Choroidal and Orbital Metastases from Thyroid Cancer

Abstract

Background:

Metastases of thyroid carcinomas to the choroid and/or orbit are infrequent. PubMed was searched for English-language articles and case reports published from 1977 to 2012. In our survey, we looked for reports of orbital and/or ocular metastases from the thyroid and found 31 reported cases from 1979 to 2012.

Summary:

At the time of onset of ocular symptoms, the vast majority of patients had a long history of thyroid malignancy and evidence of widely disseminated metastatic disease. The age of the reported patients ranged from 29 to 83 years. Among the 22 reported cases of thyroid carcinomas with metastases to the choroid from 1979 to 2012, the most common primary tumor was papillary thyroid carcinoma (PTC); this occurred in seven patients. This was followed by medullary thyroid carcinoma in six cases and follicular thyroid carcinoma (FTC) in five cases. Orbital metastases were reported in nine patients with thyroid carcinomas (PTC=4, FTC=3, Hürthle cell=1, not specified=1). Patients with choroidal metastases presented with decreased or blurred vision, eye pain, and flashes in 81%, 5%, and 5% of cases, respectively. The diagnosis of a choroidal tumor was usually based on noninvasive diagnostic techniques such as ultrasonography, transillumination, computer tomography (CT), and/or magnetic resonance imaging (MRI) scanning. ¹³¹I scanning revealed uptake in the orbit in 26% of cases with choroidal and/or orbital PTC or FTC. For a metastasis that causes a definitive loss of vision and/or persistent pain, the treatment of choice was enucleation. The other treatment options were brachyradiotherapy using ¹²⁵I episcleral radioactive plaque insertion, external beam radiation, ¹³¹I therapy, chemotherapy, and/or targeted therapy with small molecules.

Conclusions:

The orbit and globe are not common sites for metastatic thyroid carcinomas. Diagnosis of a choroidal tumor is usually based on clinical judgment and results of noninvasive diagnostic techniques such as ultrasonography, transillumination, CT, and/or MRI scanning. Fundoscopic examination and ocular ultrasonography by an ophthalmologist are recommended for identification and monitoring of choroidal metastatic deposits.

Introduction

T he orbit and globe are not common sites for metastatic thyroid carcinomas (1). The aim of our article was to review the published literature about choroidal and orbital metastases of thyroid carcinomas and to present our case report of patients with metastatic Hürthle cell thyroid carcinomas (HCTCs) and choroidal metastases that accumulated ¹³¹I.

Method of Literature Search

PubMed was searched for English-language articles and case reports published from 1977 to 2012. The search was conducted using various combinations of the following keywords: thyroid carcinoma, papillary thyroid carcinoma (PTC), anaplastic thyroid carcinoma (ATC), insular thyroid carcinoma, medullary thyroid carcinoma (MTC), follicular thyroid carcinoma (FTC), HCTC, uveal metastasis, choroid, choroid metastasis, orbital metastases, iris metastasis, and ocular metastasis. In our survey, we looked for reports of orbital and/or ocular metastases from the thyroid and found 31 reported cases from 1979 to 2012.

Results

Epidemiology of choroidal and orbital metastases from all types of cancer

Metastases to the orbit and/or eye from all types of cancer are infrequent (1 –6). As noted by Bernstein-Lipschitz et al. (7), “Metastases of cancer to the orbit and choroid are often found in terminally ill patients with widespread disease. Since in many cases there are no visual symptoms and an autopsy is not performed, the exact incidence of choroidal and orbital metastases in cancer patients is hard to determine.” In a series of 1264 consecutive patients referred for a suspected orbital mass over a 30-year period, Shields et al. (5) found only 91 (7%) metastatic tumors. Char et al. (6) noted just 36 such lesions among 612 (6%) patients with an orbital mass. Among solid tumor malignancies, the ones most commonly found to metastasize to the eye and/or orbit were from the breast and lung, followed by prostatic carcinomas (4). In a series of 950 uveal metastases that were diagnosed in 520 eyes of 420 consecutive patients over a 20-year period among solid tumor malignancies, the ones from the breast (47%) and lung (21%) were most common to metastasize to the eyes (3).

Epidemiology of choroidal metastases from thyroid cancer

In a series of 950 uveal metastases that were diagnosed in 520 eyes of 420 consecutive patients among solid tumor malignancies, only 0.5% of metastases were derived from thyroid carcinomas (3). Similarly, in a series of 227 cases of carcinomas metastatic to the eye or orbit, Font and Ferry (1) reported only one case that had its origin from the thyroid gland. In a review of the English literature, Arat and Boniuk (8) found reports of 12 clinically well-documented cases of choroidal metastases and 2 cases of iris metastases from thyroid carcinomas.

We found that among 22 reported cases of thyroid carcinomas with metastases to the choroid from 1979 to 2012, the most common primary tumor was PTC, occurring in seven patients. This was followed by MTC in six cases and FTC in five cases. Only one case report of choroid metastasis was published describing a patient with HCTC, clear cell carcinoma, insular carcinoma, or squamous thyroid carcinoma. The age of the patients with choroidal metastases reported in Table 1 (4,8 –28) ranged from 29 to 83 years; the median age was 56 years. The median age of the patients with choroidal metastases of PTC, MTC, and FTC was 55, 42.5, and 74 years, respectively.

Table 1.

Patients with Choroidal Metastases

Reference	Age ^a (years), sex	Clinical presentation	Primary tumor type	Ophthalmologic examination	Other metastases	Time to symptoms ^b	Treatment of choroidal metastasis
Ritland et al., 1999 (11)	80, W	Lateral visual field loss in the left eye	FTC	19 mm×15 mm×11 mm orange-brown tumor nasally in the left eye	Lung, mediastinal tumor, bone	40 years	¹³¹I therapy (accumulation in choroidal metastasis), ¹²⁵I plaque
Scott et al., 2008 (16)	50, M	Blurred vision and metamorphopsia in the left eye	FTC	12.9 mm×11 mm×5.6 mm mass in the macula	Lung, bone	5 years	RTX, chemotherapy, bevacizumab
Slamowits et al., 1979 (4)	64, W	Dyschromatopsia of the right eye, light perception, because a total retinal detachment followed spontaneous vitreous hemorrhage	FTC	Pink choroidal mass 9 mm, which accumulated radioactive iodine on diagnostic scan	Right and left paratracheal lesion, bone, lung	7 years	RTX
Arat and Boniuk, 2007 (8)	83, M	1-month bilateral progressive loss of vision	FTC	Iris+bilateral choroid: red iris mass in the left eye, two orange choroidal lesions in the right eye, large subretinal hemorrhage in the posterior pole with a central reddish vascular lesion in the left eye	Lung, bone, liver, skin (widespread metastasis)	Init.	¹³¹I therapy (complete response in iris and partial in choroid)
Seneviratne et al., 2011 (12)	74, W	Asymptomatic	FTC	Large yellow choroidal metastatic lesion in the periphery of the right eye with marked choroidal excavation	Bone, lung, abdominal wall	22 years	RTX
Dutton and Barbour, 1994 (10)	70, M	6 months of decreased vision in right eye	HCTC	Ciliary body pigmented mass 12 mm×13 mm extending beneath the anterior choroid	Lung, right suprarenal metastasis	3 years	¹²⁵I plaque
Present case	69, W	Half of her left visual field became progressively blurred	HCTC	Yellow solid choroidal lesion, measuring 6.5 mm in diameter, causing exudative retinal detachment above the papilla	Bone, lung	7 months	RTX, ¹³¹I therapy (uptake in choroid lesion), chemotherapy
Biswas et al., 2000 (21)	37, M	Right eye vision loss, light perception only	Clear-cell TC	Yellow choroidal mass 15.6 mm thickness	No data available	4 years	Eye enucleation
Avram et al., 2004 (9)	81, M	Vision impairment in the left eye	PTC	Bilateral choroidal lesions	Neck recurrence, mediastinal LN, lung, bone, skin	17 years	¹³¹I therapy (improvement of vision)
Anteby et al., 1992 (13)	55, W	Light flashes in the left eye	PTC	Choroidal mass height 2.7 mm	Mediastinal LN, lung	8 years	¹³¹I therapy (regression of choroid lesion)
Ahmadi et al., 2001 (24)	43, W	Vision loss in the left eye	PTC	Choroidal mass	Lung, bone, brain	30 years	RTX, chemotherapy
Bucerius et al., 2008 (15)	61, W	Decreased and altered color vision in the right eye	PTC	Prominent mass at the posterior pole, prominence of 4.6 mm, linear dimension of 8.25 mm	Mediastinal LN, lung, malignant pleural effusion, skin	3.5 years	RTX
Tran et al., 2011 (23)	36, W	Sudden loss of vision in the nasal field of the left eye	PTC	Bilateral choroidal lesions: left eye, temporal choroidal lesion with retinal detachment; right eye, small subretinal mass	Multiple bone lesions, lung	6 months	¹³¹I therapy (no uptake), RTX (20 Gy in 5 fractions), enucleation of the left eye, palliative chemotherapy, sorafenib
Singh et al., 2003 (14)	70, M	Pain and loss of vision in the left eye for 1 year	PTC occult microcarcinoma	Orange-colored mass in the left eye: 12 mm×11 mm×8 mm, total exudative detachment	No other metastases were detected	Init.	Eye enucleation
Yunta Abarca et al., 1999 (22)	42, M	Sudden partial loss of vision in the left eye	PTC (tall-cell variant)	Choroid mass and hemorrhagic retinal detachment	Bone, brain, skin	4 years	RTX
Søndergaard Pedersen et al., 2007 (26)	29, W	Keratoconjuctivitis sicca and corneal ulceration; choroid metastases asymptomatic	MTC (MEN 2B)	Right eye, five creamy-white choroidal lesions measuring 1–6 mm in diameter; left eye, two small lesions	Bone	NA	Observation (died after 3 months)
Shields et al., 2002 (27)	36, W	No data available	MTC (MEN 2B)	Right choroidal metastasis	Widespread metastases	16 years	RTX
Rosário et al., 2005 (17)	43, M	Blurred vision of the left eye	MTC (sporadic)	Yellow choroidal mass	Cervical and mediastinal LN, lung, liver, bone	8 years	RTX
Bianciotto et al., 2008 (25)	56, M	Asymptomatic	MTC (sporadic)	Bilateral choroidal lesion: right, 2.5 mm×2.5 mm×2 mm; left, 13 mm×12 mm×3 mm	Mass in the right upper eyelid, lung, cervical lymph node, liver	36 years	Observation
Yildiz et al., 2011 (18)	63, M	Sudden loss of vision in the right eye	MTC (sporadic)	Bilateral choroidal metastasis; right, optic disc and choroid lesion 6 mm×6 mm×3 mm; left, 0.7 mm×0.7 mm×1 mm	Widespread metastases: bone, liver, lung, lymph nodes	1 year	Observation (died after 2 months)
Palm and Paridaens, 2007 (19)	42, M	1-month decreasing visual acuity in the right eye	MTC (sporadic)	Bilateral choroidal metastasis: right, yellow 9.5 mm×4 mm; left, no size available	Widespread metastases; mediastinal LN, lungs, bones, bilateral adrenals	Init.	RTX of both eyes
Ozpacaci et al., 2012 (20)	76, M	Total loss of vision in the left eye	Insular TC	Choroidal mass	Left cervical LN, massive bilateral lung metastases	Init.	Eye enucleation
Puri et al., 2001 (28)	46, M	Nasal field loss in the left eye over 2 weeks	Squamous TC	Large dome-shaped single lesion in temporal half of left eye with exudative detachment	No data available	2 years	No data available

Age at initial presentation to the ophthalmologist.

Time to eye symptoms from initial diagnosis.

FTC, follicular thyroid carcinoma; HCTC, Hürthle cell carcinoma; MTC, medullary thyroid carcinoma; MEN 2B, multiple endocrine neoplasia type 2B; LN, lymph nodes; PTC, papillary thyroid carcinoma; TC, thyroid carcinoma; W, woman; M, man; RTX, external-beam radiation; init., initial presentation; NA, data not available.

Most of the patients with choroidal metastases from our review (Table 1) had a known history of thyroid carcinomas that occurred between 0.2 and 36 years (mean 10.4; median 4.5 years) after the thyroid carcinoma diagnosis. The vast majority of patients with choroidal metastases from our review had evidence of widely disseminated metastatic disease (4,9 –20). However, the initial presentation of choroid metastasis originating from a thyroid carcinoma was reported in four cases (8,14,19,20), and one of them had only an occult thyroid carcinoma with a diameter of 2 mm (14). Bilateral choroidal involvement was reported in six cases (27%): three cases of MTC, two cases of PTC, and one case of FTC.

Epidemiology of orbital metastases from thyroid cancer

In the review by Slamovits et al. (4) from 1979, thyroid metastases to the eye or orbit were reported in 16 cases, 11 of which were orbital metastases. However, in our review, we found 22 cases (4,8 –28) of well-documented thyroid eye metastases and only 9 cases of orbital metastases (PTC=4, FTC=3, HCTC=1, not specified=1). Orbital metastases (Table 2) affected bone (2,7,29 –32), muscle (33 –35), and lacrimal gland (7) in six cases, three cases, and one case, respectively.

Table 2.

Patients with Orbital Metastases

Reference	Age ^a (year), sex	Clinical presentation	Primary tumor type	Site of orbital metastasis	Other metastases	Time to symptoms ^b	Treatment of orbital metastasis
Basu et al., 2001 (29)	54, W	Left-sided proptosis, epiphora, and blurred vision	FTC	Lateral wall of the left orbit	Solitary bone orbital metastasis	Init.	¹³¹I therapy (uptake in metastasis)
Bernstein-Lipschitz et al., 1990 (7)	56, W	Diplopia, ptosis, and discomfort in her right orbit	FTC	Lacrimal fossa and destruction of the orbital roof	Solitary bone orbital metastasis	Init.	Surgical debulking
Friedman et al., 1990 (33)	72, M	Pain and redness involving the right eye	FTC	Medial rectus muscle of the right eye	Bone	6 months	Patient declined therapy
Vanderpump and Tunbridge, 1992 (34)	61, M	3-month double vision and painful swelling in the right eye	HCTC	Right medial rectus muscle	Diffuse bone metastases	Init.	Transantral orbital decompression, RTX
Betharia, 1985 (30)	16, W	Diplopia, protrusion of the right eye	NS	Temporal part of right orbit (detected by ¹³¹I uptake on postablative imaging)	Data not available	2 years	¹³¹I therapy, RTX
Boughattas et al., 2005 (31)	25, W	Asymptomatic	PTC	Right supraorbital ridge	Lung	Init.	Not available (¹³¹I uptake in metastasis)
Repanos et al., 2011 (35)	75, M	9-month history of right eye diplopia, proptosis, and reduced visual acuity	PTC	Mid-portion of the right medial rectus muscle	Mediastinum, lung	Init.	Orbital exenteration
Rocha Filho et al., 2008 (32)	66, W	Proptosis of the right eye for 1 year	PTC	Frontal bone mass	Diffuse bone metastases	Init.	RTX, chemotherapy
Daumerie et al., 2000 (2)	59, W	Painless progressive left upper eyelid swelling and exophtalmus	PTC (FV)	Supratemporal quadrant of the left orbit	Bone, mediastinum	Init.	¹³¹I therapy (uptake in metastasis)

Age at initial presentation to the ophthalmologist.

Time to eye symptoms from initial diagnosis.

NS, not specified (follicular cell origin); FV, follicular variant.

The age of the patients with orbital metastases ranged from 16 to 75 years; the median age was 59 years. The patients with orbital metastases of PTC or FTC had median ages of 62.5 and 56 years, respectively.

An orbital metastasis was the initial presentation of thyroid carcinomas in seven of nine cases (78%). None of the patients with orbital metastases had MTC. This probably reflects a lower incidence and propensity of MTC to cause bone metastases compared to differentiated carcinomas of the follicular epithelium.

Symptoms and signs of choroidal metastases

As noted by Shield et al. (3), decreased vision is the common symptom if a choroidal metastasis involves the optic nerve or macula. If a metastasis is associated with an overlying retinal detachment, it can present with flashing lights and floaters (3). In a series of 520 eyes with uveal metastases from solid tumor malignancies, the predominant symptoms were decreased or blurred vision in 70% of the patients (3). Furthermore, only 11% of the patients with choroidal metastases were asymptomatic (3). The patients with choroidal metastases of thyroid carcinomas from our report presented with decreased or blurred vision, flashes, and pain in 81%, 5%, and 5% of cases, respectively. Only three patients (15%) were asymptomatic.

Symptoms and signs of orbital metastases

The metastatic involvement of the orbit originating from any malignancy is a common cause of unilateral proptosis (5). Unilateral proptosis can be of neoplastic origin, even if thyroid function tests suggest hyperthyroidism, and it necessitates investigation with a computer tomography (CT) scan of the orbit (33). Char et al. (6) reported on 31 patients treated because of orbital metastases of various origins. Their patients presented with diplopia (48%), proptosis (26%), pain (19%), decreased vision (16%), and ptosis (10%). Patients with orbital metastases from our report (Table 2) presented with diplopia (44%), proptosis (56%), pain (22%), decreased vision (22%), and ptosis (11%). Only one of our patients was asymptomatic.

Diagnostics of choroidal and orbital metastases from cancers

After abrupt changes in visual acuity, a fundoscopic examination and ocular ultrasonography by an ophthalmologist are recommended for the identification and monitoring of choroidal metastatic deposits (9). Diagnosis of a choroidal tumor is usually based on clinical judgment and results of noninvasive diagnostic techniques such as ultrasonography, transillumination, CT, and/or MRI scanning (11).

Shields et al. (3), in a survey of 520 eyes with uveal metastases from various solid tumor malignancies, reported that the posterior choroid accounted for most metastatic foci (88%), while metastatic foci were detected also in the iris (9%) and ciliary body (2%). Furthermore, choroidal metastases assumed a yellow color in 94% of cases when viewed through the ophthalmoscope (3). However, choroidal metastases in PTCs, FTCs, or HCTCs were red, yellow, or orange color in only 40% of cases based on our review (Table 1). Furthermore, choroidal metastases in FTCs assumed a yellow color in only one of four cases. On the other hand, metastases were yellow in all three cases with MTCs in whom the color was described.

Diagnostics of choroidal and orbital metastases of thyroid cancer

Choroidal metastases are diagnosed mostly based on clinical examinations and ultrasonography (11). When the initial presentation of a malignancy is a choroidal or orbital metastasis, a fine-needle aspiration biopsy (FNAB) may be performed to find out the origin of the primary tumor (11). It is the most useful diagnostic tool (6), because it is safe and reliable. Instead of an FNAB, a biopsy using a 25-gauge vitrector may be carried out in selected cases, performing a transretinal choroidal biopsy to confirm the diagnosis (16). Using a 25-gauge vitrector is regarded as a safe procedure (16).

The diagnosis of orbital metastases also can be established by an open biopsy. Usually, an open biopsy was performed if the correct diagnosis was not determined when a focal mass was present, or if a metastasis had to be therapeutically debulked regardless of the histology (6). An open biopsy was performed in six of the nine patients in the reviewed literature; only one patient had a core biopsy, and none had an FNAB.

Positive immunochemical staining for the presence of thyroglobulin in metastatic cells is the most conclusive diagnostic evidence that the origin of a metastasis is the thyroid (7). Follicular thyroid cells are the only ones that have the ability to produce thyroglobulin, and most differentiated tumors of follicular cell origin retain this ability (36). In addition, the accumulation of ¹³¹I shown by scintigraphy is specific for metastases of differentiated thyroid carcinomas. The uptake of ¹³¹I in the choroidal metastasis of PTCs, FTCs, or HCTCs (Table 1) was reported in 3 of 14 patients (21%). On the other hand, uptake of ¹³¹I in orbital metastases was reported in three of nine (33%) patients with PTCs, FTCs, or HCTCs (Table 2).

Treatment of choroidal metastases from thyroid cancer

Enucleation is the treatment of choice for metastases of thyroid carcinomas to the eye that cause a definitive loss of vision and/or persistent pain (14,20,21,23). The other treatment options are ¹³¹I therapy (8,9,11,13,23), external beam radiation (4,12,15 –17,19,22 –24,27), brachyradiotherapy using ¹²⁵I episcleral radioactive plaque insertion (10,11), chemotherapy (16,23,24), and targeted therapy with monoclonal antibodies (16) and/or small molecules (23).

Treatment with ¹³¹I

The treatment of choroidal metastases with ¹³¹I was reported in 5 of 13 patients with PTC, FTC, or HCTC (8,9,11,13,23). The ¹³¹I treatment had no effect on only one of them (23). Anteby et al. (13) found that choroidal metastasis from PTC responded to ¹³¹I treatment. The choroidal metastasis height decreased from 2.7 to<1 mm four months after the ¹³¹I treatment (13). Furthermore, therapy with ¹³¹I may be followed by a decrease in the size of the lesions as well as improvement of vision (9). Arat and Boniuk (8) observed a complete resolution of an iris metastasis and a regression of one of the choroidal metastases from PTCs after ¹³¹I therapy. Unfortunately, only Arat and Boniuk (8) reported the duration of effect of the ¹³¹I treatment; this was longer than 18 months. Because thyroxine withdrawal causes prolonged thyrotropin (TSH) stimulation, it may lead to accelerated progression of metastatic lesions, with important clinical consequences, especially for patients with brain and choroidal metastases (9). Therefore, administering ¹³¹I therapy after recombinant human TSH (rhTSH) stimulation should be considered to minimize tumor progression and clinical sequelae (9).

External beam radiation

In the case of nonradioactive iodine–avid tumors, ocular external beam radiation remains a therapeutic option (24). External beam radiation is a good treatment option because it is noninvasive and can produce a long-lasting effect. Ocular external beam radiation was effective in six of the ten patients with choroid metastases (4,12,15 –17,19,22 –24,27). Beneficial effects of radiation lasted from 5 to 16 months. However, total retinal detachment occurred in two cases, and the progression of choroidal metastases was reported in three other cases (one immediate, one after 5 months, and one after 16 months).

¹²⁵I episcleral radioactive plaque insertion

Another effective approach is brachyradiotherapy using ¹²⁵I episcleral radioactive plaque insertion (10,11). Ritland et al. (11) reported that tumor thickness decreased from 11 to 6.4 mm 3 months after the ¹²⁵I plaque insertion therapy. Duton et al. (10) reported that the effect lasted 24 months.

Tran et al. used chemotherapy as a palliative procedure (23). Advances in the understanding of molecular biology in metastases originating from DTC enabled recent favorable results with small-molecule therapy in patients with metastatic thyroid carcinoma (37 –39). Tran et al. (23) used sorafenib, while Scott et al. (16) used bevacuzimab in their patients.

Treatment of orbital metastases of thyroid cancer

As noted by Char et al. (6), in a patient with orbital metastases and suddenly decreased vision due to a mass compressing the optic nerve, surgical debulking of the tumor is the optimal treatment, and vision may be restored in such cases. Surgical debulking was performed in two cases in the reviewed literature (9,34), while orbital exenteration was performed in one case (35).

Bougattas et al. (31) reported uptake of ¹³¹I in orbital metastases on postablative ¹³¹I imaging. Three patients were treated with ¹³¹I; in two of them, a good response was observed in the orbital metastasis (2,29).

External beam radiation is another treatment used in patients with a solitary orbital metastasis that was diffuse or that involved an important structure, such as the muscle, globe, or nerve (6). It was performed in three patients (30,32,34), but it was reported to be effective in only one of these cases (32). As emphasized by Char et al., it is imperative to obtain a brain MRI scan before irradiating a metastatic orbital tumor, because often patients have silent brain lesions when they present with an orbital disease (6). Failure to obtain these imaging studies can result in patients having the same anatomical area re-irradiated with resultant increased morbidities (6).

Illustrative Case: Metastatic HCTC to the Choroid Detected by Post-Therapeutic ¹³¹I Scintigraphy

In July 2010, a 69-year-old woman was referred to the Institute of Oncology Ljubljana for further diagnosis and treatment because of a CT-proven 5th lumbar vertebral metastasis of unknown origin. FNA cytology of the left thyroid nodule was suspicious for PTC. The serum thyroglobulin level and the anti-thyroglobulin antibody concentration were elevated to >5000 μg/L (reference <80 μg/L) and 165 kU/L (reference <30 kU/L), respectively.

In August 2010, she underwent a total thyroidectomy, with exploration of the cervical lymph nodes. Histopathology revealed moderately differentiated HCTC. The dominant lesion in the left lobe measured 6.3 cm×4 cm and was widely invasive. Furthermore, focal vascular invasion was present. According to the TNM classification, the tumor was staged as pT3N1M1.

After thyroid surgery, the patient received suppressive doses of l-thyroxine. Three weeks later, a right hemilaminectomy of L5 and a metastasectomy were performed to decompress the L5 and S1 spinal nerves. The tumor had invaded the dura and the L5 radix. The histopathology of the metastasis confirmed the diagnosis of metastatic HCTC. In October 2010, ¹³¹I (3.74 GBq) ablation of the thyroid remnant using rhTSH was performed. The post-therapeutic whole-body scintigraphy revealed lesions in the bones and lungs and also an increased accumulation of ¹³¹I in the projection of the left orbit, which might have been caused by physiological accumulation of iodine in the tear gland or by metastasis (Fig. 1A). A chest CT scan showed pathologic mediastinal hilar lymph nodes, and a small diffuse hematogenous pulmonary metastasis. In December 2010, external beam radiation (a total dose of 40 Gy; 2.50 Gy per fraction) of the lumbar spine (L4 to S1 segment) was performed, with concomitant chemotherapy using 20 mg of Adriamycin and 2 mg of Vinblastine, administered by a 12-hour infusion once a week.

FIG. 1.

Comparison of whole-body scintigraphies obtained in October 2010 (A) and in June 2011 (B), 2 days after administration of radioactive iodine.

In February 2011, the patient noted impaired vision in her left eye. During the next month, half of her left visual field became progressively blurred. An ocular examination was unremarkable apart from an early stage of nuclear and cortical cataract formation in both eyes. Fundoscopy of the left eye revealed an exudative retinal detachment in the upper nasal quadrant with a solid lower detachment, which covered part of the papilla. A developing macular detachment was also present. Ophthalmoscopy of the right eye was normal. The fluorescein angiogram showed hyperfluorescence in the upper part of the left retina above the papilla. The echography of the left eye revealed an irregular solid choroidal lesion, measuring ∼6.5 mm in diameter, with some circular hypoechogenic regions, causing exudative retinal detachment above the papilla. The echographic image was typical of an ocular metastasis. The MRI scan of the head confirmed a mass in the choroid of the left eye (Fig. 2). Since ¹³¹I accumulated in this lesion, it was diagnosed as a thyroid carcinoma metastasis to the eye. However, ¹³¹I treatment of the choroid metastasis was not an option, as the uptake of ¹³¹I in the choroid metastasis was minimal, while multiple ¹³¹I-avid metastases were present elsewhere. Therefore, external-beam radiation with a total dose of 40 Gy was performed, as it was considered to be noninvasive and could produce a long-lasting effect. This was followed by administration of a therapeutic dose of 7.55 GBq of ¹³¹I after rhTSH application. Only a trace of ¹³¹I accumulated within the ocular metastasis. The control eye echography performed in July 2011 showed a partial regression of the metastatic choroidal lesion (measuring 5 mm in thickness). The last ophthalmologic examination in June 2012 revealed no increase in metastasis. However, a complete loss of vision in the left eye, because of total exudative detachment of the retina, was present.

FIG. 2.

Magnetic resonance-imaging (T1) coronal (A) and axial (B) scan showing a left intraocular nasal mass, indicating progression of the disease.

Unfortunately, despite good uptake of the administered ¹³¹I, new metastatic lesions in the right femur and cranium were detected by a post-therapeutic ¹³¹I scintigraphy (Fig. 1B). Another MRI scan of the head was performed in August 2011, which excluded brain metastases and showed a new metastatic lesion in the cranium. An MRI scan performed in June 2012 provided evidence that the lesion had begun to grow, and therefore it was treated with external radiation. In September 2012, a rapid progression of multiple metastatic lesions systemic was detected; therefore chemotherapy was initiated in accordance with our institutional guidelines.

Conclusion

In conclusion, the orbit and globe are not common sites for metastatic thyroid carcinomas. The diagnosis of a choroidal and orbital metastasis from thyroid carcinoma is usually based on clinical judgment and results of ultrasonography, transillumination, CT, and/or MRI scanning. Effective treatment options for a metastasis of thyroid carcinomas to the eye include external-beam radiation, ¹³¹I therapy, and brachyradiotherapy using a ¹²⁵I episcleral radioactive plaque insertion. Enucleation is the treatment of choice for the minority of patients with a metastasis that causes a definitive loss of vision and/or persistent pain.

Footnotes

Disclosure Statement

The authors declare that there are no commercial associations that might create a conflict of interest in connection with this article.

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Choroidal and Orbital Metastases from Thyroid Cancer

Abstract

Background:

Summary:

Conclusions:

Introduction

Method of Literature Search

Results

Epidemiology of choroidal and orbital metastases from all types of cancer

Epidemiology of choroidal metastases from thyroid cancer

Epidemiology of orbital metastases from thyroid cancer

Symptoms and signs of choroidal metastases

Symptoms and signs of orbital metastases

Diagnostics of choroidal and orbital metastases from cancers

Diagnostics of choroidal and orbital metastases of thyroid cancer

Treatment of choroidal metastases from thyroid cancer

Treatment with 131I

External beam radiation

125I episcleral radioactive plaque insertion

Treatment of orbital metastases of thyroid cancer

Illustrative Case: Metastatic HCTC to the Choroid Detected by Post-Therapeutic 131I Scintigraphy

Conclusion

Footnotes

Disclosure Statement

References

Treatment with ¹³¹I

¹²⁵I episcleral radioactive plaque insertion

Illustrative Case: Metastatic HCTC to the Choroid Detected by Post-Therapeutic ¹³¹I Scintigraphy