The Neuroradiology Journal 20: 662-665, 2007

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Small Cell Carcinoma of the Lung Presenting with Ocular Metastasis A Case Report E. MAVILI, S. BURCU GORKEM, H. DONMEZ, M. OZTURK Department of Radıology, Erciyes University Medical Faculty; Kayseri, Turkey

Key words: ocular imaging, ocular metastasis, ocular MRI, lung carcinoma

SUMMARY – Metastasis to the eye is rare but it may be the presenting symptom. Therefore awareness of the radiological findings of metastasis may aid in establishing its diagnosis. Here we report an ocular metastasis of small cell carcinoma of the lung presenting with pulmonary and ocular manifestations.

Introduction Small cell lung carcinoma which constitutes 23.1% of lung tumours has a significantly worse prognosis. The most common sites for metastasis of small cell lung carcinoma are liver, bone and bone marrow. Metastasis to the eye is uncommon 1. Despite its rarity it can be the presenting symptom in lung cancers 2. Therefore awareness of the radiological findings in ocular metastasis may aid in the diagnosis. Here we present the radiologic findings of a small cell lung carcinoma presenting with ocular metastasis. Case Report A 48-year-old man was admitted to hospital with a two-month history of coughing, weightloss, and pain in the right eye. PA chest radiography and chest CT scan were obtained and ophtalmological examination was performed. PA chest radiography disclosed a mass in upper zone of the left lung. Axial images of the chest CT showed infiltrations and a mass located in the superior segment of the left inferior lobe. The left main pulmonary artery was infiltrated by the mass. There were lymphnodes located in the subcarinal space. Bronchoscopy was carried out and biopsy and brochioalveolar lavage 662

were taken to confirm the diagnosis. The histopathological and microscopic findings were compatible with a small blue cell tumour. The immunohistochemical evaluation showed the lesion was a small cell lung carcinoma. With these findings the patient was inoperable. On ophtalmalogic examination visual acuity was 10/10 in the left eye and finger counting in the right eye. Fundoscopy revealed a lobulated solid lesion and overlying total retinal detachment in the right eye. Orbital ultrasonography was carried out using a real-time mechanical sector scanner with 8 MHz transducer (Toshiba SSA-250A, Tokyo, Japan). Sonography of the right eye showed a 20×17 mm hyperechogenic solid lesion in the medial wall of right bulbus oculi (figure 1). The lesion extended towards the lens and the lens was distorted. At the posterolateral wall a hypoechoic area representing detachment was seen. Non-enhanced magnetic resonance imaging of the orbits showed a 2 cm T1W hypointense lesion with hyperintense areas and T2W hyperintense relative to the vitreous body. The lesion was at the medial wall of the right bulbus oculi extending towards the lens and the lens was laterally displaced (figure 2A, B). The contrast enhanced T1W image revealed heterogenous enhancement of the lesion (figure 2C). A 15 mm retinal detachment T1W hypointense and T2W hyperintense to the vitreous body was lying at the posterola-

E. Mavili

Figure 1 Sonography of the right eye shows a hyperechogenic solid lesion at the medial wall and hypoechoic area at the posterolateral wall representing detachment of the right bulbus oculi.

teral side of the optic disc and did not show enhancement. Because the patient was inoperable he was treated with local radiotherapy. Two months later visual acuity of the right eye showed no improvement. The patient refused enucleation and six months later he died from disseminated disease. Discussion Uveal melanomas and intraocular metastases from extraorbital tumors are the most common ocular malignancies in adults. Metastatic carcinoma is the most common form of intraocular malignancy, the lung being the second most prevalent primary location after the breast 3. The choroid is more often involved than the iris and ciliary body because arterial distribution is more abundant posteriorly compared with the anterior uvea. The increased incidence in posterior choroidal lesions may be due to easier diagnosis, as these lesions are more likely to be symptomatic than anterior lesions 3,4. The lesion in our patient was also located posteriorly.

Small Cell Carcinoma of the Lung Presenting with Ocular Metastasis

Patients with metastatic tumors to the posterior uvea generally present with decreased visual acuity. The second most common symptoms are field defects and floaters 5. In this case the presenting symptoms were coughing, weight-loss, and pain in the right eye. The diagnosis of ocular metastases is based primarily on clinical findings supplemented by imaging studies. The diagnostic procedures include ultrasonography, computed tomography/ MRI, fine-needle aspiration, or wedge biopsy 2. We performed ultrasonography and MRI. Differential diagnosis of ocular lesions includes primary choroidal melanomas, benign lesions such as hemangioma and inflammatory granulomas 6. Hemangioma is the most common benign tumor of the orbital cavity and can be capillary or cavernous. The choroidal hemangiomas are hyperintense on T1W images and isointense on T2W images 9. It is very important to distinguish between metastatic disease and primary malignant uveal melanoma. On sonographic examinations morphological differences between metastases and melanomas were detected in tumor shape, echogenity and frequency of retinal detachment. In the literature melanomas of the eye are usually round and hypoechoic 7. Metastatic tumors are discoid in shape and hyperechoic compared with melanoma. The presence of retinal detachment is found significantly different in melanomas and metastatic tumors. In the literature some investigators found retinal detachment nearly three times more in melanomas than in metastatic tumors 8. Whereas others reported that 90% of metastatic tumors were associated with a retinal detachment. In the presented case, sonographic findings were 20×17 mm sized hyperechogen solid lesion in the right bulbus oculi with retinal detachment. The metastatic choroidal lesions are essentially isointense relative to the vitreous body on T1W images and relatively hypointense on T2W images 9. This is distinct from all other tumors except for the amelanotic melanoma. In the literature amelanotic melanomas are nearly isointense or perhaps slightly hyperintense relative to the vitreous body on T1W images and hypointense on T2W images to the vitreous body 7. Contrast enhancement does not aid in differential diagnosis because both metastases and melanomas enhance 8. In agreement with the literature the MRI intensities of the lesion in our patient were hypointense T1W and hyperintense on T2W images. Our patient had a diagnosis of SCLC 663

Small Cell Carcinoma of the Lung Presenting with Ocular Metastasis

E. Mavili

A

B

C

Figure 2 Non-enhanced T1-W MRI shows a hypointense lesion with hyperintense areas (A) and non-enhanced T2W images shows a hyperintense lesion (B) at the medial wall of right bulbus oculi extending towards the lens and displacing the lens laterally. On contrast enhanced images heterogenous enhancement of the lesion is seen (C). Retinal detachment lying at the posterolateral side of the optic disc was hypointense on T1W (A) and hyperintense on T2W images (B) and did not enhance after intravenous contrast injection (C).

therefore we assumed the lesion in the eye was not a second malignancy, but a metastasis and our radiological findings supported this diagnosis. If histopathological and the immunohistochemical evaluation had been performed they would have shown cells with round or elongated nuclei, inconspicuous nucleoli and focal areas of clumped chromatin with several areas of necrosis and hemorrhage as the metastasis of small cell lung carcinoma 10. We think that our lesion

had areas of necrosis and hemorrhage making it inhomogeneous with hyperintense and hypointense components on T1W images. In conclusion, imaging techniques help differentiate metastases from primary lesions and melanoma of the eye. We can use sonography and especially MRI of the orbits in patients who reject biopsy or enucleation for the histopathological examination to diagnose the metastatic lesions of SCLC.

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The Neuroradiology Journal 20: 662-665, 2007

References 1 Ruckdeschel JC, Schwartz AG, Bepler G et Al: Cancer of the lung: NSCLC and SCLC In Abeloff MD, Armitage JO, Niederhüber JE, Kastan MB, McKenna FB, eds. Clinical Oncology. 3rd ed. Philedelphia, Pa: Elsevier 2004: 75. 2 Koçak Z, Tabakoğlu E, Benian O et Al: Bilateral choroidal metastases as an initial manifestation of small-cell carcinoma of the lung. Tuberk Toraks 54: 61-64, 2006. 3 Shields CL, Shields JA, Gross NE et Al: Survey of 520 eyes with uveal metastases. Ophthalmology 104: 12651276, 1997. 4 Demirci H, Shields CL, Chao A et Al: Uveal metastasis from breast cancer in 264 patients. Am J Ophthalmol 136: 264-271, 2003. 5 Mussari S, Amichetti M, Bolner A et Al: Choroidal metastasis from carcinoma of the hypopharynx: A case report. Tumori 85: 294-96, 1999. 6 Goldberg RA, Rootman J, Cline RA: Tumors metastatic to the orbit: A changing picture. Surv Ophthalmol 35: 1-24, 1990. 7 Deepak G. Bedi Daniel S. Gombos Chaan S et Al: Sonography of the Eye Am J Roentgenol 187: 10611072, 2006. 8 Lemke AJ, Hosten N, Wiegel T et al: Intraocular metastases: differential diagnosis from uveal melanomas

with high-resolution MRI using a surface coil. Eur Radiol 11:2593-2601, 2001. 9 Peyster RG, Augsburger JJ, Shields JA et Al: Intraocular tumors: evaluation with MR imaging. Radiology 168:773-779, 1988. 10 Moura LR, Yang YF, Ayres B et Al: Clinical, histologic, and immunohistochemical evaluation of iris metastases from small cell lung carcinoma. Can J Ophthalmol 41:775-777, 2006.

E. Mavili, MD Department of Radıology Erciyes University Medical Faculty 38039 Kayseri - Kayseri Turkey Tel.: 003524374937 E-mail: [email protected]

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Small cell carcinoma of the lung presenting with ocular metastasis. A case report.

Metastasis to the eye is rare but it may be the presenting symptom. Therefore awareness of the radiological findings of metastasis may aid in establis...
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