Choroidal metastases from follicular thyroid carcinoma are uncommon and usually present as an amelanotic lesion against a background of known systemic disease. We present the case of a 56-year-old woman with a thyroid metastatic focus with unusual clinical presentation, systemic involvement, and early response to systemic treatment. A review of the literature accompanies this case presentation.
A 56-year-old lady was referred to the Ocular Oncology Service with a seven-year history of deteriorating visual acuity in the left eye. Patient had a 15-year history of sarcoidosis associated with recurrent uveitis. Best-corrected visual acuity was at 6/36 OS 6/6 OD. At presentation there was no active uveitis. Posterior segment examination revealed an elevated lesion inferotemporally to the macula of the left eye measuring 6.5 × 6.8 mm that was pale orange in colour and difficult to discern clinically from the surrounding retina (Figure
(a) Pale orange lesion involving the macula and extending inferotemporally before treatment. Clinical appearance is consistent with a circumscribed choroidal haemangioma. (b) After four months a pale, fibrotic scar has developed in the site of the original lesion following treatment.
Thyroid gland biopsy proved the mass was a follicular cell carcinoma of the thyroid and systemic staging revealed stage 4 disease due to the presence of bone metastases in the left iliac crest and in the right femur, the latter causing a pathologic fracture. Patient underwent total thyroidectomy. Excision was incomplete and patient received 2 initial sessions of adjuvant treatment of radioactive iodine (131I) therapy (4.9 and 5.8 GBq, resp.). The pathologic fracture was managed with internal fixation and adjuvant external beam radiotherapy (EBRT) with 35 Gy at 15 sessions in the iliac crest and 20 Gy in the femur.
Following radioactive treatment of the thyroid gland the visual acuity reduced to counting fingers. Fundus examination indicated a dramatic change in the appearance of the lesion from an orange, dome-shaped elevated mass to a flat fibrosed scar of pale-greenish colour (Figure
Over the next five years the choroidal scar remained stable; no other ocular metastases were diagnosed, but the patient developed pulmonary metastases and a subcutaneous sternal nodule. She received 9 additional sessions of 131I (2.9–9.5 GBq) and two more sessions of EBRT in the nodule. She also followed monthly pamidronate infusions.
Choroidal metastases are the most common intraocular tumour, with an estimated incidence of 20,000 per annum in the United States. However, they are rarely seen by ophthalmologists as these patients tend not to experience visual symptoms [
The 5-year relative survival rates for thyroid cancer have increased from 93% in 1983–1985 to 97% in 1995–2001 because of current treatment regimes [
The early response of the choroidal metastasis to radioactive iodine is interesting. Ocular metastases may respond to systemic treatment such as chemotherapy but they may take many months to change in appearance. This dramatic, rapid fibrosis of a choroidal metastasis has, to our knowledge, not been described previously following 131I ablation treatment of follicular cell carcinoma of the thyroid gland.
Different types of thyroid carcinoma have been associated with the development of choroidal metastases such as papillary, follicular cell, Hurthle cell, and medullary cell carcinoma [
Previously reported cases of choroidal metastases secondary to follicular cell thyroid cancer (FTC).
Reference | Age, sex | Presentation | Fundus | Location of concurrent metastases | Time from initial diagnosis | Treatment |
---|---|---|---|---|---|---|
Ritland et al. [ |
80, f | Lateral visual field loss | Orange brown tumour nasally | Lung, bone, and mediastinum | 40 yrs | 131I |
Scott et al. [ |
50, m | Blurred vision metamorphopsia | 5.6 mm in elevation 12.9 × 11 | Lung and bone | 5 yrs | RTx, chemotherapy, and bevacizumab |
Slamovits et al. [ |
64, f | Dyschromatopsia, total retinal detachment following vitreous haemorrhage | Pink mass, radioactive iodine accumulation | Paratracheal, bone, and lung | 7 yrs | RTx |
Arat and Boniuk [ |
83, m | Bilateral progressive loss of vision | Iris and bilateral choroidal lesions. Right eye: 2 orange-coloured lesions. Left eye: large reddish vascular lesion with subretinal haem | Lung, bone, liver, and skin | Initial presentation | 131I |
Seneviratne et al. [ |
74, f | Asymptomatic | Large yellow lesion in periphery | Lung, bone, and abdominal wall | 22 yrs | RTx |
Guignier et al. [ |
75, m | Decline in visual acuity | Amelanotic lesion with serous detachment | N/A | N/A | RTx |
vf: visual field, RTx: radiotherapy.
In summary, metastatic thyroid cancer to the choroid can appear similar to circumscribed choroidal haemangioma. Response to systemic treatment with radiolabeled iodine was dramatic and produced complete regression of the choroidal lesion within 3 months. No local ocular treatment was required.
The authors declare that there is no conflict of interests regarding the publication of this paper.