Optic Disc Metastasis as the Presenting Sign of Lung Adenocarcinoma

A 67-year-old woman noticed vision loss in her right eye and was found to have an elevated, well-circumscribed white mass within the right optic disc. The patient underwent an evaluation which revealed 4 brain metastases and a large left hilar mass that proved to be adenocarcinoma of the lung. Because she continued to lose vision, the optic disc metastasis was treated with stereotactic radiotherapy. Although she reported vision improvement, she died soon afterward. There are 9 previous reports in the English literature of isolated optic disc metastasis as the presenting sign of cancer. Familiarity with the features of optic disc metastasis can lead to earlier recognition and treatment of the underlying malignant neoplasm.

Photo Essay Section Editor: Timothy J. McCulley, MD Optic Disc Metastasis as the Presenting Sign of Lung Adenocarcinoma Jonathan A. Micieli, MD, CM, Edward A. Margolin, MD FIG. 1. There is a well-circumscribed white mass with fine blood vessels on the surface of the right optic disc. The left fundus is unremarkable. Abstract: A 67-year-old woman noticed vision loss in her right eye and was found to have an elevated, well-circumscribed white mass within the right optic disc. The patient underwent an evaluation which revealed 4 brain metastases and a large left hilar mass that proved to be adenocarcinoma of the lung. Because she continued to lose vision, the optic disc metastasis was treated with stereotactic radiotherapy. Although she reported vision improvement, she died soon afterward. There are 9 previous reports in the English literature of isolated optic disc metastasis as the presenting sign of cancer. Familiarity with the features of optic disc metastasis can lead to earlier recognition and treatment of the underlying malignant neoplasm. Journal of Neuro-Ophthalmology 2016;36:399-401 doi: 10.1097/WNO.0000000000000428 © 2016 by North American Neuro-Ophthalmology Society Department of Ophthalmology and Vision Science, University of Toronto, Toronto, Ontario, Canada. The authors report no conflicts of interest. Address correspondence to Edward A. Margolin, MD, Department of Ophthalmology and Vision Sciences, University of Toronto, 801 Eglington Avenue West, Suite 301, Toronto, ON, M5N 1E3; E-mail: [e-mail] Micieli and Margolin: J Neuro-Ophthalmol 2016; 36: 399-401 A 67-year-old woman noticed a gradual decline in vision in her right eye over 3 weeks. She was reported to have right optic disc edema, and her erythrocyte sedimentation rate was elevated at 80 mm/h. She was treated with methylprednisolone 1 gm IV for 3 days followed by prednisone 50 mg daily for presumed giant cell arteritis. A temporal artery biopsy was negative, and she was referred to our neuro-ophthalmology service. On our evaluation 2 months after her visual symptoms began, the patient reported that her vision continued to slowly decline in the right eye. She denied other neurological symptoms. Her medical history was unremarkable, and her medications included prednisone 50 mg/d, rabeprazole, and aspirin, which were all initiated during her recent episode of vision loss. On examination, visual acuity was 20/40 in each eye with a right relative afferent pupillary defect. The anterior segment of each eye appeared normal. Funduscopy of the right eye revealed a well-circumscribed white mass on the surface of the optic nerve head, whereas the left fundus was normal (Fig. 1). Visual field testing revealed an enlarged blind spot and inferonasal defect in the right eye, and the left visual field was normal (Fig. 2). Physical and neurological examinations were otherwise unremarkable. Brain magnetic resonance imaging 399 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay FIG. 2. The right visual field shows inferior loss, and the left field is normal. revealed four ring-enhancing lesions in the cerebellum and left posterior parietal lobe (Fig. 3). Imaging of the chest in search of a primary cancer demonstrated a left hilar mass measuring over 6 cm in maximum dimension with enlarged mediastinal lymph nodes (Fig. 4). Biopsy of the mass revealed adenocarcinoma of the lung. The patient underwent treatment with systemic chemotherapy, including cisplatin and etoposide and weekly carboplatin and paclitaxel and whole-brain radiation. Six weeks later, visual acuity had declined in the right eye to 20/60 with worsening of the right visual field. The patient underwent low-dose stereotactic radiotherapy to treat the optic disc metastasis. Her condition continued to decline and systemic treatment was stopped 4 months later. She was referred to palliative care and died shortly thereafter. FIG. 3. Postcontrast axial T1 magnetic resonance imaging reveals ring-enhancing lesions (arrows) in the left parietal lobe (A) and cerebellum (B). 400 Micieli and Margolin: J Neuro-Ophthalmol 2016; 36: 399-401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay Our case highlights the clinical features of optic disc metastasis, which may be the presenting sign of malignancy. Early recognition of this rare entity can lead to more rapid initiation of systemic treatment, hopefully salvaging vision and leading to an improved prognosis for survival. FIG. 4. Magnetic resonance imaging of the chest demonstrates a left hilar mass measuring over 6 cm in maximum dimension (arrow) with enlarged mediastinal lymph nodes. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: Jonathan Micieli, Ed Margolin; b. Acquisition of data: Jonathan Micieli, Ed Margolin; c. Analysis and interpretation of data: Jonathan Micieli, Ed Margolin. Category 2: a. Drafting the manuscript: Jonathan Micieli, Ed Margolin; b. Revising it for intellectual content: Jonathan Micieli, Ed Margolin. Category 3: a. Final approval of the completed manuscript; Jonathan Micieli, Ed Margolin. REFERENCES The majority of metastatic cancers to intraocular structures involve the uveal tract and metastases to the optic disc are rare (1). Most metastatic neoplasms that involve the optic nerve are carcinomas, although cutaneous melanoma also has been reported (2). A review of the English literature produced 9 patients with isolated optic disc metastases as the presenting sign of cancer of which 3 were reported to be secondary to lung cancer (3-10). One of these reports included pathology from the primary lung neoplasm (3), which proved to be small-cell lung cancer. The other 2 case reports did not provide the pathology. In addition, there are reports of 52 cases of metastatic disease involving the optic disc with adjacent choroidal metastases. The most common primary tumors were breast (21 cases), lung (14 cases), and prostate (3 cases) followed by 1 case from the mediastinum (6), esophagus (11), pancreas (7), intestine (3), thyroid (12), larynx (13), and cutaneous melanoma (2). We did not find any cases of proven lung adenocarcinoma metastatic to the optic disc in the English language literature even when the adjacent choroid was included. There are no consensus treatment guidelines for patients with decreased vision from optic disc metastasis. In the largest series to date, Shields et al (3) recommended that patients undergo external beam radiation (35-40 Gy) to the posterior segment of the eye and the anterior orbit, in addition to the appropriate systemic chemotherapy. Micieli and Margolin: J Neuro-Ophthalmol 2016; 36: 399-401 1. Shields CL, Shields JA, Gross N, Schwartz G, Lally S. Survey of 520 uveal metastases. Ophthalmology. 1997;104:1265- 1276. 2. Pollock SC, Awh CC, Dutton JJ. Cutaneous melanoma metastatic to the optic disc and vitreous. Arch Ophthalmol. 1991;109:1352-1354. 3. Shields JA, Shields CL, Singh AD. Metastatic neoplasms in the optic disc. Arch Ophthalmol. 2000;118:217-224. 4. Muci-Mendoza R, Arevalo F, Ramella M, Fuenmayor-River D. Optic nerve metastasis from oat cell lung adenocarcinoma: regression after radiotherapy. Ophthalmic Surg Lasers. 2001;32:349-351. 5. Cherington FJ. Metastatic adenocarcinoma of the optic nerve-head and adjacent retina. Br J Ophthalmol. 1961;45:227-230. 6. Ballantyne AJ. A case of metastatic sarcoma of the optic nerve and retina. Trans Ophthalmol Soc UK. 1906;26:111. 7. Ring HG. Pancreatic carcinoma with metastasis to the optic nerve. Arch Ophthalmol. 1967;77:798-800. 8. Gallie BL, Graham JE, Hunter WS. Optic nerve head metastasis. Arch Ophthalmol. 1975;93:983-986. 9. Arnold AC, Hepler RS, Foos RY. Isolated metastasis to the optic nerve. Surv Ophthalmol. 1981;26:75-83. 10. Yang HS, Jeong HR, Kim CW, Yoon YH, Kim JG. Histological heterogeneity between primary cancer in a pathologic confirmed case of isolated optic disc metastasis of prostate adenocarcinoma. Graefes Arch Clin Exp Ophthalmol. 2013;251:375-378. 11. Ginsberg J, Freemond AS, Calhoun JB. Optic nerve involvement in metastatic tumors. Ann Ophthalmol. 1972;87:642-645. 12. Yildiz I, Sen F, Tuncer S, Kilic L, Basaran M, Bavbek S. Optic disc and choroidal metastasis from sporadic medullary thyroid carcinoma: case report and review of the literature. Onkologie. 2011;34:630-633. 13. Adachi N, Tsuyama Y, Mizota A, Fujimoto N, Suehiro S, AdachiUsami E. Optic disc metastasis presenting as an initial sign of recurrence of adenoid cystic carcinoma of the larynx. Eye (Lond). 2003;17:270-272. 401 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.