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A 67-year-old white female patient with metastatic breast cancer, currently taking capecitabine plus trastuzumab, presented with 2 weeks of painless reduced vision in her right eye (OD). Her breast cancer was diagnosed in 2007 as stage IA estrogen-receptor positive, progesterone-receptor negative (ER+, PR−), and human epidermal growth factor 2 (ERBB2; formerly HER2) negative, initially treated with lumpectomy plus left breast radiotherapy followed by doxorubicin, cyclophosphamide, paclitaxel, and anastrazole. In 2017, metastases were found in the lumbar spine and lung and treated with fulvestrant and palbociclib plus left brachial plexus radiotherapy. Later, progressive liver metastasis and repeat biopsy with equivocal ERBB2 testing led to treatment with capecitabine plus trastuzumab.
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Breast cancer with bilateral choroidal metastases
C. Obtain MRI of the head and orbits
The key to the correct diagnosis of bilateral choroidal metastases is the recognition of characteristic solid yellow choroidal tumors with subretinal fluid in a patient with known metastatic cancer. MRI confirmed a lesion in the posterior right globe in addition to multiple metastases in the cerebellum (Figure 2). Ocular adverse effects from chemotherapy do not manifest as solid choroidal tumors, and treatment should be continued. Both corticosteroids and intravitreal anti-VEGF are not proven in treating choroidal metastases.1,2
The differential diagnosis for vision changes in a patient undergoing treatment for malignancy is broad and includes tumor invasion into ocular or neural structures, paraneoplastic syndromes, secondary vascular disease, and adverse effects of chemotherapy or radiotherapy. Thus, prompt ophthalmic evaluation is important for patients with cancer who have persistent visual symptoms.
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Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Hospital, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (email@example.com).
Published Online: August 22, 2019. doi:10.1001/jama.2019.12691
Conflict of Interest Disclosures: None reported.
Funding/Support: Support provided, in part, by the Eye Tumor Research Foundation (Dr Shields).
Role of the Funder/Sponsor: The Eye Tumor Research Foundation had no role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: We thank the patient for granting permission to publish this information.
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