Rapid Onset Bitemporal Hemianopia as the Presenting Sign of Metastatic Adenocarcinoma of the Lung

Photo and Video Essay Section Editors: Kimberly M. Winges Michael J. Gilhooley, MA, MB, BChir, DPhil Rapid Onset Bitemporal Hemianopia as the Presenting Sign of Metastatic Adenocarcinoma of the Lung Arjan S. Dhoot, MD, MEng (C), Yousuf Ahmed, MD, Derek S. Tsang, MD, MSc, Jonathan A. Micieli, MDCM FIG. 1. A. Humphrey 24-2 SITA-Fast visual fields at presentation showing an incomplete bitemporal hemianopia. B. Optical coherence tomography of the retinal nerve fiber layer (left) and macular ganglion cell–inner plexiform layer (right) was normal. A 67-year-old Caucasian nonsmoking woman with a history of type 2 diabetes mellitus and hypertension presented with a two-week history of painless vision loss, left greater than right. She was otherwise asymptomatic and did not endorse any nausea, vomiting, fatigue, recent weight loss, headaches, polyuria, or polydipsia. Neuro-ophthalmic assessment revealed a best-corrected visual acuity of 20/25 in Faculty of Medicine (ASD), University of Toronto, Toronto, Canada; Institute of Biomedical Engineering (ASD), Faculty of Applied Science and Engineering, University of Toronto, Toronto, Canada; Department of Family Medicine (YA), Dalhousie University, Halifax, Canada; Radiation Medicine Program (DST), Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; and Department of Ophthalmology and Vision Sciences (JAM), University of Toronto, Toronto, Canada. The authors report no conflicts of interest. Address correspondence to Jonathan A. Micieli, Kensington Vision and Research Centre, 340 College Street, Suite 501, Toronto, ON, Canada, M5T 3A9; E-mail: [e-mail] e184 the right eye and 20/70 in the left eye. Her color vision was 6/14 in the right eye and 4/14 in the left eye with Ishihara color plates. Her anterior segment examination, dilated fundus examination, pupils, intraocular pressures, extraocular muscles, and cranial nerve examination were unremarkable. There was no relative afferent pupillary defect (RAPD). Neurologic examination was also unremarkable. Humphrey 24-2 visual field testing revealed bitemporal hemianopia and optical coherence tomography (OCT) of the retinal nerve fiber layer (RNFL) and ganglion cell layer–inner plexiform layer (GCIPL) were normal (Fig. 1). The bitemporal hemianopia localized the disease to the optic chiasm and the rapid onset of her symptoms was concerning for an aggressive process. She was therefore admitted to the hospital for an urgent MRI of the brain and orbits with contrast. MRI revealed a 1.3- · 1.6- · 2.2-cm bilobed sellar enhancing mass with suprasellar extension and multiple, enhancing intra-axial lesions (Fig. 2). The sellar/suprasellar Dhoot et al: J Neuro-Ophthalmol 2024; 44: e184-e186 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay FIG. 2. A. Coronal MRI of the sella T1 (left), T2 (middle), and postcontrast T1 (right) demonstrating a 1.3- · 1.6- · 2.2-cm bilobed markedly enhancing sellar/suprasellar mass lesion extending superiorly to displace and distort the right more than left optic chiasm superiorly. B. Postcontrast T1 axial MRI showing multiple enhancing lesions representing leptomeningeal metastatic disease. mass lesion was extending superiorly to displace and distort the right more than left optic chiasm superiorly. The optic chiasm was found to be in a normal position, overlying the diaphragm sellae. There was optic nerve compression bilaterally. Subsequent computed tomography (CT) revealed a large 3.8- · 3.5- · 3.3-cm spiculated mass in the left upper lobe of the lung and multiple smaller masses throughout the lung, liver, axial skeleton, adrenal glands, and lymph nodes (Fig. 3). She had an ultrasound-guided liver biopsy that revealed adenocarcinoma of lung origin. Endocrinological workup was normal apart from a mildly elevated prolactin, which was believed to be because of stalk effect. Because of her new-onset generalized fatigue, weakness, and advanced metastatic disease (Stage IV), she declined neurosurgical intervention for the sellar/suprasellar mass. Given proximity of the suprasellar mass to the optic chiasm and innumerable brain metastases, the patient underwent whole brain radiotherapy (RT; 20 Gy in 5 fractions, Fig. 4). Her visual function was subjectively stable during RT. Just before starting systemic therapy and 2 weeks after RT, she developed symptomatic hemorrhagic transformation in the brain metastases. Four days later, she developed new occlusive right middle cerebral artery infarct. The patient opted for supportive care, and she passed away 1 month after her FIG. 3. Computed tomography (CT) of the chest (A) showed a spiculated mass (red arrow) within the left upper lobe measuring 3.8 · 3.5 · 3.3 cm. B. CT of the liver demonstrates multiple hypodense lesions representing metastases. Dhoot et al: J Neuro-Ophthalmol 2024; 44: e184-e186 initial neuro-ophthalmology presentation. A telephone conversation with the patient the week before she passed revealed that her visual function remained stable. Pituitary metastases are rare, with only 3.6% of pituitary masses resulting from metastatic cancer (1). In a review of the literature from 1957 to 2018, lung and breast cancer were the 2 most common metastases to the pituitary gland followed by thyroid, renal, and liver (2). A single institution study identified 52 cases of metastatic pituitary masses in 50 years, with 12 of these cases being primary lung tumors (3). The posterior pituitary has a rich vascular supply and is the most common site of metastasis, resulting in diabetes insipidus because of a lack of antidiuretic hormone production and release. Patients with metastases to the sellar/suprasellar region may also present with visual field defects as the mass compresses or infiltrates the optic chiasm, as was observed in our case (1,4). When considering vision changes in general, metastases to the sella from primary endometrial, prostate, and colon adenocarcinomas have presented in this manner (3). In a review of the literature, we identified 18 cases of lung adenocarcinoma metastatic to the sellar region presenting with visual changes, including bitemporal hemianopia, cranial nerve palsies, ptosis, decreased visual acuity, and ophthalmoplegia. Among these, only 2 studies described Goldmann visual field testing to reveal bilateral temporal field defects (5,6). This indicates a paucity of data on the specific type of initial visual field in these patients. We were able to obtain OCT RNFL and GCIPL at presentation, which confirmed the rapidity of onset because there was no atrophy of the optic nerve or inner retina visible. In the previous study on 52 patients with pituitary metastases, no visual fields or detailed description of the visual fields were provided in the 6 patients with lung cancer metastases discovered before the primary tumor (3). In total, 56% of patients in this study had visual impairment, e185 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo and Video Essay FIG. 4. Whole brain radiotherapy plan. A. Digitally reconstructed radiograph, derived from radiation planning CT, showing lateral field aperture. B. Axial view of radiotherapy plan through the suprasellar region, with crosshairs showing the metastatic deposit that is causing optic pathway compression receiving at least 20 Gy. C. Sagittal reconstruction of radiotherapy plan. The isodose lines represent regions of the brain receiving at least 5 Gy (purple), 18 Gy (brown), 19 Gy (pink), 20 Gy (indigo), or 21 Gy (yellow). but it is unknown how many patients with lung cancer had visual field defects. Our patient presented with a classic bitemporal hemianopia without clinical or endocrinological signs of panhypopituitarism. It has been emphasized that bitemporal hemianopia is an uncommon visual field defect in suprasellar masses in clinical practice (7). Regarding treatment, there are limited data on the ideal modality from a vision perspective. Transsphenoidal resection has been reported to be successful in an otherwise asymptomatic patient presenting with vision loss from metastatic lung adenocarcinoma to the pituitary region (6,8). However, the visual field defect was not described in detail and the onset of symptoms was much longer (2 months) than that observed in our case (2 weeks). Radiotherapy has been described in other cases and may be effective in stabilizing or improving vision (5,9). Many patients with advanced metastatic disease are not surgical candidates making RT an attractive option. Patients with Stage IV lung adenocarcinoma have a ,5% survival rate (10). If these patients are identified in a timely manner, there is presumably the potential for an improved overall outcome. Moreover, preserving the patient’s vision will also enhance their remaining quality of life when a timely diagnosis is made. In conclusion, rapid onset vision loss from a bitemporal hemianopia should raise concern for an unusual mass such as metastatic cancer. This may represent widespread and advanced disease, even in the absence of systemic symptoms. Early recognition may result in improved outcomes and quality of life. STATEMENT OF AUTHORSHIP Conception and design: A. S. Dhoot, Y. Ahmed, D. S. Tsang, J. A. Micieli; Acquisition of data: A. S. Dhoot, Y. Ahmed, D. S. Tsang, J. A. Micieli; Analysis and interpretation of data: A. S. Dhoot, Y. Ahmed, e186 D. S. Tsang, J. A. Micieli; Drafting the manuscript: A. S. Dhoot, Y. Ahmed, D. S. Tsang, J. A. Micieli; Revising the manuscript for intellectual content: A. S. Dhoot, Y. Ahmed, D. S. Tsang, J. A. Micieli; Final approval of the completed manuscript: A. S. Dhoot, Y. Ahmed, D. S. Tsang, J. A. Micieli. REFERENCES 1. Max MB, Deck MDF, Rottenberg DA. Pituitary metastasis: incidence in cancer patients and clinical differentiation from pituitary adenoma. Neurology. 1981;31:998–1002. 2. Javanbakht A, D’Apuzzo M, Badie B, Salehian B. Pituitary metastasis: a rare condition. Endocr Connect. 2018;7:1049–1057. 3. Heshmati HM, Scheithauer BW, Young WF. Metastases to the pituitary gland. Endocrinologist. 2002;12:445–449. 4. 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