This letter discusses a case study of a 50-year-old woman with breast cancer who developed a choroidal metastasis in her left eye. Systemic chemotherapy was ineffective at controlling the growth of the choroidal lesion. She received an intravitreal injection of bevacizumab, which led to significant regression of the choroidal tumor over a 6 month period with no recurrence over 24 months of follow up. The letter suggests intravitreal bevacizumab may be an effective treatment for choroidal metastases when systemic chemotherapy proves insufficient.

1. A O S
Journal Name Manuscript No.
1 6 8 4
B Dispatch: 4.8.09
Author Received:
Journal: AOS CE: Blackwell
No. of pages: 2 PE: Sangeetha C
Acta Ophthalmologica 2009
1 In December 2006, a 50-year-old chemical stains expressed negative oes-
2
3
Letter to the Editor woman with breast carcinoma was
referred to our uveitis service with
trogen receptors, weakly positive
progesterone receptors and negative
4 painful visual loss in the left eye. Pre- Her-2. The subject had undergone
5 viously, the patient had been diag- modified radical mastectomy and axil-
6 Regression of choroidal nosed with breast carcinoma, grade 3, lary lymph nodes dissection in August
7 metastasis secondary to T2N0M0, stage IIA. Immunohisto- 2005 and subsequent chemotherapy
8
9 breast carcinoma with
LOW RESOLUTION COLOUR FIG
10 adjuvant intravitreal
11
12
injection of bevacizumab
13
14 Hsin-Yu Yao,1 Chi-Ting Horng,2
15 Jiann-Torng Chen1 and Ming-Lin Tsai1
16 1
17 Department of Ophthalmology, Tri-Ser-
18 vice General Hospital, National Defence
19 Medical Centre, Taipei, Taiwan (A) (B)
2
20 Department of Ophthalmology, Kaoh-
siung Armed Forces General Hospital,
21
Kaohsiung, Taiwan
22
23 doi: 10.1111/j.1755-3768.2009.01684.x
24
25
26 Editor,
27
28
29
T he choroid, which is supplied by
rich vessels, is the most common
site of intraocular metastasis. Choroi-
30 dal metastases originate most com- (C) (D)
31 monly from a primary cancer of the
32 breast or lung. Systemic chemotherapy
33 is in widespread use and is efficient in
34 the control of choroidal metastatic
35 tumours. However, vision may be
36 endangered or intolerable ocular pain
37 may occur and progress despite sys-
38 temic chemotherapy. Therefore, addi-
39 tional approaches are necessary. The
40 treatment modalities for choroidal
41 metastasis vary and include external (E) (F)
42 beam radiotherapy, brachytherapy,
43 laser photocoagulation and enucle-
44 ation (Kanthan et al. 2007). However,
45 current treatments have several draw-
46 backs, such as limited facilities, the
47 possibility of radiation-related ocular
48 damage, loss of vision, etc.
49 Bevacizumab, an anti-vascular endo-
50 thelial growth factor therapy, has been
51 proven to be effective in the treatment
52 of metastatic carcinoma of the colon or (G) (H)
53 rectum by the Food and Drug Admin-
54 1 istration. Moreover, previous research 4 Fig. 1 (A) Fundus examination shows a subretinal mass over the superior arcade. (B) B-scan
55 has shown that the choroidal metastas- ultrasonography shows a choroidal mass with high anterior surface reflectivity and low-
56 tic lesion may manifest angiogenesis to-moderate internal reflectivity. (C) T1W1 magnetic resonance imaging demonstrates an
57 and its pathogenesis depends on the intraocular lesion around 6 mm thick and 10 mm in basal diameter. (D) Histology of the lung
58 haematogenous dissemination of the discloses metastasis from breast carcinoma (haematoxylin and eosin; original magnification
· 100). (E) The choroidal mass has progressed and evolved into the macula despite systemic
59 primary malignancy. Thus, bevacizu- chemotherapy. (F) Optical coherence tomography (OCT) reveals a choroidal mass accompanied
60 mab was considered to represent a by fluid accumulation. (G) Fundus examination shows a dramatic reduction in tumour size at
61 promising approach to the treatment 6 months after intravitreal injection of bevacizumab. (H) OCT reveals no residual choroidal
62 of choroidal metastasis. tumour or fluid accumulation.
1

2. Acta Ophthalmologica 2009
1 with cyclophosphamide, doxorubicin residual lesion or fluid accumulation Further studies are necessary to eluci-
2 and 5-fluorouracil. On ophthalmic were observed on optical coherence date its optimal uses.
3 examination, her best corrected visual tomography (Fig. 1H). Two years
4 acuity (BCVA) was 20 ⁄ 25 in the right later, the patient remained stable and
5 eye and 20 ⁄ 400 in the left. Fundus there was no recurrent choroidal mass. References
6 examination revealed a subretinal Survival time in choroidal metasta-
7 mass over the superior arcade (Fig. 1 sis is reported to be poor because cho- Amselem L, Cervera E, Dı´ az-Llopis M,
Montero J, Garcia-Pous M, Udaondo P,
8 A). B-scan ultrasonography showed a roidal metastasis represents the Garcia-Delpech S & Salom D (2007): Intravi-
9 dome-shaped choroidal lesion (Fig. 1 disseminated stage of cancer. In a ran- treal bevacizumab (Avastin) for choroidal
10 B). Magnetic resonance imaging dem- domized trial, bevacizumab was metastasis secondary to breast carcinoma:
11 onstrated an intraocular lesion around approved in combination with paclit- short-term follow-up. Eye 21: 566–567.
12 6 mm thick and measuring 10 mm axel for the treatment of patients with Kanthan GL, Jayamohan J, Yip D & Con-
13 across its base (Fig. 1C). Optical metastatic breast carcinoma (Michel way RM (2007): Management of metastatic
14 coherence tomography indicated a 2 & Xavier 2008). Amselem et al. (2007) carcinoma of the uveal tract: an evidence-
based analysis. Clin Experiment Ophthal-
15 choroidal mass accompanied by fluid reported that off-label use of intravi-
mol 35: 553–565.
16 accumulation (Fig. 1F). The patient treal bevacizumab might achieve Kuo IC, Haller JA, Maffrand R, Sambuelli
17 underwent a positron emission tomog- short-term regression of choroidal RH & Reviglio VE (2008): Regression of a
18 raphy (PET) scan which showed hyper- metastasis secondary to breast carci- subfoveal choroidal metastasis of colorectal
19 dense lesions in the lung and mediasti- noma for 3 weeks. Kuo et al. (2008) carcinoma after intravitreous bevacizumab
20 nal lymph nodes. Biopsy guided by declared a similar efficacy in the treat- treatment. Arch Ophthalmol 126: 1311–
21 computed tomography was performed ment of choroidal metastasis from 1313.
22 and confirmed the diagnosis of multi- colorectal carcinoma. In our case, Marty M & Pivot X (2008): The potential of
anti-vascular endothelial growth factor
23 ple metastases of breast carcinoma intravitreal injection of 2.5 mg bev- therapy in metastatic breast cancer: clinical
24 (Fig. 1D). The patient therefore under- acizumab led to a significant regres- experience with anti-angiogenic agents,
25 went systemic chemotherapy with pac- sion of the choroidal lesion. In focusing on bevacizumab. Eur J Cancer 44:
26 litaxel and gemcitabine. However, a addition, there was no recurrent cho- 3 912–920.
27 progressive choroidal mass was noted. roidal mass during the 24-month fol-
28 Best corrected VA deteriorated to low-up. The possible mechanisms of
29 counting fingers and the choroidal intravitreal bevacizumab may involve
30 mass evolved into the macular region anti-angiogenic and anti-permeability Correspondence:
31 (Fig. 1E). An adjuvant intravitreal effects on angiogenesis in choroidal Ming-Ling Tsai MD, PhD
32 injection of bevacizumab (2.5 mg in metastasis. Synergistic effects of intra- Department of Ophthalmology
33 0.1 ml) was administered and a signifi- vitreal bevacizumab combined with Tri-Service General Hospital
34 cant reduction in mass was achieved. concurrent chemotherapy, such as 325, Section 2, Cheng-Kung Road
35 Six months after the injection, the sub- paclitaxel, may also play an important Nei-Hu District 114
36 ject’s BCVA improved to 20 ⁄ 30 and role. Taipei
Taiwan
37 fundus examination demonstrated the Intravitreal bevacizumab provides a
Tel: + 886 9 6839 2245
38 almost entire regression of the choroi- potential option for adjuvant therapy Fax: + 886 2 2938 8737
39 dal mass (Fig. 1G). Furthermore, no in patients with choroidal metastasis. Email: doc30845@yahoo.com.tw
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