choroidal metastases
Introduction
Introduction to choroidal metastases The choroidal blood vessels are abundant, the blood flow is slow, and there is no lymphatic duct in the eye. The systemic tumor can be transferred to the uvea by blood, especially the choroid is the most common, accounting for 50%-80% of the uveal metastatic tumor. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: retinal detachment, iridocyclitis, glaucoma
Cause
The cause of choroidal metastasis
(1) Causes of the disease
Most patients have a history of malignant tumors in other parts of the body. Most of the primary cancers in women are breast cancer, followed by lung cancer or bronchial cancer. The primary cancer in male patients is mainly lung cancer, bronchial cancer, followed by kidney cancer and prostate cancer. Other cancers, such as gastrointestinal cancer, pancreatic cancer, thyroid cancer, renal cell carcinoma, skin malignant melanoma, etc., have also been reported in the eye or in the uvea. In a few cases, intraocular metastatic lesions preceded Before the diagnosis of primary cancer in other organs, there are very few cases where the primary cancer lesion is unclear, especially in male patients.
(two) pathogenesis
The tumor thrombus in the blood flow is through the internal carotid artery, the ophthalmic artery and its branches include the posterior ciliary artery, the posterior ciliary artery or the central retinal artery enters the eye, and 10 to 20 ciliary short arteries far exceed the other The number of arteries, therefore, has the greatest chance of metastasis to the choroid and is concentrated in the posterior pole of the eye, so the patient has decreased vision early.
Choroidal metastasis occurs in one or both eyes, about 25% of both eyes are onset, and both eyes are often followed by occasional, occasionally affected, early reports of monocular eyes more than the right eye, because the left common carotid artery branches directly from the aortic arch, unlike The right common carotid artery passes through the innominate artery, so the tumor thrombus easily enters the left eye, but later reports found no difference in bilateral incidence. Most cases of choroidal metastasis can provide a history of malignant tumor or surgical treatment, especially breast cancer, on the lung or Gastrointestinal, malignant tumors of the urinary tract, metastatic carcinoma of the eye can be diagnosed before the primary cancer is diagnosed. The ophthalmologist's understanding of metastatic cancer may be the earliest diagnosis of malignant tumors. In some cases, the primary cancer is still unknown, especially Male patient.
Prevention
Choroidal metastasis cancer prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Complication
Choroidal metastasis Complications retinal detachment iridocyclitis glaucoma
Retinal detachment, iridocyclitis and secondary glaucoma.
Symptom
Choroidal metastasis of cancer symptoms common symptoms eye pain eyeball prominent visual field defect retinal detachment retinal edema visual deformity pigmented gray spotted white nodules
Metastatic cancer most often enters the posterior choroid through the short ciliary artery around the optic nerve, where it infiltrates and grows to form a lesion. Therefore, the patient complains of decreased vision, which may be accompanied by a flash or floating mosquito; if the tumor grows in the posterior pole, Progressive hyperopia and central dark spots may occur. As the tumor grows, the central dark spot also increases. Metastatic cancer is often accompanied by exudative retinal detachment, and visual field defects appear in the relatively detached area. The extent of visual field defect area tends to be detached from the retina. Small, because choroidal metastasis only grows along the choroidal infiltration, does not destroy the cone of the retina, the rod cells, so the retina still retains a certain function, if the tumor advances or the tumor grows to cause extensive retinal detachment, the detached retina can be the iris The lens is pushed forward to the anterior chamber, the secondary anterior chamber becomes shallow, the secondary glaucoma occurs, the eye pain increases, the intraocular pressure increases, and the upper scleral vasoconstriction expands. Because the invasive growth of the tumor may infiltrate the ciliary nerve, some patients will There are eye pains and headaches, which are a feature of metastatic cancer that is different from other choroidal tumors such as choroidal melanin. When patients with malignant tumors decreased visual acuity, visual distortion, eye pain and other symptoms, should be vigilant eye cancer metastasis, and the need for timely for further examination.
Eye examination: In the posterior pole of the fundus, the binocular ophthalmoscope or the pre-mirror examination, through the retina, there are one or more flat, solid tumors with round or oval shapes and unclear borders. Very few can also be a globular or mushroom-like shape. It is difficult to distinguish from choroid-free melanoma. The color of the tumor is mostly gray or yellow-white; a few are orange-red like the color of choroidal hemangioma. Some people think it is carcinoid. (carcinoid) or thyroid metastatic cancer; and brown or brownish black is metastatic carcinoma from the skin or contralateral choroidal melanoma, often with flat retinal detachment on the surface of the tumor, detachment from retinal edema, opacity or pigmented spots, retina It is rapidly developed and becomes spherical or even completely detached after several weeks. It is characterized by exudative retinal detachment, that is, the liquid under the retina can move with the position of the patient's head. The tumor around the optic disc often spreads diffusely, and the choroidal involvement is large. There is edema in the optic disc, and even cotton vellus spots appear. The vitreous is generally less affected, and there is no obvious turbidity. For example, the iris ciliary body also has metastasis, or swelling. Due to the rapid growth of necrosis, symptoms such as iridocyclitis and secondary glaucoma may occur. Metastatic cancer may spread to the outside of the eye along the choroidal macrovascular layer, or may invade the scleral blood vessels or the posterior sclera to the posterior sac. .
Examine
Examination of choroidal metastases
1. Primary tumor correlation tests such as carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP) and the like.
2. Pathological examination: When the non-invasive diagnosis method can not be diagnosed, the choroid specimen can be taken through the vitreous for fine needle aspiration for biopsy and immunohistochemistry to confirm the diagnosis. The tumor thrombus resides in the choroid with blood flow. In the small vessel layer, the choroid is thickened by tumor infiltration, and the tumor does not penetrate the vitreous membrane; the retinal neuroepithelial can be detached, but rarely adheres to the choroid, so the cone and the rod cells are less damaged, and the cell morphology and structure of the choroidal metastasis And the arrangement retains the characteristics of primary cancer. In patients with primary breast cancer, cancer cells often appear as adenoids or form epithelial nests; lung or bronchial adenocarcinomas are often adenoid or irregular cell cords; lung oat cell carcinoma The tumor cells are small in size, arranged in a nest, and have no acinar-like structure; the primary origin in the stomach and thyroid gland is a focal bulge; the melanoma from the skin generally contains more melanin, and the cells differentiate well, often Maintain the tissue pattern of the primary tumor, poor differentiation, histological examination often can not understand the characteristics of its primary tumor, need special staining, electron microscopy, immunohistochemistry or detection of blood cancer Antigens for further identification.
3. Fundus fluorescein angiography: due to the location of the metastasis, the course of the disease, the type of primary tumor, the clinical manifestations, the images are also different, because the tumor is mainly composed of cells, the interstitial and blood vessels are less, and the early tumor of fluorescein angiography It is a dark area with no choroidal background fluorescence, followed by needle tip or spot-like fluorescence, late leakage and mottled-like strong fluorescence. Compared with choroidal melanoma, the fluorescence appears more uniform; there is no tumor sometimes seen in melanoma. Internal large diameter vessels, early tumors showed dark areas without choroidal background, to the arteriovenous period, retinal blood vessels crawled on it, accompanied by telangiectasia and hemangioma-like changes, until the venous phase, then in the weak fluorescence zone Speckle-like strong fluorescence gradually appears in the interior, often appearing at the edge, sometimes with slight leakage and fusion, and interspersed with patches that block the fluorescence, making the entire lesion appear mottled, and the late fluorescence is still strong, in the tumor The edge is composed of a number of fine points and a wide range of strong fluorescent bands. It is also one of the characteristic manifestations of choroidal metastases. However, in some cases, the middle part of the lesion is under contrast. Chengzhong is always a large weak fluorescent area, which may cause cancerous tumors to grow rapidly and necrosis in the middle.
4. Indocyanine green (ICGA) examination: Isolated tumors can show similar images to FFA, but the fluorescence intensity is weak and late. If the tumor is flat and thin, the choroidal vessels below can often be seen through the tumor. For FFA examination, if the whole tumor is strongly fluorescent and cannot be differentiated from other tumors; or if the small point leakage is difficult to distinguish from other diseases such as Harada disease, it can be used for ICGA examination.
5. Ultrasound examination: The characteristics of ultrasound are helpful for diagnosis. A-ultrasound scan shows mid-high intratumoral reflex waves, which is different from the low or moderate internal reflex of melanoma. B-scan is different in thickness. Flat bulge, wide at the bottom, are >15mm, height is 2~5mm, some lesions only show choroidal thickening, more echoes in the tumor, uneven distribution of strength and weakness, often retinal detachment.
6. Visual field examination: The early planar field of view can detect the absolute dark spots that match the tumor.
7. Imaging findings: CT showed an equal density of ridges or flattened thickening in the posterior segment of the eye, single or multiple, with mild enhancement, accompanied by subretinal fluid, MRI examination of T1-weighted images mostly high signal intensity, surface It can be irregularly nodular; T2-weighted images are often high-signal, often with retinal detachment, and MRI can also show intracranial metastases, which can be helpful for diagnosis and treatment.
Diagnosis
Diagnosis and diagnosis of choroidal metastasis
Have a history of malignant tumors, especially in both eyes, multifocal lesions, should consider the diagnosis of choroidal metastases, lack of tumor history, often caused by misdiagnosis or missed diagnosis, for adult or elderly, fundus examination found that the posterior pole under the retina has gray or yellow-white Flattened mass and retinal detachment should be suspected of choroidal metastasis, pay attention to the history of primary cancer or surgical history, through physical examination, imaging examination carefully search for the primary lesion and other metastases of the body, fluoroscopy of the eye, Ultrasound, visual field, CT or MRI scans are lack of specificity for diagnosis, but comprehensive judgment may be helpful for diagnosis.
Early need for chorioretinitis, uveal granuloma, late vasodilation with rhegmatogenous retinal, non-pigmented choroidal melanoma, isolated choroidal hemangioma, choroidal osteoma, age-related macular degeneration with choroidal exudation and hemorrhagic pigment epithelium Deviation from isophasic identification.
