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Asymptomatic choroidal metastases in disseminated breast and lung cancer
Intraocular metastases are the most common malignancy of the eye, and the primary cause is breast cancer followed by lung cancer.1 The high incidence of breast cancer (one in every eight women are affected) and prolonged survival because of effective treatment explains in part its metastatic frequency.
Ocular metastases most frequently occur to the highly vascular choroid. The incidence of asymptomatic choroidal metastases among patients with breast carcinoma in clinical series has been reported to vary between 8 and 10%.2,3
The incidence of ocular metastases in autopsy studies is expectedly higher, since occult microscopic disease is detected.
Bloch and Gartner 4 observed ocular metastases in 36% of patients who died of breast cancer. Font and Ferry5 found a similar incidence of ocular metastases, in 41% of patients who died of breast cancer.
The figures from some of these series are old and outdated.
In the January issue of this journal Barak et al6 report on the current incidence of asymptomatic choroidal metastases in patients with disseminated breast or lung cancer. In their clinical series of 169 patients, they report a 0% incidence of choroidal metastases in patients with disseminated breast cancer, and a 2% incidence in patients with lung cancer.
We carried out a similar screening programme in 68 asymptomatic patients with metastatic breast carcinoma.7 We also found a similar incidence of 0% for choroidal metastases.
On the basis of these reported figures, a screening programme for asymptomatic choroidal metastases cannot be justified. Why are these figures so low?
Enhanced systemic oncological treatments with chemotherapy and hormonal therapy for metastatic disease may cause regression of choroidal metastases. Barak et al noted that chemotherapy agents such as taxanes are known to penetrate choroidal tissues, and that choroidal metastases are sensitive to these agents, resulting in their reduced detection rate.
The cost of performing numerous examinations on unaffected individuals is obviously high, and the yield is low.
At present, there is not enough evidence to suggest that ophthalmologists should have an active role in screening asymptomatic patients.
In my opinion, resources should be directed towards promptly investigating and managing patients with a history of disseminated breast cancer who report any visual loss or metamorphopsia. Visual loss in these patients represents severe dysfunction, and early treatment with radiation therapy is of paramount importance to maximise their quality of life.