye and 6/6 in the left eye. His fundus fluorescein angiography revealed the presence of choroidal mass with features of retinal detachment [Figure 1]. An ultrasound B scan of the eye demonstrated the tumor height of 10 mm [Figure 2].
Figure 1: Fundus fluorescein angiography revealed the presence of choroidal mass with features of retinal detachment

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Figure 2: USG B scan of the eye demonstrated the tumor height of 10 mm

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On further investigation, a contrast enhanced computed tomography of the chest revealed evidence of multiple speculated soft tissue masses in the posterior segment of the upper lobe of left lung, largest measuring 1.6 × 1.3 cm. Enlarged mediastinal lymph nodes were noted in the left paratracheal and left tracheo bronchial region [Figure 3]. PET/CT showed mild focal fluoro-deoxy-glucose uptake in the posterior part of left eyeball. Moderate FDG uptake (SUV max 7.4) was noted in an irregular soft tissue lesion in the upper lobes of left lung. Choroidal biopsy was performed and it showed small clusters of epithelial cells with hyper chromatic nuclei and moderate cytoplasm. The tumor cells showed cytoplasmic positivity for pancytokeratin and were strongly positive for neurone specific enolase (NSE) [Figure 4]. Overall features were consistent with metastatic small cell carcinoma. As the lung lesion was very small and was in relation to major vessels, so it was not amenable for fine needle aspiration cytology or biopsy.
Figure 3: CECT of the chest revealed evidence of multiple speculated soft tissue masses in the posterior segment of the upper lobe of left lung, largest measuring 1.6 × 1.3 cm. Enlarged mediastinal lymph nodes were noted in the left paratracheal and left tracheo bronchial region

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Figure 4: Histopathological examination of the choroidal biopsy by Hematoxylin and Eosin stain showed epithelial cells (arrows) with high N:C ratio, nuclear moulding with few residual choroidal pigment containing cells (arrow heads). (c) These tumor cells showed strong membranous positivity for pancytokeratin and (d) cytoplasmic and nuclear positivity for NSE. The tumor cells were negative for TTF-1 (not shown). All IHC was performed using primary antibodies obtained from Dako cytomation and color was developed using HRP tagged universal antibody using the Envision+ kit from Dako cytomation

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The patient received intravitreal injection bevacizumab 2.5 mg repeated every month for five cycles. He also received six cycles of chemotherapy with injection Cisplatin 100 mg/m 2 in three divided doses day1-day3 and injection Etoposide 100 mg/m 2 day1-day3 repeated at three weekly intervals. The patient received external beam radiotherapy to the right eye 30 Gray (Gy) in 10 fractions over 2 weeks. At 6 months follow up, patient has partial improvement in vision in right eye (visual acuity 6/18).


 > Discussion Top


Metastatic cancer is the most common malignancy of the eye. The incidence of metastatic cancer in the eye is likely under estimated, because patients suffering from systemic carcinoma are frequently so ill that they ignore or are unaware of ocular symptoms. The most commonly affected site is the choroid, particularly the posterior pole. [1],[2] In 20-40% of cases, lesions are bilateral. [3] The most common primary sites for choroidal metastasis are breast, lung, skin melanoma, pancreas, kidney, and prostate. [1],[2] The incidence for the breast cancer is reported to be 37-41%, while lung cancer is considered to be responsible for no more than 7% of choroidal metastases. [4],[5] It is generally considered that the metastatic lesions occur at the final stages of the disease, where the mean survival is not expected to be more than 6 months and the majority of the patients already suffer from the typical lung cancer symptoms. [6] Our patient presented with initial symptom of dimness of vision due to choroidal metastasis which is very rare. A thorough review of the literature revealed only 15 cases of lung cancer patients suffering from choroidal metastasis as the first clinical sign.

Treatment for ocular metastases is palliative, because the presence of such metastases suggests hematogenous spread of cancer. In line with this, the aims for treatment are to maximize quality of life, and restore or preserve vision. This may be achieved with either radiotherapy or chemotherapy. Surgery does not play an important role other than diagnostic biopsy, as surgery carries great potential for morbidity and often there is no need for tumor debulking. Letson, et al. described six patients with choroidal metastasis who were treated with chemotherapy and underwent regression. [7] Thus, chemotherapy alone can be used in patients with chemo-responsive primary tumor. If the patient is undersystemic chemotherapy and the ocular tumoris asymptomatic, no ocular treatment is indicated. But in our patient, there was no improvement in vision after six cycles of systemic chemotherapy. So we had put our patient on intravitreal injection bevacizumab as systemic chemotherapy was inadequate to control ocular complications. In ophthalmology, it has been widely used as an intravitreal agent for treatment of proliferative (neovascular) eye diseases. [8] There have been a number of reports on anti-angiogenic therapy for ocular tumors. [9] A case of choroidal metastasis secondary to breast carcinoma was reported where metastatic tumor was treated with a single injection of intravitreal bevacizumab (4 mg), and it partially regressed. [10] We delivered three cycles of intravitreal bevacizumab 2.5 mg at one monthly interval. But even after this kind of intraocular therapy, there was only subjective improvement (vision 6/36 in the right eye) for a very short duration of time.

In such refractory cases, radiation therapy in the form of external beam radiotherapy, plaque radiotherapy, and proton beam irradiation has been recommended. [11] The dose of external beam radiotherapy required for the successful palliation of choroidal metastasis for most primary tumors is 30 Gy in daily fractions of 300 Gy. Occasionally, patients with prolonged survival are more likely to require a total dose of 45-50 Gy in daily fractions of 200-250 Gy to achieve possible long-term control. [12]

So in a patient with choroidal mass, we always have to keep in mind secondary metastasis as a differential diagnosis.

 
 > References Top

1.Ferry AP, Font RL. Carcinoma metastatic to eye and orbit. I.A clinicopathologic study of 227 cases. Arch Ophthalmol 1974;92:276-86.  Back to cited text no. 1
    
2.Stephens RF, Shields JA. Diagnosis and management of cancer metastatic to the uvea: A study of 70 cases. Ophthalmology 1979;86:1336-49.   Back to cited text no. 2
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3.Shields JA. Diagnosis and management of intraocular tumors. St Louis: Mosby; 1983. p. 83-121.  Back to cited text no. 3
    
4.Fernandes BF, Fernandes LH, Burnier MN Jr. Choroidal mass as the presenting sign of small cell lung. Can J Ophthalmol 2006;41:605-8.  Back to cited text no. 4
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5.Kreusel KM, Wiegel T, Stange M, Bornfeld N, Hinkelbein W, Foerster MH, et al. Choroidal metastasis in disseminated lung cancer: Frequency and risks factors. Am J Ophthalmol 2002;134:445-7.  Back to cited text no. 5
    
6.Arevalo JF, Fernandez CF, Garcia RA. Optical coherence tomography characteristics of choroidal metastasis. Ophthalmology 2005;112:1612-9.  Back to cited text no. 6
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7.Letson AD, Davidorf FH, Bruce RA Jr. Chemotherapy for treatment of choroidal metastases from breast carcinoma. Am J Ophthalmol 1982;93:102-6.  Back to cited text no. 7
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8.Mason JO 3rd, Nixon PA, White MF. Intravitreal injection of bevacizumab (Avastin) as adjunctive treatment of proliferative diabetic retinopathy. Am J Ophthalmol 2006;142:685-8.  Back to cited text no. 8
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9.Rosenblatt MI, Azar DT. Anti-angiogenic therapy: Prospects for treatment of ocular tumors. Seminophthalmol 2006;21:151-60.  Back to cited text no. 9
    
10.Amselem L, Cervera E, Díaz-Llopis M, Montero J, Garcia-Pous M, Udaondo P, et al. Intravitreal bevacizumab (Avastin) for choroidal metastasis secondary to breast carcinoma: Short-term follow-up. Eye 2007;21:566-7.  Back to cited text no. 10
    
11.Tsina EK, Lane AM, Zacks DN, Munzenrider JE, Collier JM, Gragoudas ES, et al. Treatment of metastatic tumors of the choroid with proton beam irradiation. Ophthalmology 2005;112:337-43.  Back to cited text no. 11
    
12.Burmeister BH, Benjamin CS, Childs WJ. The management of metastases to eye and orbit from carcinoma of breast. Aust NZ J Ophthalmol 1990;18:187-90.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
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