|Year : 2023 | Volume
| Issue : 1 | Page : 29
Choroidal metastasis secondary to renal tumor
Andres Felipe Ramirez Ossa1, Sebastián Vallejo López1, Diana Carolina Gómez Calle2
1 Department of Ophthalmology, University of Antioquia, Medellín, Colombia
2 Department of Ophthalmology, University of Antioquia; Department of Ophthalmology, San Vicente Foundation Hospital, Medellín, Colombia
|Date of Submission||14-Jun-2023|
|Date of Acceptance||03-Jul-2023|
|Date of Web Publication||31-Aug-2023|
Andres Felipe Ramirez Ossa
Department of Ophthalmology, University of Antioquia, Medellín 050030
Source of Support: None, Conflict of Interest: None
Renal tumors correspond to a small part of the total number of neoplasms. However, they can cause metastasis, mainly in the lungs, bones, and liver. In the eye, the uvea is the structure with the highest affinity due to its high vascularity, and its presence is considered a poor prognostic factor for patient survival. A case report of a patient diagnosed with a renal cell tumor with metastasis in multiple body parts, including the choroid, is presented. A review of the literature in this regard is also carried out.
Keywords: Choroid, kidney neoplasms, neoplasm metastasis
|How to cite this article:|
Ramirez Ossa AF, López SV, Gómez Calle DC. Choroidal metastasis secondary to renal tumor. Pan Am J Ophthalmol 2023;5:29
| Introduction|| |
Renal tumor represents approximately 2.5% of all malignant neoplasms; 85% of these are classified as renal cells tumor., This type of neoplasm has a greater predilection for presenting metastases in the lungs, bones, and liver. In the eye, the uvea is considered the structure with the greatest affinity to cause tumor seeding due to its high vascularization and blood flow. Within it, the choroid receives 88%–90% of the cases, typically presenting as a solitary, yellowish mass accompanied by subretinal fluid. Clinically, these findings can be confused with other types of neoplasms, such as melanoma or infections, for their morphological characteristics. The most frequent primary tumors that cause choroidal metastases originated in the breast and the lungs, while renal tumor only corresponds to 1%–4% of cases.,
| Case Report|| |
A 56-year-old man with a history of type 2 diabetes mellitus, arterial hypertension, and dyslipidemia, medically controlled. He was admitted to the emergency room for a month with constitutional symptoms, weight loss, lower urinary tract symptoms, and pain in the right knee and hip, which prevented him from walking. He was diagnosed with renal carcinoma, with lymph node, pulmonary, pleural, hepatic, and adrenal metastases [Figure 1]. In addition, multiple lytic lesions compromised the entire femoral neck and fractures at the lesser trochanter [Figure 2]. It was classified as stage IV T4N1M1 right renal cell adenocarcinoma (conventional type).
|Figure 1: Renal carcinoma, with lymph node, pulmonary, pleural, hepatic, and adrenal metastases|
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|Figure 2: Multiple lytic lesions compromised the entire femoral neck and fractures at the lesser trochanter|
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He was evaluated by ophthalmology for having an upper left scotoma. Fundoscopy revealed vascular tortuosity, with a superior temporal cottony-white spot; In addition, there were two choroidal lesions, one small and elevated peripherally in the upper temporal arcade with a granular center and ill-defined edges; and another larger one in the lower nasal arch with a creamy appearance, elevated, with perilesional serous detachment [Figure 3].
|Figure 3: Choroidal lesion in the lower nasal arch with a creamy appearance, elevated, with perilesional serous detachment|
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B-mode ocular ultrasound was performed, showing two lesions, the first one in the lower nasal quadrant, dome-shaped with associated retinal detachment, with 1.9 mm of height and 6 mm at the base and medium reflectivity. Another is in the retro equatorial and superotemporal region of smaller size without retinal detachment, moderate-to-high reflectivity with 0.8 mm of height and 2.4 mm of the base [Figure 4].
|Figure 4: B-mode ocular ultrasound in the lower nasal quadrant, dome-shaped with associated retinal detachment. Another is in the retroequatorial superotemporal region with moderate-to-high reflectivity|
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| Discussion|| |
The uvea and the choroid are the area of the eye where metastases occur more frequently, reaching approximately 90%. In reports by Shields et al., the most common primary tumor was the breast, followed by the lung, and in a meager percentage, the renal tumor; these data, to a certain extent, are supported by authors from other latitudes where choroidal metastasis with a renal primary neoplasm only occurred in 1% of patients. Patients with metastasis from a renal neoplasm usually present with symptomatic disease in about 60% of cases. Therefore, choroidal involvement must be ruled out in all cancer patients with visual manifestations. However, it is common that the ophthalmologic findings precede knowledge of the presence of an existing neoplasm.
When considering the clinical characteristics of choroidal metastases, between 60% and 82% are present unilaterally, yellowish in 86%, and orange in 8%, accompanied by subretinal fluid in 72%.,, Sometimes, it is difficult to differentiate between melanoma and infectious conditions such as tuberculosis. In primary renal cases, creamy or orange-colored lesions have been reported, with exudative retinal detachment, which can be associated with hemorrhages.,,,, It has been described that orange lesions suggest that the primary lesion is not only renal but also a thyroid or carcinoid tumor.
The ultrasound is a helpful tool for the diagnostic approach of choroidal neoplasms, where the metastases present an average baseline diameter of 9.5 mm and thickness of 3.2 mm, with hyperreflective content in 80% of cases. In metastases of renal origin, the average base size is in a range of 2.8–10.4 mm and 6.5 mm thick, it is usually a single and unilateral mass in 90% of cases, described as a dome lesion with medium-to-high reflectivity and irregular structure,,,, however, there is a case report in the literature where a low internal reflectivity mass is described.
It is essential to consider that these patients have severe and life-threatening diseases; therefore, systemic or local therapy is not always considered. However, in these patients, it has been seen that there is a spontaneous regression of choroidal lesions after nephrectomy, and the possibility of using antiangiogenic drugs to control the disease has been considered. On the other hand, since it is present in patients with marked oncological illness, it does not represent a benefit in the survival of these patients. This is supported by survival analysis, where patients with primary renal choroidal metastasis achieve survival of 26% at 2 years and <10% at 5 years.,,
In conclusion, choroidal metastases from renal carcinoma are a rare condition. In general, these patients present a poor general state, so the eye is hardly considered or considered. For this reason, it is essential that, given a high index of suspicion and with an adequate investigation, the patient is evaluated according to her complaint. It should also be considered that between 8% and 30% of uveal metastases appear before detecting a primary neoplasm and even 16%–25% of cases are never detected. Thus, the ophthalmological diagnostic process is fundamental in unknown cases and the patient's survival.
Statements of ethics
This study adhered to the tenets of the World Medical Association Declaration of Helsinki. The patient gave written informed consent to publish their case.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
The authors have no conflicts of interest to declare. The authors alone are responsible for the content and writing of the article.
| References|| |
Hammad AM, Paris GR, van Heuven WA, Thompson IM, Fitzsimmons TD. Spontaneous regression of choroidal metastasis from renal cell carcinoma. Am J Ophthalmol 2003;135:911-3.
Ferry AP, Font RL. Carcinoma metastatic to the eye and orbit. I. A clinicopathologic study of 227 cases. Arch Ophthalmol 1974;92:276-86.
Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin 2007;57:43-66.
Shields CL, Welch RJ, Malik K, Acaba-Berrocal LA, Selzer EB, Newman JH, et al.
Uveal metastasis: Clinical features and survival outcome of 2214 tumors in 1111 patients based on primary tumor origin. Middle East Afr J Ophthalmol 2018;25:81-90.
] [Full text]
Kang HG, Kim M, Byeon SH, Kim SS, Koh HJ, Lee SC, et al.
Clinical spectrum of uveal metastasis in Korean patients based on primary tumor origin. Ophthalmol Retina 2021;5:543-52.
Imai Y, Matsuura T, Hisakane A, Moritake J, Bando S, Yamada H, et al
. A case of renal cell carcinoma choroidal metastasis diagnosed from vision disorders. Hinyokika Kiyo 2019;65:33-7.
Kreusel KM, Bechrakis N, Wiegel T, Emmerlich T, Foerster MH. Clinical characteristics of choroidal metastasis. Ophthalmologe 2003;100:618-22.
Kaliki S. Uveal metastases: Providing clues to the diagnosis and prognosis! Clin Exp Ophthalmol 2021;49:102-3.
SciELO – Brasil – Metastatic and Aggressive Renal Cell Carcinoma Mimicking a Unilateral Choroidal Tuberculoma Metastatic and Aggressive Renal Cell Carcinoma Mimicking a Unilateral Choroidal Tuberculoma. Available from: https://www.scielo.br/j/abo/a/krPDTNfJVPbsdkYfF8L3Cgw/?lang=en
. [Last accessed on 2022 Jul 4].
Kurashige Y, Otani A, Yoshimura N. Choroidal metastasis of renal cell carcinoma: A case report. Jpn J Ophthalmol 2010;54:111-2.
Elghissassi I, Inrhaoun H, Ismaili N, Errihani H. Choroidal metastasis from tubulopapillary renal cell carcinoma: A case report. Cases J 2009;2:6681.
Blasi MA, Maceroni M, Caputo CG, Sammarco MG, Scupola A, Lenkowicz J, et al.
Clinical and ultrasonographic features of choroidal metastases based on primary cancer site: Long-term experience in a single center. PLoS One 2021;16:e0249210.
Chao AN, Perez-Ordonez B, Hanout M, Rose K, Krema H. Simultaneous choroidal and conjunctival metastases from renal cell carcinoma. Indian J Ophthalmol 2020;68:1652-4.
] [Full text]
Langmann G, Müllner K. Spontaneous regression of a choroidal metastasis from renal carcinoma. Br J Ophthalmol 1994;78:883.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]