New concepts in the diagnosis and management of choroidal metastases

Abstract

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.

Optical coherence tomography angiography (OCTA) applications in ocular oncology

“…In the absence of a reliable history of systemic cancer (e.g., subclinical lung cancer), the conundrum of diagnosis can be a challenge for the ocular oncologist. There are many different modalities useful in the differentiation of metastasis from other choroidal masses [ 62 ]. The reports regarding OCTA findings in choroidal metastasis are scarce and most of them counter-intuitively report signal void and hypovascularity in the regions of CM [ 27 , 62 ].…”

Choroidal metastasis as the presenting feature of metastatic lung carcinoma

“…It is often accompanied with multi‐organ metastases, and has a poor prognosis because initially these lesions are generally asymptomatic. The breast is the most common primary site for choroidal metastasis, followed by lungs . The survival of such cases with lung primary is no more than six months…”

“…The breast is the most common primary site for choroidal metastasis, followed by lungs. 2 The survival of such cases with lung primary is no more than six months. 3 At 32 years old, this is the second youngest case of choroidal metastases secondary to lung cancer so far reported, the youngest reported being 25 years of age.…”

Photodynamic Therapy of Presumed Choroidal Metastasis Secondary to Colorectal Carcinoma: Literature Review

“…Lesions that are too thick might not be eligible for vPDT, since the wavelength (689 nm) of the laser used will not penetrate the entire tumor. Moreover, visual acuity seems to improve after vPDT probably due to the decrease of subretinal fluid [39].…”

“…Intravitreal treatment might be a good therapeutic option for patients with a metastatic disease as it preserves the quality of life without reducing clinical effectiveness. Mathis et al suggested beginning with a single dose followed by a monthly as-needed regimen [39]. It could be proposed for multimetastatic patients under systemic chemotherapy with short life expectancy, as it improves or preserves the vision in most cases without time-consuming treatment.…”