Decreased prevalence of asymptomatic choroidal metastasis in disseminated breast and lung cancer: argument against screening

Abstract

Aim: To determine the frequency of visually asymptomatic choroidal metastases in patients with disseminated breast and lung carcinomas in order to establish optimal patient management policies. Methods: All patients with confirmed metastatic disease treated in our institution between January 2002 and December 2003 were invited to undergo a funduscopic examination and a B-scan ultrasound evaluation. Results: Of the 169 study participants, 77 had breast cancer (64 with metastases in one organ and 13 with multiple-organ involvement) and 92 had lung cancer (85 with metastases in one organ and 7 with multipleorgan involvement). No patient with metastatic breast cancer and two patients with metastatic lung disease (each with multiple-organ involvement) were found to have choroidal metastases. The choroidal metastases were detected by both the funduscopic and ultrasound examinations. Conclusions: The 2.17% incidence of choroidal metastasis in disseminated lung cancer and the 0% incidence in disseminated breast cancer speaks against the practicality of screening for early detection of choroidal metastasis among these patients, even though it would lead to early implementation of appropriate, often vision saving, therapeutic management. Its low incidence probably testifies to progress achieved by enhanced systemic oncological treatment policies that have been introduced into routine patient management over the past few years. B reast and lung carcinomas are the most common primary sites for choroidal metastases.1 The incidence of choroidal metastasis from metastatic breast cancer was 0-9.7% in clinical trials 2-5 and up to 30% in histopathological trials. 6 The incidence of choroidal metastases from metastatic lung cancer was reported to be 2-6.7% in clinical trials.2 7 The need for screening for asymptomatic choroidal metastasis among patients with disseminated disease continues to be a matter of controversy.8 Although a metastasis causes considerable visual disability and presents a very difficult therapeutic challenge, the cost of conducting numerous examinations on unaffected individuals is obviously high. As such, there must be compelling evidence of clinical benefits for operating an early detection programme in asymptomatic patients. We designed this study to determine the frequency of choroidal metastases in patients seen in our medical centre, who had disseminated breast and lung cancer, in order to determine whether such a clinical screening programme was justified. Our goal was to identify a subgroup of patients with early choroidal involvement who would profit from early implementation of appropriate changes in treatment. METHODSThe local institutional review board approved the study. The participants were consenting patients with proved disseminated lung or breast cancer to at least one site. Between January 2002 and December 2003, 169 unselected patients were screened for choroidal metastases in the Department of Ophthalmology, Tel Aviv Sourasky Medical Center, a large urban university-affiliated tertiary c...

Management of choroidal metastases

“…According to Barak et al, the prevalence of CM in patients previously treated with carboplatin-docetaxel upfront for metastatic lung cancer was low (2%) [4]. Such prevalence under systemic treatment may suggest that chemotherapy alone is efficient in controlling CM.…”

“…The prognostic is usually considered very poor. CM occur in 4-12% of patients with solid tumors (mainly breast and lung cancers but also any other tumor type) in autopsy series and 0-11% in screening programs for patients with disseminated breast or lung cancers [1][2][3][4].…”

Ocular metastases

“…In 2007, Fenton and Barak both reported a 0% incidence of choroidal metastases following ophthalmic screening of asymptomatic British patients with metastatic breast carcinoma. 3,4 Only 2% of patients suffering disseminated lung cancer were found to have asymptomatic choroidal metastases. 4 They argued that the high cost of an ophthalmic screening programme could not be justified with such a low detection rate.…”

“…3,4 Only 2% of patients suffering disseminated lung cancer were found to have asymptomatic choroidal metastases. 4 They argued that the high cost of an ophthalmic screening programme could not be justified with such a low detection rate. Therefore, there is now a strong argument not to screen for asymptomatic choroidal metastases.…”

Choroidal metastases from lung adenocarcinoma

“…Symptomatic lesions are usually derived from breast cancer, while asymptomatic lesions are more frequently associated with lung neoplasms. Screening lung cancer populations has yielded relatively low incidence rates (7.1%) and therefore screening is not warranted [6]. Treatment modalities include external beam radiotherapy, local brachytherapy, surgical approaches and systemic chemotherapy.…”