Multimodal imaging of retinal metastasis masquerading as an acute retinal necrosis

Abstract

BackgroundTo report the multimodal imaging and histology of a case of metastatic esophageal cancer with vitreoretinal involvement resembling acute retinal necrosis (ARN) in a patient receiving systemic chemotherapy.Case presentationA 69-year-old Japanese man with a history of stage 4 esophageal carcinoma, treated with three cycles of 5-fluorouracil (5-FU) and cisplatin (CDDP) chemotherapy as well as 30 sessions of radiation therapy, presented with new onset of blurry vision in the right eye (OD). Visual acuity was 20/200 OD. Fundus examination OD revealed 2+ nuclear cataract, veil-like vitreous opacity, a tractional retinal detachment, and white retinal lesions in the macula and periphery masquerading as an ARN. Due to the poor view and uncertainty regarding diagnosis, combined cataract extraction and 25 gauge pars plana vitrectomy was performed. Polymerase chain reaction and cytologic analysis were performed on the vitreous samples, which was negative for all infectious entities but positive for poorly differentiated malignant cells. The vitreous biopsy was consistent with the primary endoscopic esophageal biopsy. Ultra-wide view fundus imaging revealed multifocal white intraretinal lesions in the macula and periphery. Optical coherence tomography through these white opacities displayed hyper-reflective inner retinal lesions with no choroidal involvement, suggestive of retinal metastasis. Observation and palliative support was continued until the patient passed away 3 months after diagnosis.ConclusionRetinal metastasis may mimic infectious syndromes such as ARN and are associated with a very poor prognosis. Outside of the retina, no further central nervous system metastasis was found. 5-FU is known to cross the blood–brain-barrier but may be inadequate in preventing retinal metastasis.

Metastatic squamous cell carcinoma masquerading as acute retinal necrosis

“… 6 While there have been no cases of squamous cell pulmonary carcinoma presenting in this fashion, cases of secondary vitreoretinal lymphoma and esophageal carcinoma metastasizing to the retina have resembled acute retinal necrosis. 4 , 7 In another similar case, a 62-year-old male with a history of lung cancer presented with decreased vision and clinical features of cyclomegaloviral retinitis. He was treated empirically, but viral cultures were negative.…”

Posterior segment manifestations of ocular metastasis

“…Some may experience metamorphopsia, photopsia, or visual field defects due to associated retinal detachment. The presentation is often unilateral and unifocal [5 & ], typically observed as irregular yellow-whitish opacification of the retina with overlying vitreous cells that can appear similar to necrotizing retinitis caused by toxoplasmosis or viral infection [41,[43][44][45]. It is important to consider this possibility, particularly in patients undergoing chemotherapy that can lead to immunosuppression.…”

Isolated Anterior Optic Nerve and Vitreous Metastases From Esophageal Cancer

“…For example, one patient presenting with unilateral vision loss, weight loss, and dysphagia was diagnosed with a choroidal metastasis from the esophagus (1). Retinal metastasis was also found in 3 patients diagnosed with an esophageal adenocarcinoma (3–5). Like our case report, these patients had significant vitreous haze, and 2 of them had OCT findings depicting retinal deposits from metastatic esophageal cancer.…”