Tyrosine Kinase Inhibitors in the Treatment of Choroidal Metastases from Non-Small-Cell Lung Cancer: A Case Report and Review of Literature

Posterior segment manifestations of ocular metastasis

PURPOSE OF REVIEW

This article reviewed and summarized recent published data on ocular imaging findings and treatment of posterior segment manifestations of ocular metastasis.

RECENT FINDINGS

Advanced ocular imaging can help differentiate ocular metastases from other mimicking lesions, including primary intraocular tumors or infections. Recently, case reports have demonstrated the successful use of targeted systemic therapy to achieve local control of vitreous and choroidal metastases.

SUMMARY

Metastasis can lead to a wide variety of posterior segment ocular manifestations. The choroid is the most common metastatic site, whereas tumor metastasizing to the retina and optic disc are rare. Patients with possible metastatic eye disease are recommended to undergo extensive investigation to determine the underlying primary cancer and ongoing systemic metastases. Currently, there is no consensus on the treatment strategy. Treatment generally includes systemic chemotherapy in combination with local treatment, such as radiotherapy, laser therapy, or anti-vascular endothelial growth factor (anti-VEGF) treatment.

Incidental finding of regressed solitary unilateral choroidal metastasis from lung adenocarcinoma with EGFR exon-19 deletion treated with erlotinib

A 49-year-old Asian Indian woman, with a previous history of biopsy proven stage IV primary lung adenocarcinoma with metastasis to liver, bones and central nervous system, presented with 1-month history of photopsia in right eye. She was on oral erlotinib since 6 months. Dilated fundus examination of right eye revealed a solitary dome-shaped brownish elevated lesion of approximately 1-disc diameter along the inferotemporal midperiphery with surrounding areas of hypopigmentation. Based on multimodal imaging, a diagnosis of resolved solitary unilateral choroidal metastasis from lung carcinoma in the right eye was made. In view of inactive and regressed choroidal metastasis, no intervention was mandated.

Epidermal growth factor receptor-mutant non-small cell lung Cancer and Choroidal metastases: long-term outcome and response to epidermal growth factor receptor tyrosine kinase inhibitors

Background

Choroidal metastases are the most common eye metastatic site. The prevalence of choroidal metastases in NSCLC patients has been reported to vary from 0.2 to 7% in historical series. Although previously reported, little is known about choroidal metastasis in Epidermal Growth Factor Receptor (EGFR)-mutant Non-small cell lung cancer (NSCLC). This study sought to describe the prevalence of choroidal metastases among patients with EGFR-mutated NSCLC and their characteristics, and to estimate their impact on prognosis.

Methods

We conducted a single-center retrospective study including all consecutive metastatic EGFR-mutant NSCLC patients, from Sept. 2015 to Oct. 2018. The EGFR-mutant NSCLC patients were identified via the Department of Genetics’ files. Patients who exhibited choroidal metastases were compared to patients without choroidal metastases. Kaplan-Meier analysis and log-rank test were conducted to assess median overall survival (OS) from diagnosis for the two groups. The study was approved by the IRB as CEPRO number #2020–010.

Results

Prevalence of choroidal metastases in EGFR-mutated NSCLCs was 8.4% (7/83). Five were women, and four current or former smokers. Molecular analysis showed three tumors with exon 19 deletion, three with L858R mutation, and one with complex exon 21 mutation. The choroidal metastases were symptomatic in six/seven patients. Visual disturbances decreased in all but one symptomatic cases upon EGFR TKI, and the choroidal response was maintained over time.

Median follow-up was 42.2 mo (95%CI [37.2–47.1]). Median OS in the choroidal metastasis group was 23.4 mo (95%CI [0.1–51.4]) versus 27.9 mo (95%CI [16.9–38.9]) in the non-choroidal metastasis group (p = 0.32). In the choroidal metastasis group, 2-year and 5-year OS were 47.6 and 0%, respectively, versus 55.8 and 26.3% in the non-choroidal metastasis subset.

Conclusions

Choroidal metastases in NSCLC EGFR-mutant patients are rare but should be systematically suspected in case of visual disturbance. TKIs are efficient for treating visual symptoms. Whether choroidal metastases confer a worse prognosis remains unclear owing to the third-generation EGFR TKI osimertinib first-line registration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-020-07630-6.

Treating Choroidal Metastases and Improving Vision with Osimertinib in EGFR T790M-Mutated Lung Adenocarcinoma: A Case Report and Review of the Literature

A 41-year-old never-smoking female was diagnosed with epidermal growth factor receptor (EGFR)-mutated T2bN3M1b lung adenocarcinoma with axillary lymph nodes. She complained of blurred vision in the left eye (2/60) and was subsequently found to have a left choroidal metastasis. Treatment with tyrosine kinase inhibitor (TKI) erlotinib was started, and after 1 year of disease stability, she developed unsteadiness and worsening visual disturbance (1/60). Brain imaging showed 24 new brain metastases, which were treated with Gamma Knife stereotactic radiosurgery. An enlarging axillary lymph node was biopsied, which identified the T790M mutation, and she commenced the novel TKI osimertinib. Three weeks later, her choroidal lesion had regressed from 3.1 mm to 2.2 mm, and after 2 months of osimertinib, her visual acuity had improved to 6/9. At the last follow-up 8 months after initiation of osimertinib, her choroidal metastasis remains stable, and visual acuity has improved to 6/6. Evidence suggests that osimertinib's efficacy in treating cerebral metastases is superior to that of chemotherapy and other EGFR-TKIs (gefitinib and erlotinib); however, the literature is sparse with regards to the use of osimertinib for the treatment of intraocular disease. In this case, the need for intense daily radiation treatment with its associated toxicities was negated, and as such we propose that osimertinib may be a promising treatment for choroidal metastasis secondary to EGFR-mutated lung adenocarcinoma.

Choroidal metastasis from non-small-cell lung cancer responsive to Osimertinib: a case report : Efficacy of a third-generation epidermal growth factor tyrosine kinase inhibitor

PURPOSE

To report a case of a choroidal metastasis from a non-small-cell lung cancer (NSCLC) with an epidermal growth factor receptor (EGFR) mutation, which responded to Osimertinib, a third-generation EGFR-tyrosine kinase inhibitor (TKI).

BACKGROUND

First- and second-generation EGFR-TKis have been widely used for advanced NSCLC patients; however, acquired resistance to these inhibitors, as T790M mutation, could be present in resistant cases. Third-generation EGFR-TKis have emerged as potential therapeutics to overcome this resistance.

METHODS

A 54-year-old lady, affected by pulmonary adenocarcinoma with systemic metastases, was diagnosed with choroidal metastasis and since tumor biopsy was positive for the EGFR-T790M mutation, she was included in ASTRIS study, and she received 80 mg tablet of Osimertinib once a day.

RESULTS

After a 2-week course of daily therapy with Osimertinib, the improvement of visual acuity was evident with the marked disappearance of visual field defects. We also report a dramatic anatomical reduction of choroidal mass on fundus examination and SD-OCT. These features remained stable at the 4-month follow-up visit.

CONCLUSION

This report demonstrates that Osimertinib is effective for choroidal metastasis of NSCLC harboring an EGFR-T790M mutation, which has progressed on or after first- or second-generation EGFR-TKI therapy.