0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

Pulmonary Metastasis Masquerading as Anterior Uveitis FREE

Muge R. Kesen, MD; Deepak P. Edward, MD; Lawrence J. Ulanski, MD; Howard H. Tessler, MD; Debra A. Goldstein, MD
Arch Ophthalmol. 2008;126(4):572-574. doi:10.1001/archopht.126.4.572.
Text Size: A A A
Published online

Uveal metastasis is the most common intraocular malignancy,1 but iris involvement accounts for only 5% to 10% of cases.2,3 Most iris metastases are carcinomas, with breast, lung, and gastrointestinal tract carcinomas representing the majority of primary tumors. Renal cell carcinoma is also reported to result in metastasis to the iris.4 There is no history of a previously diagnosed primary tumor in 32% of cases.3 We report a case in which an iris lesion led to the detection of lung cancer.

A 65-year-old white woman noted pain in her left eye, was diagnosed with anterior uveitis, and was treated with topical steroid drops. Two weeks later an iris mass was noted. The mass enlarged during a 2-week period, resulting in her referral to the University of Illinois at Chicago.

Her ocular history was significant for cataract surgery in each eye. Her medical history was significant for chronic obstructive pulmonary disease, with a 50-pack/y smoking history. Work-up prior to referral included normal complete blood cell count findings, negative fluorescent treponemal antibody absorption (FTA-ABS), and normal purified protein derivative findings. Chest radiography revealed minimal scarring in the left lung base.

Visual acuity was 20/20 OU. Slitlamp examination results in the right eye were normal. The left anterior chamber had +3 cells. There was a dome-shaped elevation of the nasal iris with overlying aggregates of cells that had the appearance of mutton-fat keratic precipitates (Figure 1A). The mass measured 4.7 × 3.5 mm and was deep to the anterior stroma. Gonioscopy revealed iris elevation with white cellular aggregates without synechiae (Figure 1B). Fundus examination results were unremarkable. Ultrasound biomicroscopy revealed a solid mass with cystic spaces involving the iris and the ciliary body with overlying aggregates (Figure 1C).

Place holder to copy figure label and caption
Figure 1.

Iris mass in the left eye. A, In the left eye, the nasal iris mass deep to the iris stroma with overlying metastatic seeding appearing as pseudokeratic precipitates (arrows). B, Gonioscopy showing the mass and aggregates of tumor cells shed into the angle (arrows). C, Ultrasound biomicroscopy of the iris mass showing the multicystic nature of the mass and the lack of scleral invasion. Arrows indicate cystic spaces within the mass. D, Anterior view of the entire iris mass.

Graphic Jump Location

Biopsy of the mass revealed a poorly differentiated small-cell neoplasm with mitotic activity (Figure 2A). Immunohistochemistry showed strong AE1/AE3 (pancytokeratin) immunoreactivity consistent with epithelial origin (eFigure 1). Immunolabeling results with HMB-45, S-100, Mel A, neuron-specific enolase, CD45, CD20, and CD3 were negative.

Place holder to copy figure label and caption
Figure 2.

Histopathology. A, Photomicrograph showing the iris stroma replaced by small cells, hyperchromatic nuclei, and scant cytoplasm (hematoxylin-eosin, original magnification ×10). Inset, Note mitotic figures within the tumor infiltrate (arrow) (hematoxylin-eosin, original magnification ×40). B, Computed tomographic scan showing the left perihilar soft tissue mass (arrow).

Graphic Jump Location

A computed tomographic scan of the chest and abdomen revealed multiple pulmonary nodules and a left perihilar soft tissue mass suspicious for malignancy. There were bilateral adrenal masses and multiple soft tissue masses within the mesentery suspicious for metastatic lesions. Complete blood cell count and liver function test results were normal.

Two weeks later the patient developed jaundice. Follow-up computed tomography demonstrated a new mass in the head of the pancreas. Endobronchial biopsy of the left lower lobe mass revealed an undifferentiated small-cell carcinoma (eFigure 2). The patient declined chemotherapy and was lost to follow-up.

Metastases to the iris may appear as nodules, iridocyclitis, rubeosis iridis, iris atrophy, hypopyon, hyphema, or secondary glaucoma.5 Metastatic lesions characteristically appear as grayish white, yellow, orange, or brown, gelatinous, vascularized nodules on the surface of the iris.6

This case is unusual in that the initial presentation was uveitis with pseudokeratic precipitates, presumably secondary to tumor shedding. Also, the tumor was within the iris rather than on it. There was no known history of cancer, and chest radiography was read as unremarkable. Diagnosis was made only after biopsy of the iris tumor, which suggested a pulmonary malignancy, and pulmonary lesions were seen on subsequent computed tomography. Retrospective re-review of the chest radiograph revealed no lung nodules; however, fullness of the left hilum was noted. Had this been appreciated earlier, a computed tomographic scan of the chest might have revealed cancer prior to the iris biopsy.

Correspondence: Dr Goldstein, Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, 1855 W Taylor St, M/C 648, Chicago, IL 60612 (debrgold@yahoo.com).

Financial Disclosure: None reported.

Nelson  CCHertzberg  BSKlintworth  GK A histopathologic study of 716 unselected eyes in patients with cancer at the time of death. Am J Ophthalmol 1983;95 (6) 788- 793
PubMed Link to Article
Stephens  RFShields  JA Diagnosis and management of cancer metastatic to the uvea: a study of 70 cases. Ophthalmology 1979;86 (7) 1336- 1349
PubMed Link to Article
Shields  JAShields  CLKiratli  Hde Potter  P Metastatic tumors to the iris in 40 patients. Am J Ophthalmol 1995;119 (4) 422- 430
PubMed
Wyzinski  PRootman  JWood  W Simultaneous bilateral iris metastases from renal cell carcinoma. Am J Ophthalmol 1981;92 (2) 206- 209
PubMed
de Rivas  P Marti  TAndreu  DCarreras  MQuintana  M Metastatic bronchogenic carcinoma of the iris and ciliary body. Arch Ophthalmol 1991;109 (4) 470
PubMed Link to Article
Shields  CLShields  JAGross  NESchwartz  GPLally  SE Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104 (8) 1265- 1276
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Iris mass in the left eye. A, In the left eye, the nasal iris mass deep to the iris stroma with overlying metastatic seeding appearing as pseudokeratic precipitates (arrows). B, Gonioscopy showing the mass and aggregates of tumor cells shed into the angle (arrows). C, Ultrasound biomicroscopy of the iris mass showing the multicystic nature of the mass and the lack of scleral invasion. Arrows indicate cystic spaces within the mass. D, Anterior view of the entire iris mass.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Histopathology. A, Photomicrograph showing the iris stroma replaced by small cells, hyperchromatic nuclei, and scant cytoplasm (hematoxylin-eosin, original magnification ×10). Inset, Note mitotic figures within the tumor infiltrate (arrow) (hematoxylin-eosin, original magnification ×40). B, Computed tomographic scan showing the left perihilar soft tissue mass (arrow).

Graphic Jump Location

Tables

References

Nelson  CCHertzberg  BSKlintworth  GK A histopathologic study of 716 unselected eyes in patients with cancer at the time of death. Am J Ophthalmol 1983;95 (6) 788- 793
PubMed Link to Article
Stephens  RFShields  JA Diagnosis and management of cancer metastatic to the uvea: a study of 70 cases. Ophthalmology 1979;86 (7) 1336- 1349
PubMed Link to Article
Shields  JAShields  CLKiratli  Hde Potter  P Metastatic tumors to the iris in 40 patients. Am J Ophthalmol 1995;119 (4) 422- 430
PubMed
Wyzinski  PRootman  JWood  W Simultaneous bilateral iris metastases from renal cell carcinoma. Am J Ophthalmol 1981;92 (2) 206- 209
PubMed
de Rivas  P Marti  TAndreu  DCarreras  MQuintana  M Metastatic bronchogenic carcinoma of the iris and ciliary body. Arch Ophthalmol 1991;109 (4) 470
PubMed Link to Article
Shields  CLShields  JAGross  NESchwartz  GPLally  SE Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104 (8) 1265- 1276
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

77,674 Views
2 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs