Management of choroidal metastases

Choroidal metastases from thoracic cancer: a retrospective study on clinical characteristics and treatment efficacy

Objective

This study aimed to examine the clinical characteristics of choroidal metastases (CMs) and assess the efficacy of various treatment strategies for CMs in a specific patient cohort.

Methods

This retrospective case series study included 32 patients (38 eyes) diagnosed with CM at the Department of Ophthalmology, Peking University People's Hospital, between 2009 and 2022. The cohort included 10 male patients (10 eyes) and 22 female patients (28 eyes), with a mean age of 52.53 ± 10.81 years. Detailed medical histories and multiple ophthalmic examinations were performed for all patients, with diagnoses confirmed by two senior ophthalmologists. Clinical characteristics, treatment responses, and follow-up outcomes were analyzed.

Results

Lung cancer was the most common primary tumor (53.1%), with six patients initially presenting with ocular symptoms. Initial ultrasound imaging revealed a mean tumor height of 3.02 mm and a mean basal diameter of 11.09 mm. Optical coherence tomography (OCT) revealed irregular, highly reflective foci with undulating anterior surfaces, and fluorescein angiography (FFA) revealed early choroidal tumor masking and late-phase mottled hyperfluorescence with occasional leakage. Indocyanine green angiography (ICGA) revealed hypofluorescence in early and late phases, with slightly mottled hyperfluorescence in the late phase. The follow-up period ranged from 3 months to 4 years (median 4 months), during which systemic and local treatments effectively controlled or delayed tumor progression in most patients.

Conclusion

Lung and breast cancers are the leading sources of CMs, with bilateral or multifocal lesions more frequently linked to breast cancer. Treatment for CMs should be meticulously individualized and should take into account the patient's overall condition, tumor burden, and precise tumor location. Local treatment is essential for patients with significant ocular symptoms. A combination of local and systemic treatments has been shown to lead to a more significant reduction in tumor burden.

EFFICACY OF EPIDERMAL GROWTH FACTOR RECEPTOR TYROSINE KINASE INHIBITOR IN TREATING CHOROIDAL METASTASIS FROM NON-SMALL-CELL LUNG CANCER: A 10-Year Review

BACKGROUND/PURPOSE

To describe the clinical characteristics of choroidal metastasis in patients with non-small-cell lung carcinoma and report treatment outcomes following targeted therapy versus conventional radiotherapy and/or chemotherapy.

METHODS

A retrospective review was conducted in 2 hospitals in Hong Kong between 2013 and 2023. Outcomes included tumor response and visual function following treatment.

RESULTS

A total of 25 eyes of 21 Chinese patients with choroidal metastasis secondary to metastatic non-small-cell lung carcinoma were identified. The majority of patients were nonsmokers. At the time of diagnosis, 88% of eyes were visually symptomatic with a mean visual acuity of 20/100. There were 52% of tumors locating within the macula. Tyrosine kinase inhibitor monotherapy, tyrosine kinase inhibitor with radiotherapy, and radiotherapy and/or chemotherapy groups were observed to demonstrate similar tumor response from 1 month and comparable ocular progression-free indices. Untreated patients had deteriorated vision without any tumor response. The tyrosine kinase inhibitor monotherapy group achieved the most rapid and differential vision gain than other groups.

CONCLUSION

Tyrosine kinase inhibitor achieved durable disease control in epidermal growth factor receptor mutation-positive non-small-cell lung carcinoma patients with choroidal metastasis, while improving visual function. Tyrosine kinase inhibitor can be considered as an alternative to conventional orbital radiotherapy or chemotherapy for these patients in view of the rapid visual recovery.

Management of choroidal/ciliary body metastasis in the era of targeted cancer therapy

Introduction

Choroidal metastases from systemic malignancies are the most common intraocular malignancies in adults. External beam radiation (EBR) has historically been first-line therapy for metastatic tumors to the choroid. However, good responses have been described with newer targeted biologics. The optimal management strategy for patients with choroidal metastatic tumors in the era of targeted cancer therapy is not known. We aim to describe management of these tumors in a "real-world" setting using both radiation and systemic therapy.

Methods

We conducted a retrospective review of patients with choroidal/ciliary body metastases managed by the ocular oncology service at our institution over a five-year period. Demographic data, tumor type, treatment, visual outcomes, and mortality data were recorded.

Results

26 patients (33 eyes) with choroidal/ciliary body metastasis were identified. Primary malignancies included lung (8) breast (8), renal (3), esophageal (3), carcinoid (2), squamous cell carcinoma of the tonsil (1), and testicular cancer (1). Average time from diagnosis of ocular metastasis to death was 8 months (1-34). 20 eyes were treated with EBR and 13 eyes were treated with other modalities. Final logMAR visual acuity for eyes treated with radiation was 0.11 (0-3). Final visual acuity for eyes treated with other modalities was 0.18 (0-.70), with local tumor control in 20/23 eyes that had follow up after treatment. The difference between final visual acuity in these groups was not visually significant p=0.48.

Conclusion

Patients with choroidal/ciliary body metastasis treated with either EBR or systemic therapy can have good visual outcomes. More work needs to be conducted to determine the optimal first-line treatment of ocular metastasis for specific tumor subtypes.

Clinical manifestation and outcome of lung cancer patients with ocular metastasis: 16 case reports and systematic review

Ocular metastasis is a rare type of distant metastasis of lung cancer. Limited information is available regarding ocular symptoms, diagnosis, treatment, and prognosis. We reported 16 patients diagnosed with ocular metastasis from lung cancer treated at our hospital from January 1988 to March 2024 and conducted a systematic review of 100 patients retrieved from the PubMed database from January 2014 to December 2023. A pooled analysis was performed using individual-level patient data to generate the hazard ratio (HR) of the association between patient characteristics and overall survival. A total of 116 patients, 100 patients from the literature and 16 patients from our center, diagnosed with ocular metastasis from lung cancer were included in this study. Choroid metastasis was presented in 77 (66.4%) patients and was significantly associated with the onset of lung cancer with ocular symptoms and decreased vision; iris metastasis was significantly associated with small cell lung cancer (SCLC), high intraocular pressure, and ocular pain. Multivariate analyses revealed that males (HR, 2.488; 95% confidence interval [CI], 1.127-5.495), age ≥ 60 years (HR, 3.196; 95% CI, 1.391-7.341), and onset with ocular symptoms (HR, 4.312; 95% CI, 1.675-11.099) were significantly associated with overall survival. For non-SCLC (NSCLC) patients, compared with chemotherapy, targeted therapy (HR, 0.238; 95% CI, 0.087-0.651) and combined therapy (HR, 0.133; 95% CI, 0.017-0.822) have greater therapeutic efficacy. Chemotherapy combined with immunotherapy and targeted therapy are more effective than chemotherapy alone for ocular metastatic NSCLC patients. For patients with targetable mutations, new-generation tyrosine kinase inhibitors (TKIs) are preferred.

Personalized treatment approaches in intraocular cancer

Background

Intraocular malignant tumors represent a severe disease that threatens vision as well as life. To better extend the life of the patient, preserve visual function, and maintain ocular aesthetics, selecting the appropriate timing and methods of treatment becomes crucial.

Main text

With the continuous advancement of medical technology, the techniques and methods for treating intraocular malignant tumors are constantly evolving. While surgery was once considered the optimal method to prolong patient survival and prevent local recurrence, the discovery and application of various treatments such as radiotherapy, laser therapy, chemotherapy, cryotherapy, and monoclonal antibodies have led to a greater diversity of treatment options. This diversity offers more possibilities to develop personalized treatment plans, and thereby maximize patient benefit. This article reviews the various treatment methods for intraocular malignant tumors, including indications for treatment, outcomes, and potential complications.

Conclusions

Differentiating small intraocular malignant tumors from pigmented lesions is challenging, and ongoing monitoring with regular follow-up is required. Small to medium-sized tumors can be treated with radiotherapy combined with transpupillary thermotherapy. Depending on the tumor's distance from the optic disc, surgery with partial resection may be considered for distant tumors, while proximal tumors may require complete enucleation. Systemic chemotherapy has been widely applied to patients with retinal tumors, lymphomas, and intraocular metastatic cancers, but has limited efficacy in patients with choroidal melanoma. Antagonists of Vascular Endothelial Growth Factor (Anti-VEGF) drugs can improve patient vision and quality of life, while the efficacy of immunotherapy and molecular targeted therapy is still under research.

Ocular metastases profile in a tertiary hospital in São Paulo, Brazil

OBJECTIVE

Ocular metastases are the most common intraocular tumours in adults. Data regarding the occurrence of these tumours in the Brazilian population is scarce. We aimed to investigate the profile of ocular metastases of patients referred to tertiary hospital service in São Paulo, Brazil.

DESIGN

Retrospective study.

PARTICIPANTS

Patients referred to the Ocular Oncology service of the Federal University of São Paulo with initial diagnostic hypothesis of ocular metastasis.

METHODS

Data was retrospectively collected from medical records from June 2017 to June 2023. Age, sex, primary tumour site, previous knowledge of the systemic diagnosis, laterality, initial visual acuity (VA), local or systemic treatment and mean follow-up period were obtained.

RESULTS

A total of 37 cases were referred to the ocular oncology division due to a suspected ocular metastasis, 15 (40.5%) were confirmed. Mean age at diagnosis was 53.47 ± 16.01 years old, the majority (86.7%) of patients already knew the systemic diagnosis. Breast cancer (66.7%) was the most common primary site, followed by Lung cancer (26.7%). Both eyes were affected in 66.67% of the cases, all patients had metastases at the choroid (100.0%), and the mean initial VA was 1.37 ± 1.04 logMAR. Chemotherapy was the main systemic treatment modality (73.3%), and most patients had no ocular treatment (53.3%). The mortality rate along the follow-up period was 30.0%.

CONCLUSIONS

Considering the number of new patients absorbed by the Ocular Oncology service over the study period, the frequency of ocular metastases was relatively low. The patients' characteristics was comparable to data published in the international literature.

Improving visual acuity with nivolumab plus ipilimumab plus two cycles of chemotherapy following a diagnosis of lung adenocarcinoma with choroidal metastasis: A case report and literature review

A 75-year-old woman presented at our hospital with bilateral visual impairment. Ophthalmological examination revealed multiple choroidal tumours. Chest computed tomography revealed a tumour shadow in the right lower lobe and multiple lymph node metastases in the mediastinum and pulmonary hilum. Following a detailed examination, the patient was diagnosed with primary lung adenocarcinoma (cT1cN3M1c Stage IVB) with choroid metastases. The tumour proportion score of programmed death ligand 1 (PD-L1) was 1% and EGFR exon 20 insertion mutations were also detected. The patient was administered combination chemotherapy with nivolumab and ipilimumab. Primary lung and metastatic tumours, including the choroid, were reduced, and visual disturbances improved completely. Herein, we describe a rare case in which a combination of chemotherapy with nivolumab and ipilimumab significantly reduced vision loss due to choroidal metastasis.

Clinical Outcomes of Radiation Therapy for Choroidal Metastases and A Literature Review

INTRODUCTION

Radiation therapy (RT) for choroidal metastasis (CM) aims to preserve vision and achieve local control (LC), thereby maintaining quality of life. The present study reports the clinical outcomes of RT for CM and reviews the literature.

METHODS

We retrospectively collected data on 11 patients with CM; their primary tumors were breast cancer (n=3), lung cancer (n=3), leukemia (n=2), lymphoma (n=2), and gastric cancer (n=1). Four patients had bilateral CM. The median radiation dose was 39 Gy in 13 fractions (range, 20-50 Gy in 10-25 fractions). We investigated changes in visual acuity, tumor responses, morbidities, LC, and overall survival (OS). A systematic review of literature published between 1990 and 2020 was performed using the PubMed database.

RESULTS

One, 1, and 6 patients had improved, stabilized, and worse visual acuity, respectively (data missing for 3 patients). Nevertheless, eight patients considered their visual acuity to have improved or remained the same after RT. Among 15 lesions in 11 patients, complete and partial responses were observed in 2 and 6, respectively (data missing for 7 lesions in 4 patients). Three-year LC and OS rates were 100 and 32%, respectively. Grade ≥ 3 morbidities were not observed. In the literature review, the most common primary cancer was breast cancer followed by lung cancer. Improvements in or the stabilization of visual acuity was observed in 80% of patients (range, 47-100), and the median survival time was 11 months (range, 4.9-23).

CONCLUSION

RT is an efficient and safe palliative treatment for CM without severe toxicity.

Posterior segment manifestations of ocular metastasis

PURPOSE OF REVIEW

This article reviewed and summarized recent published data on ocular imaging findings and treatment of posterior segment manifestations of ocular metastasis.

RECENT FINDINGS

Advanced ocular imaging can help differentiate ocular metastases from other mimicking lesions, including primary intraocular tumors or infections. Recently, case reports have demonstrated the successful use of targeted systemic therapy to achieve local control of vitreous and choroidal metastases.

SUMMARY

Metastasis can lead to a wide variety of posterior segment ocular manifestations. The choroid is the most common metastatic site, whereas tumor metastasizing to the retina and optic disc are rare. Patients with possible metastatic eye disease are recommended to undergo extensive investigation to determine the underlying primary cancer and ongoing systemic metastases. Currently, there is no consensus on the treatment strategy. Treatment generally includes systemic chemotherapy in combination with local treatment, such as radiotherapy, laser therapy, or anti-vascular endothelial growth factor (anti-VEGF) treatment.

Intensity-Modulated Radiation Therapy for Bilateral Choroidal Metastases Involving Macula and Optic Disc

This case report discusses the case of a 76-year-old woman with choroidal metastasis from breast cancer who was treated with intensity-modulated radiation therapy (IMRT). Choroidal metastasis is a common ocular tumor, and the occurrence of this condition has increased due to improved diagnostic tools and longer survival of metastatic patients. IMRT is an innovative radiation therapy technique that reduces complications and improves the curative effect by concentrating radiation on the tumor while minimizing exposure to surrounding tissues. In this case, the patient had a history of breast cancer and was undergoing chemotherapy when she presented with vision loss and blurred vision. Imaging tests confirmed choroidal metastasis, and IMRT was performed under the guidance of a radiation oncologist. After treatment, the choroidal lesion dramatically reduced in size, and the patient's vision improved. The text concludes that radiation therapy, including IMRT, is becoming more common as a treatment for ocular metastasis to improve vision and preserve the eye. When choosing radiation therapy, it is essential to consider the size of the tumor and the impact on surrounding tissues. IMRT is an effective treatment that enables precise and concentrated irradiation of the tumor tissue while minimizing exposure to normal tissues.

Solitary choroidal metastasis of distal cholangiocarcinoma: A case report

Metastatic choroidal carcinoma is rare and generally has a poor prognosis. The present case report describes a case of choroidal metastasis from distal cholangiocarcinoma, which was successfully managed using stereotactic radiotherapy (SRT). A 67-year-old Japanese man underwent pancreaticoduodenectomy for distal cholangiocarcinoma. The pathological stage was T2N0M0 stage IIA, according to the Union for International Cancer Control 8th edition. After surgery, the patient received adjuvant chemotherapy with oral TS-1® for 1 month. A total of 2 months after surgery, the patient was readmitted to hospital due to decreased visual acuity. Fundoscopy revealed a macular hole in the right eye that accounted for the decreased visual acuity. Additionally, Goldmann three-mirror contact lens examination revealed a 4-mm choroidal mass with a yellowish color situated at a considerable distance from the optic nerve. Magnetic resonance imaging revealed an enhanced choroidal mass. Based on the findings of ophthalmologic examinations and the patient's history of cholangiocarcinoma, they were diagnosed with choroidal metastasis from distal cholangiocarcinoma. SRT was administered at a total dose of 40 Gy divided into 8 Gy fractions. A total of 1 year after SRT, the patient achieved complete remission without decreased visual acuity. The patient remains alive and in good health without recurrence, 4 years after the diagnosis of choroidal metastasis. To the best of our knowledge, this is the second reported case of intraocular metastasis from cholangiocarcinoma. In conclusion, SRT may provide an opportunity to control metastatic choroidal carcinoma without decreasing visual acuity.

BILATERAL CHOROIDAL METASTASIS WITH CONCURRENT UNILATERAL RHEGMATOGENOUS RETINAL DETACHMENT IN A PATIENT WITH STAGE IV BREAST CANCER

PURPOSE

To describe an unusual case of bilateral choroidal metastasis with simultaneous rhegmatogenous retinal detachment in the right eye.

METHODS

Case Report.

PATIENT

A 65-year-old woman with Stage IV breast cancer and gradual deterioration of vision in the right eye.

RESULTS

Dilated fundus examination of the right eye revealed a large solitary choroidal mass with exudative retinal detachment and with an incidental discovery of a lower peripheral break with subretinal fluid, and the left eye revealed multiple choroidal masses. The diagnosis of bilateral CM was confirmed using optical coherence tomography. Pars plana vitrectomy with silicone oil injection was performed for the right eye followed by external beam radiotherapy to both choroids, which resulted in anatomical and visual success for 6 months.

CONCLUSION

Prompt ophthalmologic evaluation is a must in patients with advanced breast or lung malignancy with recent blurring of vision. External beam radiotherapy is a safe, available, relatively cheap, and effective means for managing CM. Choroidal metastasis with a concurrent vision-threatening pathology requiring intraocular surgery represents a dilemma, and the risks and benefits should be weighed carefully with proper counseling of the patient.

How to Manage a Patient with Ocular Metastases?

Ocular metastases are the most frequent ocular malignant tumors; their prevalence is estimated around 5-10% and is even higher in patients with breast or lung cancer. They represent various clinical situations, but they share the same hierarchical multidisciplinary therapeutic challenge with respect to the way systemic and local therapies should be selected in combination or sequentially in the personalized medical history of a patient. The challenges include tumor control, eye preservation, and the minimization of iatrogenic damage to sensitive tissues surrounding the tumor in order to preserve vision. These aims should further contribute to maintaining quality of life in patients with metastases. Many patients with choroidal metastases have systemic molecular treatment for their primary tumor. However, secondary resistance to systemic treatment is common and may ultimately be associated with cancer relapse, even after an initial response. Therefore, it makes sense to propose local treatment concomitantly or after systemic therapy to provide a more sustainable response. The aim of this review is to present current therapeutic strategies in ocular metastases and discuss how to tailor the treatment to a specific patient.

30 years of ocular proton therapy, the Nice view

PURPOSE

Radiotherapy with protons (PT) is a standard treatment of ocular tumors. It achieves excellent tumor control, limited toxicities, and the preservation of important functional outcomes, such as vision. Although PT may appear as one homogenous technique, it can be performed using dedicated ocular passive scattering PT or, increasingly, Pencil Beam Scanning (PBS), both with various degrees of patient-oriented customization.

MATERAIAL AND METHODS

MEDICYC PT facility of Nice are detailed with respect to their technical, dosimetric, microdosimetric and radiobiological, patient and tumor-customization process of PT planning and delivery that are key. 6684 patients have been treated for ocular tumors (1991-2020). Machine characteristics (accelerator, beam line, beam monitoring) allow efficient proton extraction, high dose rate, sharp lateral and distal penumbrae, and limited stray radiation in comparison to beam energy reduction and subsequent straggling with high-energy PBS PT. Patient preparation before PT includes customized setup and image-guidance, CT-based planning, and ocular PT software modelling of the patient eye with integration of beam modifiers. Clinical reports have shown excellent tumor control rates (∼95%), vision preservation and limited toxicity rates (papillopathy, retinopathy, neovascular glaucoma, dry eye, madarosis, cataract).

RESULTS

Although demanding, dedicated ocular PT has proven its efficiency in achieving excellent tumor control, OAR sparing and patient radioprotection. It is therefore worth adaptations of the equipments and practice.

CONCLUSIONS

Some of these adaptations can be transferred to other PT centers and should be acknowledeged when using non-PT options.

Effective Systemic Treatment of Choroidal Metastases NSCLC With Surgery After Crizotinib: A Case Report

Choroidal metastasis as an initial presenting feature of lung cancer with EML4-ALK translocation is exceedingly rare and greatly impacts patient quality of life (QOL). There are no recommended treatments for such patients, and palliative care remains limited. It is unclear whether surgical resection of primary pulmonary lesions, systemic antitumor therapy, targeted therapy, or localized ocular therapy are effective in treating choroidal metastases in EML4-ALK rearranged oligometastatic non-small cell lung cancer (NSCLC). Here, we present the case of choroidal metastases secondary to lung cancer and EML4-ALK translocation in a 57-year-old woman who firstly underwent resection of lung lesions followed by oral administration of crizotinib without local treatment or systemic chemotherapy. Since then she had a rapid and complete response to crizotinib with 27 months of progression-free survival.

Treatment of Choroidal Metastasis from Epidermal Growth Factor Mutant Non-Small Cell Lung Cancer with First-line Osimertinib Therapy

Purpose

To illustrate the regression of a metastatic lesion through ophthalmic imaging and correlating findings with standard chest imaging and treatment with osimertinib, an oral chemotherapy agent specific to Epidermal Growth Factor Receptor + Non-small Cell Lung Cancer (EGFR+ NSCLC).

Case Report

A 63-year-old Asian male presented to ophthalmology with a complaint of left blurry vision. Initial ophthalmic exam revealed a choroidal lesion and imaging results highlighted a spiculated lung mass with brain and bony metastases. Osimertinib was chosen for its specificity and ability to cross the blood-brain barrier. Follow-up ophthalmic and radiographic imaging were repeated over the course of treatment.

Conclusion

After the initiation of osimertinib, ophthalmic and computed tomography imaging highlighted the regression of the ocular metastatic disease and primary malignancy, respectively.Osimertinib is an effective first-line treatment of EGFR+ NSCLC and corresponding metastatic sites. Additionally, ophthalmic imaging can be used to monitor general response to chemotherapy agents when ocular metastasis is identified.

Carbohydrate antigen 125, carbohydrate antigen 15-3 and low-density lipoprotein as risk factors for intraocular metastases in postmenopausal breast cancer

The prognosis of patients with postmenopausal breast cancer (PBC) could be improved by the early detection of intraocular metastases (IOMs). However, serum biomarkers for IOMs in PBC remain elusive. In the current study, we investigated patients with PBC, and compared serum parameters in an IOM and a non-IOM group, and then differentiated the risk factors related to IOMs. A comparison between an IOM and a non-IOM (NIOM) group was performed using Student t-test and a Chi-Squared test. After constructing a Poisson regression model to identify risk factors, we plotted receiver operating characteristic curves to evaluate the predictive value of significant risk factors in detecting IOMs. The incidence of IOMs in PBC was 1.16%. The histopathology results were not significantly different between the 2 groups. The levels of serum carbohydrate antigen 125 (CA-125), carbohydrate antigen 15-3 (CA15-3) and alkaline phosphatase were significantly elevated in IOMs compared with NIOMs (P = .082, P < .001, and P < .001, respectively). Compared with NIOMs, age, carbohydrate antigen 19 to 9, hemoglobin, calcium, total cholesterol, low-density lipoprotein (LDL) and apolipoprotein A1 were remarkably lower in IOMs (P = .038, P < .001, P < .001, P = .032, P = .041, P < .001, and P = .001, respectively). Poisson regression suggested that CA-125, CA15-3 and LDL were contributing to IOMs in PBC as risk factors (OR = 1.003, 95% CI: 1.001-1.005; OR = 1.025, 95% CI: 1.019-1.033; OR = 0.238, 95% CI: 0.112-0.505, respectively). A receiver operating characteristic curve revealed that the cut-off values for CA-125, CA15-3 and LDL were 16.78 0 U/mL, 63.175 U/mL, and 2.415 mmol/L, respectively. The combination of CA-125 and CA15-3 showed significant diagnostic value (area under the curve [AUC] = 0.982, P < .001). Our investigation suggests that CA-125, CA15-3 and LDL remarkably predict IOMs in PBC as risk factors, and the combination of CA-125 and CA15-3 shows considerable diagnostic value.

A Comprehensive Understanding of Choroidal Metastasis from Lung Cancer

The incidence of lung cancer with intraocular metastasis is low, of which choroidal metastasis is the most painful metastatic lesion. The clinical symptoms resulting from choroidal metastasis from lung cancer easily detected although they are rarely identified prior to the diagnosis of the primary malignancy. The quality of life of patients is inevitably impaired. Some lung cancer patients complain of ocular symptoms as the first manifestation of lung cancer. Early diagnosis and treatment can significantly overcome or delay the visual impairment and improve prognosis. The main therapeutic modalities include systemic and local treatments, while observation is also a treatment option. Currently, the feasibility and effectiveness of various treatment options are controversial worldwide. Herein, we summarize the underlying mechanisms, epidemiology, clinical features, auxiliary examinations, diagnosis, and recent treatment options for intraocular metastases.

Clinical Spectrum of Uveal Metastasis in Korean Patients Based on Primary Tumor Origin

PURPOSE

To describe the clinical features and prognosis of patients with uveal metastasis in Korea.

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Patients diagnosed at 2 tertiary high-volume centers between November 2005 and November 2019.

METHODS

Evaluation of multimodal imaging and electronic medical records.

MAIN OUTCOME MEASURES

The clinical features and outcomes were assessed based on the primary cancer site.

RESULTS

A total of 134 uveal metastases (128 choroidal, 3 iris, and 3 ciliary body tumors) were diagnosed in 95 eyes of 80 patients. Mean age at diagnosis was 56 years (median, 55 years; range, 24-86 years), with a minor preponderance of women (61%). Tumors were bilateral in 15 patients (19%) and the primary origin was established in 49 patients (61%) before ocular detection. The primary tumor originated in the lung (48%), breast (24%), gastrointestinal tract (10%), liver (3%), pancreas (3%), kidney (1%), cervix (1%), and nasopharynx (1%), with some remaining unknown (10%). The overall 5-year survival rate was 21%. Kaplan-Meier analysis revealed that the worst survival was found in pancreatic cancers (mean survival, 5.9 months; P = 0.045), and the best survival was found in gastrointestinal tract cancers (mean survival, 44.5 months).

CONCLUSIONS

The primary tumor origins in Korean patients with uveal metastases differed from those reported in primarily population-based studies of White patients, with a higher prevalence of lung and gastrointestinal tract cancers.

Rapid resolution of choroidal metastatic tumour secondary to lung cancer following treatment with alectinib

A 64-year-old man presented with reduced vision in the right eye (visual acuity of 6/24 Snellen). The patient reported having a chronic cough and recent weight loss with difficulty in swallowing and abnormal liver function test 8 months prior to his presentation. He was a chronic smoker for 45 years, having quit a year earlier. Fundus examination showed a unifocal large yellow-brown subretinal mass involving the posterior segment of the eye and associated with subretinal fluid. The patient was diagnosed with a choroidal metastasis and was referred urgently to the oncology team who confirmed the presence of non-small cell lung cancer with distant metastases. He started treatment with alectinib (second-generation tyrosine kinase inhibitor). A few weeks later, his vision improved and, on examination, there was complete resolution of the choroidal mass and the associated subretinal fluid. Alectinib led to rapid resolution of his choroidal secondary and has excellent ocular safety profile.

Choroidal metastases: case report and review

Introduction:

Choroidal metastases are the most frequent intraocular secondary tumours, with a prevalence of 2–7% according to the literature. Our aim was to review a clinical case of choroidal metastasis.

We present a case of a 63-year-old male patient diagnosed in 2018 with lung adenocarcinoma cT4N0M1. The patient had three metastases in the brain, which were successfully treated with radiosurgery (RS). The patient was treated with chemotherapy with pemetrexed–cisplatin schedule. Five months after diagnosis, the patient presented with decreased vision in the right eye. After ophthalmologic evaluation, he was diagnosed with a right choroidal metastasis, which was treated with external beam radiotherapy with 20 Gy in five fractions, resulting in improved visual acuity and a complete clinical and radiological response.

The patient took part in a clinical trial that continued with systemic chemotherapy. Twenty-two months after radiotherapy to the eye, the patient has good visual acuity without any side effects.

Conclusions:

Choroidal metastasis treated with radiotherapy achieves good local control, with limited side effects, allowing an improvement in visual acuity and consequently, an improvement in the patient´s quality of life.

Epidermal growth factor receptor-mutant non-small cell lung Cancer and Choroidal metastases: long-term outcome and response to epidermal growth factor receptor tyrosine kinase inhibitors

Background

Choroidal metastases are the most common eye metastatic site. The prevalence of choroidal metastases in NSCLC patients has been reported to vary from 0.2 to 7% in historical series. Although previously reported, little is known about choroidal metastasis in Epidermal Growth Factor Receptor (EGFR)-mutant Non-small cell lung cancer (NSCLC). This study sought to describe the prevalence of choroidal metastases among patients with EGFR-mutated NSCLC and their characteristics, and to estimate their impact on prognosis.

Methods

We conducted a single-center retrospective study including all consecutive metastatic EGFR-mutant NSCLC patients, from Sept. 2015 to Oct. 2018. The EGFR-mutant NSCLC patients were identified via the Department of Genetics’ files. Patients who exhibited choroidal metastases were compared to patients without choroidal metastases. Kaplan-Meier analysis and log-rank test were conducted to assess median overall survival (OS) from diagnosis for the two groups. The study was approved by the IRB as CEPRO number #2020–010.

Results

Prevalence of choroidal metastases in EGFR-mutated NSCLCs was 8.4% (7/83). Five were women, and four current or former smokers. Molecular analysis showed three tumors with exon 19 deletion, three with L858R mutation, and one with complex exon 21 mutation. The choroidal metastases were symptomatic in six/seven patients. Visual disturbances decreased in all but one symptomatic cases upon EGFR TKI, and the choroidal response was maintained over time.

Median follow-up was 42.2 mo (95%CI [37.2–47.1]). Median OS in the choroidal metastasis group was 23.4 mo (95%CI [0.1–51.4]) versus 27.9 mo (95%CI [16.9–38.9]) in the non-choroidal metastasis group (p = 0.32). In the choroidal metastasis group, 2-year and 5-year OS were 47.6 and 0%, respectively, versus 55.8 and 26.3% in the non-choroidal metastasis subset.

Conclusions

Choroidal metastases in NSCLC EGFR-mutant patients are rare but should be systematically suspected in case of visual disturbance. TKIs are efficient for treating visual symptoms. Whether choroidal metastases confer a worse prognosis remains unclear owing to the third-generation EGFR TKI osimertinib first-line registration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07630-6.

Alectinib in the treatment of ocular metastases of ALK rearranged non small cell lung cancer: Description of 2 case reports

RATIONALE

Choroidal metastasis is a rare metastatic location although the most common intraocular neoplasm. In general, choroidal metastases respond favorably to systemic therapy targeted toward the primary neoplasm. In patients with choroidal metastasis of ALK rearranged non small cell lung cancer (NSCLC), targeted therapy using Alk inhibitors gradually replaced radiotherapy as the best treatment. Alectinib is a second-generation ALK inhibitors. Here we describe 2 clinical cases of patients with choroidal metastasis of ALK rearranged NSCLC who received Alectinib as first-line therapy achieving disease control and quality of life improvement.

PATIENTS CONCERNS

In case report 1, 62-year-old man presented with scintillated scotomas at the level of the right eye; in case report 2, 69-year-old man presented with respiratory distress, persistent cough resistant to medical therapy, pain, and blurred vision.

DIAGNOSES

In case report 1, fundus and ultrasonographic examination showed circumscribed choroid thickening with dome-like appearance compatible with repetitive lesion. Computed tomographic/y (CT) showed multiple bilateral pulmonary nodular formations and adenocarcinoma of the lung was diagnosed by a transbronchial biopsy.In case report 2, CT showed a primary lesion of 36 × 27 mm in the middle lobe with bilateral lung metastases and lymphadenopathies. Multiple hepatic metastases and minor suspicious bone repetitions. A liver biopsy made a diagnosis of adenocarcinoma compatible with pulmonary primitiveness. An ocular fluoroangiography evidenced a left choroidal metastasis.

INTERVENTIONS

Case report 1, 2, medical treatment with Alectinib 1200 mg/day was initiated.

OUTCOMES

In case report 1, a few days after beginning the treatment, both systemic symptoms like respiratory distress and low vision were palliated. Reassessment by CT confirmed treatment response. In case report 2, clinically, visus disorders had already improved 2 weeks after beginning treatment. CT showed pulmonary, nodal, and hepatic response. Stability of bone metastases occurred after 2 months. In addition, ocular ultrasonography documented the regression of previously reported lesions confirmed treatment response.

LESSONS

Alectinib works very well in intracranial metastases and is assumed to be so on the ocular ones as well, with benefit for the patient in quality of life.

Presumed Choroidal Metastasis From Oncocytic Carcinoma of the Parotid Gland: A Case Report

Purpose:

This article reports a case of presumed choroidal metastasis from an oncocytic carcinoma of the parotid gland.

Methods:

A 70-year-old man with history of an oncocytic carcinoma of the parotid gland presented owing to a 1-month history of progressive blurred central vision shortly after metastatic surveillance workup revealed liver, lung, and spine metastases. Fundus examination of the right eye showed a yellow choroidal mass surrounding the optic nerve and extending inferonasally, which is associated with subretinal fluid involving the foveal center. A-scan and B-scan ultrasonography were remarkable for a dome-shaped choroidal mass with medium-to-high internal reflectivity. Fluorescein angiography revealed pinpoint foci of hyperfluorescence over the choroidal lesion with late leakage. Magnetic resonance imaging of the brain showed evidence of metastatic disease to the cerebellum. While the patient underwent systemic chemotherapy, external beam radiotherapy was used to treat the eye.

Results:

Four months later, visual acuity improved, the tumor reduced in size, and the subretinal fluid resolved. Systemic workup disclosed no new metastases.

Conclusion:

Oncocytic carcinoma of the parotid gland is a rare and aggressive malignant neoplasm with frequent recurrences and distant metastases. The current case suggests that oncocytic carcinoma can metastasize to the choroid and, consequently, ocular metastasis surveillance is advised in these patients.

Photodynamic Therapy for Choroidal Metastasis Tumor Control and Visual Outcomes in 58 Cases: The 2019 Burnier International Ocular Pathology Society Lecture

PURPOSE

To determine outcomes after photodynamic therapy (PDT) for choroidal metastasis.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Forty-three patients with 40 eyes harboring 58 choroidal metastases.

METHODS

Treatment with standard fluence PDT using verteporfin.

MAIN OUTCOME MEASURES

Tumor control and visual outcomes.

RESULTS

The primary cancer originated in the lung (n = 17 [39%]), breast (n = 16 [37%]), kidney (n = 3 [8%]), thyroid (n = 2 [6%]), and other sites (n = 5 [10%]). The mean patient age at entry was 61 years. Ocular symptoms included decreased visual acuity (n = 23 [53%]), visual field defect (n = 2 [5%]), floaters (n = 7 [16%]), flashes (n = 3 [7%]), and asymptomatic (n = 8 [19%]). The median entering visual acuity (Snellen equivalent) was 20/40. The median tumor diameter was 5.0 mm, and median thickness by ultrasonography was 2.0 mm. The median distance to the optic disc was 3.0 mm, and that to the foveola was 2.0 mm. Of the 43 patients, 35 maintained follow-up (40 eyes, 45 tumors), and PDT achieved tumor control with 1 session (n = 32 tumors [71%]) or 2 sessions (n = 3 tumors [7%]) and failed to achieve regression (n = 10 tumors [22%]). The 10 metastases for which treatment failed were managed further with plaque radiotherapy (n = 3), proton beam radiotherapy (n = 1), external beam radiotherapy (n = 1), systemic chemotherapy (n = 4), and observation (patient preference; n = 1). A comparison of clinical features for tumor control (PDT alone vs. PDT plus additional therapy) revealed those controlled with PDT alone were more likely to be adenocarcinoma (73% vs. 30%; P = 0.02) and those eyes were more like to achieve final visual acuity of 20/20 to 20/40 (66% vs. 30%; P = 0.03), with better median final Snellen visual acuity (20/30 vs. 20/70; not significant). Primary cancer site or ocular tumor features (size, location, color, shape, related subretinal fluid) did not impact tumor control. In the entire group of 40 eyes, visual acuity improved or remained stable in 28 (70%) and decreased in 12 (30%), related to subfoveal scar, persistent subretinal fluid, reactive exudation, radiation maculopathy, and brain metastasis. At last follow-up (mean, 20 months), of the entering 43 patients, 9 (21%) were alive and 34 (79%) had died of systemic metastasis.

CONCLUSIONS

Photodynamic therapy with verteporfin is an effective outpatient method for small to medium choroidal metastatic tumors, providing tumor control in 78% of eyes and visual outcome of 20/20 to 20/40 in 66% of eyes.

CEA as a risk factor in predicting ocular metastasis from colorectal cancer

Objective: Colorectal, closely following pulmonary and breast, is the third predilection site of cancer that lead to death all over the world. Ocular metastasis (OM) of colorectal cancer (CRC) is becoming increasingly common and presents a poor prognosis. In this study, we detected some recognized tumor biomarkers and tried to differentiate the discrepancy between CRC patients with and without OM in order to clarify the risk factor for OM in patients with colorectal cancer. Methods: 1735 patients with colorectal cancer in total from August 2005 to August 2017 were involved in this study. Nonparametric rank sum test and Chi-square test were applied to prescribe whether there were significant differences between OM group and non-ocular metastasis (NOM) group. And binary logistic regression analysis was used to determine the risk factor. Then, we used receiver operating curve (ROC) to assess the diagnostic value of OM in CRC patients. Results: The incidence of OM in CRC patients was 1.12%. No significant differences were found in gender, age, histopathological type, tumor classification and tumor differentiation between OM group and NOM group. Nonparametric rank sum test approved that OM group had higher serum CEA level compared with NOM group. Binary logistic regression indicated that CEA was a risk factor for OM in colorectal cancer patients (p<0.001). ROC curve showed that AUC of CEA was 0.877. The cutoff value of CEA was 12.45 ng/ml, whose sensitivity is 1.000 and its specificity is 0.877. Conclusion: Based on our study, CEA was a risk factor of ocular metastasis in colorectal cancer patients.

Choroidal metastases as initial manifestation of a papillary thyroid carcinoma: A case report

The case is presented of 78 year-old who consulted due to decreased visual acuity in right eye for several months. Indirect ophthalmoscopy revealed an orange-yellow coloured choroidal mass at the posterior pole, without retinal detachment. Computed tomography showed a thyroid mass in the isthmus, as well as multiple pulmonary nodules and metastatic foci. The findings of transbronchial lung biopsy were compatible with metastatic dissemination. Fine-needle aspiration biopsy of thyroid nodule was diagnostic for a with columnar cell variant of papillary thyroid cancer. Positron emission tomography confirmed papillary thyroid carcinoma. The patient underwent total thyroidectomy and radioactive iodine therapy.

Photodynamic Therapy with Verteporfin for Choroidal Metastasis Refractory to Radiotherapy

A 54-year old female with longstanding metastatic breast cancer was referred for management of choroidal metastases. She was first treated with external beam radiotherapy and experienced some response before later suffering progression of her eye disease. We then treated her using full fluence Photodynamic therapy (PDT) with Verteporfin, which resulted in regression of her lesions until she passed away due to other illnesses. This is the first documented successful application of PDT for choroidal metastasis from a primary breast cancer refractory to external beam radiotherapy.

The predictive value of high-density lipoprotein for ocular metastases in colorectal cancer patients

Purpose: Colorectal cancer (CRC) is a common tumor of the digestive tract that tends to metastasize and leads to high mortality. Ocular metastases (OM) from colorectal cancer are being increasingly diagnosed, and they can lead to a poor prognosis. Serum lipids are a known risk factor for cardiovascular disease, and are also relevant to the occurrence of CRC. In this study, we examined the levels of serum lipids and tried to determine whether there were correlations with the occurrence of OM in patients with colorectal cancer, in order to determine whether serum lipid levels may be a risk factor for OM in this patient population.

Patients and methods: Records from a total of 703 patients treated for colorectal cancer from August 2005 to August 2017 were involved in this study. Student’s t-tests, nonparametric rank sum tests, and Chi-square tests were applied to describe whether there were significant differences between the OM group and non-ocular metastases (NOM) group. We used binary logistic regression analysis to determine the risk factors and receiver operating curve (ROC) analyses to assess the diagnostic value for OM in CRC patients.

Results: There were no significant differences in gender, age, histopathology type, or tumor classifications between the OM and NOM groups. The levels of serum TC, HDL, and LDL were significantly different between patients with and without lymph node metastases as well as male and female patients. The OM group had higher serum HDL levels compared to the NOM group. Binary logistic regression indicated that HDL was a risk factor for OM in colorectal cancer patients. The ROC curves showed that the AUC of HDL was 0.660. The cutoff value of HDL was 1.27 mmol/L, with a sensitivity of 0.619 and a specificity of 0.650.

Conclusion: HDL levels are correlated with ocular metastases in colorectal cancer patients.

New concepts in the diagnosis and management of choroidal metastases

The most frequent site of ocular metastasis is the choroid. The occurrence of choroidal metastases has increased steadily due to the longer survival of metastatic patients and the improvement of diagnostic tools. Fundoscopy, ultrasonography, and fluorescein angiography are now complemented by indocyanine green angiography and optical coherence tomography. Choroidal tumor biopsy may also confirm the metastatic nature of the tumor and help to determine the site of the primary malignancy. There is currently no consensus on the treatment strategy. Most patients have a limited life expectancy and for these complex treatments are generally not recommended. However, recent advances in systemic therapy have significantly improved survival of certain patients who may benefit from an aggressive ocular approach that could preserve vision. Although external beam radiation therapy is the most widely used treatment, more advanced forms of radiotherapy that are associated with fewer side effects can be proposed in select cases. In patients with a shorter life expectancy, systemic therapies such as those targeting oncogenic drivers, or immunotherapy can induce a regression of the choroidal metastases, and may be sufficient to temporarily decrease visual symptoms. However, they often acquire resistance to systemic treatment and ocular relapse usually requires radiotherapy for durable control. Less invasive office-based treatments, such as photodynamic therapy and intravitreal injection of anti-VEGF, may also help to preserve vision while reducing time spent in medical settings for patients in palliative care. The aim of this review is to summarize the current knowledge on choroidal metastases, with emphasis on the most recent findings in epidemiology, pathogenesis, diagnosis and treatment.

Late distant recurrence of breast carcinoma and metastasis to the main bronchus and choroid: A case report

RATIONALE

Metastases of breast carcinoma to the main bronchus and choroid are rare, but have been reported in relevant literature. Late distant recurrence of breast carcinoma after more than 20 years is extremely rare. Herein, we report a 57-year-old woman with late distant recurrence and metastasis to the main bronchus and choroid almost 28 years after surgery.

PATIENT CONCERNS

At the age of 29, the patient underwent chemotherapy and endocrine treatment after a right side mastectomy to remove breast carcinoma. The patient was hospitalized for a cough with blood-tinged sputum, dysphagia, and blurred vision in the left eye at the age of 57.

DIAGNOSES

On evaluation, laboratory findings detected the elevated serum tumor markers of CA12-5, CA15-3, NSE, and Cyfra21-1. The imaging showed left lung metastase, multiple lymph node metastases, and small suspected metastases in the both sides of parietal lobes. Fundus fluorescein angiography showed choroidal occupying lesion of the left side which indicates secondary metastasis and retinal detachment. Combined with the pathological finding via fiberoptic bronchoscopic biopsy, the patient was clinically diagnosed with a late distant recurrence of breast carcinoma.

INTERVENTIONS

The patient received oral endocrine therapy of letrozole, but she refused chemotherapy, radiotherapy and other topical treatments.

OUTCOMES

At the 3-month follow-up visit, the multiple lesions of the left lung and lymph nodes had partially regressed, and the lesion of right parietal lobe had disappeared. The patient's clinical symptoms, such as blood-tinged sputum and dysphagia, had significantly improved.

LESSONS

We have described this case and reviewed the relevant literature concerning late distant recurrence of breast carcinoma. Importantly, this case indicates that patients with HR positive breast carcinoma are more likely to develop late distant recurrence and clinicians should not ignore the follow-up examinations even more than 20 years after the surgery.

A rare presentation of choroidal metastasis from primary esophageal adenocarcinoma successfully treated with intensity-modulated radiation therapy

Purpose

In this case report, we present a case of choroidal metastasis from a primary esophageal adenocarcinoma that was treated successfully with intensity-modulated radiation therapy.

Observations

A 65-year-old male with known stage IV esophageal adenocarcinoma presented with a central scotoma in his left eye and was ultimately found to have a large choroidal metastatic lesion with overlying subretinal fluid. IMRT was administered over the course of four weeks, resulting in restoration of the patient's vision, regression of the metastatic lesion, and resolution of the subretinal fluid. As of 16 months following completion of radiation, there remains no evidence of choroidal recurrence or radiation-associated ocular complications.

Conclusions

and Importance: To our knowledge, this is the first published case report of a choroidal metastasis from esophageal cancer responding durably to IMRT. IMRT should therefore be considered a viable treatment option for this rare disease.

Choroidal metastasis of a minor salivary gland adenoid cystic carcinoma: A case report

CASE REPORT

A 61-year-old man with a lower lip minor salivary gland adenoid cystic carcinoma, suffered from a unilateral progressive visual acuity loss due to choroidal metastasis.

DISCUSSION

Adenoid cystic carcinoma is a rare primary tumour with significant metastatic potential. Our patient presented with a unilateral choroidal metastasis. According to the current literature, 8 cases of choroidal metastasis of salivary gland adenoid cystic carcinoma have been reported. This is the second case reported of choroidal metastasis with origin in a minor salivary gland, and the first one with origin in the minor salivary glands of the lower lip.

Successful management of retinal metastasis from renal cancer with everolimus in a monophthalmic patient: a case report

Background

The retina is an uncommon site for metastases, in particular from solid tumors. Some authors have reported a recent increase in the incidence of metastases in infrequent sites, such as brain or bone, probably due to the expanded treatment options and the resulting improved survival. Choroidal metastasis is the most common type of intraocular malignancy. The most common primary sites associated with choroidal metastasis are breast cancer in women and lung cancer in men. Treatment options are limited, but they must be discussed and adapted to the patient profile.

Cases presentation

We report a case of a 62-year-old Moroccan man with a history of monophthalmitis secondary to a war injury of 30 years’ duration. He has been followed for 28 months for metastatic clear-cell renal carcinoma. The first-line treatment was effective for 24 months, before disease progression as retinal metastasis and accentuation of lung metastases. A second-line treatment with everolimus resulted in marked improvement of symptoms, complete recovery of visual function, and partial response in retinal localization.

Conclusions

Choroidal metastasis of renal cancer is a rare situation that must be actively sought in order to arrive at a suitable therapeutic approach.

The liquid biopsy: a tool for a combined diagnostic and theranostic approach for care of a patient with late-stage lung carcinoma presenting with bilateral ocular metastases

INTRODUCTION

Liquid biopsies (LB) are used routinely in clinical practice in two situations for late stage non-small-cell lung cancer (NSCLC) patients, (i) at the initial diagnosis when looking for activating mutations in EGFR in the absence of analyzable tissue DNA and, (ii) during tumor progression on a tyrosine kinase inhibitor treatment to look for the resistance mutation T790M in EGFR. LB is not presently recommended in daily practice for the diagnosis of NSCLC. Areas covered: We report the diagnosis of a NSCLC in a patient with bilateral ocular metastases after detection of a deletion in exon 19 of EGFR when using plasma DNA. Without histological analysis, the origin of the primary ocular metastasis was uncertain. In this context, a LB showing an activating mutation in EGFR and circulating tumor cells positive for TTF1 led to the diagnosis of NSCLC and targeted therapy. Expert commentary: When no tumor tissue sample is available a LB can be used to diagnose for metastatic NSCLC, when a mutation in EGFR is identified. While a tissue biopsy is the gold standard approach for the diagnosis of a NSCLC and for identification of activating mutations, LB can exceptionally provide both a diagnosis of the primitive tumor and indicate appropriate therapy based on a molecular analysis.

Clinical outcomes of hypofractionated radiation therapy for choroidal metastases: Symptom palliation, tumor control, and survival

PURPOSE

External beam radiation therapy (RT) is an effective palliative treatment for patients with choroidal metastases and is aimed at preserving vision and obtaining local tumor control. Delivery of 30 to 40 Gy in 2-Gy daily fractions is a standard approach at many centers. This study reports the outcomes of a hypofractionated schedule of 20 Gy in 5 fractions in this palliative setting.

METHODS AND MATERIALS

We conducted a retrospective review of patients who were treated with RT (20 Gy in 5 fractions) for choroidal metastases between January 1999 and November 2012. The primary outcome measures were change in visual acuity and tumor response. Secondary outcomes included toxicities of RT, tumor control, and overall survival (OS) from diagnosis of choroidal metastases. Univariate and multivariable Cox regression modeling was used to investigate the predictors for OS.

RESULTS

Fifty-five patients with 71 affected eyes were included. Decreased vision was the presenting symptom in 43 eyes (61%). Visual acuity improved from a median of 20/70 at baseline to 20/40 at last follow-up and remained stable or improved in 56 eyes (80%). Tumor regression was observed in 64 eyes (91%) with complete response in 47 eyes (67%). Local progression occurred in 4 eyes (6%). The median survival after diagnosis of choroidal metastases was 13 months. No acute complications were observed in 49 patients (89%). Mild acute toxicities included transitory dryness in 5 patients and episcleritis in 1 patient. Cataracts, retinopathy, optic neuropathy, pigmentary maculopathy, and neovascular glaucoma developed in 4 eyes (6%), 1 eye, 7 eyes (10%), 5 eyes (7%), and 1 eye, respectively. No variables were statistically significantly associated with OS.

CONCLUSIONS

A short fractionation schedule of 20 Gy in 5 fractions is a well-tolerated treatment that effectively preserves vision and gains local tumor control for many patients with choroidal metastases. This hypofractionated approach would help reduce the burden of a longer treatment course in this palliative patient population.

Successful Treatment with Alectinib for Choroidal Metastasis in Anaplastic Lymphoma Kinase Rearranged Non-small Cell Lung Cancer

Choroidal metastasis is rare in cancer patients and it may cause visual disturbances that reduce their quality of life. In non-small cell lung cancer (NSCLC), targeted therapy against actionable driver mutations has gradually replaced radiotherapy as the treatment of choice for choroidal metastasis. Recently, there have been several case reports of choroidal metastasis in patients with anaplastic lymphoma kinase (ALK)-rearranged NSCLC. We herein report the case of a 40-year-old Japanese woman diagnosed with choroidal metastasis of an ALK-rearranged NSCLC who received alectinib as the first-line chemotherapy. Alectinib may be the best treatment for choroidal metastasis in patients harboring an ALK translocation because of its favorable side effect profile involving visual disturbances.

Intraocular metastasis: comparison of clinical presentation with a known and unknown primary tumour

OBJECTIVE

The purpose of the present study is to review the frequency of intraocular metastases as first presentation of systemic disease, and to identify clinical and tumour characteristics.

METHODS

Retrospective study of consecutive cases diagnosed of intraocular metástasis at a referral intraocular tumours unit between 1993 and 2014. General, epidemiological and ophthalmological characteristics were recorded.

RESULTS

A total of 21 patients, with a mean age 62.7 years (31-89) were diagnosed with intraocular metástasis between 1993 and 2014. Both eyes were affected in 4 cases. Location was choroid in 20 cases. The intraocular tumour was the first manifestation of the systemic disease in 13 patients (61.9%). Primary tumour was breast in 47.6% and lung in 23.8%. Diagnosis of the primary tumour was performed by systemic studies, and only 1 patient required intraocular biopsy. Regarding the treatment, the majority of cases were controlled with systemic therapy, with 4 cases requiring additional external beam radiotherapy, and only one enucleation. No clinical differences were found between the cases with known and unknown systemic neoplasia, except in exudative retinal detachment, which was more frequent in the second group.

CONCLUSIONS

Although intraocular metastases are the most frequent intraocular tumour, they are not a frequent cause of consultation. In more than half of the cases it is the first presentation of unknown systemic neoplasia as a solitary non-pigmented intraocular mass. Early diagnosis is crucial to establish the appropriate treatment, preserve visual function, and improve the prognosis of the patient.

Mechanisms of phosphenes in irradiated patients

Anomalous visual perceptions have been reported in various diseases of the retina and visual pathways or can be experienced under specific conditions in healthy individuals. Phosphenes are perceptions of light in the absence of ambient light, occurring independently of the physiological and classical photonic stimulation of the retina. They are a frequent symptom in patients irradiated in the region of the central nervous system (CNS), head and neck and the eyes. Phosphenes have historically been attributed to complex physical phenomena such as Cherenkov radiation. While phosphenes are related to Cherenkov radiation under high energy photon/electron irradiation conditions, physical phenomena are unlikely to be responsible for light flashes at energies used for ocular proton therapy. Phosphenes may involve a direct role for ocular photoreceptors and possible interactions between cones and rods. Other mechanisms involving the retinal ganglion cells or ultraweak biophoton emission and rhodopsin bleaching after exposure to free radicals are also likely to be involved. Despite their frequency as shown in our preliminary observations, phosphenes have been underreported probably because their mechanism and impact are poorly understood. Recently, phosphenes have been used to restore the vision and whether they might predict vision loss after therapeutic irradiation is a current field of investigation. We have reviewed and also investigated here the mechanisms related to the occurrence of phosphenes in irradiated patients and especially in patients irradiated by proton therapy for ocular tumors.

Multimodal imaging of suspicious choroidal neoplasms in a primary eye-care clinic

Small suspicious choroidal neoplasms commonly present a diagnostic challenge in primary eye-care clinics, where they are most likely to present. Differentiating benign from malignant choroidal neoplasms is essential for facilitating early diagnosis and treatment, potentially decreasing the risk of metastasis and vision loss in some cases. The purpose of this review is to describe the clinical, spectral-domain optical coherence tomography and fundus autofluorescence features of suspicious choroidal neoplasms in a case series of patients presenting to a primary eye-care clinic at the Veterans Health Administration, Cleveland, Ohio, USA.

[Choroidal metastasis from a lung adenocarcinoma treated by intravitreal injection of anti-VEGF and external beam radiotherapy: A case report]

Choroidal metastases of lung cancer are very uncommon. This localization should be suspected on blurred vision and confirmed with an ophthalmological examination. Its treatment is not entirely codified. We report a case of blurred vision secondary to bilateral choroidal metastasis in a patient with choroidal metastases from a lung adenocarcinoma, treated by intravitreal anti-vascular endothelial growth factor (VEGF) injection and external beam radiotherapy. According to a literature review, we analyzed the place of the targeted treatments used alone or combined with the radiotherapy.

Gamma Knife Radiosurgery for Uveal Metastases: Report of Three Cases and a Review of the Literature

PURPOSE

Uveal metastases are ophthalmologic tumors that have historically been treated by fractionated external beam radiation therapy or invasive brachytherapy. The need for rapid response and less invasive management options led the authors to explore the use of Gamma Knife stereotactic radiosurgery (SRS) for this common problem.

DESIGN

Interventional case series.

METHODS

To prevent eye movement during the procedure, all 3 patients underwent a retrobulbar anesthetic block followed by magnetic resonance imaging to detect the target. All tumors were treated in a single procedure using the 4C or Perfexion Gamma Knife. The tumors received a minimal tumor dose of 14-20 Gy. Two patients also underwent SRS for additional intracranial metastases.

RESULTS

At follow-up, performed between 4 and 15 months after SRS, all 3 patients demonstrated a reduction in uveal tumor volumes. One patient developed decreased visual acuity secondary to radiation retinopathy.

CONCLUSION

In this early experience, SRS was found to be an effective management option for uveal metastases associated with systemic cancer. Patients can be screened and treated effectively early after diagnosis using a joint approach between ophthalmologists and neurosurgeons. Systemic oncologic care can continue without interruption.