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Bilateral Choroidal Metastases Revealing an Advanced Non-Small Cell Lung Cancer

2009; Elsevier BV; Volume: 88; Issue: 3 Linguagem: Inglês

10.1016/j.athoracsur.2009.02.019

1552-6259

Francisco J. Ascaso, Jesús Castillo, Francisco J. García, José Á. Cristóbal, Ana María de Caso Fuertes, Á. Artal,

Ocular Diseases and Behçet’s Syndrome

Choroidal metastases are metastatic lesions to the choroid layer of the eye. Although infrequent, they may be the initial manifestation of lung cancer. To date, only 10 cases of choroidal metastasis as the first sign of lung carcinoma have been reported. We present a 42-year-old woman with choroidal metastasis as the initial manifestation of an advanced lung carcinoma. Choroidal metastases are metastatic lesions to the choroid layer of the eye. Although infrequent, they may be the initial manifestation of lung cancer. To date, only 10 cases of choroidal metastasis as the first sign of lung carcinoma have been reported. We present a 42-year-old woman with choroidal metastasis as the initial manifestation of an advanced lung carcinoma. Choroidal metastases (CM) are metastatic lesions to the choroid layer of the eye. CM is detected in 2% to 7% of patients with metastatic lung cancer and is generally discovered at the end-stage of the disease. Although infrequent, CM may be the initial manifestation of lung cancer. To date only 10 cases of CM as the first sign of lung carcinoma have been reported. A 42-year-old woman complained of decreased vision in her left eye. She acknowledged smoking 1 pack of cigarettes daily for 15 years, but had not smoked for the last 5 years. Her visual acuity was 20/30 in the right eye and 20/200 in the left eye. A funduscopic examination revealed 2 yellow CMs along the temporal vascular arcades in the right eye (Fig 1), and another with associated serous retinal detachment in the left posterior pole (Fig 2). A computed tomography of the chest revealed a subcentimetric nodular lesion in the pulmonary lingula and several mediastinal lymph nodes (Fig 3). A transbronchial biopsy showed a poorly differentiated non-small-cell lung carcinoma, immunohistochemically positive for cytokeratin 7 and for thyroid transcription factor 1 (Fig 4).Fig 2A left eye funduscopy revealed a choroidal metastasis (arrows) at the posterior pole with associated serous retinal detachment.View Large Image Figure ViewerDownload (PPT)Fig 3High-resolution computed tomography scan showed mediastinal (preaortics, aortopulmonary window, paratracheal, precarinal) and left hilar lymph nodes.View Large Image Figure ViewerDownload (PPT)Fig 4A transbronchial biopsy specimen showed a poorly differentiated non-small cell lung carcinoma, immunohistochemically positive for cytokeratin 7 and thyroid transcription factor 1 (original magnification ×400).View Large Image Figure ViewerDownload (PPT) Histopathologic analysis showed the pulmonary lesion was an adenocarcinoma. Serum carcinoembryonic antigen, neuron-specific enolase, and cytokeratin fragment 19 (CYFRA 21-1) levels were elevated. A bone gammagraphy revealed multiple skeletal metastases (Fig 5). MRI showed multiple brain metastases and meningeal infiltration. The lung cancer was graded as a stage IV carcinoma. The patient is currently receiving chemotherapy with paclitaxel and carboplatin and receives regular follow-up. CMs, the commonest intraocular malignancy, are metastatic lesions to the choroid layer of the eye. Autopsy studies reported that 9% to 10% of patients who died of cancer had ocular metastasis, and most of them were localized in the choroid. CM occurs almost exclusively in metastatic disease, years after diagnosis of the primary neoplasm. So, CM develops in about 3% to 10% of patients with metastatic cancer, and at least 60% of all patients with CM have in addition other distant metastases at the time of diagnosis of choroidal involvement. This fact has been related to the abundant supply of posterior ciliary arteries to the choroid [1Donaldson M.J. Pulido J.S. Mullan B.P. et al.Combined positron emission tomography/computed tomography for evaluation of presumed choroidal metastases.Clin Experiment Ophthalmol. 2006; 34: 846-851Crossref PubMed Scopus (7) Google Scholar, 2Linares P. Castanon C. Vivas S. et al.Bilateral choroidal metastasis as the initial manifestation of a rectal cancer.J Gastroenterol Hepatol. 2004; 19: 726-727Crossref PubMed Scopus (9) Google Scholar]. CM is detected in 2% to 7% of patients with metastatic lung cancer. Lung cancer is the most common cause of CM in men. In women, however, lung cancer is responsible for no more than 12% of CM, being only the second most frequent origin after breast cancer. It is generally discovered at the end-stage of the disease, occurring with a mean interval of 6 to 10 months, covering the period from diagnosis of the primary cancer to the onset of ocular symptoms [1Donaldson M.J. Pulido J.S. Mullan B.P. et al.Combined positron emission tomography/computed tomography for evaluation of presumed choroidal metastases.Clin Experiment Ophthalmol. 2006; 34: 846-851Crossref PubMed Scopus (7) Google Scholar, 3Kreusel K.M. Bornfeld N. Hosten N. Wiegel T. Foerster M.H. Solitary choroidal metastasis as the first sign of metastatic lung carcinoid.Arch Ophthalmol. 1998; 116: 1396-1397Crossref PubMed Scopus (18) Google Scholar]. Although infrequent, CM may be the initial manifestation of lung cancer. A review of the medical literature revealed only 10 reported cases of clinically symptomatic CM as an initial presentation of lung carcinoma [1Donaldson M.J. Pulido J.S. Mullan B.P. et al.Combined positron emission tomography/computed tomography for evaluation of presumed choroidal metastases.Clin Experiment Ophthalmol. 2006; 34: 846-851Crossref PubMed Scopus (7) Google Scholar, 2Linares P. Castanon C. Vivas S. et al.Bilateral choroidal metastasis as the initial manifestation of a rectal cancer.J Gastroenterol Hepatol. 2004; 19: 726-727Crossref PubMed Scopus (9) Google Scholar, 3Kreusel K.M. Bornfeld N. Hosten N. Wiegel T. Foerster M.H. Solitary choroidal metastasis as the first sign of metastatic lung carcinoid.Arch Ophthalmol. 1998; 116: 1396-1397Crossref PubMed Scopus (18) Google Scholar, 4Conlon M.R. Collyer R.T. Joseph M.G. Siebert L.F. Metastatic choroidal choriocarcinoma: a clinicopathological study.Can J Ophthalmol. 1991; 26: 321-324PubMed Google Scholar, 5Simsek T. Ozdamar Y. Berker N. Choroidal mass as an initial presentation of lung cancer.Med Oncol. 2008; 25: 400-402Crossref PubMed Scopus (13) Google Scholar, 6Fernandes B.F. Fernandes L.H. Burnier Jr, M.N. Choroidal mass as the presenting sign of small cell lung.Can J Ophthalmol. 2006; 41: 605-608PubMed Scopus (14) Google Scholar, 7Arevalo J.F. Fernandez C.F. Garcia R.A. Optical coherence tomography characteristics of choroidal metastasis.Ophthalmology. 2005; 112: 1612-1619Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 8Kreusel K.M. Wiegel T. Stange M. Bornfeld N. Hinkelbein W. Foerster M.H. Choroidal metastasis in disseminated lung cancer: frequency and risks factors.Am J Ophthalmol. 2002; 134: 445-447Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar]. When the primary tumor is lung cancer, CM is often unilateral and unique [3Kreusel K.M. Bornfeld N. Hosten N. Wiegel T. Foerster M.H. Solitary choroidal metastasis as the first sign of metastatic lung carcinoid.Arch Ophthalmol. 1998; 116: 1396-1397Crossref PubMed Scopus (18) Google Scholar]. However, this patient showed bilateral and multilocal CM. It is important to notice ophthalmologic symptoms, because lung cancer may metastasize to the choroid [5Simsek T. Ozdamar Y. Berker N. Choroidal mass as an initial presentation of lung cancer.Med Oncol. 2008; 25: 400-402Crossref PubMed Scopus (13) Google Scholar]. The presence of CM can indicate a widespread dissemination of the disease, and detailed systemic evaluation should be performed. Our patient had concurrent extraocular metastases (brain, bone, and nodes). Adenocarcinoma type lung cancer, female gender, and an age younger than 50 years are all considered as significant favorable prognostic factors. Although all of them were present in this case, the recognition of a CM always indicates a poor prognosis [4Conlon M.R. Collyer R.T. Joseph M.G. Siebert L.F. Metastatic choroidal choriocarcinoma: a clinicopathological study.Can J Ophthalmol. 1991; 26: 321-324PubMed Google Scholar]. The mean survival in patients with disseminated lung cancer and CM is 2 to 6 months [1Donaldson M.J. Pulido J.S. Mullan B.P. et al.Combined positron emission tomography/computed tomography for evaluation of presumed choroidal metastases.Clin Experiment Ophthalmol. 2006; 34: 846-851Crossref PubMed Scopus (7) Google Scholar]. In conclusion, the possibility of CM in patients with choroidal masses should always be considered whether there is a diagnosis of cancer elsewhere [7Arevalo J.F. Fernandez C.F. Garcia R.A. Optical coherence tomography characteristics of choroidal metastasis.Ophthalmology. 2005; 112: 1612-1619Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar].