Vascular co-option in lung cancer metastatic to the eye after treatment with bevacizumab

We examined a 57-year-old male who presented to the Bascom Palmer Eye Institute in Oct 2009 with a 6-month history of floaters in his left eye (OS). He had reported flashes in the OS 3 months prior and had undergone laser retinopexy without resolution of symptoms and was now diagnosed as uveitis. Past medical history was significant for stage IV non-small cell carcinoma of the lung diagnosed in Aug 2005 and treated with left pneumonectomy. Within 1 year, brain metastases developed and were treated with whole brain irradiation, 6-thioguanine, temozolomide, and stereotactic radiosurgical treatment of some larger masses. In June 2009, recurrent brain metastases were detected. Cerebrospinal fluid was negative for malignant cells. Chemotherapy was resumed. Erlotinib was stopped 2 months prior to presentation, and a 6-week prior MRI of the brain showed no evidence of tumor. Treatment with bevacizumab, capecitabine, and camptosar was ongoing. He had an implantable venous access device in the right subclavian vein present for 4 years. The skin over the device was intact and uninflamed. He was afebrile.

Vision was 20/15 in the right eye (OD) and 20/40 OS. Pupil exam was normal with a 10% subjective reduction in light brightness OS. There was mild conjunctival injection in the OS more than in the OD. He had 1+ anterior chamber cell OS and no cell OD. There were no posterior synechiae. Examination of the vitreous and retina OD was entirely normal. In the OS, there were 2+ vitreous cells, with clumping (Fig. 1). The cells appeared to ramify on the surface of the retina with well-defined cellular clumps along the retinal arteries and veins (Fig. 2). Optical coherence tomography confirmed a preretinal location (Fig. 2).

Fungal endophthalmitis was considered. A diagnostic pars plana vitrectomy was performed with intravitreal injection of 5 μg amphotericin. The vitreous specimen was sent for histopathology and culture. No organisms were identified on gram stain. Corynebacterum grew from a single medium used to culture the vitreous and was interpreted as a contaminant. Blood and urine cultures were negative. Millipore preparations of the vitreous specimen revealed cellular evidence of adenocarcinoma (Fig. 3). Immunocytochemistry was positive for TTF-1(thyroid transcription factor-1) indicating a lung primary (Fig. 3).

The patient was referred to his oncologist for further evaluation and treatment. Temozolomide was added. He relocated to Maryland. In March 2010, multiple lymph nodes showed metastatic disease on PET scan, and he was switched to single agent chemotherapy with gemcitabine. Vision was 20/70. Some cellular clumps had resolved, and there were other new ones, including a large peripapillary lesion (Fig. 4), which remained stable in size over the next 2 months. The right eye remained clinically uninvolved.