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Clinicopathologic Reports, Case Reports, and Small Case Series
September 2002

Branch Retinal Artery Occlusion Caused by an Embolus of Metastatic Gastric Adenocarcinoma

Author Affiliations
 

W.RICHARDGREENMD

Arch Ophthalmol. 2002;120(9):1209-1211. doi:

We report a case of branch retinal artery occlusion caused by an embolus of metastatic gastric adenocarcinoma. A 67-year-old man sought treatment for sudden visual loss in his left eye. He had a medical history of gastric cancer with liver metastasis. Findings on funduscopic examination included localized edema of the inner retina consistent with a supratemporal branch retinal artery occlusion and a yellowish-white subretinal mass surrounded by shallow retinal detachment superior to the equator. Histopathological and immunohistochemical examinations of the eye obtained post mortem showed positive staining of the choroidal tumor for epithelial membrane and carcinoembryonic antigens. In addition, an embolus of tumor cells was found to cause occlusion of the retinal artery.

Occlusion of the retinal artery is mostly ascribed to either embolus, thrombus, or vasculitis. It is strongly associated with carotid atheromatous plaque or cardiac valvular diseases with vegetation. Other causes, such as atrial myxoma, temporal arteritis, periarteritis nodosa, and systemic lupus erythematosus, have been described but are relatively rare.1 Embolism caused by neoplastic cells is extremely rare.2,3 We report a case of gastric adenocarcinoma that metastasized to the choroid and occluded a branch retinal artery with an embolus of carcinoma cells.

Report of a Case

A 67-year-old man was referred to our clinic for sudden visual loss in his left eye. He had been diagnosed with gastric adenocarcinoma and metastatic liver cancer 2 years previously and had undergone total gastrectomy and partial resection of the liver. He had no history of hypertension, diabetes mellitus, heart disease, or cerebral infarction. On examination, the corrected visual acuity was 20/30 OD and light perception OS. Intraocular pressures were 13 mm Hg OD and 10 mm Hg OS. A relative afferent pupillary defect was observed in the left eye. External and slitlamp examinations were unremarkable bilaterally. Funduscopic examination revealed milky-white retinal edema consistent with branch retinal artery occlusion in the supratemporal quadrant and a yellowish-white subretinal mass surrounded by shallow retinal detachment in the superior quadrant of the left eye (Figure 1).

Figure 1.
A funduscopic photograph shows
milky-white retinal edema in the supratemporal quadrant, which is compatible
with branch retinal artery occlusion. Note also the yellowish-white subretinal
mass surrounded by shallow retinal detachment superior to the equator of the
left eye.

A funduscopic photograph shows milky-white retinal edema in the supratemporal quadrant, which is compatible with branch retinal artery occlusion. Note also the yellowish-white subretinal mass surrounded by shallow retinal detachment superior to the equator of the left eye.

Ultrasonography disclosed a mass with strong internal echoes in the same region, suggestive of a subretinal tumor. The provisional diagnosis of the mass lesion was metastatic adenocarcinoma to the choroid associated with branch retinal artery occlusion. Fluorescein angiographic and computed tomographic examinations could not be performed because of the patient's poor general condition. Laboratory values included a carcinoembryonic antigen level of 722 ng/mL (reference level, <5 ng/mL) and a carbohydrate antigen 19-9 level of 2567 U/mL (reference level, <37 U/mL). Cultures of arterial blood were negative for bacteria, and splenomegaly was absent. A chest radiograph showed no concrete evidence of a metastatic tumor. Three weeks after admission, the patient died because of the deterioration of his general condition. Both eyes were obtained post mortem, fixed in formaldehyde, and processed routinely for light microscopy. Macroscopic examination disclosed a solid tumor with a mottled dark-brown color that measured 12 mm × 6 mm in the choroid of the left eye. Microscopic examination of the tumor disclosed extensive infiltration of the choroidal stroma by cords and lobules of a malignant epithelial neoplasm consistent with metastatic mucin-secreting adenocarcinoma. The tumor cells formed tubules and glandular structures (Figure 2A), and the periodic acid–Schiff and alcian blue stains confirmed the presence of numerous intracytoplasmic vacuoles of mucin (Figure 2B). Immunohistochemical stains showed intense positive immunoreactivity for epithelial membrane antigen (Figure 3A) and carcinoembryonic antigen (Figure 3B). The histopathological findings of the choroidal metastasis resembled the patient's primary tumor (Figure 4) and were consistent with a moderately well-differentiated gastric adenocarcinoma. A micrometastasis was also identified in the ciliary body inferior to the muscle. In addition, an embolus of tumor cells was found to totally occlude the lumen of the supratemporal retinal arteriole near the optic disc (Figure 5). The cytological characteristics of the tumor embolus were quite similar to those of the choroidal tumor. The right eye was normal on gross examination, and there were no particular histopathological changes.

Figure 2.
A, Hematoxylin-eosin staining
shows the tumor to be a moderately well-differentiated adenocarcinoma based
on the presence of tubulelike or glandlike structures. B, Positive periodic
acid–Schiff staining is indicative of mucin production by carcinoma
cells, especially by cells forming glandlike structures (original magnification
×180).

A, Hematoxylin-eosin staining shows the tumor to be a moderately well-differentiated adenocarcinoma based on the presence of tubulelike or glandlike structures. B, Positive periodic acid–Schiff staining is indicative of mucin production by carcinoma cells, especially by cells forming glandlike structures (original magnification ×180).

Figure 3.
A, Positive immunostaining for
epithelial membrane antigen on the membrane of cells is related to the tubulelike
or glandlike structures of the tumor. B, Diffuse and strongly positive immunostaining
for carcinoembryonic antigen of the tumor is shown (original magnification
×180).

A, Positive immunostaining for epithelial membrane antigen on the membrane of cells is related to the tubulelike or glandlike structures of the tumor. B, Diffuse and strongly positive immunostaining for carcinoembryonic antigen of the tumor is shown (original magnification ×180).

Figure 4.
A representative microphotograph
shows moderately well-differentiated adenocarcinoma of the stomach. The section
was taken from the surgical specimen (original magnification ×180).

A representative microphotograph shows moderately well-differentiated adenocarcinoma of the stomach. The section was taken from the surgical specimen (original magnification ×180).

Figure 5.
The retinal artery is completely
occluded by a tumor embolus (original magnification ×180).

The retinal artery is completely occluded by a tumor embolus (original magnification ×180).

Comment

The present study clearly shows that the choroidal tumor was metastatic adenocarcinoma. Histopathological examination also confirmed that the supratemporal retinal arteriole was occluded by an embolus of tumor cells. The histopathological and immunohistochemical studies, including positive immunoreactivity markers for epithelial membrane antigen and carcinoembryonic antigen, are consistent with metastatic gastric adenocarcinoma; a primary tumor with known hepatic metastasis had been treated 2 years earlier. The patient is presumed to have died from widespread systemic metastases because postmortem examination was limited to the eyes.

To our knowledge, retinal artery occlusion caused by an embolism of tumor cells is very rare, and there are only a few reports that clearly describe this condition. Occlusion of the central retinal artery by chondrosarcoma and bronchial carcinoma cells was described by Burde and Henkind2 and Tarkkanen et al,3 respectively. Zamora et al4 reported a case of branch retinal artery occlusion in a patient with papillary fibroelastoma of the mitral valve, but there was no histopathological demonstration of the embolus. Metastasis of carcinoma cells to the retina alone appears to be a rare event. Smoleroff and Agatston5 reported a case of gastroesophageal carcinoma that metastasized into the nerve fiber layer of the retina. Shields et al6 studied 520 eyes with uveal metastasis and found only 5 to have metastatic lesions in the retina.

However, there was no description of arterial occlusion in their series. In patients with end-stage disease, particularly those with malignancies, embolism due to bacterial endocarditis, nonbacterial thrombotic endocarditis, or thrombi formed with disseminated intravascular coagulation syndrome may be encountered in the retinal artery.7,8 In the present case, there was no strong clinical or laboratory evidence of infection, valvular diseases, or disseminated intravascular coagulation. Complete obstruction of the arterial lumen by the tumor embolus as shown in our case is uncommon, whereas venous and lymphatic invasion by malignant cells is more common because it can be observed in routine surgical specimens. A major factor that contributes to the formation of tumor emboli is the expression of adhesion molecules,9 but emboligenic factors such as those mentioned above may accelerate their formation.

In conclusion, we report a clinicopathological correlation of a case of metastatic gastric adenocarcinoma to the choroid that had branch retinal artery occlusion due to a tumor embolus. Ophthalmologists should be aware of this cause of acute visual loss in their differential diagnoses of retinal artery occlusion in patients with a history of malignancy.

The authors have no proprietary interest in any aspect of this report.

Corresponding author and reprints: Akihiro Ohira, MD, PhD, Department of Ophthalmology, Shimane Medical University, 89-1 Enya, Izumo, Shimane 693-8501, Japan (e-mail: aohira@shimane-med.ac.jp).

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