Ann Thorac Surg 2005;79:1782-1784
© 2005 The Society of Thoracic Surgeons
Case report
Iris Metastasis of Esophageal Cancer
Yoshinobu Ichiki, MD*,a,
Masaru Morita, MDa,
Koichi Yano, MDa,
Kenji Sugio, MDa,
Kosei Yasumoto, MDa,
Naofumi Hirose, MDb
a Second Department of Surgery, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
b Department of Ophthalmology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
Accepted for publication November 7, 2003.
* Address reprint requests to Dr Ichiki, Second Department of Surgery, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
y-ichiki{at}med.uoeh-u.ac.jp
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Abstract
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Ocular metastasis in patients with esophageal cancer is quite rare. Several cases have been reported in the literature, but no successful treatments for such metastases have ever been described. We herein report a case of esophageal cancer in which the ocular metastasis was controlled by systemic chemotherapy.
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Introduction
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Ocular metastasis of esophageal cancer is sometimes reported in breast cancer and lung cancer; however, it is extremely rare in esophageal cancer. After ocular metastasis occurs, the patient's quality of life is extremely limited. Our experience in treating a case of ocular metastasis of esophageal cancer with systemic chemotherapy proved to be effective for both the ocular metastasis and the primary lesion.
A 58-year-old Japanese man noticed a white nodule in his right iris for 4 months when he finally consulted the Ophthalmology Department at the University of Occupational and Environmental Health, School of Medicine, in Japan (Fig 1A). An ophthalmologic examination revealed the patient to have normal vision with a normal view. A white nodule of the iris compatible with the findings of a malignant tumor was observed. A computed tomographic scan revealed wall thickening in the lower thoracic esophagus. A tumorous lesion with ulceration was discovered 35 cm from the dental arch by esophagoscopy. Moderately differentiated squamous cell carcinoma was diagnosed based on a biopsy specimen. For the purposes of undergoing further examination and to receive treatment for esophageal cancer, the patient was admitted to the Second Department of Surgery.
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Fig 1. (A) Ophthalmic examination on admission. A white nodule was detected in the right iris. (B) Ophthalmic examination after the second course of chemotherapy. The white nodule in the right iris was found to have disappeared.
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On admission the patient felt neither dysphagia nor retrosternal pain. A barium swallow revealed a tumor that existed mainly on the right side wall of the lower thoracic esophagus (Fig 2). Both pericardial invasion and aortic invasion of the esophageal carcinoma were suspected on a computed tomographic scan; however, the esophageal lumen was preserved. Lymph node metastasis was recognized in the lower para-esophageal region and in the para-aortic region. Distant hematologic metastasis was only found in the right iris. No other metastases were detected by whole body computed tomography and bone scintigraphy. A biopsy of the right iris revealed the tumor to be moderately differentiated squamous cell carcinoma, which was thus compatible with metastasis from esophageal cancer.
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Fig 2. A barium swallow of the esophagus on admission. Irregular stenosis was detected in the lower thoracic esophagus.
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Because the esophageal cancer was so far advanced, we performed chemoradiotherapy rather than an operation. The chemoradiotherapy consisted of 130 mg cisplatin administered to the patient on day 1, with a daily dose of 1.3 g of 5-fluorouracil that was continuously infused intravenously from days 1 to 5. Furthermore, a total dose of 70.2 Gy (1.3 Gy/fr x 2/day) of radiation was administered for the primary esophageal cancer. After the first course of chemotherapy, leukocytopenia, thrombopenia, and nausea (as grades 3, 2 and 1, respectively, of the Japanese Clinical Oncology Group) were recognized as adverse effects. After this treatment, the primary tumor decreased to half of its pretreatment size. In addition, the metastasis to the iris had almost completely disappeared by this time.
Bone marrow suppression after the first course of chemotherapy continued for a few months. As the second course of chemotherapy, a 70% dose of the first course treatment was administered. After the second course of chemotherapy, leukopenia and thrombopenia (as grades 1 of the Japanese Clinical Oncology Group) appeared as side effects. The tumor size had decreased to one third of its pretreatment size. An ophthalmic examination revealed the metastasis to the iris had completely disappeared (Fig 1B). Furthermore, no metastasis to the iris was recognized by magnetic resonance imaging. An additional two courses of the chemotherapy were administered. The patient subsequently died due to lymph node metastasis and cachexia 11 months after the diagnosis of esophageal carcinoma; however no visual disturbance occurred.
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Comment
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Ocular metastasis of cancer is sometimes reported in breast cancer and lung cancer; however it is extremely rare in esophageal cancer [1], although several cases with ocular metastasis of esophageal carcinoma have been reported [2–7]. The primary tumor in ocular metastasis cases is generally far advanced. Therefore, dysphagia tends to be the most common chief complaint of esophageal cancer with ocular metastasis. In the current case, the opportunity to detect the disease was not due to the symptoms of esophageal cancer (ie, dysphagia) but due to those of ocular metastasis. Therefore, it is suggested that esophageal cancer may potentially be one of the underlying diseases of ocular metastasis even though this combination may be extremely rare. In most case reports, the general condition was already so poor that curative therapy could not be performed when ocular metastasis was detected [2–4]. In one case [5], chemotherapy (methotrexate, 5-fluorouracil) was performed and the ocular metastasis temporarily improved. However, this case had a recurrence of the ocular tumor, and enucleation of the eyeball was performed due to eyeball pain. The enucleation of ocular metastasis as distant hematologic metastasis is not a curative therapy against cancer but only a palliative therapy. In a few of the cases that we investigated, enucleation was performed as a palliative therapy against glaucoma and eyeball pain [4–6]. Enucleation of the eyeball should be avoided if ocular metastasis is not associated with any severe clinical symptoms. In the current case, ocular metastasis disappeared after chemotherapy. Furthermore, enucleation could be avoided and no eye symptoms occurred up until death. Ocular metastasis suggests that the disease may be a potentially systematic disease with multiple organ metastases. Chemotherapy is initially indicated for ocular metastasis. Combined eye irradiation may be another choice of treatment.
We have described quite a rare case of a patient whose eye symptoms led to the detection of the primary disease of esophageal cancer for which systemic chemotherapy was quite effective in treating the ocular metastasis. Systemic chemotherapy is effective for the treatment of esophageal cancer with metastasis. Chemotherapy plays an important role regarding the patient's quality of life, especially in cases with ocular metastasis. Therefore, we consider the findings of this case to be useful for thoracic surgeons.
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Acknowledgments
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We thank Brian T. Quinn for his critical comments.
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References
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Abstract
Introduction
