|Year : 1968 | Volume
| Issue : 2 | Page : 72-75
A case of metastatic carcinoma of choroid from breast
Eye Infirmary, Medical College Hospitals, Calcutta, India
|Date of Web Publication||22-Dec-2007|
S P Das
Eye Infirmary, Medical College Hospitals, Calcutta
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Das S P. A case of metastatic carcinoma of choroid from breast. Indian J Ophthalmol 1968;16:72-5
Cancer in general is quite common, but metastatic intraocular tumour is very rare. BEDELL (1943) collected 250 cases of choroidal metastasis from the literature and remarked, "few ophthalmologists ever encounter more than one case in their private practice". Carcinoma metastatises in the uvea much more frequently than sarcoma or malignant melanoma. This is explained by REESE (1963) as due to much higher incidence of carcinoma.
Only one case of metastatic carcinoma of choroid from breast cancer was detected in the Eye Infirmary, Medical College Hospitals, Calcutta over a period of 9 years (1950-1958).
| Case report|| |
N.R., a 38-year old female, was admitted on 15th April, 1958 in the Eye Infirmary, Medical College Hospitals, Calcutta, with the presenting complaint of marked fall in vision in the right eye within a week. She gave a history that she had mastectomy done for her right breast in another hospital eight months back and she was treated with deep X-ray therapy for her breast cancer six months back.
On admission, the visual acuity in the right eve was 3/60 which could not be improved with lenses. On fundus examination of the right eye there was a solid opaque detachment of the retina in the posterior region of the eye. The raised portion of the retina had a pinkish colour. There was slight hemorrhage and pigmentary change over the involved area. On repeated examinations, no hole could be detected in the fundus. The remainder of the fundus showed no significant change. Tension was 35 mm. Hg. (Schiotz). The detached retina was found dark on transillumination.
The left eve was entirely normal and the vision was 6/6 without glass. Physical examination at the time of admission showed entirely negative findings except the marks of mastectomy operation over the right side of the body. X-ray of chest was done and no metastasis could be detected.
Laboratory Studies were as follows:
Wassermann reaction and Kahn test were negative. Tuberculin tests in 1/100,000 and 1/10,000 were negative. Blood sugar was 80 mg. per cent.
Haemogram : Leukocytes, 6820 per c mm (neutrophils 70 per cent; lymphocyte 25 per cent; eosinophils 3 per cent; monocyte 2 per cent); haemoglobin 78 per cent; erythrocytes 3,880,000 per c. mm. The urine showed no gross abnormality.
The case was then presented to the hospital board. The final opinion of the board was that the lesion was a secondary detachment of choroid due to metastatic tumour coming from primary site of breast carcinoma.
The retinal detachment increased gradually and on 1st June, the visual acuity was reduced to perception of light only. X-ray of chest was repeated and this time also there was no sign of metastasis.
On 3rd June, 1958, the patient was having severe pain in the right eye and the tension was then 70 mm. Hg. (Schiotz). On 4th June, 1958, the right eye had to be enucleated for severe pain. The enuclented right eye-hall was sent for histopathological examination.
Gross : The specimen of right eye was of normal external appearance. On bisecting the eye, there was a diffuse mas in the right half of the choroid making it thickened. The posterior limit of the mass was up to the optic nerve. The mass was more prominent in the posterior portion of the choroid. There was a small amount of serous fluid between the tumour and the detached retina. The mass was soft in feel and pale pink in colour. The margins of the mass were irregular but it appeared to be well defined. The remainder of the eye showed no gross changes.
Microscopic : [Figure - 1],[Figure - 2],[Figure - 3]
The neoplasm in the choroid showed the picture of alveolar adenocarcinoma. The alveoli were of various shapes and sizes and consisted of round or polygonal cells. The cells had large vesicular nuclei with indistinct cytoplasm. Mitosis were abundant. There was no pigment in the tumour cells. The stroma between the alveoli consisted of dense fibrous tissue. Small multiple hemorrhages were present in the tumour indicating degenerative changes. The tumour extended up to the optic nerve, but the nerve itself was not invaded by the tumour cells. The tumour was found in the right half of the choroid only. Other tissues of the eye were not invaded by the tumour cells.
The patient was asked to come to the hospital at the interval of 10 days. On 19th October, 1958, the patient died from generalised metastasis at home.
| Discussion|| |
Metastatic carcinoma of the uveal tract is very rare. Only the present case of uveal metastatic tumour was detected in the Eye Infirmary Medical College Hospitals, Calcutta, over a period of nine years, although carcinoma in general is quite common as elsewhere. According to GIRL (1939) this is due to fact that metastasis are blood borne and that the ophthalmic artery arises from the internal carotid artery at almost right angles and, therefore, cancer cells in the blood stream are swept past the ophthalmic artery and deposited in the brain and meninges. STALLARD (1933) estimated the incidence of metastatic carcinoma of the eye to 1: 140,000 from the records of Royal London Ophthalmic Hospital Clinic. GODTFREDSEN (1944) in the analysis of 8,712 carcinoma patients noted only 6 cases with metastasis to the choroid. In his series he found 1,287, patients with carcinoma of the breast, of which 2 had choroidal metastasis. DUKE-ELDER (1940) suggested that metastases to the eye may be more frequent than would appear from the literature. He pointed out that in most of the cases the patient is almost gravely ill, sometimes more or less in moriband state and the clinical picture is dominated by the general condition while the patient himself or herself does not notice what may be a minor defect in one eye.
The posterior uvea is said to be more affected than the anterior uvea (DUKE-ELDER, 1940); REESE, 1963), DUKE-ELDER), reasons that majority of the embodi would naturally pass through 20 short posterior ciliary arteries than the two long posterior or the five or more anterior arteries. Another reason may be that carcinomatous metastasis is very rare in muscle, and ciliary body is composed of muscle tissue. SANDERS (1938) observed that choroidal involvement was more common than that of the iris and ciliary body in the ratio of 156: 17. In LEMOINE AND McLEOD's series (1936) of 229 cases of uveal metastasis, the choroid was involved in 156. In the present case, both macroscopically and microscopically the choroid alone was found to be involved by the tumour mass.
CORDES (1944) in his review of literature found that the age group most commonly affected was between the ages of 40 and 49 years and lie could find only isolated cases which had been reported in patients younger than 30 years or older than 70 years. The present case was 38 years of age.
The left eye is said to be most frequently affected than the right (DUKE-ELDER, 1940; REESE, 1963). But in the present case the primary tumour was in the right breast and the metastatic umour was in the right side of the choroid of the right eye.
The site of primary tumour is mostly the breast (DUKE-ELDER, 1940; REESE, 1963). USHER (1923 and 1926) gave the figure as 72 per cent, COHEN (1937) 70 per cent and GIRL (1939) 60 per cent. The incidence of carinoma of breast particularly the female breast as noted in this institution is as common as in other parts of the World, but only the present case of uveal metastasis from carcinoma of female breast was noted during the last nine years. SCHINZ (1939) noted only 3 cases of ocular metastasis in a series of 536 cases of breast carcinoma. The comparatively higher incidence of metastasis to the eye from primary breast cancer has been explained by LEMOINE AND McLEOD (1936) on the postulation that cancer cells of the breast have a special affinity for tiveal tissue. REESE (1963) thinks that in most cases of cancer, some of the tumour cells enter the blood stream whereas only rarely do the cells remain viable and grow at the implanted sites; the ability of various types of cancer cells to remain viable, away from their primary sites, varies greatly and may vary from time to time according to certain inconstant factors like resistance of the host; the cells of carcinoma of the breast are among the most rugged of all cancer cells and have the ability to survive and even propagate under circumstances unfavourable to other cancer cells.
The interval between the diagnosis of primary tumour and the detection of metastatic tumour in the uvea vary from weeks to years (REESE, 1963). In the present case, the interval was 8 months.
The treatment of choice in metastatic tumour of the eye is irradiation, because the lungs have already been involved and there must be implanted foci elsewhere particularly in the brain indicating the worst prognosis, at least so far as the life is concerned (DUKE-ELDER, 1940; REESE, 1963). In the present case, enucleation of the eye had to be performed because of the severe pain in the eye following secondary glaucoma.
| Summary|| |
A case of metastatic carcinoma of the choroid from primary site of breast is reported. The primary tumour in the breast was on the right breast and the metastatic tumour in the choroid was in the right side of the choroid of the right eye.
| References|| |
BEDELL A. J.: Bilateral Metastatic Carcinoma of the Choroid. Arch. of Ophth. (Chicago) 30, 2.5 (1943).
COHEN M.: Bilateral Metastatic Carcinoma of Choroid, Report of a case. Arch. of Ophth. (Chicago) 1S. 604, (1937).
CORDES F. C.: Bilateral Metastatic Carcinoma of the Choroid with Z-ray Therapy to one eye, Amer. J. Ophtli. 27, 1.355 (1944).
DUKE-ELDER W. S.: Text-hook of Ophthalmology Vol. III (1940) Henry Kimpton, London p. 2522.
GIRL D. V. as quoted in Schwiz med. Wehnochr. 20, 1069 (1939).
GODTFREDSEN E, as quoted in 8 Acta Ophthal. 22, 394 (1944).
LEMOINE A. N. and McLEOD J. Bilateral Metastatic Carcinoma of the Choroid. Successful Roentgen Treatment of one Eye. Arch. of Ophth 16, 804, (1936).
REESE A. B. Tumours of the Eye (second edit. 1963) Paul Hoeber lose. New York p. 514.
SANDERS T. E. Metastatic Carcinoma of the Iris. Amer. J. Ophth 21, 646 (1938).
SCHINZ H. R. as quoted in 8 Mill. Monats. of Augenh. 103, 425 (1939).
STALLARD H. B, as quoted in 4. Proc. Roy. Soc. Med. 26, 1042 (1933).
USHER C. H. Frequency of Metastatic Carcinoma of the Choroid Brit. J. Ophth. 10. 180 (1926).
[Figure - 1], [Figure - 2], [Figure - 3]