Ultrasonography. A, Contact B-scan at the initial visit showing the irregular shape and irregular structure of the solid mass lesion noted superotemporally (arrows). B, Standardized A-scan showing the irregular reflectivity (arrows). Marked vascularity was noted during the dynamic portion of the examination. C, Transverse B-scan 7 months following treatment showing vitreous hemorrhage (VH), posterior vitreous detachment, and a small area of thickening in the fundus where the tumor was previously located before treatment (arrow).
Fundus photographs. In the periphery, fundus photographs show retinal pigment epithelial changes with subretinal fibrosis in the area of previously active metastatic lesions.
Khurana RN, DiBernardo C, Handa JT. Improved Systemic Chemotherapy for Metastatic Testicular Choriocarcinoma Can Result in Excellent Prognosis for Life and Vision. Arch Ophthalmol. 2008;126(7):1009-1011. doi:10.1001/archopht.126.7.1008
Although testicular germ cell carcinoma is rare, it is the most common malignant neoplasm in men between the ages of 15 and 35 years. We report a case of metastatic choriocarcinoma involving the choroid that was effectively treated with chemotherapy and had an excellent visual outcome.
A 23-year-old healthy man visited the emergency department with decreased vision in his left eye. His best-corrected visual acuities were 20/20 OD and light perception OS. There was a left afferent pupillary defect. Slitlamp and fundus examination results of the right eye were unremarkable. Dilated funduscopic examination of the left eye was limited due to a vitreous hemorrhage. Standardized A-scan and contact B-scan ultrasonography of the left eye showed a large, irregularly shaped and structured, highly vascular mass lesion in the superotemporal quadrant (Figure 1). The mass measured approximately 19.0 × 15.8 mm in diameter with a maximal thickness of 12.4 mm.
On further detailed review of systems, the patient admitted to a 6-week history of testicular pain. An initial workup revealed a testicular mass, and chest radiography revealed 2 mass lesions in the lungs. The patient was immediately referred to an oncologist for further metastatic workup. The patient was diagnosed with metastatic testicular choriocarcinoma requiring radical orchiectomy followed by a 5-cycle chemotherapy regimen of bleomycin sulfate, etoposide, and cisplatin.
The patient responded well to the chemotherapy systemically, and serial ultrasonography examinations showed a dramatic decrease in the thickness of the choroidal mass from 12.4 mm to 3.0 mm. Three months after chemotherapy, the patient was clinically in remission. The choroidal mass continued to decrease in size until it became undetectable by ultrasonography (Figure 1) and the left afferent pupillary defect resolved. However, the visual acuity was 6/200 OS from a nonclearing vitreous hemorrhage. Five months into remission without resolution of the hemorrhage, the patient underwent a 25-gauge pars plana vitrectomy of the left eye. He later developed an epiretinal membrane and cataract that required a vitrectomy with membrane peeling and cataract extraction. Three years after his initial diagnosis, the patient remains in remission with a visual acuity of 20/40 OS. Subretinal fibrosis has replaced the previously active metastatic lesions (Figure 2).
Choriocarcinoma is an extremely rare cause of choroidal metastasis. A recent meta-analysis1 reported 15 cases of testicular choriocarcinoma to the choroid. Seventy-three percent of these patients (11 of 15 patients) had a poor prognosis, with survival of less than 2 months in the majority of these cases. Most of these reports with poor survival were prior to the 1970s. Advances in chemotherapy involving cisplatin-based regimens markedly improved the prognosis in the mid-1970s. In fact, germ cell tumors have become one of the most curable solid neoplasms, with survival rates of approximately 80% for advanced disease and nearly 100% for early disease.2
The visual prognosis in metastatic choriocarcinoma to the choroid has been poor. Most patients described prior to the 1970s died without any improvement in their vision. In the 2 cured patients, one's visual acuity was not reported,3 whereas the other's was 20/1000 due to scarring from the regressed tumor.4 Despite the relative afferent pupillary defect and the large tumor mass (12.4 mm), our case had an excellent visual outcome of 20/40, highlighting the importance of close and continued ophthalmic care. During chemotherapy, serial ultrasonography examinations were essential in showing the treatment response by documenting the decrease in tumor size. Ophthalmologists must be patient with the chemotherapy before considering surgical therapy, although surgical options should still be considered after treatment if appropriate. Close follow-up in conjunction with an oncologist is required.
Correspondence: Dr Handa, Cancer Research Bldg 2, Room 144, 1550 Orleans St, Baltimore, MD 21287-9277 (firstname.lastname@example.org).
Financial Disclosure: None reported.