Metastatic adenocarcinoma of the cervix presenting as a choroidal mass: A case report and review of literature of cervical metastases to the eye

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.

[Clinical approach for solid intraocular metastases]

BACKGROUND

Intraocular metastases arising from solid tumors are found in approximately 2% of patients with metastatic tumor diseases and are therefore more frequent than originally assumed. They often affect the uvea and are associated with a poor prognosis. Due to the difficult diagnosis and an inconsistent treatment regimen, ophthalmologists have a special responsibility here.

OBJECTIVE

This article gives a summary of the various types of intraocular metastases with respect to clinical features, diagnostics, treatment and prognosis as well as recommendations for follow-up care.

METHODS

A selective literature search was carried out on the topic of intraocular metastases using PubMed and Google Scholar.

RESULTS

Intraocular metastases most frequently affect the uvea, specifically the choroid. In most cases the underlying disease is breast or lung cancer, but other rarer primary tumors have also been reported in the literature. Metastatic lesions can show very different morphological manifestations but can be distinguished based on the corresponding structure of manifestation in the eye and with the aid of targeted staging, thus providing valid information on the type of primary tumor. The treatment is partly experimental and usually depends on the primary tumor and leading symptoms of the patient. A differentiation between a curative or palliative treatment situation must always be made.

CONCLUSION

Intraocular metastases are the most frequent intraocular tumor and are usually associated with a poor prognosis. Accurate diagnostics for finding the treatment as well as interdisciplinary collaboration and the presentation of the patient on the tumor board are essential.

Uncommon Hematogenous Metastasis: Orbital Involvement in Uterine Cervical Cancer

BACKGROUND Although screening for uterine cervical cancer (UCC) and vaccination programs for human papilloma virus (HPV) have been implemented in many countries, women >65 years may not have access to or comply with cervical cancer screening. Women >65 years may present with advanced-stage cervical carcinoma with a poor outcome. Metastatic UCC is often diagnosed, and there are 2 types of metastases related to different treatments and survival rate: hematogenous metastasis and lymphatic metastasis. Hematogenous metastasis is relatively unusual, and it most commonly involves lung and bone locations. Orbital metastasis is an extremely rare hematogenous metastasis in patients with UCC. CASE REPORT A 70-year-old woman receiving dialysis presented to a local hospital due to general fatigue for 5 months. She was diagnosed with locally advanced UCC and underwent radiation therapy (RT). Twenty days after RT, skin masses appeared, and 34 days after RT, right exophthalmos induced by an orbital mass appeared. We diagnosed skin and orbital masses as metastases from UCC, and performed RT to the orbital tumor. The tumor shrank and the visual symptoms disappeared. Regrettably, the patient died of cancer 7 months after the orbital RT; however, no eye symptoms recurred until her death. CONCLUSIONS This report describes a rare presentation of UCC with metastasis to the orbit, and highlights that cervical cancer may still present at an advanced stage, particularly in older women. In this case, RT to the orbital metastasis from UCC was effective and contributed to the patient's quality of life.

Eyelid Metastasis from Cervical Cancer: A Case Report

Metastatic malignant lesions of the eyelids are less than 1% of all eyelid tumors. Eyelid metastasis from the cervix, particularly the first sign of metastasis, has not been reported. A female presented to an ophthalmologist with a gradually increasing mass on the lateral edge of the lower eyelid for 2 months and was diagnosed with stage IB1 cervical cancer 3 years ago. We performed wide local excision of the eyelid mass. The mass was histologically and immunohistochemically similar to cervical cancer. Upon metastatic examination, no lesions involving other sites or lymph nodes were found. Subsequently, local radiation therapy yielded the desired results. In the present case, the possibility of metastasis from the cervix was not considered for the first time. More attention should be paid when identifying unexplained masses in patients with a history of malignant tumors.

Orbital metastasis of squamous cell cervical cancer: A case report and review of literature

Common sites of metastatic disease seen in cervical cancer most often include the lungs and liver. Orbital metastasis secondary to cervical carcinoma is a rare form of metastatic disease. We report a 73-year-old woman who presented with ocular symptoms found to be secondary to orbital metastasis of cervical cancer. She underwent palliative radiation to the orbit and pelvis followed by systemic chemotherapy with carboplatin, paclitaxel, and bevacizumab. Prompt intervention was able to salvage her vision and improve her quality of life significantly. We identified 5 similar reported cases in which orbital metastasis was diagnosed simultaneously at the time of cervical cancer diagnosis. In these five cases, patients were treated with a combination of radiation and chemotherapy. Our case demonstrates an unusual presentation of isolated orbital metastatic disease secondary to squamous cell carcinoma of the cervix. Physicians should be aware that cervical cancer may metastasize to the eye leading to vision loss, and prompt intervention may be able to salvage one's vision and improve quality of life.

Choroid Metastasis in a Patient with Squamous Cell Carcinoma of the Uterine Cervix: A Case Report

We present the case of a 43-year-old woman with unilateral loss of vision who had a history of cervical cancer, staged as FIGO IIIB, and who had undergone previous chemotherapy and radiotherapy, but was not a surgical candidate. An examination revealed serous retinal detachment with an underlying choroidal mass in the left eye. We reviewed all available published case reports of uterine cervix metastases to the eye and adnexa and compiled all information into a table to present clinical and epidemiological findings. Unilateral choroidal metastasis arising from cervical cancer is extremely rare. In most cases, a history of cervical carcinoma is confirmed in the advanced stage of the disease. Ocular metastasis may be the presenting feature of primary cervical malignancy; therefore, to rule out malignancy in every woman who develops these clinical features, a cervical examination should be included in the workup.

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

BACKGROUND

Choroidal metastases being the sole presenting feature of lung cancer is rare. Erlotinib, a tyrosine kinase inhibitor (TKI), is used in the treatment of lung adenocarcinoma where tumor cells exhibit epidermal growth factor receptor (EGFR) mutations. We report a case of metastatic non-small-cell lung cancer (NSCLC) with choroidal metastasis, which was the sole presenting feature and which responded to erlotinib.

METHODS

We performed a retrospective case review.

CASE

A 78-year-old man presented with a choroidal mass which was found to be the presenting feature of metastatic NSCLC. Our patient, a nonsmoker, had disseminated bony metastases, and therefore was advised to undergo palliative chemotherapy, which he refused. He was therefore instituted on oral erlotinib.

RESULTS

Tumor cells expressing EGFR mutations are known to be susceptible to TKIs. Even though the tumor in our case showed no mutation, i.e. was classified as 'wild-type', our patient showed a dramatic response to erlotinib. At 1 year, the choroidal lesion had regressed and visual acuity had recovered.

CONCLUSIONS

TKIs may be beneficial in patients with choroidal metastases from NSCLC, especially those in which an EGFR mutation is noted. Even in the absence of such mutations, choroidal metastases may show a favorable effect in response to TKIs, such as erlotinib.