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Oral sunitinib malate (Sutent) is a tyrosine kinase inhibitor that prevents binding of vascular endothelial growth factor and platelet-derived growth factor to their native receptors.1 It has been approved by the US Food and Drug Administration for the treatment of renal cell carcinoma (RCC) and imatinib mesylate–resistant gastrointestinal stromal tumor. Choroidal metastasis from RCC is rare, composing only 3% of all choroidal metastases.2 Herein, we report the first case, to our knowledge, of rapid involution of choroidal metastasis secondary to RCC using sunitinib.
Report of a Case
A man in his early 50s was diagnosed as having right RCC and was treated with radical nephrectomy. Twenty-seven months later, he noticed intermittent photopsias and an inferior visual field defect in the left eye. Visual acuity was 20/25 OD and 20/20 OS. On examination, there was a 6.0 × 6.0 × 2.4-mm, predominantly amelanotic, orange, choroidal mass at the 12-o’clock position anterior to the equator in the left eye, with minimal associated subretinal fluid (Figure, A). Standardized echography demonstrated a dome-shaped lesion with high internal reflectivity and no internal vascularity (Figure, B). The patient had restaging workup the next month, and positron emission tomography and computed tomography showed left perihilar adenopathy and pulmonary nodules. Endobronchial ultrasonography and biopsy of a left perihilar mass confirmed metastatic RCC. The patient began treatment the following month with oral sunitinib malate, 50 mg once daily.
Color fundus montage photographs of the superior, predominantly amelanotic choroidal lesion in the left eye (A, C, E, and G), with corresponding B-scan images (B, D, F, and H) from initial presentation (A and B) to 1 month (C and D), 3 months (E and F), and 6 months (G and H) following the start of treatment with oral sunitinib malate. The B-scan images are all transverse sections at the 12-o’clock position anterior to the equator. The A-scan images (not shown) consistently demonstrated high internal reflectivity.
The choroidal lesion in the left eye had grown slightly a month later (Figure, C and D), but the lesion showed appreciable involution by 3 months after beginning treatment (Figure, E and F). Six months following the start of treatment, the lesion measured 7.5 × 9.0 × 0.9 mm with only faint pigment epithelial changes (Figure, G and H). His symptoms and vision remained stable and his pulmonary metastases also involuted following the initiation of sunitinib. He continues to take sunitinib malate, 50 mg/d, using the established schedule of 4 weeks of treatment followed by 2 weeks of rest. Aside from mild sore mouth and paresthesias, he continues to tolerate sunitinib well.
Sunitinib is an inhibitor of tyrosine kinase receptors and their agonists, including vascular endothelial growth factor and platelet-derived growth factor, which are involved in lymphangiogenesis and vascular angiogenesis.1 These receptors induce proteolytic degradation of the extracellular matrix and subsequent endothelial cell mitosis, cell migration, and capillary tube formation.3 In vivo animal models using intravitreal sunitinib malate at 25 mg/mL showed damage to the photoreceptor layer on light microscopy; however, no toxic effects were observed with 12.5 mg/mL.4 There are early reports of off-label use of sunitinib for abnormal corneal neovascularization5 and advanced wet age-related macular degeneration.4 Sunitinib may have a role in the management of choroidal metastases from RCC and possibly other neovascular disorders of the eye.
Corresponding Author: Eric K. Chin, MD, Department of Ophthalmology and Visual Sciences, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242 (firstname.lastname@example.org).
Published Online: October 16, 2014. doi:10.1001/jamaophthalmol.2014.3931.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Chin EK, Almeida DRP, Sacher BA, Boldt HC. Rapid Involution of Choroidal Metastasis Secondary to Renal Cell Carcinoma With Oral Sunitinib. JAMA Ophthalmol. 2015;133(1):109–110. doi:10.1001/jamaophthalmol.2014.3931
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