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CORRESPONDENCE
Year : 2017  |  Volume : 13  |  Issue : 6  |  Page : 1062-1064

Choroidal metastases as the presenting feature of adenocarcinoma of the lung: A case report and an overview of the role of radiotherapy in its management


1 Department of Radiotherapy and Oncology, Kasturba Medical College, Manipal, Karnataka, India
2 Department of Ophthalmology, Kasturba Medical College, Manipal, Karnataka, India

Date of Web Publication13-Dec-2017

Correspondence Address:
Dr. Krishna Sharan
Department of Radiotherapy, Shirdi Saibaba Cancer Hospital, Manipal - 576 104, Udupi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.176413

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 > Abstract 

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.

Keywords: Choroid, metastasis, radiotherapy, uvea


How to cite this article:
Sharan K, Shailaja S, Pai VH, Fernandes DJ. Choroidal metastases as the presenting feature of adenocarcinoma of the lung: A case report and an overview of the role of radiotherapy in its management. J Can Res Ther 2017;13:1062-4

How to cite this URL:
Sharan K, Shailaja S, Pai VH, Fernandes DJ. Choroidal metastases as the presenting feature of adenocarcinoma of the lung: A case report and an overview of the role of radiotherapy in its management. J Can Res Ther [serial online] 2017 [cited 2020 Aug 6];13:1062-4. Available from: http://www.cancerjournal.net/text.asp?2017/13/6/1062/176413


 > Introduction Top


Intraocular metastatic disease is an uncommon presentation in the practice of oncology. While symptomatic ocular metastatic disease contributes to <3% of orbital tumors,[1] asymptomatic metastases are likely to be much more common as orbit is not a routinely evaluated site for evidence of metastatic disease. Here, we report a patient who was evaluated for complaints of blurring of vision and was eventually diagnosed to have metastatic adenocarcinoma of the lung.


 > Case Report Top


A 78-year-old man presented to the Department of Ophthalmology with complaints of decrease in far and near vision in the right eye for 1 month. On examination, his unaided visual acuity in the right eye was 20/200 which improved with +2.25 diopter spherical correction to 20/30; near vision with correction was N14. He was pseudophakic in the right eye. The left eye was normal except for the presence of Grade 2 nuclear sclerosis. Fundoscopy of the right eye revealed a yellowish-white, elevated choroidal mass measuring around 4 disc diameters along the superotemporal arcade with surrounding subretinal fluid extending subfoveally [Figure 1]. B-scan ultrasound revealed a mass measuring 5.5 mm × 3.2 mm × 1.4 mm with variable internal structure and a high internal reflectivity, suggestive of choroidal metastasis [Figure 2]a. Associated exudative retinal detachment was also noted. Optical coherence tomography (OCT) showed the presence of subretinal fluid extending under the fovea [Figure 2]b.
Figure 1: Fundoscopy of the right eye showing choroidal mass measuring around 4 disc diameters (arrow) along the superotemporal arcade with the surrounding subretinal fluid extending subfoveally

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Figure 2: (a) B-scan showing a mass (yellow arrow) with variable internal structure, high internal reflectivity, and associated exudative retinal detachment (red arrow); (b) optical coherence tomography shows subretinal fluid under the fovea

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The chest X-ray revealed a mass in the right lower lung. Evaluation with a computed tomography of thorax identified a spiculated mass in the lateral basal segment of the right lung, with multiple small metastatic nodules diffusely distributed in both lungs, and lytic lesions in the lower thoracic vertebrae. Biopsy of the lung mass was reported as adenocarcinoma of the lung. Bone scan suggested extensive metastases to bones although the patient was asymptomatic. No other metastatic disease was identified on further evaluation.

Because the patient had visual symptoms and was not a candidate for aggressive systemic chemotherapy in view of age and poor performance status, he was planned upfront for palliative external beam radiotherapy (EBRT) to the involved eye, pending the immunohistochemical (IHC) analysis of the biopsy for evidence of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase mutation. Treatment was delivered on a 6 MV linear accelerator by anterolateral wedge technique, with sparing of the anterior 3rd of the eye in the lateral beam. He received 30 Gy in 10 fractions over 2 weeks. Subjective visual improvement was reported by the 2nd week. Unaided visual acuity had improved to 20/60, and best-corrected visual acuity was 20/30. On B-scan, the mass showed reduction in the size to 3.2 mm × 2.2 mm × 1.0 mm.

The biopsy specimen was deemed inadequate for IHC analysis. The patient refused to undergo a repeat biopsy and was offered a single agent palliative chemotherapy, which he refused. He agreed for empirical anti-EGFR tyrosine kinase inhibitor and was prescribed tablet gefitinib 250 mg once daily along with 4 weekly injections zoledronic acid. The patient discontinued treatment by himself after 2 weeks, citing poor tolerance. On the last follow-up, 2 months after radiotherapy, the patient's general condition had deteriorated, and he had lost a significant amount of weight. However, his vision in the right eye had improved to 20/20, near vision to N6. Fundoscopy showed a significant reduction in the choroidal mass and resolution of retinal detachment. On B-scan, the mass size was 2.2 mm × 1 mm × 1 mm [Figure 3]a, and the OCT revealed near total clearance of the subretinal fluid [Figure 3]b. There was no significant xerophthalmia or radiation keratopathy at last follow-up.
Figure 3: (a) B-scan and (b) optical coherence tomography 2 months after treatment, showing a significant reduction in size of the choroidal mass and resolution of exudative retinal detachment

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 > Discussion Top


Metastases to the eye, once considered rare, are quite frequently reported lately. They are presently recognized as the most common intraocular malignancy, found in up to 8% of cancer patients on autopsy.[2] However, most patients are asymptomatic; a study screening for ocular involvement in patients with metastatic breast cancer found a 5% incidence of choroid metastases; all of them asymptomatic.[3] On the contrary, ocular metastasis as the presenting symptom is very unusual. In a case series and literature review, between 1954 and 2012, only 55 patients were found to have presented with choroidal metastases that were eventually identified to be metastatic lung carcinoma.[4]

The treatment of uveal metastases can be either systemic or local. Systemic therapies against the primary tumor are usually effective in controlling the metastatic disease, explained by the fact that the choroid is outside the blood-ocular barrier and is well accessed by the drugs. Relative merits of systemic treatment include similar efficacy as local therapies and a lower risk of local complications such as local infections, xerophthalmia, and cataract formation. Despite these advantages, systemic therapy can be quite toxic and might not be considered for at least a few patients.

Radiotherapy is the most important form of local therapy, usually performed when the lesions fail to respond to systemic therapy. While EBRT is the most common technique, choroidal metastases have also been treated using plaque brachytherapy [5] and newer modalities such as proton beam therapy [6] and stereotactic radiosurgery.[7] Radiotherapy is quite effective in the treatment of uveal metastases. In a retrospective study, the overall response rate was 96%, with 64% of eyes having complete response.[8] A potential dose-response relationship was noted; 72% of the patients receiving more than 35.5 Gy had complete response, compared to 33% with lower doses. The magnitude of response increased with time.[8] In our patient, a good early response was sustained till his last follow-up.

Ophthalmic toxicity following EBRT to uveal metastases is generally low. Our patient did not experience any toxicity following treatment except for partial loss of eyelashes. Potential complications include radiation retinopathy, papillopathy, glaucoma, xerophthalmia, keratopathy, and cataract development. As noted in a recent review on radiation-induced ocular toxicity, serious complications are unlikely to be of the problem at doses below 30 Gy of fractionated RT.[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Kreusel KM, Bechrakis NE, Wiegel T, Krause L, Foerster MH. Incidence and clinical characteristics of symptomatic choroidal metastasis from lung cancer. Acta Ophthalmol 2008;86:515-9.  Back to cited text no. 1
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2.
Bloch RS, Gartner S. The incidence of ocular metastatic carcinoma. Arch Ophthalmol 1971;85:673-5.  Back to cited text no. 2
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3.
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. 3
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4.
Singh N, Kulkarni P, Aggarwal AN, Rai Mittal B, Gupta N, Behera D, et al. Choroidal metastasis as a presenting manifestation of lung cancer: A report of 3 cases and systematic review of the literature. Medicine (Baltimore) 2012;91:179-94.  Back to cited text no. 4
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5.
Shields CL, Shields JA, De Potter P, Quaranta M, Freire J, Brady LW, et al. Plaque radiotherapy for the management of uveal metastasis. Arch Ophthalmol 1997;115:203-9.  Back to cited text no. 5
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6.
Tsina EK, Lane AM, Zacks DN, Munzenrider JE, Collier JM, Gragoudas ES. Treatment of metastatic tumors of the choroid with proton beam irradiation. Ophthalmology 2005;112:337-43.  Back to cited text no. 6
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7.
Bellmann C, Fuss M, Holz FG, Debus J, Rohrschneider K, Völcker HE, et al. Stereotactic radiation therapy for malignant choroidal tumors: Preliminary, short-term results. Ophthalmolgy 2000;107:358-65.  Back to cited text no. 7
    
8.
Rosset A, Zografos L, Coucke P, Monney M, Mirimanoff RO. Radiotherapy of choroidal metastases. Radiother Oncol 1998;46:263-8.  Back to cited text no. 8
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9.
Jeganathan VS, Wirth A, MacManus MP. Ocular risks from orbital and periorbital radiation therapy: A critical review. Int J Radiat Oncol Biol Phys 2011;79:650-9.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3]



 

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