Choroidal Metastasis: An Uncommon Initial Manifestation of Lung Adenocarcinoma

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A 67-year-old male presented with a 3-month history of productive cough and painful vision loss in his left eye. An ophthalmological examination revealed a lesion in the posterior pole of the left eye. Magnetic resonance imaging showed a dome-shaped hyperintense signal in the posterior pole of the left eyeball on T1-weighted images [Fig 1a]. At the same time, it appeared hypointense on T2-weighted images [Fig 1b], suggesting a choroidal lesion. Further investigation with a computed tomography (CT) scan revealed a lesion in the upper lobe of the right lung, which was confirmed to be adenocarcinoma by a biopsy.

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Fig 1:

Magnetic resonance imaging of the orbits demonstrates a choroidal metastasis in the left eye. (a) Axial T1-weighted image shows a dome-shaped hyperintense lesion in the posterior pole of the left eyeball (arrow). (b) Axial T2-weighted image demonstrates corresponding hypo-intensity of the lesion (arrow), consistent with a choroidal metastatic deposit.

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Subsequently, the patient underwent an FDG positron emission tomography (PET)/CT scan, which revealed a metabolically active lesion in the right upper thoracic region on the MIP image [Fig 2a]. In addition, a heterogeneously attenuating lesion in the posterior pole of the left eyeball showed significant FDG uptake [Fig 2b, 2c]. A hypermetabolic mass lesion with irregular margins was identified in the upper lobe of the right lung [Fig 2d, fused coronal image] and metabolically active mediastinal lymph nodes. Given the working diagnosis of oligometastatic disease, the patient subsequently received four cycles of chemotherapy with pemetrexed and carboplatin.

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Fig 2:

Baseline and follow-up FDG PET/CT images showing metabolic disease and treatment response. (a) Baseline maximum intensity projection (MIP) image demonstrating a metabolically active lesion in the right upper thoracic region (arrow). (b and c) Axial CT and fused PET/CT images show significant FDG uptake in a heterogeneously attenuating lesion in the posterior pole of the left eyeball (arrow in c), consistent with choroidal metastasis. (d) Fused coronal PET/CT image reveals a hypermetabolic mass with irregular margins in the right upper lobe of the lung (arrow) along with metabolically active mediastinal lymph nodes. (e) Follow-up MIP image shows marked reduction in FDG uptake in the right upper thoracic lesion (arrow). (f and g) Axial CT and fused PET/CT images demonstrate complete metabolic resolution of the left choroidal lesion (arrow in g). (h) Follow-up fused coronal PET/CT image shows significant metabolic and size regression of the primary lung lesion (arrow).

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A follow-up FDG PET/CT scan was performed to assess the treatment response. The scan revealed a low-grade metabolically active lesion in the right upper thoracic region, as shown in the maximum intensity projection image [Fig 2e]. In the posterior pole of the left eye, the lesion displayed no significant FDG uptake on the axial CT and fused PET/CT images, indicating metabolic regression [Fig 2f and 2g]. Additionally, a regression of the mediastinal lymph nodes was noted. The fused coronal PET/CT image demonstrated a marked reduction in both FDG uptake and lesion size of the right lung upper lobe mass [Fig 2h].

This case illustrates choroidal metastasis as the initial manifestation of lung cancer, which is extremely rare. Given the concurrent occurrence of the onset of the ocular symptoms at presentation and response to chemotherapy directed toward lung cancer, the choroidal lesion was presumed metastatic from the lung primary rather than the primary tumor of the choroid itself. The presence of a solitary distant metastasis in the eye, along with its complete chemotherapy, highlights the necessity of performing a comprehensive systemic evaluation in patients who present with unusual ocular symptoms. Choroidal malignancies, whether primary or secondary, can significantly impact visual acuity and quality of life, emphasizing the need for early diagnosis and treatment.^[1-3] Although choroidal metastases are infrequent, they can manifest with ocular symptoms that may facilitate the early detection of underlying malignancies.^[4-8]The successful metabolic response to chemotherapy demonstrates the efficacy of systemic treatment for managing rare metastatic presentations such as choroidal metastases.^[9-11] This case underscores the importance of evaluating systemic causes of otherwise uncommon ocular lesions. The positive outcome achieved with chemotherapy also highlights its role in effectively managing the primary tumor and its metastases.^[12,13]