CHOROIDAL METASTASIS INDICATIVE OF DISSEMINATED BRONCHOPULMONARY CANCER: TWO CASES

Hind Janah, Meriem Choubi, Hasna Jabri, Wiam El Khattabi and Hicham Afif. Respiratory Diseases Department, “20 Aout 1953” Hospital, Casablanca, Morocco. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


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A thoracic radio showed a dense, inhomogeneous opacity with a left hilar projection at the outer boundary of the parenchymal tract. At admission, dyspneic patient, in poor general condition (WHO score of 3). The pleuropulmonary examination is more or less normal and the patient presents with left diffuse percussion left pain, heterogeneous and painful hepatomegaly, cervical adenopathy's and Axillary lesions. Thoracic CT (Fig. 1) demonstrated a left hilar tissue process associated with pleural thickening with secondary bone and hepatic sites. Soft bronchoscopy shows an infiltrative stenosis of the upper left lobar, with thickening of the lobar spur.

Figure 1:
The bronchial biopsy of tumor infiltration concluded that the adenocarcinoma was not very differentiated and infiltrating. An extended checkup showed secondary left-sided ocular tissue lesions without other cerebral parenchyma abnormalities at the cerebral CT, an ultrasound appearance compatible with multiple secondary hepatic nodules. The patient died just after confirmation of his bronchogenic carcinoma.

Case 2:-
The patient is 33 years old, construction worker, chronic smoker (10 pack per day), hashish and cannabis consumer. For the past month, the patient has had severe progressive frontal headache associated with a progressive pain in the right eye, which was complicated by a significant decrease in visual acuity 15 days later, all evolving in a context of a decline in the general state of health. The ocular ultrasound showed a total detachment of the retina in the right eye, of secondary aspect, probably in relation with choroidal metastases. A thoracic radio showed a coarse triangular homogeneous dense opacity in the upper third of the left lung, associated with a homogeneous dense opacity with right lateral projection. At admission, the patient is in good general health condition (WHO score 1), presents a right palpebral ptosis. The pleuro-pulmonary examination is unusual as well as the rest of the somatic examination. Thoracic CT (Fig. 2) showed a right parenchyma tissue process classified as stage 4, with a swollen aspect of the left adrenal, which may be secondary. The cranio-orbital CT (Fig. 3) shows two subcortical tissue-like hypodense nodular lesions parietal left and right frontal, which are enhanced annular after injection of PDC 14/17 mm and 15/12 mm, associated with peri-lesions edema without mass effect on the median structures. On the orbital stage: right vitreous is filled by a heterogeneous dense material with a homolateral detachment, thickening of the two optical nerves. Soft bronchoscopy has objectified a thickened and infiltrated upper lobar spur with tumor-like infiltration of the upper lobar with multiple tumorous buds bleeding spontaneously and tumor biopsies and the upper lobar spur concluded the existence of a neuroendocrine tumor. Right brain and eye radiotherapy was initiated, but the patient died before starting chemotherapy. Breast and lung cancer cases account for more than two-thirds of primary tumors. [3]. In the series of Kreusel et al. [4], in 84 patients with bronchopulmonary carcinoma, the prevalence of choroidal metastases was estimated to be 7.1%.
The hematogenous dissemination of the primary cancer, especially by the posterior ciliary arteries, explains the preferential localization of these metastases in the postero-superior-lateral part of the choroid, hyper-vascularized part. The presence of metastasis of the iris, ciliary bodies, optic nerve and appendages is sometimes associated with that of choroidal metastases. [5] Ocular metastases do not depend on the histological type of bronchial cancer [6.7]. Numerous observations of adenocarcinoma and bronchial carcinoid reported no significant difference in ophthalmology. [8].
Symptoms of the patient with intraocular metastasis are largely dependent on the location of the metastasis. In cases of involvement of the posterior part of the uvea, symptoms include decreased vision, decreased visual field, photopsy and / or floaters [9]. There may be pain if the tumor invades the ciliary nerves or if secondary glaucoma occurs. In cases of involvement of the anterior part of the uvea, the symptoms include a decrease in vision, a visible mass, redness to the eye and photophobia. Pain may also be present if there is secondary iritis or secondary glaucoma [9]. The diagnosis is often made by the fundus of the eye, showing prominent, yellowish, homogeneous lesions, sometimes responsible for a serious retinal detachment. In case of diagnosis difficulty, eye ultrasound can confirm the diagnosis by showing a dome tumor lesion with, sometimes, wavy or umbilical surface, as well as the angiography, which objectifies a mask effect with diffuse hypo fluorescence in early times and progressive hyper-fluorescence in later times [10].
Treatment of choroidal and papillary metastases is based on radiotherapy and / or chemotherapy [11.12]. Overall response rates reached 80% of the cases [1.12]. The visual function is improved in one third of the cases, slightly improved or stabilized in one third of the cases [4.13]. Complications are rare, observed in 5% of the cases. These include cataracts, radiation-induced neuropathy, radiation retinopathy and neo-vascular glaucoma [13].

Conclusion:-
Ocular metastases may be inaugural of bronchial cancer, but the overall prognosis is most often pejorative, since there are usually other visceral metastases. However, early diagnosis could be accompanied by an improved life expectancy.