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Clinicopathologic Reports, Case Reports, and Small Case Series
February 2003

Prostatic Adenocarcinoma Metastatic to the Anterior Uveal Tract

Arch Ophthalmol. 2003;121(2):276-278. doi:10.1001/archopht.121.2.276

Prostate cancer rarely metastasizes to the eye. When it does, it usually involves the choroid. The most common primary sites of carcinoma metastatic to the uveal tract are the breast, lung, and gastrointestinal tract. We report a case of prostate carcinoma metastatic to the ciliary body.

Report of a Case

A 76-year-old man had complaints of acute visual blurring in the right eye and dull aching pain. Nine years earlier he was diagnosed as having prostatic adenocarcinoma (Gleason score, 7) with concurrent metastasis to the left fifth rib bone (Figure 1). Because of distant metastasis at diagnosis, he opted to receive hormonal treatment (flutamide and goserelin [Zoladex]). Ocular history was unremarkable. Examination revealed visual acuity correctable to 20/20 OU. Ocular motility and visual field examination findings were unremarkable. Intraocular pressures were within normal limits. Slitlamp examination findings revealed a brown, cohesive mass containing prominent blood vessels projecting into the anterior chamber of the right eye displacing the iris (Figure 2). A microhyphema was present. There was no tumor-cell shedding into the anterior chamber. Funduscopic examination revealed no retinal detachment. No masses were present in the left eye. Ultrasound biomicroscopy (Figure 3) showed the ciliary body mass to measure 6 mm in basal diameter and 3 mm in thickness with no evidence of scleral invasion. Differential diagnosis included malignant melanoma, metastatic carcinoma, and primary adenocarcinoma.

Figure 1.
A, Findings from histopathologic examination of the original diagnostic biopsy specimen from rib bone shows diffuse infiltration of the bone marrow by a moderately differentiated adenocarcinoma(hematoxylin-eosin, original magnification ×50). B, The tumor is composed of nonpigmented pleomorphic cells in a lobular and cribriform growth pattern(hematoxylin-eosin, original magnification ×100).

A, Findings from histopathologic examination of the original diagnostic biopsy specimen from rib bone shows diffuse infiltration of the bone marrow by a moderately differentiated adenocarcinoma(hematoxylin-eosin, original magnification ×50). B, The tumor is composed of nonpigmented pleomorphic cells in a lobular and cribriform growth pattern(hematoxylin-eosin, original magnification ×100).

Figure 2.
Anterior segment photograph of the right eye. The iris is displaced by vascularized tumor pushing forward from the ciliary body and iris pigment epithelium imparting a pigmented appearance to this surface of the tumor.

Anterior segment photograph of the right eye. The iris is displaced by vascularized tumor pushing forward from the ciliary body and iris pigment epithelium imparting a pigmented appearance to this surface of the tumor.

Figure 3.
Ultrasound biomicroscopy of the right eye shows the ciliary body mass.

Ultrasound biomicroscopy of the right eye shows the ciliary body mass.

After full discussion of treatment modalities with the patient, he rejected the suggestion of undergoing a pretreatment fine-needle aspiration biopsy. Excision of the mass by iridocyclectomy was performed. During surgery, the mass was observed to be whitish-tan (Figure 4). Excision was incomplete because of tumor friability.

Figure 4.
Photograph of the submitted mass. The internal surface is bordered by ciliary body epithelium giving a pigmented appearance (tissue on right in the photograph). The cut surface of the tumor has a whitish-tan appearance consistent with microscopic findings (tissue on the left side). The tic marks indicate millimeters.

Photograph of the submitted mass. The internal surface is bordered by ciliary body epithelium giving a pigmented appearance (tissue on right in the photograph). The cut surface of the tumor has a whitish-tan appearance consistent with microscopic findings (tissue on the left side). The tic marks indicate millimeters.

Findings on histopathologic examination revealed poorly differentiated carcinoma composed of nonpigmented pleomorphic cells with large nuclei and prominent nucleoli. Mitoses were present (Figure 5). Tumor cells were similar to those in the prior biopsy specimen that led to the original diagnosis of prostatic adenocarcinoma (Figure 1). Immunohistochemical staining revealed diffuse reactivity for prostate-specific antigen and epithelial membrane antigen and nonreactivity for HMB-45 and melan-A (Figure 5). A diagnosis of metastatic prostate carcinoma was made. The patient underwent external beam radiation therapy for residual eye tumor and for new spinal cord metastases detected on systemic evaluation prompted by ocular findings.

Figure 5.
A, Findings from histopathologic examination reveal the ciliary body mass (hematoxylin-eosin, original magnification×50). B, The poorly differentiated carcinoma is composed of nonpigmented pleomorphic cells (hematoxylin-eosin, original magnification ×100). C, Immunohistochemical stain showing marked reactivity (brown staining) for prostate-specific antigen by tumor (original magnification ×50). D, Immunohistochemical stain showing nonreactivity for HMB-45 and melan-A (original magnification ×50).

A, Findings from histopathologic examination reveal the ciliary body mass (hematoxylin-eosin, original magnification×50). B, The poorly differentiated carcinoma is composed of nonpigmented pleomorphic cells (hematoxylin-eosin, original magnification ×100). C, Immunohistochemical stain showing marked reactivity (brown staining) for prostate-specific antigen by tumor (original magnification ×50). D, Immunohistochemical stain showing nonreactivity for HMB-45 and melan-A (original magnification ×50).

Comment

Prostatic adenocarcinoma is the most common form of cancer and the second leading cause of cancer death in men.1,2 Its spread can occur by direct local invasion, perineural invasion, and via the bloodstream and lymphatic system. Hematogenous spread occurs primarily to the bones.1 Distant metastases are seen in the pelvic lymph nodes, liver, and lungs.3 Although prostatic adenocarcinoma is the second most common tumor in men to metastasize to the orbit, uveal metastases are extremely rare. In a large survey by Shields et al4 of 520 eyes with uveal metastasis, only 9 patients (2%) had the prostate as the primary site.

Most patients with uveal prostatic metastases have a mean interval between the diagnosis of the primary tumor and uveal involvement of approximately 2 years.5 The interval was 9 years in our patient, despite having distant metastasis at initial diagnosis. Irradiation has provided effective therapy for choroidal metastasis.3 Our patient received 4 weeks of ocular external beam radiation therapy subsequent to the surgery for residual tumor and radiation treatment for new skeletal metastases. In general, the survival prognosis for patients with metastasis to the uveal tract is poor. Various series report an overall median survival rate of 7.4 to 10.5 months from the time of ocular diagnosis.5 All reported cases in the English literature of prostatic adenocarcinoma metastatic to the uveal tract have been to the choroid, except for one that was to the iris.5 We believe this is the first reported case of prostatic adenocarcinoma metastatic to the ciliary body.

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Article Information

This study was supported by an unrestricted grant from Research to Prevent Blindness, New York, NY.

Corresponding author and reprints: Susan Schneider, MD, Mary Knight Asbury Eye Pathology Laboratory, University of Cincinnati, A-Pavilion, Room 220, 234 Goodman St, Cincinnati, OH 45219-0777 (e-mail: eyepath_sue@hotmail.com).

References
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Keizur  JKane  CNorth  RLeidich  R Adenocarcinoma of the prostate metastatic to the choroid of the eye. Prostate. 1995;27336- 339Article
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Shields  CShields  JGross  NSchwartz  GLally  S Survey of 520 eyes with uveal metastases. Ophthalmology. 1997;1041265- 1276Article
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De Potter  PShields  CLShields  JATardio  DJ Uveal metastasis from prostate carcinoma. Cancer. 1993;712791- 2796Article
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