Metastatic carcinoma to the retina: case report

Clinical features of retinal metastases: new cases integrated in a systematic review of the literature

PURPOSE

To report a cohort of patients diagnosed with retinal metastasis (RM) and to integrate these new cases in a systematic review of the literature, analyzing the clinical features and prognosis factors of patients with RM.

METHODS

We conducted a retrospective multicenter study including patients with RM. We also performed a full literature review of all published cases with a diagnosis of RM.

RESULTS

A total of 6 new cases were described on multimodal imaging. By combining the data from the literature and from our patients, we report the characteristics of a total of 69 patients. The most frequent primary tumor sites were cutaneous melanoma (36%), lung (23%), gastro-intestinal tract (17%) and breast (12%). Multimodal imaging highlighted specific characteristics of RM. Fluorescein and indocyanine green angiography revealed early hypofluorescence followed by progressive filling of intrinsic dilated vessels. Optical coherence tomography demonstrated a hyperreflective intraretinal mass in all cases with or without subretinal fluid, hyperreflective intraretinal dots or intraretinal fluid. Ultrasonography revealed a medium-high reflective dome-shaped tumor. Fifty-nine percent of the patients died during the follow-up with a mean survival time of 8.8±8.7 months.

CONCLUSION

We described here the clinical spectrum of RM and highlighted specific features of the disease.

Presumed Retinal Metastasis from Lung Adenocarcinoma: A Case Report and Literature Review

A 63-year-old Caucasian man with metastatic lung adenocarcinoma undergoing chemotherapy and external radiotherapy was referred for routine eye examination. Although he was asymptomatic, ocular examination revealed a relatively well-circumscribed whitish retinal lesion measuring 0.5 × 0.5 × 0.5 mm located along the inferotemporal vascular arcade in the right eye. Optical coherence tomography (OCT) showed a hyperreflective dome-shaped lesion occupying the inner retinal layers with few hyperreflective dots overlying the retina in the posterior vitreous consistent with tumor cells. Fluorescein angiography revealed early hyperfluorescence and late staining without leakage at the lesion site. A diagnosis of presumed retinal metastasis from lung adenocarcinoma was made. At 2 months follow-up after completion of chemotherapy, the retinal lesion was found to have regressed completely leaving minor irregularities in the inner retinal layers on OCT. To date, there have been only 41 cases of carcinoma metastasis to the retina reported in the literature including the current case. Despite its rarity, retinal metastasis should be considered in the differential diagnosis of a white-yellow retinal mass with/without overlying vitreous cells especially in patients with a history of systemic cancer.

SIMULTANEOUS CHOROIDAL AND RETINAL METASTASES FROM LUNG CARCINOMA

BACKGROUND

Intraocular metastasis is most commonly found within the choroid because of its luxurious blood supply, whereas metastasis to the retina, from a separate blood supply, is very rare. We report a rare case of synchronous metastases from lung carcinoma to the choroid of the right eye and the retina of the left eye and a complaint of low vision in the right eye.

METHODS

We report a 63-year-old woman with progressive reduction of vision in her right eye for 1 year without previous history of cancer. The patient underwent comprehensive ophthalmic examination that included a multimodal evaluation: near-infrared reflectance scanning laser ophthalmoscopy, blue autofluorescence, and enhanced-depth imaging spectral domain optical coherence tomography (EDI SD-OCT; Heidelberg Engineering, Heidelberg, Germany).

RESULTS

Ophthalmoscopic examination revealed a yellow choroidal mass measuring 6 × 6 mm with overlying subretinal fluid and involving the macular area in the right eye. In the left eye, there was a superior juxtapapillary yellow-colored mass involving the retina and measuring 1 × 1 mm. Optical coherence tomography revealed the subretinal fluid contouring a dome-shaped choroidal mass in the right eye and intraretinal nodular tumor superior to the optic disk of the left eye. Chest computed tomography revealed a pulmonary nodule measuring 2.5 mm × 1.4 mm, and biopsy of the liver metastasis confirmed the diagnosis of mucinous lung carcinoma.

CONCLUSION

The final diagnosis was presumed choroidal metastasis in the right eye and retinal metastasis in the left eye from underlying mucinous carcinoma of the lung.

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.

Retinal metastasis simulating cytomegalovirus retinitis

A 62-year-old man with lung cancer presented with a 2-week history of decreased vision and clinical features of cytomegalovirus retinitis. The patient was empirically treated for viral retinitis, but microbiological testing of the vitreous fluid was negative. Based on the suspicion for retinal metastasis, the patient underwent pars plana vitrectomy with retinal biopsy. Surgical techniques included the use of a chandelier illumination to enable bimanual manipulation of the retinal tissue, creation a focal retinal detachment with a 41-gauge subretinal cannula, diathermy demarcation of the biopsy site, localized retinectomy with vertical scissors, endolaser, and long-acting gas tamponade. Histopathologic examination revealed sheets of tumor cells with pleomorphic nuclei and positive staining for cytokeratins consistent with metastatic adenocarcinoma. The patient subsequently underwent external beam radiation and was alive 10 months after presentation. This surgical technique may be valuable in select patients with retinal metastasis for diagnostic, therapeutic, and counseling purposes.

Treatment options for metastatic tumors to the choroid

Metastatic tumors are generally considered to be the most common intraocular tumors. These tumors may metastasize from a variety of different primary sites with breast carcinoma being the most common primary malignancy in women and lung cancer being the most common primary malignancy in men. Treatment options for these patients include systemic therapy, conventional external beam radiation, plaque brachytherapy, proton beam irradiation, photodynamic therapy, transpupillary thermotherapy, and laser photocoagulation. Overall, treatment of patients with metastatic tumors to the choroid has proven to be effective in both improving the patient's visual acuity and quality of life.

METASTATIC BREAST CARCINOMA TO THE VITREOUS

PURPOSE

To evaluate the clinical and pathologic findings in two patients with prior breast carcinoma who underwent diagnostic vitrectomy for vitreous opacities and preretinal membrane.

METHODS

The clinical histories and ophthalmic findings in two patients were reviewed. Vitrectomy specimens from the patients were processed by cytospin and standard tissue techniques, stained with hematoxylin and eosin, and examined immunohistochemically for cytokeratins. The original breast carcinoma specimens were reviewed.

RESULTS

The vitreous in both patients contained malignant cells with cytologic features consistent with metastatic carcinoma. Immunohistochemical stains were positive for cytokeratins in the cells. The cytologic findings in the vitreous cells resembled the primary breast carcinoma.

CONCLUSIONS

Breast carcinoma may metastasize to the vitreous, most likely via the retina. The clinical manifestations include vitreous cell and preretinal membrane.

Choroidal metastases from renal cell carcinoma

BACKGROUND

Choroidal metastases from renal cell carcinoma are uncommon. The authors investigated the clinical characteristics of patients with renal cell carcinoma in whom choroidal metastases developed.

METHODS

The clinical records of five patients with histopathologically confirmed renal cell carcinoma and choroidal metastases were reviewed retrospectively.

RESULTS

In four patients, choroidal metastases were either the sole initial manifestation of disease or were the initial manifestation of metastatic disease. The interval from nephrectomy to the onset of ocular signs ranged from 6 to 18 years. A reddish-orange appearance of the tumor was present in two patients, but no pathognomonic features distinguishing these tumors from other choroidal metastases were identified.

CONCLUSIONS

Ocular metastases may precede the diagnosis of renal cell carcinoma or may follow it by years or decades. This interval between its ocular and systemic presentation may be so prolonged as to obscure the relation between the choroidal metastases and the primary tumor. In patients with amelanotic or reddish choroidal lesions without known metastatic disease, evaluation of the kidney may be warranted as part of a metastatic workup to exclude metastatic renal cell carcinoma.

Metastatic adenocarcinoma to the retina in a patient with Muir-Torre syndrome

PURPOSE/METHODS

A 74-year-old woman had multiple tumors including a retinal mass. Her medical history included cutaneous sebaceous adenomas, adenocarcinoma of the breast, and colonic adenocarcinoma. Her involved eye became painful and was enucleated.

RESULTS/CONCLUSIONS

Examination of the enucleated eye disclosed metastatic adenocarcinoma to the retina with retinal detachment. The patient described has a retinal metastasis of an unknown primary tumor site with Muir-Torre syndrome, characterized by an association of a sebaceous gland tumor with an internal malignancy.

Diagnostic cytopathology of ocular fluid specimens

The brief history of the development of cytopathologic study of ocular fluids has been reviewed. The utilization of cytopathology techniques has become increasingly important with the introduction and widespread use of vitreous surgery. The cytopathologic study of ocular fluids have diagnostic value in infectious and noninfectious ocular inflammatory diseases, neoplastic lesions, some forms of secondary glaucoma, epithelial ingrowth, proliferative vitreoretinopathy, persistent hyperplastic primary vitreous and amyloidosis.

Metastatic tumor to the retina and vitreous cavity from primary melanoma of the skin: treatment with systemic and subconjunctival chemotherapy

The cases of two young women with metastatic tumors to the retinas and vitreous cavities from primary melanoma of the skin are discussed. Each presented with 20/20 central visual acuity in both eyes and complaints of floaters related to singularly unusual golden brown cellular aggregates infiltrating the vitreous cavities. Some cells appeared to be emanating from the region of the optic nerves whereas others appeared to originate from the superficial retina, presumably from the retinal vessels. The cellular aggregates were comprised of malignant melanoma cells as determined by histocytology of a vitrectomy specimen in one case and an aqueous aspirate in the other. The clinical appearance of cellular aggregates in the form of regular spherules should alert the clinician to the possibility of malignant rather than inflammatory cellular infiltration. The combined administration of repeated systemic and subconjunctival DTIC in case 1 and BCNU in case 2 was unsuccessful in promoting tumor regression. Histology of one eye, removed because of uncontrolled neovascular glaucoma, revealed numerous melanoma cells in the superficial retina and adjacent vitreous.