Choroidal Metastasis: Board Review
Learn choroidal metastasis signs, sources and B-scan clues for NBEO and OKAP with a focused board style review.
What is the most common intraocular malignancy overall?
Choroidal Metastasis in 30 Seconds
Choroidal metastasis is the most common intraocular malignancy overall and the most common intraocular malignancy in adults. It can be the first sign of systemic cancer, so board exams test quick recognition of the classic lesion pattern and the need for urgent systemic workup.
Classic Clinical Features
- Appearance: creamy yellow, amelanotic, flat or plateau-shaped choroidal lesion. Exam relevance: this color and shape favor metastasis over melanoma.
- Number: often multifocal and can be bilateral. Exam relevance: multiplicity or bilaterality supports metastatic disease.
- Location: posterior pole, favored because of the rich choroidal blood supply. Exam relevance: posterior choroid is the classic site on NBEO and OKAP.
- Subretinal fluid: exudative retinal detachment often disproportionate to the size of the lesion. Exam relevance: fluid is a high-yield clue to metastasis.
- Rapid growth: faster than a primary melanoma. Exam relevance: fast change pushes the differential toward metastasis.
Primary Sources and Workup
- Breast cancer: the most common primary source in women. Exam relevance: always ask women with a choroidal metastasis about breast cancer history.
- Lung cancer: the most common primary in men and among the most common overall. Exam relevance: lung cancer leads the differential in men on exams.
- Other primaries: prostate, gastrointestinal, kidney and thyroid. Exam relevance: know the common alternate sources for test questions.
- No known primary in a substantial proportion of cases. Exam relevance: absence of a known cancer does not exclude metastasis.
- Workup: systemic imaging and oncology referral, since the eye may be the presenting site. Exam relevance: systemic evaluation may identify an occult primary malignancy.
4 Facts Exams Always Ask
- Choroidal metastasis is the most common intraocular malignancy overall.
- It often appears creamy yellow, amelanotic, multifocal or bilateral.
- Breast cancer is the most common primary in women and lung cancer is the most common primary in men.
- B-scan usually shows medium-to-high internal reflectivity with an irregular internal structure, unlike melanoma's low-to-medium reflectivity and acoustic hollowness.
The Classic Trap
The main board trap is distinguishing choroidal metastasis from choroidal melanoma. Metastasis is creamy yellow, often multifocal or bilateral, plateau-shaped and shows medium-to-high internal reflectivity on B-scan. Melanoma is pigmented, usually solitary, dome-shaped or mushroom-shaped and shows low-to-medium reflectivity with acoustic hollowness. Reference the Choroidal Melanoma lesson.
Clinical Pearl
A creamy yellow multifocal or bilateral choroidal lesion should prompt a systemic cancer workup, because the eye can be the first site of presentation. A substantial proportion of patients have no known cancer at diagnosis, so systemic evaluation may uncover an occult primary. In a woman, breast is the leading primary. In a man, lung. Management targets the systemic disease, often with external beam radiotherapy for ocular control.
Checkpoint 1
In women, the most common primary source of choroidal metastasis is which cancer?
Checkpoint 2
In men, the most common primary source of choroidal metastasis is which cancer?
A patient with known lung cancer presents with blurred vision. Fundus exam shows a creamy yellow multifocal choroidal lesion with subretinal fluid. The lesion is flat to plateau-shaped. What diagnosis should you think of first before you compare it with choroidal melanoma?
Which clinical pattern most strongly suggests choroidal metastasis rather than primary uveal melanoma?
Sources & Reviewer Info
References
- American Academy of Ophthalmology. BCSC Section 4: Ophthalmic Pathology and Intraocular Tumors.
- Shields CL, Shields JA. Clinical Ocular Oncology.
- American Academy of Ophthalmology. EyeWiki: Choroidal Metastases.
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