The effect of intravitreal bevacizumab and transpupillary thermotherapy on choroidal metastases and literature review

How to Manage a Patient with Ocular Metastases?

Ocular metastases are the most frequent ocular malignant tumors; their prevalence is estimated around 5-10% and is even higher in patients with breast or lung cancer. They represent various clinical situations, but they share the same hierarchical multidisciplinary therapeutic challenge with respect to the way systemic and local therapies should be selected in combination or sequentially in the personalized medical history of a patient. The challenges include tumor control, eye preservation, and the minimization of iatrogenic damage to sensitive tissues surrounding the tumor in order to preserve vision. These aims should further contribute to maintaining quality of life in patients with metastases. Many patients with choroidal metastases have systemic molecular treatment for their primary tumor. However, secondary resistance to systemic treatment is common and may ultimately be associated with cancer relapse, even after an initial response. Therefore, it makes sense to propose local treatment concomitantly or after systemic therapy to provide a more sustainable response. The aim of this review is to present current therapeutic strategies in ocular metastases and discuss how to tailor the treatment to a specific patient.

Intravitreal aflibercept combined with transpupillary thermotherapy in the treatment of refractory macular edema due to primary uveal melanoma

We reported a 74 year old Asian female with a uveal tumor with subretinal fluid (SRF) and cystoid macula edema. Since she declined biopsy, multimodal imaging study was performed, including fundus photography, ultrasonography, optical coherence tomography, fluorescein angiography, and magnetic resonance imaging. Uveal melanoma was diagnosed. However, despite aggressive treatment with TTT and three adjuvant intravitreal bevacizumab doses, SRF, and cystoid macula edema were persistent. Therefore, aflibercept was administered, resulting in anatomical and functional improvement within 1 month, which lasted for 12 months. Aflibercept offered great efficacy in improving refractory macular edema in this case of primary uveal melanoma. Multimodal imaging can provide us with more diagnostic clues in differentiating the nature of intraocular tumors.

A Comprehensive Understanding of Choroidal Metastasis from Lung Cancer

The incidence of lung cancer with intraocular metastasis is low, of which choroidal metastasis is the most painful metastatic lesion. The clinical symptoms resulting from choroidal metastasis from lung cancer easily detected although they are rarely identified prior to the diagnosis of the primary malignancy. The quality of life of patients is inevitably impaired. Some lung cancer patients complain of ocular symptoms as the first manifestation of lung cancer. Early diagnosis and treatment can significantly overcome or delay the visual impairment and improve prognosis. The main therapeutic modalities include systemic and local treatments, while observation is also a treatment option. Currently, the feasibility and effectiveness of various treatment options are controversial worldwide. Herein, we summarize the underlying mechanisms, epidemiology, clinical features, auxiliary examinations, diagnosis, and recent treatment options for intraocular metastases.

Adjuvant Intravitreal Bevacizumab Injection for Choroidal and Orbital Metastases of Refractory Invasive Ductal Carcinoma of the Breast

The efficacy of combined intravitreal bevacizumab injection with systemic chemotherapy, palliative radiotherapy, and hormonal therapy to treat choroidal and orbital metastases is not known. Herein, we report the case of a 48-year-old woman with systemic chemotherapy-resistant choroidal and orbital metastases of the left eye originating from a stage IV invasive ductal carcinoma of the left breast. We describe the addition of a single intravitreal injection of bevacizumab in addition to treatment with systemic chemotherapy, hormonal therapy, and palliative radiotherapy. The patient’s outcome at 6-month follow-up was favorable, as the metastatic lesion reduced in size and visual acuity improved. Combined treatment with intravitreal bevacizumab injection, systemic chemotherapy, palliative radiotherapy, and hormonal therapy can resolve ocular metastatic lesions originating from breast cancers.

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.

[Choroidal metastasis from a lung adenocarcinoma treated by intravitreal injection of anti-VEGF and external beam radiotherapy: A case report]

Choroidal metastases of lung cancer are very uncommon. This localization should be suspected on blurred vision and confirmed with an ophthalmological examination. Its treatment is not entirely codified. We report a case of blurred vision secondary to bilateral choroidal metastasis in a patient with choroidal metastases from a lung adenocarcinoma, treated by intravitreal anti-vascular endothelial growth factor (VEGF) injection and external beam radiotherapy. According to a literature review, we analyzed the place of the targeted treatments used alone or combined with the radiotherapy.

Intraocular Metastases--A Review

Intraocular metastases almost invariably arise in the uveal tract, mostly in the posterior choroid. They are the most common type of intraocular malignancy and often the first sign of tumor dissemination. Choroidal metastases generally appear as a creamy white or pale yellow mass associated with subretinal fluid and may be multifocal and bilateral. The most common primary sites are breast and lung. Diagnosis is aided by a variety of tests, particularly ultrasonography and optical coherence tomography. Intraocular biopsy is useful in patients with clinical suspicion of uveal metastasis but no evidence of primary malignancy despite systemic evaluation. If systemic treatment fails to control the ocular tumor, a good response is usually achieved with local therapies such as external beam radiation therapy, photodynamic therapy, and transpupillary thermotherapy. The life expectancy of patients with choroidal metastases is generally poor but has been improving thanks to the therapeutic advances taking place.