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Choroidal metastasis arising from esophageal adenocarcinoma

Published:August 22, 2017DOI:https://doi.org/10.1016/j.jcjo.2017.06.014
      The majority of choroidal metastasis in the eye arises from primary tumours of the breast, lung, prostate, and gastrointestinal tract primary sites but rarely from the esophagus.
      • Buskens C.J.
      • Tan H.S.
      • Hulscher J.B.
      • de Smet M.D.
      • van Lanschot J.J.
      Adenocarcinoma of the esophagus with choroidal metastasis.
      • Eliott D.
      • Salehi-Had H.
      • Plous O.Z.
      Adenocarcinoma of the esophagus presenting as choroidal metastasis.
      • McCannel C.A.
      2015-2016 Basic and Clinical Science Course (BCSC): Retina and Vitreous Section 12.
      • Morris P.G.
      • Oda J.
      • Heinemann M.H.
      • Ilson D.H.
      Choroidal metastases from esophageal adenocarcinoma responding to chemotherapy with cisplatin and irinotecan.
      Recently, a few cases have been reported that may coincide with the increasing incidence of Barrett’s esophagus and associated esophageal adenocarcinoma.
      • Buskens C.J.
      • Tan H.S.
      • Hulscher J.B.
      • de Smet M.D.
      • van Lanschot J.J.
      Adenocarcinoma of the esophagus with choroidal metastasis.
      • Eliott D.
      • Salehi-Had H.
      • Plous O.Z.
      Adenocarcinoma of the esophagus presenting as choroidal metastasis.
      • He Q.
      • Li J.D.
      • Huang W.
      • Zhu W.C.
      • Yang J.Q.
      Metabolic syndrome is associated with increased risk of Barrett Esophagus: a meta-analysis.
      We present a case of esophageal adenocarcinoma that initially presented with signs and symptoms of choroidal metastasis.

      Case Description

      A 72-year-old Caucasian male presented with left eye peripheral vision loss, accompanied by occasional photopsias and mild intermittent eye pain. The patient had a remote history of enucleation of his right eye secondary to a traumatic injury. The patient’s review of systems was negative except for longstanding gastroesophageal reflux that was controlled by ranitidine.
      Ophthalmologic examination of the left eye revealed a superonasal choroidal mass with associated serous retinal detachment (Fig. 1). B-scan ultrasonography of the left eye demonstrated a choroidal lesion measuring 4.82 mm by 14.37 mm (Fig. 2). A-scan demonstrated moderate internal reflectivity. Systemic work-up and imaging were initiated, and the patient was referred to oncology.
      Fig. 1
      Fig. 1Colour fundus photograph of the left eye revealing a choroidal mass with associated serous retinal detachment.
      Fig. 2
      Fig. 2B-scan of the left eye showing that the lesion measured 4.82 and 14.37 mm on transverse 9 o’clock (A) and longitudinal 11 o’clock (B) scans.
      Magnetic resonance imaging of the brain revealed multiple brain lesions, and contrast-enhanced computed tomography of the chest revealed a distal esophageal mass that extended to the gastroesophageal junction. Subsequent esophagogastroduodenoscopy showed a 75% obstructing mass. Biopsies displayed moderately differentiated adenocarcinoma and amplification of the ERBB2 (HER2/neu) gene.
      Ultimately, the patient was not deemed to be a good surgical candidate, and palliative whole-brain, orbit, and eventual spine external beam radiation therapy were pursued. Subsequently, the patient underwent treatment with capecitabine and trastuzumab.

      Discussion

      The majority of metastases arise from breast or lung primaries, but choroidal metastases arising from gastrointestinal tract tumours are less common.
      • Buskens C.J.
      • Tan H.S.
      • Hulscher J.B.
      • de Smet M.D.
      • van Lanschot J.J.
      Adenocarcinoma of the esophagus with choroidal metastasis.
      • Eliott D.
      • Salehi-Had H.
      • Plous O.Z.
      Adenocarcinoma of the esophagus presenting as choroidal metastasis.
      • McCannel C.A.
      2015-2016 Basic and Clinical Science Course (BCSC): Retina and Vitreous Section 12.
      • Morris P.G.
      • Oda J.
      • Heinemann M.H.
      • Ilson D.H.
      Choroidal metastases from esophageal adenocarcinoma responding to chemotherapy with cisplatin and irinotecan.
      Nevertheless, choroidal metastases from the lower gastrointestinal tract predominate among the reported cases, whereas metastases from esophageal sources prove to be quite rare according to the literature.
      • Buskens C.J.
      • Tan H.S.
      • Hulscher J.B.
      • de Smet M.D.
      • van Lanschot J.J.
      Adenocarcinoma of the esophagus with choroidal metastasis.
      • Eliott D.
      • Salehi-Had H.
      • Plous O.Z.
      Adenocarcinoma of the esophagus presenting as choroidal metastasis.
      • Morris P.G.
      • Oda J.
      • Heinemann M.H.
      • Ilson D.H.
      Choroidal metastases from esophageal adenocarcinoma responding to chemotherapy with cisplatin and irinotecan.
      Both metastases to the choroid from squamous cell carcinoma and adenocarcinoma of the esophagus have been reported in the literature, with the first published account occurring in 1970.
      • Mullaney J.
      Squamous cell carcinoma of the oesophagus with choroidal metastasis.
      • Rosa Jr, R.
      2015-2016 Basic and Clinical Science Course (BCSC): Ophthalmic Pathology and Intraocular Tumors Section 4.
      In 2003, there were only 3 published accounts of choroidal metastasis arising from adenocarcinoma. According to an American Society of Clinical Oncology 2010 article, “esophageal carcinomas metastasizing to the uveal tract are extremely rare.”
      Because of its highly vascular nature, it is possible that virtually any cancer can spread hematogenously to the choroid. Metastatic tumours spreading to the choroid manifest clinically with progressive visual disturbances, photopsias, and floaters or are completely asymptomatic and diagnosed incidentally as yellow and possibly multilobulated structures on fundoscopic examination.
      • Morris P.G.
      • Oda J.
      • Heinemann M.H.
      • Ilson D.H.
      Choroidal metastases from esophageal adenocarcinoma responding to chemotherapy with cisplatin and irinotecan.
      • Medscape
      The appearance of esophageal adenocarcinoma metastasis to the choroid is typically no different from that of the lung and breast on fundoscopy and will give similar reflectivity on A-scan ultrasonography. As seen in our patient, echographically, metastatic choroidal lesions have irregular boarders, medium-high irregular internal reflectivity, and relatively little internal vascularity.
      • Medscape
      Compared with uveal melanomas, choroidal metastasis lesions typically exhibit a higher incidence of associated retinal detachments.
      • Medscape
      Esophageal adenocarcinoma arises from columnar metaplasia of the distal third of the esophagus (Barrett’s esophagus), often in patients diagnosed with chronic GERD and obesity.
      • He Q.
      • Li J.D.
      • Huang W.
      • Zhu W.C.
      • Yang J.Q.
      Metabolic syndrome is associated with increased risk of Barrett Esophagus: a meta-analysis.
      The malignancy has a strong male predominance (7–10×) and has a mortality rate of 85%. In recent years, there has been an increase in the number of cases of adenocarcinoma of the esophagus, associated with the increasing prevalence of GERD and Barrett’s esophagus.
      • He Q.
      • Li J.D.
      • Huang W.
      • Zhu W.C.
      • Yang J.Q.
      Metabolic syndrome is associated with increased risk of Barrett Esophagus: a meta-analysis.
      As such, physicians involved in treating these common conditions should consider this potential, although rare, ocular manifestation as the presenting symptoms of metastatic disease.

      Disclosure

      The authors have no proprietary or commercial interest in any materials discussed in this article.

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