|Year : 2014 | Volume
| Issue : 1 | Page : 37-39
Adenocarcinoma of the lung presenting as retinal detachment
Kaushik Saha1, Koushik Bose2, Arnab Saha1, Subhasis Jana3
1 Department of Pulmonary Medicine, Burdwan Medical College, Burdwan, Kolkata, West Bengal, India
2 Department of Ophthalmology, Burdwan Medical College, Burdwan, Kolkata, West Bengal, India
3 Department of Radiotherapy, Burdwan Medical College, Burdwan, Kolkata, West Bengal, India
|Date of Web Publication||20-Mar-2014|
Rabindra Pally, 1st Lane, P. O. Nimta, Kolkata - 700 049, West Bengal
Retinal detachment is a rare presentation of lung cancer. A young female presented with blurring of vision in her right eye for the last 10 days without any history of trauma. On indirect ophthalmoscopy, there was a presence of right sided retinal detachment which was treated with oral prednisolone (60 mg/day). After 1 month of continuous treatment, she came back with dry cough left sided chest pain and deterioration of her eye symptoms. Chest X-ray showed left lung mass. Computed tomography guided fine needle aspiration cytology and with immunohistochemistry confirmed adenocarcinoma of the lung. She was treated with 6 cycles of chemotherapy with paclitaxel and gemcitabine.
Keywords: Adenocarcinoma, lung, retinal detachment
|How to cite this article:|
Saha K, Bose K, Saha A, Jana S. Adenocarcinoma of the lung presenting as retinal detachment. Sahel Med J 2014;17:37-9
| Introduction|| |
Intraocular malignancies are most commonly due to metastasis from other primary sites.  Choroid is the most frequently involved site followed by iris, ciliary body, optic nerve, neural retina and vitreous.  Retinal detachment is a uncommon presentation of eye metastasis from non-small cell carcinoma of the lung. We report a young non-smoker female with primary non-small cell carcinoma of the lung presenting as optic neuritis and unilateral retinal detachment.
| Case Report|| |
The present case report is about a 32-year-old young non-smoker female patient who presented to a local eye clinic with headache and sudden onset of painless blurred vision in her right eye for the last 10 days. Her blurring of vision was not associated with floaters, flashes of light and night blindness. She had no past history of trauma or ocular surgery. She is non-diabetic and non-hypertensive. On thorough ophthalmological examination, her best corrected visual acuity was 20/200 in her right eye (oculus dexter [OD]) and 20/20 in the left eye (oculus sinister [OS]). Indirect ophthalmoscopy showed right sided retinal detachment. A diagnosis of right sided retinal detachment was made and treatment was started with high dose of oral corticosteroid (prednisolone 60 mg) and amoxicillin-clavulanic acid.
One month after this therapy, she developed an insidious onset of dry cough and left sided chest pain. She visited a local physician for her symptoms. Her complete blood count was normal. Sputum for acid fast bacilli for consecutive 2 days was negative. On the basis of her chest X-ray she was put on oral amoxicillin-clavulanic acid and azithromycin for 5 days with no relief. She was therefore referred to our pulmonary medicine outdoor for opinion. Her chest X-ray showed a homogenous opacity with irregular margin in left lower zone of lung field suggestive of mass lesion. Computed tomography (CT) scan thorax with contrast showed left lower lobe lung mass [Figure 1]a. On fiber-optic bronchoscopy, no intra-bronchial growth was found. CT guided fine-needle biopsy revealed highly cellular smear of columnar, cuboidal or polygonal cells with round to oval nuclei in fine vacuolated cytoplasm with a high nuclear/cytoplasm ratio suggestive of adenocarcinoma [Figure 1]b. Primary lung adenocarcinoma was confirmed by immunocytochemistry. It was positive for thyroid transcription factor-1 and negative for p63 and cytokeratin 5/6. Her ultrasonography of whole abdomen was normal.
|Figure 1: Computed tomographic of thorax showing left lower lobe lung mass (a) om that lesion showing highly cellular smear of columnar, cuboidal or polygonal cells with round to oval nuclei in fine vacuolated cytoplasm with a high nuclear/ cytoplasm ratio suggestive of adenocarcinoma (b)|
Click here to view
Due to the presence of her eye symptoms and right sided retinal detachment she was referred to our ophthalmologic outdoor to exclude optic metastasis. A thorough ophthalmologic examination was done. Her best corrected visual acuity remained same as before. Anterior segment and slit lamp examination was unremarkable. Pupil was normal in size and marked relative afferent pupillary defect was present. Left sided pupil was normal size and normal reacting. Ocular movement was normal in all gazes and intra-ocular pressure was OD-10 mmHg and OS-12 mmHg by applanation tonometry. Indirect ophthalmoscopic examination revealed hyperemic edematous optic disc with blurred disc margin. Inferior temporal vessels were tortuous and elevated. An ill-defined, yellow-white elevated lesion about three to four times the disc diameter in size, infero-temporal to the disc, along the inferior temporal vessels located far peripheral region of retina suggestive of a detached retina due to choroidal metastasis. Color fundus photograph also corroborated the findings of indirect ophthalmography, but it did not capture the peripheral margin of the lesion [Figure 2]. Fluorescein angiography revealed early phase hypofluorescence and late phase hyperfluorescence of the metastatic lesion, hyperfluorescence of macula associated with retinal edema [Figure 3]a and b. Optic disc was hyperfluorescence suggestive of optic neuritis. There was no leak of fluorescein in the lesion. The left eye was normal. Brain CT scan the was normal. Diagnosis of primary lung adenocarcinoma was made with right sided choroid metastasis in a young non-smoker female. She was treated with 6 cycles of chemotherapy with paclitaxel and gemcitabine and after 4 months of completion of treatment she was well with a minimal improvement of her eye symptoms.
|Figure 2: Colour fundus photograph of right eye showing an ill-defined, yellow-white elevated lesion about three to four times the disc diameter in size, infero-temporal to the disc, along the inferior temporal vessels located far peripheral region of retina suggestive of detached retina due to choroidal metastasis|
Click here to view
|Figure 3: Fluorescein angiography revealed early phase hypofluorescence (a) and late phase hyperfluorescence of the metastatic lesion, hyperfluorescence of macula associated with retinal oedema (b)|
Click here to view
| Discussion|| |
Ocular manifestation as a first presenting sign of disseminated cancer is very rare entity.  Uveal tract is the most common site of the eye involvement by metastases due to high vascular supply. The most frequently affected site within the uvea is the choroid (88%) followed by the iris (9%) and ciliary body (2%).  Amongst all the ocular metastasis in adults, the lung and breast carcinoma are the two most common primary tumors followed by genitourinary, gastrointestinal malignancy and metastases of unknown origin. , Ocular metastasis presenting as optic neuritis and retinal detachment, as in the index case is very rare. 
The most common presenting sign of ocular metastasis is dimness or blurred vision which may be unilateral or bilateral depending on the site and extent of involvement followed by pain, photopsia, red eye, floaters and field defects. Choroid metastasis is hematogenous probably due to its high vascularity. On fluorescein angiography, in the early phase these lesions shows hypofluorescence and become progressively hyperfluorescent in the late phases. 
Lung cancer in young usually presents as benign symptoms initially. Most lung cancer in early stage are therefore easily overlooked and almost all the lung cancer in young age group presents as advanced disease.  When a lung cancer presents in a young it is generally aggressive in nature due to highly vascular invasion and poor differentiation of malignant cells. 
The diagnosis of the choroidal metastasis in a young patient with lung cancer usually indicates an advanced disease stage with metastasis. It is also a very poor prognostic indicator with reported median survival of 3.3 months (range: 0.5-19 months). 
| Conclusion|| |
Choroidal lesion in a patient with unexplained chronic dry cough and pulmonary mass lesion should raise a suspicion of lung cancer with rare choroidal metastasis.
| References|| |
|1.||Singh A, Singh P, Sahni K, Shukla P, Shukla V, Pant NK. Non-small cell lung cancer presenting with choroidal metastasis as first sign and showing good response to chemotherapy alone: A case report. J Med Case Rep 2010;4:185. |
|2.||Weiss L. Analysis of the incidence of intraocular metastasis. Br J Ophthalmol 1993;77:149-51. |
|3.||Buys R, Abramson DH, Kitchin FD, Gottlieb F, Epstein M. Simultaneous ocular and orbital involvement from metastatic bronchogenic carcinoma. Ann Ophthalmol 1982;14:1165-7, 1170-1. |
|4.||George B, Wirostko WJ, Connor TB, Choong NW. Complete and durable response of choroid metastasis from non-small cell lung cancer with systemic bevacizumab and chemotherapy. J Thorac Oncol 2009;4:661-2. |
|5.||Goldberg RA, Rootman J. Clinical characteristics of metastatic orbital tumors. Ophthalmology 1990;97:620-4. |
|6.||Char DH, Miller T, Kroll S. Orbital metastases: Diagnosis and course. Br J Ophthalmol 1997;81:386-90. |
|7.||Mack HG, Jakobiec FA. Isolated metastases to the retina or optic nerve. Int Ophthalmol Clin 1997;37:251-60. |
|8.||Davis DL, Robertson DM. Fluorescein angiography of metastatic choroidal tumors. Arch Ophthalmol 1973;89:97-9. |
|9.||Pemberton JH, Nagorney DM, Gilmore JC, Taylor WF, Bernatz PE. Bronchogenic carcinoma in patients younger than 40 years. Ann Thorac Surg 1983;36:509-15. |
|10.||Sekine I, Yokose T, Ogura T, Suzuki K, Nagai K, Kodama T, et al. Microsatellite instability in lung cancer patients 40 years of age or younger. Jpn J Cancer Res 1997;88:559-63. |
[Figure 1], [Figure 2], [Figure 3]