In August 2012, a 43-year-old man was hospitalized for the sudden onset of visual impairment (left eye). He reported not having had any traumas in the days before hospital admission, but referred having suffered for one month from headache, mostly located in the left eye area. He underwent a fluoroangiography, which showed an extensive bullous exudative left retinal detachment that involved the whole left retina, and was due to multiple, non-primitive, choroidal retinal neoplasias (Figure 1). Computed Tomography (CT)-scan and Magnetic Resonance Imaging of the brain showed the presence of abnormal tissue in the right retina and in most part of the left retina, where a clinically significant oedema was present.
Thorax CT-scan revealed a nodule in the right lung, in the median lobe, with the enlargement of right mediastinal lymph nodes. Bronchoscopy diagnosed an adenocarcinoma of the lung. Bone scan showed the involvement of several bones, cervical and dorsal vertebral bodies, and sternum. Biopsy of the right lung lesion was performed during bronchoscopy and an adenocarcinoma of the lung was diagnosed. Genetic characterization showed the presence of EGFR wild-type, KRAS wild-type, and EML4-ALK rearrangement which were diagnosed by FISH. Clinical TNM at the diagnosis was T2aN2M1, and distant localizations were in the bone and bilateral choroids mostly on the left eye.
The patient reported pain in his head, neck, dorsal back region, and severe asthenia; he could only see a few lights in his lower left visual field. He had been staying in bed most of his daily time for one week. He started to receive crizotinib 250 mg BID orally at the beginning of October 2012. Treatment was well tolerated, with a few G1 episodes of diarrhoea.In a few weeks, symptoms improved with the resolution of pain and asthenia, and the patient could finally resume normal daily activities. Surprisingly, he reported an improvement in his left eye, as demonstrated by the comparison of basal CT-scan and CT-scan after 45 days of treatment (Figure 2), and at the end of January 2013 he was admitted to eye surgery. The patient underwent phacoemulsification with lens implant, 23 g vitrectomy and an infusion of perfluorocarbon liquid (PFCL) to smoothen the left retina. Endolaser was performed in the superior temporal retina area; finally, ocular tamponade with silicone oil 1000 cts was performed.In the following months, the retina remained adherent (Figure 3). However, the eyesight was limited to the lower sector of the visual field for the presence of exudative lower mass with no signs of expansion, as well as for the blurring caused by tamponade with silicone oil.
Nevertheless, patient started to drive again and began a new job, thus resuming his normal daily activities.
CT-scans showed partial regression of the right lung nodule, as well as of the mediastinal lymph nodes. Bone scan revealed reduction of the previously evidenced activity in the bone. After 15 months, CT-scans showed signs of progression: while choroidal metastases were stable, as well as bone metastasis, the nodule in the right lung and the mediastinal lymph nodes showed a progression of about 21% according to RECIST criteria. Patient stopped treatment with crizotinib and switched to a second-generation anti-ALK therapy (Alectinib, Roche), thus obtaining a partial response of the lung nodule and mediastinal lymph nodes two months later, still ongoing after 7 months, and stabilization of the choroidal metastases.
