Iris metastasis preceding diagnosis of gastric signet ring cell adenocarcinoma: a case report

[Clinical approach for solid intraocular metastases]

BACKGROUND

Intraocular metastases arising from solid tumors are found in approximately 2% of patients with metastatic tumor diseases and are therefore more frequent than originally assumed. They often affect the uvea and are associated with a poor prognosis. Due to the difficult diagnosis and an inconsistent treatment regimen, ophthalmologists have a special responsibility here.

OBJECTIVE

This article gives a summary of the various types of intraocular metastases with respect to clinical features, diagnostics, treatment and prognosis as well as recommendations for follow-up care.

METHODS

A selective literature search was carried out on the topic of intraocular metastases using PubMed and Google Scholar.

RESULTS

Intraocular metastases most frequently affect the uvea, specifically the choroid. In most cases the underlying disease is breast or lung cancer, but other rarer primary tumors have also been reported in the literature. Metastatic lesions can show very different morphological manifestations but can be distinguished based on the corresponding structure of manifestation in the eye and with the aid of targeted staging, thus providing valid information on the type of primary tumor. The treatment is partly experimental and usually depends on the primary tumor and leading symptoms of the patient. A differentiation between a curative or palliative treatment situation must always be made.

CONCLUSION

Intraocular metastases are the most frequent intraocular tumor and are usually associated with a poor prognosis. Accurate diagnostics for finding the treatment as well as interdisciplinary collaboration and the presentation of the patient on the tumor board are essential.

Case Report: A testicular torsion as an initial presentation of a patient with metastatic cecum signet-ring cell cancer

Secondary neoplasms of the testes from solid tumors are rare and usually present as a painless mass. Metastatic cecum signet-ring cell cancer of the testis is extremely rare. The orchioncus usually shows hypervascularity on color Doppler ultrasound. The present study reports an unusual case of testicular secondary signet-ring cell carcinoma mimicking missed testicular torsion in a 55-year-old male patient with right scrotal swelling and intermittent pain for 10 days. As color Doppler ultrasound showed an avascular distribution of the enlarged right testis, missed testicular torsion was initially diagnosed. Right-sided orchiectomy was performed, and pathology of the resected testis revealed an intestinal-type adenocarcinoma with mucinous and signet-ring cell features. This pathological feature led to further endoscopic colorectal biopsy of the digestive tract, which revealed poorly differentiated adenocarcinoma of the cecum with signet ring cell features similar to those of testicular specimens. In conclusion, differential diagnosis should be considered for rare testicular neoplasms, as was seen in this rare occurrence of testicular torsion in a patient who initially presented with metastatic colorectal cancer. A correct preoperative diagnosis can change the management and outcome. This report shares our reasons for misdiagnosis and opinions on diagnosing and treating this kind of case.

Primary Tumour Type, Clinical Features, Treatment and Outcome of Patients with Iris Metastasis

PURPOSE

To describe the primary tumour type, clinical features, treatment and outcome of patients with Iris metastasis.

METHODS

Retrospectively analyzed articles published from 1934 to 2019 in the PubMed database.

RESULTS

In total, 133 eyes of 125 patients with iris metastatic carcinoma were retrieved. The average age at metastasis diagnosis of the patients was 56 ± 15 years; 60 left eyes and 49 right eyes were involved. The most common primary tumors were lung carcinoma (42%) and breast carcinoma (15%). Approximately one-third of the patients were first diagnosed in the ophthalmology department before the primary tumor was detected. Twenty-two percent of iris metastases were discovered before and 33% were discovered after systemic metastasis. The most common complaints were blurred vision and pain. The clinical features included iris masses, neovascularization and keratic precipitates. 57 patients (64%, N = 90) had an elevated intraocular pressure. Local administration of radiation therapy or intraocular injections of anti-VEGF drugs relieved eye discomfort and controlled the high intraocular pressures.

CONCLUSIONS

Iris nodules with increased intraocular pressure and neovascularization may indicate iris metastasis. Lung cancer is the most common primary tumor.

An isolated vaginal metastasis from intestinal signet ring cell carcinoma: a case report and literature review

Background

Isolated vaginal metastases from intestinal signet ring cell carcinoma are extremely rare. There are no reported cases in the domestic or foreign literature. The characteristics of such cases of metastasis remain relatively unknown. As a life-threatening malignant tumor, it is very important to carry out a systemic tumor examination and transvaginal biopsy, even though clinical symptoms are not typical and there is no systemic tumor history.

Case presentation

We present a case of an isolated vaginal metastasis from intestinal cancer in a 45-year-old female patient. The patient experienced a small amount of irregular vaginal bleeding and difficulty urinating. She had no history of systemic cancer. An early physical examination and transvaginal ultrasound (TVS) showed marked thickening of the entire vaginal wall. Pelvic nuclear magnetic resonance imaging (MRI) and a colposcopic biopsy were used to diagnose her with chronic vaginitis. An analysis of the vaginal wall biopsy showed signet ring cell carcinoma. Colorectal colonoscopy revealed advanced interstitial signet ring cell carcinoma as the primary source of vaginal wall infiltration. We review previous case reports of vaginal metastases from colorectal cancer and discuss the symptoms, pathological type, and outcomes.

Conclusions

We hypothesize that vaginal wall thickening and stiffness accompanied by chronic inflammatory-like changes may be clinical features of a vaginal metastasis of signet ring cell carcinoma of the intestine. We also emphasize that it is very important to perform a systemic tumor examination in a timely manner when a patient has the abovementioned symptoms.

Iris metastasis as the initial presentation of upper gastrointestinal tract carcinoma: a case report

BACKGROUND

We report a case of a patient with iris metastasis as the initial manifestation of a systemic cancer: upper gastrointestinal tract carcinoma.

CASE PRESENTATION

A 24-year-old Asian man presented to our hospital with complaints of red left eye, decreased visual acuity, pain, and photophobia for about 3 weeks with no prior history of cancer or any other medical abnormality. Ocular examination showed a pinkish white lesion on the superonasal part of the iris. The patient's intraocular pressure was progressively increasing despite medications, followed by lymphadenopathy 4 weeks later. Comprehensive examination was performed along with a complete systemic workup, which detected systemic malignancy. Histopathology and immunohistochemistry revealed signet ring cells, which indicated an upper gastrointestinal tract tumor as a primary source of iris metastasis. The systemic condition of the patient deteriorated rapidly thereafter and led to his death in the 12th week of the disease.

CONCLUSION

A red eye with iris lesions in otherwise healthy individuals should be considered as a possible initial manifestation of underlying systemic malignancy. Prompt referral of such patients to an oncologist is warranted.

Spontaneous rupture of the eyeball due to choroidal metastasis of gastric carcinoma: A case report

RATIONALE

Although metastatic tumor is the most common intraocular malignancy, choroidal metastasis from gastric cancer is relatively rare. We present the exact course of a spontaneous rupture of the eyeball with choroidal metastasis from gastric carcinoma (GC) and the applied surgical interventions.

PATIENT CONCERNS

A 59-year-old male presented with pain and vision loss on his left eye for 6 months. He was diagnosed with GC, for which he received systemic chemotherapy for a year.

DIAGNOSES

Preoperative B-scan, color fundus photography, computed tomography, and magnetic resonance imaging showed a choroidal tumor in his left eye. The spontaneous rupture of the corneoscleral limbus from 2 to 5 o'clock, combined secondary glaucoma, exudative retinal detachment and choroidal detachment were found.

INTERVENTIONS

The ruptured corneoscleral limbus was sutured and the orbit was lavaged with 0.4% cisplatin during the enucleation.

OUTCOMES

Histopathology confirmed high homology of the choroidal metastasis and GC. He survived for 2 months after surgery, without pain or orbital neoplasms.

LESSONS

Choroidal metastasis from GC rapidly progressed to spontaneous rupture of the eyeball. Careful eyeball enucleation followed by orbital lavage with chemotherapeutics may reduce metastasis risk beyond the eyeball. Additional therapeutic interventions should be considered in patients resistant to single systemic chemotherapy.

Calcified mucinous adenocarcinoma of the stomach metastatic to the iris: a case report

Background

Gastric cancer has a wide spectrum of clinical features, imaging manifestations, and pathology. Punctate calcifications in gastric cancer are infrequent but are usually found in mucinous adenocarcinoma. However, there have only been a few autopsy case reports describing the correlation between the radiology and pathology findings of calcified mucinous adenocarcinoma of the stomach. We present an autopsy case of mucinous gastric adenocarcinoma with iris metastases as the initial symptom.

Case presentation

A 74-year-old Japanese woman presented with blurred vision. Her treating ophthalmologist diagnosed acute iritis with secondary glaucoma. The histopathological and immunohistochemical features of a trabeculectomy specimen favored metastatic carcinoma, most likely of gastrointestinal tract origin. Esophagogastroduodenoscopy revealed multiple irregularly shaped ulcerative lesions, multiple erosions, and thickened folds in the corpus of her stomach. Histologic examination of a gastric tissue specimen obtained by endoscopic biopsy revealed poorly differentiated carcinoma with signet ring cell features. Computed tomography revealed a tumor with multiple punctate calcifications in the thickened gastric wall with diffuse low attenuation and multiple lymph node metastases, including the para-aortic lymph nodes, and peritoneal dissemination. She was diagnosed with stage IV gastric cancer (T4N3M1) and underwent seven cycles of 5-weekly TS-1, a novel oral fluoropyrimidine derivative, plus cisplatin therapy. Serial follow-up computed tomography revealed successive increases in the gastric wall calcifications. Her disease stabilized, but she died of aspiration pneumonia 8 months after the first visit. Autopsy tissue specimens had miliary, punctate calcifications present in abundant extracellular mucin pools in the submucosa, corresponding to the thickened low-attenuating middle layer on computed tomography. The final diagnosis was mucinous gastric adenocarcinoma because mucinous adenocarcinoma is diagnosed when more than half of the tumor area contains extracellular mucin pools.

Conclusions

We report the pathology and computed tomography imaging characteristics of a case of calcified mucinous adenocarcinoma of the stomach metastatic to the iris, including findings at autopsy. Metastatic carcinomas in the iris originating in the stomach are exceedingly rare. Multiple punctate calcifications were present in pools of extracellular mucin, a diagnostic clue for mucinous adenocarcinoma. Possible mechanisms underlying scattered punctuate calcifications in gastric mucinous adenocarcinoma warrant further investigation.