Choroidal metastases in testicular choriocarcinoma, successful treatment with chemo- and radiotherapy: a case report
BMC Urology
Choroidal metastases in testicular choriocarcinoma, successful treatment with chemo- and radiotherapy: a case report
Ivo Guber 0
Leonidas Zografos 0
Ann Schalenbourg 0
0 Jules-Gonin Eye Hospital, University of Lausanne, Switzerland , Avenue de France 15, CH-1004 Lausanne , Switzerland
Background: Choriocarcinoma is a very rare cause of ocular metastasis. Only 18 male patients have been reported on, 4 of whom survived, but with significant loss of vision. Case presentation: A 26-year-old Caucasian man, suffering from testicular choriocarcinoma with pulmonary, cerebral, renal, hepatic and osseous metastases, underwent left radical orchiectomy. While being treated with chemotherapy, he presented with loss of vision in the left eye. Ophthalmoscopy revealed bilateral non-pigmented, hemorrhagic choroidal tumours, compatible with secondary lesions. Continued chemotherapy and stereotactic radiotherapy of the skull and spine lead to full remission with excellent vision, after more than 4 years of follow up. Conclusion: Testicular choriocarcinoma is an exceptional cause of choroidal metastasis, potentially asymptomatic and with specific clinical features. Radiotherapy can complement radical orchiectomy and chemotherapy, to achieve full remission and maintain good vision.
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Background
Intraocular metastases are present in up to 10% of
patients with systemic malignancies [1]. With tumour
cells spreading hematogenously, the posterior choroid is
frequently involved because of its rich vasculature [2]. In
females, the most common primary site is the breast,
whereas, in males, it is the lung.
Choriocarcinoma is a highly malignant metastatic
tumour, derived from undifferentiated placental
trophoblasts (gestational choriocarcinoma) or from
non-placental totipotent cells, present in the testis, the ovary or
the pineal gland (non gestational choriocarcinoma). It
is characterized by the large amounts of chorionic
gonadotropin produced.
Choriocarcinoma is a rare cause of choroidal
metastasis. Only 18 male patients have been reported on, and
most of them had a poor prognosis [2-4]. We present a
man who developed bilateral choroidal metastases from
a testicular choriocarcinoma under chemotherapy. The
ocular tumours regressed following irradiation. Four
years later, he is in remission and has excellent vision.
Case presentation
A 26-year-old man was referred to the Jules-Gonin Eye
Hospital with loss of vision and a non-pigmented
tumour in his left eye. In the previous two weeks, he
had been diagnosed with a left testicular tumour and
multiple metastases to the lung, brain, cerebellum,
kidney, liver and spine. Histopathology following left radical
orchiectomy had revealed a non-seminomatous
testicular choriocarcinoma, positive for b-human chorionic
gonadotropin (b-HCG) and pancytokeratin, slightly
positive for a-fetoprotein (AFP) while negative for
carcinoembryonic antigen (CEA). Serum levels were for b-HCG
271 052 U/l (normal < 3.0 U/l)), for AFP 0.9 ng/ml
(normal < 10 ng/ml) and for LDH 1757 U/l (normal <
450 U/l). He was receiving chemotherapy with
bleomycin, etoposide and cisplatin.
Visual acuity was 6/6 in the right eye and counting
fingers (CF) in the left eye. The left posterior fundus
showed a large amelanotic choroidal tumour associated
with a hemorrhagic retinal detachment. On B-scan
ultrasonography, thickness was 7 mm. In the right
inferior choroid, a second non pigmented, flat lesion was
also present, compatible with a diagnosis of bilateral
choroidal metastases (Figure 1).
Figure 1 Panoramic fundus pictures: Choroidal metastases from testicular choriocarcinoma at presentation: RE (Right Eye): a non
pigmented, flat lesion is discovered in the inferior choroid. LE (Left Eye): a large amelanotic tumour with associated hemorrhagic retinal
detachment occupies the posterior pole and is responsible for the vision loss.
Chemotherapy was continued, with a total of 4 cycles
over 3 months time. Additionally, a stereotactic
radiotherapy of the spine and head was performed, the latter
including the posterior part of both eyes, using two
lateral accelerated photon fields of 6 MV with a total dose
of 30.80 Gy in 14 fractions.
After four years follow-up, the patient is in remission
without any evidence of metastases. All tumour markers
are within normal ranges (b-HCG < 0.1 U/l; AFP 1.2
ng/ml; LDH 284 U/l). Visual acuity is 6/6 in the right
Discussion
We describe a rare case of a patient with bilateral
choroidal metastases secondary to testicular
choriocarcinoma, successfully treated with chemo- and
radiotherapy.
MacDonald described the first case in 1936 [5]. A
meta-analysis of the literature in 2006 listed 14 male
Figure 2 Panoramic fundus pictures: Four years after chemo- and radiotherapy, both lesions have become flat chorioretinal scars.
Despite the unfavourable localisation of the left scar near the fovea, visual acuity has recovered to 6/9.
patients with testicular choriocarcinoma, as well as one
with med (...truncated)