We present a case of chemotherapeutic regression of a metastatic breast carcinoma to the choroid in a male patient. The rapid response to systemic tamoxifen prevented the patient from receiving local radiotherapy and helped confirm the suspected diagnosis of a choroidal metastasis.
A 76-year-old man was referred with an inferior field defect. Right funduscopy revealed a solitary, pale, elevated choroidal mass underlying the superior temporal arcade (Figure 1). The mass was 3.7 mm high with a maximum basal diameter of 6.8 mm. The lesion showed low internal reflectivity on ocular ultrasound. No choroidal lesions were seen in the left fundus. The differential diagnosis was either an amelanotic melanoma or a metastatic deposit. He was investigated for metastatic disease prior to planned treatment with ruthenium plaque brachytherapy.
A color fundus photograph of a pale, elevated choroidal mass underlying the right superior temporal vascular arcade.
A shadow was detected on his chest x-ray film. On examination, the left nipple and areola were hard, indurated, and enlarged. Regional lymph nodes were palpable. A spiculated mass with microcalcification was seen on left mammography (Figure 2). Fine-needle aspiration biopsy revealed a grade II ductal carcinoma that was positive for estrogen and progesterone receptors. He had a left mastectomy with axillary clearance and postoperative local radiotherapy. He was given oral tamoxifen, 20 mg daily.
Mammogram of the left breast showing a spiculated mass behind the nipple (arrow) with microcalcification, skin thickening, and nipple retraction, typical of a ductal carcinoma.
At breast cancer staging, no metastatic disease was detected in the liver, bone marrow, or chest. Therefore, the presumed ocular diagnosis of a choroidal secondary was questioned. No ocular treatment was undertaken, but the patient was reviewed by the ocular oncology service after his mastectomy. The right choroidal mass was found to have completely regressed to a flat, atrophic chorioretinal scar following 4 months of treatment with systemic tamoxifen (Figure 3).
After 4 months of treatment with systemic tamoxifen, a flat area of chorioretinal atrophy was seen in the previous location of the choroidal metastasis.
Breast cancer in men accounts for less than 1% of all male cancers and less than 1% of all diagnosed breast cancers. Visual symptoms from choroidal metastases are rarely the initial manifestation of primary breast carcinoma, even in women.1
Male breast cancer differs from female breast cancer in many ways. The average age of the male patients at diagnosis is 60 years (10 years older than women). Expression of estrogen, androgen, and progesterone steroid receptors is higher in men than in women. Therefore, hormonal manipulation with tamoxifen (a nonsteroidal estrogen antagonist) constitutes an essential part of adjuvant therapy for metastatic disease.
Choroidal metastases respond well to treatment with radiotherapy.2 Treatment options for a choroidal metastasis include external beam radiotherapy (4000 rad [40 Gy] administered in 20 fractions) and brachytherapy. External beam radiotherapy is generally preferable to brachytherapy when there is a risk of visual deterioration. However, radiation adverse effects can include cataract formation, skin changes, lash loss, dry eye, and potential radiation retinopathy and optic neuropathy. In contrast with systemic tamoxifen, radiation does not control other potential metastatic lesions, which are very likely to exist and may not be clinically detectable. Systemic tamoxifen has significant advantages over localized radiation treatments, given the traditionally poor survival rate of such patients.
Systemic chemotherapy for metastatic breast cancer disease has been shown to induce regression of choroidal metastasis, preserving vision and allowing in vivo monitoring of the success of chemotherapy.3 To our knowledge, this is the first report of tamoxifen-induced regression of a choroidal metastasis from a breast primary in a man. The hormone receptor–positive choroidal metastasis showed complete regression while systemic tamoxifen was administered, allowing preservation of the vision. Tamoxifen has been reported to induce regression of cerebral metastases in a man with metastatic breast cancer.4 Regression was seen after 6 months of treatment with 20 mg of tamoxifen daily.
It is very unusual to have a clinically solitary ocular metastasis without liver or lung involvement. In this case, the ocular diagnosis was in doubt: however, observation of the effect of systemic tamoxifen on the tumor was helpful in confirming the diagnosis of a metastatic breast deposit.
Correspondence: Dr Cohen, Ocular Oncology Services, Saint Bartholomew’s Hospital, West Smithfield, London EC1A 7BE, England (firstname.lastname@example.org).
Financial Disclosure: None.
Cohen VML, Moosavi R, Hungerford JL. Tamoxifen-Induced Regression of a Choroidal Metastasis in a Man. Arch Ophthalmol. 2005;123(8):1153-1154. doi:10.1001/archopht.123.8.1153