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Original Investigation |

Retinal Metastasis From Systemic Cancer in 8 Cases

Carol L. Shields, MD1; Jeffrey F. McMahon, BS1; Hatice T. Atalay, MD1; Murat Hasanreisoglu, MD1; Jerry A. Shields, MD1
[+] Author Affiliations
1Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
JAMA Ophthalmol. 2014;132(11):1303-1308. doi:10.1001/jamaophthalmol.2014.2406.
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Published online

Importance  Metastatic tumors of the retina are rare, simulate retinitis, and are associated with poor patient survival.

Objective  To describe the clinical features and outcomes of patients with retinal metastasis from systemic cancer.

Design, Setting, and Participants  Retrospective case series of 8 patients with retinal metastasis from cutaneous melanoma (n = 4), breast cancer (n = 2), esophageal cancer (n = 1), and lung cancer (n = 1). At presentation, the mean patient age was 62 years and all were white.

Intervention  Treatment included plaque radiotherapy (n = 1) for localized disease or enucleation (n = 3) for extensive tumor hemorrhage (n = 1), total retinal detachment (n = 1), or pain (n = 1). For 4 preterminal patients, observation was preferred.

Main Outcomes and Measures  Clinical features and systemic outcomes.

Results  The mean interval from primary cancer diagnosis to retinal metastasis was 63 months. Initial misdiagnosis as retinitis (n = 5), hemangioma (n = 1), choroidal neovascular membrane (n = 1), or nerve fiber layer infarction (n = 1) for a mean interval of 5 months was recorded. Visual acuity in the affected eye was 20/40 to 20/60 (n = 5) or 20/400 to light perception (n = 3). The tumors were unilateral (n = 7), involved the macula (n = 3), and had a mean distance to the foveola of 6 mm. In one case, dense vitreous blood precluded fundus visualization. The mean tumor basal dimension was 7.4 mm, and the mean thickness was 2.3 mm. The tumors appeared white (n = 2), yellow (n = 4), or brown (n = 1); were located in the inner retina (n = 6) or full-thickness retina (n = 1); and had vitreous seeds (n = 3), vitreous hemorrhage (n = 2), retinal hemorrhage (n = 4), subretinal fluid (n = 4), and/or intraretinal exudation (n = 1). Fluorescein angiography disclosed early retinal hypofluorescence and late hyperfluorescence with staining. Fine-needle aspiration biopsy confirmed the diagnoses (n = 4). Metastasis-related death occurred in 5 patients within 1 month in each case. Of the remaining 3 patients, 2 were alive at 4 and 17 months and 1 was too sick to return.

Conclusions and Relevance  Retinal metastases resemble retinitis, often with delay in diagnosis and poor life prognosis.

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Figure 1.
Case 1

A 64-year-old woman with lung carcinoma without metastatic disease developed blurred vision to 20/50 in the affected eye. A, Funduscopy revealed a white retinal mass with intrinsic vascularity and mild overlying vitreous hemorrhage. B, Fluorescein angiography confirmed intrinsic vascularity with staining but without dilated feeding vessels. C, Ultrasonography revealed a dense, domed-shaped retinal mass measuring 1.7 mm in thickness. Optical coherence tomography (horizontal) through the lesion showed full-thickness retinal replacement by tumor (D) and intact macula with minor drusen (E). F, Fine-needle aspiration biopsy showed malignant cells, with positive staining for epithelial markers (G) (AE1/AE3); this is consistent with metastatic lung carcinoma of the retina.

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Figure 2.
Case 7

A 75-year-old woman with breast carcinoma developed blurred vision to 20/40 in the affected eye. A, Funduscopy revealed a yellow retinal mass with intrinsic hemorrhage and surrounding retinal exudation. B, Fluorescein angiography showed a slightly hyperfluorescent mass with intrinsic vascularity and without dilated feeding vessels. C, Optical coherence tomography (vertical) through the lesion showed an inner retinal mass with outer retinal compression and contiguous edema. Note the lack of choroidal tumor. D, Optical coherence tomography (horizontal) through the macula showed outer retinal densities consistent with exudation.

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Figure 3.
Case 3

A healthy 59-year-old man developed floaters. A, Funduscopy revealed an ill-defined white retinal mass with chorioretinal scarring. B, Fluorescein angiography documented linear intrinsic blood vessels. C, Ultrasonography revealed a moderately echogenic, abruptly elevated intraocular mass. D, Gross pathologic analysis showed the yellow-white multinodular mass arising in the retina and without choroidal invasion. The mass proved to be cutaneous melanoma metastasis to the retina. Subsequently, metastases to other organs were detected.

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Figure 4.
Case 2

A 45-year-old man with a 6-year history of cutaneous melanoma with multisystem metastasis developed decreased visual acuity to 20/400 OS. A, Funduscopy revealed chorioretinal scars with overlying serous retinal detachment. B, Fluorescein angiography documented ill-defined staining indicative of metastasis; based on general poor prognosis, observation was advised. C, Eight months later, ultrasonography revealed dense vitreous debris. D, Gross pathologic analysis of the enucleated eye showed diffuse vitreous hemorrhage with yellow material that proved to be melanoma metastasis. The retina was infiltrated with metastatic melanoma and the choroid showed no tumor.

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