Choroidal and orbital metastases from thyroid cancer

Malignancies with a tendency to metastasize to the eyelid or ocular structures

Metastatic tumors to the eye and eyelid are generally seen in patients with disseminated metastases in the setting of advanced disease. Occasionally, they can present as the first sign of occult malignancy. The choroid is the most common site of intraocular metastases secondary to its dense vascular supply. Similar to the eye, metastatic tumors to the eyelid can present with a variety of clinical findings and are most often seen in patients with a known history of cancer. The most common skin malignancy that can spread to ocular structures is cutaneous melanoma, whereas the most common noncutaneous malignancy is breast cancer followed by lung cancer. In pediatric patients, metastatic disease to the eye is rare and can be seen in neuroblastoma and Ewing sarcoma. The overall prognosis of metastatic lesions involving the eye and eyelid is typically poor, with a mean survival of months. Ophthalmologists play an important role in the diagnosis of metastatic disease of the eye and eyelid; therefore, it is imperative for patients to undergo a complete ophthalmic examination and systemic workup if they have new-onset vision changes and a known history of cancer. Early diagnosis and management with systemic and local therapies can maximize quality of life and preserve vision.

Orbital Radioiodine Uptake in Epithelial Conjunctival Inclusion Cyst on Scintigraphy in a Patient With Differentiated Thyroid Cancer

ABSTRACT

Abnormal focal accumulation of 131I is generally a reliable indicator of differentiated thyroid cancer metastases. However, many examples of false-positive 131I uptake were reported but only a few with orbital accumulation of radioiodine. We report the case of a 68-year-old woman with differentiated thyroid cancer who underwent thyroid remnants ablation with radioiodine. A focus of considerable 131I uptake corresponding to a small, periorbital tumor was detected on posttherapy whole-body 131I scan and head SPECT/CT. The tumor was surgically removed, and pathology revealed a conjunctival inclusion cyst with no features of thyroid tissue. Orbital 131I uptake was not detected on follow-up scans.

Choroidal sarcoid granuloma: a case report and review of the literature

BACKGROUND

Choroidal sarcoid granulomas are often diagnosed in patients without a prior history of sarcoidosis. They are often mistaken for choroidal metastasis, choroidal nevi, amelanotic choroidal melanomas, and uveal lymphomas; however, are easily treatable when accurately identified.

OBSERVATIONS

We searched PubMed, Medline, and Scopus for English-Language case reports published before September 2021. Additionally, we presented a case of a 45-year-old woman with a right-sided amelanotic choroidal mass whose diagnosis was delayed by a COVID-19 infection. Of the 26 cases reported in the literature, 46% were female, 38% were African American, and 19% had bilateral involvement. There was a mean age of 42.15 years and a mean follow-up period of 27 months. The most common complaint was of a progressive, painless blurring of vision, and only five patients had been previously diagnosed with sarcoidosis. The choroidal granulomas were typically described as yellow lesions, single or multiple, found temporal to or at the macula. Most patients were administered steroids, with 69% receiving them systemically, 5% topically, and 8% locally with a triamcinolone injection. All patients reported symptomatic improvement at their final follow-up with resolution of the mass in 65% of patients and improved visual acuity in 76%.

CONCLUSION

Primary testing including fundoscopy, fluorescein angiography, fundus autofluorescence, A/B-scan, and OCT are useful for diagnosis, differentiation from other choroidal lesions, and monitoring treatment response. Steroids are a mainstay of treatment for sarcoidosis and are effective at treating choroidal granulomas. Therefore, early recognition and diagnosis of choroidal granulomas is imperative as treatment can be curative and sight-sparing.

Choroidal metastases as initial manifestation of a papillary thyroid carcinoma: A case report

The case is presented of 78 year-old who consulted due to decreased visual acuity in right eye for several months. Indirect ophthalmoscopy revealed an orange-yellow coloured choroidal mass at the posterior pole, without retinal detachment. Computed tomography showed a thyroid mass in the isthmus, as well as multiple pulmonary nodules and metastatic foci. The findings of transbronchial lung biopsy were compatible with metastatic dissemination. Fine-needle aspiration biopsy of thyroid nodule was diagnostic for a with columnar cell variant of papillary thyroid cancer. Positron emission tomography confirmed papillary thyroid carcinoma. The patient underwent total thyroidectomy and radioactive iodine therapy.

Uveal metastasis in 1111 patients: Interval to metastasis and overall survival based on timing of primary cancer diagnosis

Purpose

To evaluate interval between primary cancer diagnosis and uveal metastasis and assess survival outcomes based on whether the primary cancer was diagnosed before or after uveal metastasis.

Methods

In this retrospective analysis, all patients with uveal metastasis evaluated on the Ocular Oncology Service, Wills Eye Hospital, Philadelphia, PA, USA between February 1, 1974 and June 1, 2017 were included. Features and outcomes based on timing of primary cancer diagnosis, whether before or after diagnosis of uveal metastasis, were assessed.

Results

A total of 2214 uveal metastases were diagnosed in 1310 eyes of 1111 consecutive patients. Primary cancer was known prior to uveal metastasis in 742 patients (67%) and not known in 369 (33%). Of those not known, the primary cancer was later found in 192 patients (17%) and never found in 177 patients (16%). For those with known primary cancer, mean interval from primary cancer diagnosis to uveal metastasis was 5.2 years with differences in primary sites of gastrointestinal (2.1 years, p = 0.003), lung (2.2 years, p < 0.001), breast (6.5 years, p < 0.001), and thyroid (13 years, p < 0.001). By Kaplan-Meier analysis, the 5-year overall survival showed no difference between patients with primary cancer found before (28%) vs after (20%) vs never found (33%), relative to uveal metastasis.

Conclusion

Of 1111 patients with uveal metastasis, early-onset uveal metastases were found with lung and gastrointestinal tract cancers, whereas late-onset metastases were found with breast and thyroid cancers. Overall survival did not vary on whether the primary tumor was diagnosed before, after, or never found, relative to uveal metastasis.

Orbital Radioiodine Uptake on Scintigraphy in a Patient with Thyroid Cancer

BACKGROUND

Orbital radioiodine uptake in patients with thyroid cancer is very uncommon with only a few reported cases, most of them being metastasis. The accumulation of ¹³¹I in nonthyroidal tissues and body fluids can lead to false-positive results in scintigraphy, which are sometimes difficult to differentiate from true metastases.

CASE REPORT

A post-therapy ¹³¹I whole-body (WBI) scintigraphy in an asymptomatic 57-year-old female with papillary thyroid carcinoma (PTC) previously treated with total thyroidectomy and 6 ablative radioiodine doses showed a focal uptake in the right eyeball region. The lesion, placed in the orbital space, was surgically removed, and histology revealed a conjunctival inclusion cyst.

DISCUSSION

Ocular and orbital metastases from thyroid cancer, as well as some non-neoplastic disorders or contamination, are possible causes for ¹³¹I uptake in the orbital region in scintigraphy. Conjunctival inclusion cyst is a condition associated with incidental ¹³¹I uptake that had not been reported before and should be ruled out as a non-metastatic cause of orbital radioiodine uptake in patients with PTC.

A Case of Radioactive Iodine Uptake Found in Artificial Eye

Radioactive iodine (RAI) therapy is widely used as an adjunctive treatment in patients with differentiated thyroid cancer. Although I has high avidity in the functioning thyroid, and in differentiated thyroid cancer lesions, physiological and nonspecific uptake of I in healthy or benign tissue may contribute to false-positive findings on an I scan. Here, we present an interesting image of RAI uptake in the eye region post-RAI treatment, which has been identified as tear contamination in the artificial eye.

New concepts in the diagnosis and management of choroidal metastases

The most frequent site of ocular metastasis is the choroid. The occurrence of choroidal metastases has increased steadily due to the longer survival of metastatic patients and the improvement of diagnostic tools. Fundoscopy, ultrasonography, and fluorescein angiography are now complemented by indocyanine green angiography and optical coherence tomography. Choroidal tumor biopsy may also confirm the metastatic nature of the tumor and help to determine the site of the primary malignancy. There is currently no consensus on the treatment strategy. Most patients have a limited life expectancy and for these complex treatments are generally not recommended. However, recent advances in systemic therapy have significantly improved survival of certain patients who may benefit from an aggressive ocular approach that could preserve vision. Although external beam radiation therapy is the most widely used treatment, more advanced forms of radiotherapy that are associated with fewer side effects can be proposed in select cases. In patients with a shorter life expectancy, systemic therapies such as those targeting oncogenic drivers, or immunotherapy can induce a regression of the choroidal metastases, and may be sufficient to temporarily decrease visual symptoms. However, they often acquire resistance to systemic treatment and ocular relapse usually requires radiotherapy for durable control. Less invasive office-based treatments, such as photodynamic therapy and intravitreal injection of anti-VEGF, may also help to preserve vision while reducing time spent in medical settings for patients in palliative care. The aim of this review is to summarize the current knowledge on choroidal metastases, with emphasis on the most recent findings in epidemiology, pathogenesis, diagnosis and treatment.

Intraocular metastasis of medullary thyroid carcinoma investigated by transscleral fine-needle aspiration. A case report and review of the literature

Medullary thyroid carcinoma occurs in a sporadic setting and may also be inherited in an autosomal dominant fashion, which is related with germline mutations of the RET gene. Metastases are often present at the time of a diagnosis-most frequently within the cervical lymph nodes, followed by the liver, lungs, and bones. Intraocular metastases are extremely rare. We present a case of choroidal metastasis as a first presentation of disease progression in a patient with Multiple Endocrine Neoplasia type 2A syndrome (MEN2A) who had undergone thyroidectomy 33 years earlier for medullary thyroid carcinoma. Transscleral aspirate smears showed necrotic malignant cells suggesting amelanotic malignant melanoma or metastatic neuroendocrine tumor. The similar cells were found on parotid fine-needle aspiration. The diagnosis of metastatic medullary thyroid carcinoma was definitely established on the parotidectomy specimen based on its characteristic morphological and immunohistochemical features. This is the only case of ocular metastasis from medullary thyroid carcinoma found in the English literature that was investigated by pathological examination using transscleral fine-needle aspiration biopsy.

Thyroid-associated orbitopathy in patients with thyroid carcinoma: A case report of 5 cases

RATIONALE

Thyroid-associated orbitopathy (TAO) is most often seen in patients with autoimmune thyroid disease. Data about TAO occurred in patients with thyroid carcinoma are rare. We give a report of 5 patients to present the clinical characteristics, treatment, and prognosis of this type of case.

PATIENT CONCERNS

Five thyroid carcinoma patients presented with orbitopathy. Among them, two patients (patient 1 and 4) were hyperthyroid and TSH receptor antibody (TRAb) positive, two patients (patient 3 and 5) were euthyroid and displayed slightly elevated TRAb titres, one patient (patient 2) was euthyroid and TRAb negative.

DIAGNOSES

They were diagnosed as thyroid carcinoma and TAO.

INTERVENTIONS

Patient 1 underwent total thyroidectomy, intravenous glucocorticoids (GCs) therapy, orbital decompression surgery and oral GCs therapy. Patient 2 and 3 only received total thyroidectomy. Patient 4 received sub-total thyroidectomy and oral GCs therapy. patient 5 didn't received thyroidectomy and underwent intravenous GCs therapy for 2 courses.

OUTCOMES

Patient 1,2,3 showed an improvement of TAO at the final follow-up. Patient 4,5 showed no improvement of TAO at the final follow-up.

LESSONS

When TAO present in patients with thyroid nodules, the possibility of thyroid carcinoma should be considered, and the nature of these nodules should be carefully evaluated. In some patients with thyroid carcinoma and TAO, the remission of TAO can be seen post total thyroidectomy. But for other patients, besides thyroidectomy, an adequate dose and course of intravenous GCs treatment and even ocular surgery are also needed.

Choroidal metastases: origin, features, and therapy

The choroid is the most common ocular site for metastatic disease, owing to abundant vascular supply. The primary cancers that most commonly lead to choroidal metastases include breast cancer (40-47%) and lung cancer (21-29%). Bilateral, multifocal metastases are most often secondary to breast cancer, whereas unilateral, unifocal metastasis are more commonly found with lung cancer. The treatment of choroidal metastasis depends on the systemic status of the patient and number, location, and laterality of the choroidal tumors. Treatment options include observation in patients with poor systemic status or those with resolved or asymptomatic disease; systemic chemotherapy, immunotherapy, hormone therapy, or whole eye radiotherapy if the metastases are active, multifocal and bilateral; plaque radiotherapy, transpupillary radiotherapy, or photodynamic therapy for active, solitary metastasis; and enucleation for those with blind painful eye. A database search was performed on PubMed, using the terms “choroidal metastasis,” or “choroidal metastases,” in combination with terms such as “treatment,” “features,” or “diagnosis.” Relevant articles were extracted and reviewed.

Choroidal Metastasis as an Unusual Initial Presentation of Transitional Cell Carcinoma of the Kidney

Metastases of transitional cell carcinoma (TCC) of the renal pelvis to the eye is a very rare event, as only one previous case has been described in the literature. We present a patient with choroidal metastasis secondary to TCC of the renal pelvis, with a review of the relevant literature. A 61-year-old male presented with sudden-onset loss of vision of the left eye. Upon evaluation and assessment, the patient was found to have unilateral choroidal metastasis secondary to TCC of the renal pelvis. He is currently on palliative chemotherapy with carboplatin and gemcitabine. External beam radiation therapy is a common mode of treatment and will be considered accordingly.

Cancer and Referred Facial Pain

Orofacial pain may be a symptom of diverse types of cancers as a result of local or distant tumor effects. The pain can be presented with the same characteristics as any other orofacial pain disorder, and this should be recognized by the clinician. Orofacial pain also can arise as a consequence of cancer therapy. In the present article, we review the mechanisms of cancer-associated facial pain, its clinical presentation, and cancer therapy associated with orofacial pain.

Choroidal metastases from thymic carcinoma during pregnancy: Case Report

BACKGROUND

Rare sites of metastases, atypical symptoms and paraneoplastic syndromes are often neglected or misinterpreted, especially when they represent early symptoms of an underlying malignant disease. Hence, an interdisciplinary approach to these patients is essential to avoid tumor progression and metastatic spread in order to provide curative treatment options to the patients. We here report the case of a young woman presenting with visual loss which led to diagnosis of a thymic carcinoma.

CASE PRESENTATION

A 28-year old white woman presented with subacute loss of vision in the last trimester of her first pregnancy which was first interpreted as an exacerbation of a pre-existing dermatomyositis and treated with steroids. After failure of steroid therapy choroidal metastases from an undifferentiated thymic carcinoma were diagnosed. This also shed a new light on the dermatomyositis the patient had been suffering from for seven years possibly representing a paraneoplastic syndrome from the tumor. Despite aggressive chemotherapy, the patient died from progressive disease eight years after first onset of dermatomyositis and 14 months after initial diagnosis of the thymic carcinoma.

CONCLUSIONS

Choroidal metastases from a thymic carcinoma have never been reported before but should be included into the differential diagnosis of choroidal masses.

Metastatic follicular thyroid carcinoma masquerading as olfactory neuroblastoma: with skull-base, cranium, paranasal sinus, lung, and diffuse bone metastases

Skull-base metastasis is rarely reported in thyroid carcinoma. We are presenting an unusual interesting case mimicking metastatic renal cell carcinoma with intense clear cell morphology, the thyroid origin of which was detected via positron emission tomography/computerized tomography scan proposed by the oncology council, while we were monitoring the subject with the initial diagnosis of paranasal sinus tumor. A mass was detected in the left nasal cavity in the endoscopic examination of the 68-year-old female patient referred by the ophthalmology clinic with the preliminary diagnosis of retro-orbital tumor upon being admitted with proptosis. A soft tissue lesion at a size of 68 × 39 × 53 mm located intracranially was detected by the brain computerized tomography. The biopsy taken and the immunohistochemical results were not satisfactory. Intense fluorodeoxyglucose involvement was observed in both lobes of the thyroid gland at positron emission tomography/computerized tomography taken with the recommendation of the council. Moreover, hypermetabolic nodules were seen in both lung parenchyma areas, whereas intense hypermetabolic lytic lesions were observed in the skeletal system. Thyroglobulin and thyroid transcription factor 1 stains displayed a strong staining on paraffin block. On the basis of these characteristics, the case was regarded as compatible metastatic follicular thyroid carcinoma, with skull-base, cranial, retro-orbital, paranasal sinus, lung, and bone metastases. This case showed us that multidisciplinary work and assessment of the oncology council play a highly critical role in making the diagnosis and guiding the treatment.

Retinal metastasis from unknown primary: diagnosis, management, and clinicopathologic correlation

A 75-year-old man was incidentally found to have a yellow-white retinal lesion with scattered hemorrhages. He was empirically treated elsewhere for viral retinitis without resolution and later transferred to the Vanderbilt Eye Institute, where retinal biopsy with silicone oil tamponade showed retinal metastasis. He had no prior history of cancer, and multiple systemic imaging evaluations failed to identify a primary site. Histopathology and immunohistochemistry of the biopsy were consistent with non-small-cell lung carcinoma. Due to the radiation-attenuating properties of silicone oil, the patient underwent silicone oil removal prior to receiving external beam radiotherapy (EBRT). The retinal metastasis responded completely to EBRT, and at final follow-up, 18 months after initial presentation, no primary tumor has been identified.

Unusual Case of Papillary Thyroid Carcinoma with Choroidal Metastasis

BACKGROUND

The choroid is a rare site of thyroid cancer metastases, and has been described in patients with evidence of advanced breast, lung, and prostate carcinomas. To the authors' knowledge, only seven reported cases exist with choroidal metastasis secondary to papillary thyroid carcinoma (PTC). This study describes an additional patient with metastatic PTC with simultaneous appearance of choroidal mass and cutaneous deposits while on systemic therapy with a tyrosine kinase inhibitor (TKI). These infrequent sites of metastasis are typically associated with a dismal prognosis following the diagnoses. However, this patient has not shown evidence of choroid or cutaneous recurrence one year following local targeted and systemic therapy.

PATIENT FINDINGS

The case is presented of a 70-year-old male with widely metastatic PTC to the lymph nodes, lung, and mediastinum who was found to have choroidal metastasis six years after his initial diagnosis.

SUMMARY

The patient was asymptomatic and was found to have an incidental right choroidal mass on routine ophthalmology exam. Magnetic resonance imaging of the orbit revealed an isolated right choroid lesion suspicious for melanoma or metastasis. Concurrent to this discovery, he was noted to have progression of the lung and mediastinal disease along with new dermal lesions on the chest wall suspicious for dermal metastasis. Both the choroid and dermal metastases occurred while being on a TKI. Given his previous history of male breast carcinoma, a biopsy of the choroid was performed, which confirmed PTC. The patient developed endophthalmitis and subsequently underwent enucleation of the right eye. The choroid mass was completely excised, measured 3.5 mm×9.5 mm with negative margins, and histopathology was consistent with metastatic PTC. Pulmonary, mediastinal, and cutaneous lesions regressed after external beam radiation therapy, following which systemic therapy was changed to a different multikinase inhibitor.

CONCLUSION

A rare and unique case is reported of choroidal metastasis from PTC that presented with concurrent new dermal metastasis in addition to lung and mediastinal lymph node progression. Furthermore, the patient developed choroid and dermal lesions while on a TKI and remained stable without recurrence in these regions after switching to an alternate multikinase inhibitor.

Orbital metastasis as initial manifestation of a widespread papillary thyroid microcarcinoma

Papillary thyroid carcinomas (PTCs), particularly microcarcinomas, rarely metastasise to the orbit. We report a case of a 49-year-old woman with a right supraorbital mass and unremarkable physical examination of the thyroid gland region. Orbital CT scan showed an expansile lytic lesion in the orbital plate of the frontal bone with a soft tissue component. An incision biopsy revealed metastatic well-differentiated thyroid carcinoma. Thyroid ultrasound was normal except for a subcentimetre nodule in the right lobe. The patient underwent total thyroidectomy where histopathology showed a subcentimetre follicular variant PTC. She subsequently received radioactive iodine therapy. Post-therapy whole body scan revealed metastatic thyroid tissues in the right orbital and posterior parietal, and left shoulder and hip areas. Although infrequent, metastatic thyroid carcinoma should be considered in patients with orbital metastasis even when neck examination is normal. In rare cases, this may be the initial manifestation of a widely metastatic papillary thyroid microcarcinoma.

[Uveal metastasis of thyroid carcinomas. About 3 cases]

OBJECTIVE

To study the characteristics of ocular metastases of thyroid carcinomas through three observations of patients.

RESULTS

Three patients aged respectively 41, 55 and 66 years were followed for thyroid carcinoma. All patients were treated by surgery followed by IRA therapy. They developed ocular metastases after a mean period of 10 years after thyroidectomy. They presented in addition multiple secondary sites such as bone, lungs and cerebrum. The uveal lesion was unilateral and localized at the choroid or iris. The predominant symptomatology was decreased visual acuity. The diagnosis was based on ophthalmoscopic examination and post-IRA therapy scan and was confirmed by anatomopathological study. Treatment options were respectively IRA therapy, sectoral iridectomy and enucleation. Evolution was fatal in 2 cases and towards aggravation for one case.

CONCLUSION

Uveal metastases of thyroid cancer are associated with a pejorative prognosis. Ophthalmologic follow-up is necessary when patient presents warning sign mainly with metastatic follicular carcinoma. Conversely, thyroid carcinoma should be considered in the differential diagnosis of a uveal mass of unknown origin.

Choroidal metastasis from follicular cell thyroid carcinoma masquerading as circumscribed choroidal haemangioma

Choroidal metastases from follicular thyroid carcinoma are uncommon and usually present as an amelanotic lesion against a background of known systemic disease. We present the case of a 56-year-old woman with a thyroid metastatic focus with unusual clinical presentation, systemic involvement, and early response to systemic treatment. A review of the literature accompanies this case presentation.