A RARE CASE OF VITREOUS HEMORRHAGE AND NEOVASCULAR GLAUCOMA AS A MANIFESTATION OF NON SMALL CELL LUNG ADENOCARCINOMA WITH CHOROIDIAL METASTASIS
Rajput G. C1, Deepti Mahajan2, Chaudhary K. P3, Sood T4
HOW TO CITE THIS ARTICLE:
Rajput G. C, Deepti Mahajan, Chaudhary K. P, Sood T. “A Rare Case of Vitreous Hemorrhage and Neovascular Glaucoma as a Manifestation of Non-Small Cell Lung Adenocarcinoma with Choroidial Metastasis”. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 27, July 07; Page: 7507-7514,
DOI: 10.14260/jemds/2014/2926 ABSTRACT: BACKGROUND: Tumor metastasis to the eye is a rare complication of lung cancer. Metastasis to the choroid in patients with lung cancer is associated mainly with small cell carcinoma. Hemorrhage is an unusual finding with choroidal metastatic disease. Single case reports have highlighted this rare association. CASE: We report a rare case of non -small cell lung adenocarcinoma diagnosed on broncoscopic biopsy, presenting as choroidal metastasis with vitreous hemorrhage, unilateral retinal detachment and neovascular glaucoma. A 50years old non-smoker female, known case of non -small cell lung adenocarcinoma, presented with severe pain and sudden onset loss of vision in the left eye. She had signs of severe intraocular inflammation, elevated intraocular pressure and neovascular glaucoma. Based on the fundus, ultrasonography and M.R.I Brain findings the possibility of metastasis to the choroid, vitreous hemorrhage with serous exudative retinal detatchment was kept. Vitreous tap revealed vitreous hemorrhage. CONCLUSION: Vitreous hemorrhage due to choroidal metastasis as a symptom of lung cancer is very uncommon. A great index of suspicion is essential when a choroidal lesion appears in the eye of a patient of cancer, as it is associated with numerous complications. The aim should be improving, stabilizing and preventing the vision related complications by early treatment with radiation therapy.
KEYMESSAGE: In a diagnosed patient of cancer presenting with decreased vision, pain, intractable glaucoma and severe intraocular inflammation, the possibility of metastatic carcinoma to the eye and its complications should be kept in mind in cases with the aim of improving, stabilizing and preventing the vision related complications by early treatment with radiation therapy.
INTRODUCTION:Intraocular metastases occur in 5-7% of patients with cancer. The incidence of ocular metastases from lung cancer is reported to be 2-7% according to the international literature.[2, 3] Choroidal metastases are metastatic lesions to the choroid layer of the eye. Choroidal metastasis have been mainly reported in highly proliferating tumors as small cell carcinomas. This is a rare case in which they were present with non small cell carcinoma. Complications of choroidal metastases include retinal detachment, which may occur in up to 90% of patients and, rarely, massive subretinal or intravitreal hemorrhage. Hemorrhage is an unusual finding with choroidal metastatic disease. Single case reports have highlighted this rare association. Vitreous hemorrhage has been described with uveal metastasis from occult lung cancer and hemorrhagic retinal detachment with metastatic renal cell carcinoma. CASE: A 50years old female non-smoker, known case of non small cell mucinous adenocarcinoma lung diagnosed on broncoscopic biopsy (Fig 1–A), with type 2 diabetes mellitus and hypertension presented with sudden onset decreased vision left eye since 2 days on 21/10/2013. Visual acuity was 6/36. Dilated fundus examination (Fig. 2 –A) disclosed yellow, elevated lesion in the peripapillary region suggestive of choroidal metastasis, inferior exudative retinal detachment, disc edema with choroidal folds. F.F.A (Fig. 2-B) showed hyper fluorescence due to disc edema, blocked fluorescence due to choroidal lesionand late diffuse staining in the peripapalliary region.
Ultrasonographic examination (Fig. 2 –C) showed a dome-shaped lesion with low height to base ratio, high internal reflectivity and serous exudative detachment. MRI brain (Fig. 2 –D )detected 2 altered signal intensity areas involving the superior and nasal quadrants of posterior segment of the left eye with extension to optic nerve head, hyperintense on T2W1 and flair and isointense on T1W1.Metastasis in the choroid, vitreous humor with vitreous hemorrhage left eye was documented. Metastasis was reported in the high dural region of the left side brain, hyperintense on T2W1and flair and hypointense on T1W1.
She was given whole brain radiotherapy with the left eye kept in focus for 7 days for the metastasis to the brain and eye and chemotherapy- cisplatin 40 mg and paclitaxel 260mg i.v. for the lung adenocarcinoma. She did not respond well. The patient’s visual deficits continued to worsen. 5 months after her initial presentation, her vision was finger counting at 3ft with worsening ocular pain. Her I.O.P was 50.5mmHg and she had signs of severe intraocular inflammation and neovascular glaucoma. Fundus showed media haze grade 4.B-Scan revealed total retinal detachment, vitreous hemorrhage and choroidal thickening.(Fig. 3 -A). A repeat MRI brain showed vitreous hemorrhage with retinal detachment (Fig3-B). AC tap revealed inflammatory cells and vitreous tap (Fig 2- C) revealed R.B.Cs, inflammatory cells and melanophages. Her I.O.P was brought down to 17.3mmHg by anti -glaucoma medications but she lost vision in the left eye due to glaucomatous optic atrophy. She was attached to the department of radiotherapy for External beam radiotherapy. Due to disease progression evident on CT scan, she was treated with her 5th cycle of chemotherapy. The aim of treatment was to relieve her of pain due to neovascular glaucoma.
Based on the fundus, ultrasonography, M.R.I and vitreous tap findings the possibility of choroidal metastasis was kept. The malignant cells have been mainly confined to the choroidal mass. Vitreous hemorrhage, retinal detachment and neovascular glaucoma were the implications of the choroidal tumor. Retinal detachment with high I.O.P suggested the possibility of anterior uveal tract metastasis leading to angle closure with pupillary block. The tumor predominantly involves the horizontal meridian of the iris or ciliary body. The cause of blindness was high I.O.P that lead to glaucomatous optic atrophy.
DISCUSSION:The choroid is the most common location for metastatic seeding, due in large part to its rich vascular supply. These lesions frequently arise from a silent primary. One recent meta-analysis approximated the number of cases presenting in such fashion was 55 cases. Of these 55 cases, 42% were adenocarcinoma and 22% of the patients were never-smokers. At the time of ocular diagnosis, 66% patients reported a history of a primary cancer, and 34% patients had no history of cancer. Of the 34% patients with no prior cancer, after complete oncologic evaluation, the most frequent primary cancer was lung carcinoma (35%).
Stephens and Shields reviewed 70 cases of choroidal metastasis and found that blurred vision was the presenting complaint in 80% of patients, and pain in 14%, photopsia in 13%, red eye and floaters in 7% and field defects in 3%. The patients with worse visual acuity were generally those who had ipsilateral choroidal metastasis with retinal detachment or those with secondary glaucoma. Secondary glaucoma was present in about 40% of patients. The mechanism of increased intraocular pressure appeared to be involvement of the anterior chamber angle by solid tumor or loose seeding of tumor cells or bleeding in the anterior chamber, causing obstruction of aqueous outflow.
DIAGNOSIS: It is important to obtain a comprehensive history as 66–97% of patients evaluated for a metastatic choroidal lesion already would have been diagnosed with a primary neoplasm elsewhere. It can be diagnostically challenging to distinguish a metastatic lesion from a primary ocular neoplasm. Uveal melanoma is the most common primary intraocular malignancy. Metastatic choroidal lesions are generally plateau or dome shaped and are often associated with retinal detachment.
Several methods are available for direct characterization of choroidal lesion, including ultrasonography, fundus autofluorescence and FNAB.
Ultrasonography differentiates between choroidal melanoma, metastasis and hemangioma with 90% accuracy. On fluorescein angiography, in the early phase these lesions shows hypo fluorescence and become progressively hyperfluorescent in the late phases. Intraocular tumor biopsy is generally not recommended because of the possible risk of dissemination of malignant cells. Brain imaging is useful before initiation of radiotherapy to assist in treatment planning as 22% of the patients of choroidal metastasis had concurrent C.N.S involvement. THERAPY: Early treatment offers the best hope for the preservation of vision in metastatic uveal cancer. In general, choroidal metastases respond favorably to systemic therapy targeted toward the primary neoplasm. However, local therapy is warranted when there is an enlargement of the lesion, pain, or when the ocular lesion is the sole metastatic finding. Radiation therapy is given with goals of pain control and visual improvement. Therapeutic doses range from 25 to 50Gy in 10 to 20 fractions, with response occurring in the majority of cases. Side effects of radiotherapy include dry-eye syndrome, cataract, neovascular glaucoma and radiation retinopathy or papillopathy.
In instances where residual visual function remains, radiotherapy (brachytherapy or external beam), laser photocoagulation, and more recently intraocular delivery of bevacizumab may be offered. Brachytherapy is most suitable for discrete small to medium sized lesions, whereas larger lesions close to the optic nerve and macula are more amenable to external beam delivery.
Treatment for ocular metastases is palliative because the presence of such metastases suggests hematogenous spread of cancer. Surgery has not played an important role other than diagnostic biopsy, as surgery carries great potential morbidity and often there is no need for tumor debulking.
CONCLUSION:The diagnosis of the choroidal metastasis in a patient with lung cancer usually indicates an advanced disease with a very poor prognostic indicator with reported median survival of 3.3months (range: 0.5-19 months). Reversal of rapid progression to blindness did not prove possible in this patient. However, if such lesions are detected early, they can be treated effectively with radiation therapy to improve both vision and quality of life of the patient, even if no therapy can stop the inexorable progressive loss of vision. A complete metastatic work up of a cancer patient should be done as choroidal metastasis may be the first sign of a relapse of a known primary malignant neoplasm or the initial presentation of an unknown primary.
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