Download Jessica O`Neil

Jessica O’Neil, O.D.
ABSTRACT:
Regression of metastatic tumor to the choroid, involving the
macula, found in an asymptomatic 66 year old female concurrently being treated for
breast cancer by mastectomy and chemotherapy. No further treatment necessary at this
time.
I.
Case History
-66 year old, white female
-Presented for consult for retinal lesion OS
-No known ocular history; last DFE was over 5 yrs ago
-Patient currently being treated for breast cancer post mastectomy.
-Patient currently taking Femara 2.5 mg, Motrin 400 mg, and Zometa
4mg/5ml
II.
Pertinent findings
-Corrected VA- OD 20/25+1 OS 20/25
-No APD
-EOMS- full and smooth
-Confrontation fields FTFC
-Color vision 7/7 OU
-IOP 15 mmHg OU
-Amsler Grid- Normal OU
-DFE
Vitreous OD PVD, OS Clear
CD .25/.25 OU
Maculae OD clear, OS 4DD white lesion with Large RPE clumping- NO
fluid, exudates, hemorrhages, CNMV, lipofusin or drusen
Vessels WNL OU
Periphery OD inferior arcade 1.5DD choroidal hypo-pigmentation
(window defect), OS clear
B-scan no elevation-WNL OU
FLANG- no leakage OU
III. Differential Diagnosis
-Primary dx- Metastatic tumor
-Others- Macular degeneration, exudative retinal detachment, RPE
detachment, amelanotic choroidal melanoma, choroidal detachment,
retinoblastoma, choroidal osteoma, acute chorioretinitis, retinal vascular
occlusive disease.
IV. Diagnosis and Discussion
-A regressing metastatic tumor was found in the left eye of this patient.
Testing in office revealed no elevation, nor leakage of the tumor. Pigment
in retina is due to disruption of the RPE from the tumor growth and will
likely remain as current presentation. Patient was diagnosed with stage 4
breast cancer in November of 2007. She reports not being able to leave
her bed and dementia soon after her diagnosis. After only a couple of
months on a new medication for cancer, she reports regaining awareness
as well as walking abilities. Patient has been taking Femara for the past
eight months with great success. She has not undergone any other
chemotherapy or radiation; only the new FDA approved oral medication
called Femara. Femara is an aromatase inhibitor that blocks aromatase
from converting androgens into estrogen. Estrogen is needed for some
tissues (including tumor tissue) to survive. Inhibiting the estrogen will
shrink the tumors relying on it to proliferate. Patient reports repeated total
body CT scans show no progression of the cancer and our testing shows
likely regression of the metastatic tumor. Disruption of the RPE, give this
lesion a unique presentation. At first glance, one might assume a retinal
degeneration is to blame. With lack of atrophy, hemorrhage, exudates,
inflammation, or detachment, it is clear to see that the disruption is due to
a once active tumor. Prior medical history is key to diagnosis of this
lesion. The two most likely cancers to metastasize to the eye are breast and
lung cancer. The breast is the most common primary site for 87.5% of all
uveal metastases (Soysal). The malignant emboli reach the choroid by
traveling through the short posterior ciliary arteries and travel to the
posterior pole (Michaelson). The metastases may occur in either the
choroids or the retina with both eyes being affected in about 1/3 of the
time (Michaelson). Mean survival time to death after ocular diagnosis was
17 months in a study of metastatic tumors of the uvea conducted by Hulya
Soysal, M.D.
V.
Treatment, Management
-At this time, no treatment is necessary.
Patient’s current use of Femara is
key to keeping the cancer from proliferating and spreading. Patient will
keep future appointments with her oncologist and will be monitored by her
optometrist with dilated fundus exams, and b-scans for elevation or
proliferation of the tumor. Literature shows that first choice treatment for
metastatic tumors are chemotherapy and hormonal therapy for
disseminated disease, and external beam radiation therapy (EBRT) for
those that do not respond to initial treatment (Soysal). Proton beam
irradiation is proven to be very effective against metastatic tumors of the
choroid. Tsina et. al., reported that 84% of radiation treated tumors
regressed completely in five months of treatment. None of these
reoccurred. Enucleation is not required in nearly all cases.
VI. Conclusion
-When evaluating retinal lesions, medical histories are very informative
and necessary for diagnosis of many ocular diseases. Ancillary testing is
necessary to help properly diagnose and treat these malignant lesions.
Prompt treatment is key to regain vision and prevent further proliferation
of these tumors. Being diagnosed with these lesions does not necessarily
mean losing one’s vision, but can mean a chance to extend one’s life.