History
CC: Sudden loss of inferior field of vision of my right eyeHPI: 57 y/o female -2 day h/o inferior altitudinal field loss OD- Noticed when closing OS to apply make-upPMH: HTNPSH: NoneMeds: ASA, HCTZSH: 1PPD smoker x 30 yearsFH: Mother died at 82 y/o of metastatic cancer, primary
unknown
Examination
VA: 20/50 OD; 20/20 OS
Pupils: Trace APD OD
Motility: Full OU
Confrontation VF: Inferior field defect OD; WNL OS
SLE: 1+NSC OU
Fundus Photography
Fundus Photography
FA
23 sec 34 sec 1:30
1:32 3.51 4.13
Ultrasound
A-scan: Medium to high internal reflectivityB-scan: Acoustic solidarity
Differential Diagnosis?
A-scan: Low internal reflectivity withreduction in amplitude. High amplitudeSpike = break in Bruch’s membrane.
B-scan: Solid mass with mushroom shape
A-scan: High internal reflectivity
B-scan: Highly reflective plate-like lesion with orbital shadowing beyond lesion
FA can help distinguish if CNV
A-scan: High internal reflectivity
B-scan: Solid elevated mass
B-scan: Thickening of the retina, choroid and sclera with fluid beneath Tenon’s capsule and squaring of optic nerve shadow
A-scan: Medium to high internal reflectivityB-scan: Acoustic solidarity
Working Diagnosis
• Is this choroidal mass with exudative detachment a primary lesion or a metastatic lesion to the choroid?
• Need thorough systemic evaluation– PCP contacted– 1 wk prior pt presented with blurred vision OD & SOB– Found to have 13cm x 15cm left breast mass– Lab Work: Liver function tests wnl– CT Chest: Breast mass, lung nodules, liver lesions– Breast Biopsy: Infiltrating ductal carcinoma, ER/PR Negative– MRI brain: Frontal, occipital, and cerebellar lesions– PET Scan: Breast mass, lung, bone, adrenal, hepatic uptake
Stage 4 Metastatic Breast Cancer
Incidence of ocular metastasis
-1872: first description of a metastatic tumor to the eye in a patient with carcinoma
-Since then realization that ocular mets are not that rare
-Bloch and Gartner (1971) 10% patients with autopsy proven carcinoma had ocular mets
- Most common intraocular malignancy- choroidal metastasis
-Hard to gauge exact incidence as patients often are asymptomatic or present with advanced CA and eye exam never performed
Demirci, Shields C, et al. Uveal Metastasis from breast Cancer in 264 Patients. Ophthalmology 2003 264-271
Shields C, Shields J, et al. Survey of 520 Eyes with Uveal Metastases. Ophthalmology 1997 1265-1273
Epidemiology
• For American women lifetime risk breast cancer- one in eight (12.5%) & lifetime risk death from breast cancer is 3.4%
• Breast Cancer is the most common malignancy to metastasize to the uvea
• Mean age at ocular diagnosis is 58 years, most cases (40-70 yrs)
• At time of ocular diagnosis 66% reported a history of a primary cancer and 34% had no history of cancer
Primary Sites of Choroidal Mets
Males (N=137) Females (N=287)
Lung 40% Breast 68%
Unknown 29% Lung 12%
GI 9% Unknown 12%
Kidney 6% Others 4%
Prostate 6% GI 2%
Skin 4% Skin 1%
Others 4% Kidney <1%
Breast 1%
Breast Cancer Metastases
Most Common Sites:
• Lung (71%)
• Bone (71%)
• Lymph nodes (67%)
• Liver (62%)
• Pleura (50%)
• Ocular (9%-37%)
Clinical Features Uveal MetsAppearance:
– 99% choroidal mets from breast cancer were yellow in color– 77% plateau-shaped– 65% a/w subretinal fluid– Exudation and hemorrhage rare
Symptoms: - 75% Blurred vision - 6% Floaters - 5% Photopsias - 7% Asymptomatic
Location:– 89% Posterior to equator– 62% Unilateral and 38% bilateral to Uvea
Met Sites:– 85% to Choroid, 3% to Iris, <1% to Ciliary body– Other: 5% Optic nerve; <1% Conjunctiva, Orbit, Retina, Adnexa
Prognosis
• Average patient survival: 8-9 months after ocular diagnosis
• Primary tumor type determines prognosis• Metastatic malignant melanoma: worst
prognosis 1-2 months• Metastatic breast carcinoma: prognosis of
12 months
Survival Rates for Uveal Mets from Breast CA
Treatment Choroidal Mets• Plaque Radiotherapy
– Systemically healthy patients with solitary uveal metastasis or those with metastasis that failed other treatment
• External beam radiation • Chemotherapy & hormone therapy
– Used to manage disseminated systemic disease – Aromatase inhibitors - Estrogen receptor positive breast cancer
responded to aromatase inhibitors similar to ERBT with no radiation side effects
• Observation– Uveal metastases that are inactive or regressed– Asymptomatic tumors
Manquez et al. Management of Choroidal metastases from breast carcinomas using aromatase inhibitors, Current Opinion in Ophthalmology 2006, 251-256
Survival Rates + Brain Mets
• Not treated with Whole Brain Radiation Treatment (WBRT) or treated with corticosteroids alone: 1-2 months
• Median survival is increased to 3-6 months with WBRT & corticosteroids
• WBRT prevents any further deterioration of neurologic function
Back to our patient
• Patient was started on Decadron
• Radiation-Oncology->Palliative Radiation to whole brain (WBRT) recommended (18 days)
• Systemic chemotherapy to follow
Before Radiation Therapy
After completion of 18 day course of radiation therapy but prior to chemotherapy
Mass slightly smaller with regularly arranged pigment clumping on tumor surface
Before radiation therapy
After Radiation Therapy
1 Month follow-up s/p Radiation
• Va 20/50 OD, 20/20 OS
• Pupils: Trace APD OD
• Motility: Full ou
• Confrontation VF: Inferior field defect OD persists
Visual Prognosis Poor
• Age > 55 years
• Choroidal tumor base diameter > 15mm
• Pre-radiotherapy visual acuity 20/40 or worse
But….Before radiation therapy After radiation therapy