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Ocular Tumor in a Woman With Breast and Kidney Carcinomas

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 54-year-old White woman with a history of lobular breast carcinoma in situ treated with lumpectomy as well as chromophobe kidney cell carcinoma treated with partial nephrectomy was referred for evaluation of an asymptomatic, amelanotic choroidal mass in her left eye, suspicious for metastatic disease. On examination, best-corrected visual acuity was 20/20 OU and intraocular pressures were normal in both eyes at 10 mm Hg. Slitlamp biomicroscopy of the anterior chamber was within normal limits in both eyes. Dilated fundus examination revealed normal findings in the right eye and clear vitreous with a subretinal mass in the left eye inferior to the optic disc and measuring 3 × 2 mm in base. Color fundus photography of the left eye (Figure, A) showed an amelanotic lesion under the retina inferior to the optic disc and 3 mm from the foveola surrounded by a subtle orange halo. Fundus autofluorescence (Figure, B) showed the lesion to be hyperautofluorescent. Optical coherence tomography (OCT) imaging of the lesion showed the mass was primarily in the sclera and pushed and thinned the overlying choroid (Figure, C).

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Focal scleral nodule

D. Observe with no additional testing or intervention

The patient’s history of previous breast and kidney cell carcinomas caused suspicion for choroidal metastasis. Breast carcinoma is the most common primary cancer leading to ocular metastasis, comprising approximately 37% to 53% of metastatic choroidal tumors, often appearing as a unifocal, yellow lesion in a middle-aged woman.1 However, in this case, the OCT showed the lesion completely confined to the sclera, with no choroidal component and causing elevation and thinning of the overlying choroid. Metastasis to the uvea commonly arises within the choroid (90% of cases) because of its rich vascularity, but metastasis to the sclera is exceptionally rare.13 Confirmatory testing with fine-needle aspiration biopsy (choice A) is not required since there is no suspicion for choroidal malignancy. Treatment with plaque radiotherapy (choice B) is not appropriate since this is not a malignant tumor posing risk of growth or metastasis. Initiation of intravitreal methotrexate (choice C) is not appropriate as the lesion is benign and does not represent lymphoma or an inflammatory process.

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Article Information

Corresponding Author: Carol L. Shields, MD, Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, 840 Walnut St, Ste 1440, Philadelphia, PA 19107 (carolshields@gmail.com).

Published Online: December 22, 2022. doi:10.1001/jamaophthalmol.2022.5544

Conflict of Interest Disclosures: Dr Shields was supported in part by the Eye Tumor Research Foundation. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Shields  CL , Welch  RJ , Malik  K ,  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(2):81-90. doi:10.4103/meajo.MEAJO_6_18PubMedGoogle ScholarCrossref
2.
Welch  RJ , Malik  K , Mayro  EL ,  et al.  Uveal metastasis in 1111 patients: interval to metastasis and overall survival based on timing of primary cancer diagnosis.   Saudi J Ophthalmol. 2019;33(3):229-237. doi:10.1016/j.sjopt.2019.07.006PubMedGoogle ScholarCrossref
3.
Sarah  B , Ahmed  G , Saloua  B ,  et al.  Nodular scleritis revealing metastasis of breast cancer: diagnosis not to be neglected.   Case Rep Ophthalmol Med. Published online January 29, 2020. doi:10.1155/2020/8689463PubMedGoogle ScholarCrossref
4.
Hong  PH , Jampol  LM , Dodwell  DG , Hrisomalos  NF , Lyon  AT .  Unifocal helioid choroiditis.   Arch Ophthalmol. 1997;115(8):1007-1013. doi:10.1001/archopht.1997.01100160177006PubMedGoogle ScholarCrossref
5.
Shields  JA , Shields  CL , Demirci  H , Hanovar  S .  Solitary idiopathic choroiditis: the Richard B. Weaver lecture.   Arch Ophthalmol. 2002;120(3):311-319. doi:10.1001/archopht.120.3.311PubMedGoogle ScholarCrossref
6.
Fung  AT , Kaliki  S , Shields  CL , Mashayekhi  A , Shields  JA .  Solitary idiopathic choroiditis: findings on enhanced depth imaging optical coherence tomography in 10 cases.   Ophthalmology. 2013;120(4):852-858. doi:10.1016/j.ophtha.2012.09.017PubMedGoogle ScholarCrossref
7.
Fung  AT , Waldstein  SM , Gal-Or  O ,  et al.  Focal scleral nodule: a new name for solitary idiopathic choroiditis and unifocal helioid choroiditis.   Ophthalmology. 2020;127(11):1567-1577. doi:10.1016/j.ophtha.2020.04.018PubMedGoogle ScholarCrossref
8.
Lingam  G , Sen  AC , Lingam  V , Bhende  M , Padhi  TR , Xinyi  S .  Ocular coloboma-a comprehensive review for the clinician.   Eye (Lond). 2021;35(8):2086-2109. doi:10.1038/s41433-021-01501-5PubMedGoogle ScholarCrossref
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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