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Metastatic Carcinoma of the Iris*
ORBITONOMETRY IN UNILATERAL EXOPHTHALMOS
221
11. Kearns, T. P., Henderson, J. W., and Haines, S. F.: Clinical orbitonometry in Graves' disease. Am. J. Ophth., 36:45-55 (Jan.) 1953. 12. Faldi, S.: Further clinical trials with Copper's orbitonometer. Gior. ital. oftal., 6:498-502 (SeptOct.) 1953. 13. Benedict, W. L.: Diseases of the orbit: Jackson memorial lecture. Am. J. Ophth., 33:1-10 (Jan.) 1950. 14. Kearns, T. P. and Wagener, H. P.: Ophthalmologic diagnosis of meningiomas of the sphenoidal ridge. Am. J. M. Sc, 226:221-228 (Aug.) 1953.
METASTATIC CARCINOMA O F T H E IRIS* DAHAR CURY,
M.D.
Huntington Park, California
The eye is an uncommon site for metastatic new growths. These growths are usual ly multiple and often bilateral. To date eight histologically verified cases confined to the iris have been reported. 1-8 Microscopic ex amination of the primary site has been re ported in three cases.4"8 It is the purpose of this paper to report two additional cases of metastatic carcinoma of the iris. In Case 1, the tumor, when first observed, clinically was confined to the iris but had extended to the adjacent ciliary body at the time of enucleation. CASE REPORTS
CASE 1 (patient of Dr. Eric Richardson) This 57-year-old white man complained of a dry, hacking cough for some months which began in the spring of 1952. A diagnosis of carcinoma of the right lung was made in June, 1952. On July 11, 1952, a right pneumonectomy was performed at St. Clare's Hospital. At the time of operation no metastases were found in the regional lymph nodes. Two weeks after the operation and while the patient was still in the hospital the left eye became inflamed and painful. A small, grayish-white mass with many newly formed blood vessels was present on the temporal surface of the iris near the pe riphery. This mass grew in size and vascularity. The intraocular pressure was increased to 60 mm. Hg (Schi^tz). The eye was removed on September 18, 1952, under local anesthesia because of intract able pain. The pathologic study of the resected lung re vealed bronchogenic carcinoma. * From the ENO Laboratory, New York Eye and Ear Infirmary, New York,
The patient died in October, 1952, four months after the diagnosis of cancer of the lung had been made. There had occurred very rapid and wide spread metastases, many of them to the bones of the skull and legs. Pathologic report. Gross. A globe of normal size and shape is submitted. Sections are eccentric and only portions of the lens and anterior chamber are visible. That portion of the anterior chamber seen is filled with a dense heavy-staining mass which has indented the lens behind. Microscopic. That portion of the cornea near the limbus is mainly seen in the sections studied. There is some vascularization in the middle and outer third. The endothelium is obscured for the most part by the mass in the anterior chamber. The epithelium is intact. The stroma is not re markable, and the angle meshwork is normal nasally. On the temporal side, the meshwork is compressed by the mass in the temporal angle. Some of the cells from this mass are seen in the Canal of Schlemm on this side. Almost the entire chamber is filled with a tumor mass which appears to have emanated from the temporal iris and anterior portion of the ciliary body. The nasal angle is the only area not filled by the mass. This region contains an albuminous coagulum in which are floating a few tumor cells and red blood cells. The temporal iris is almost completely missing, having been destroyed by the tumor. The tumor has invaded the posterior cham ber, temporally, and has exerted pressure against the lens. There is extensive necrosis throughout the tumor obscuring much of the cytology. The tumor is composed chiefly of large, uni formly faint-staining cells with prominent small nucleoli. There are numerous mitotic figures. There is a suggestion of granular formation. Several large blood spaces are seen lined by tumor cells. The tumor has caused a pressure necrosis in the medial half of the nasal iris. The iris has lost its normal crypts and folds. The stroma is marked by sanguineous extravasation and perivascular
222
DAHAR CURY
Fig. 1 (Cury). Case 1. This section shows the metastatic bronchogenic carcinoma from the lung filling the anterior chamber and infiltrating the iris. round cell infiltration. The posterior pigment layer has lost many of its festoonations and is frag mented in places, especially medially, where the iris is connected by adhesive bands to the lens behind and to remnants of the temporal iris. The temporal iris, as noted, has been destroyed by hemorrhagic necrosis due to tumor invasion. On the temporal side of the ciliary body, the tumor has invaded the anterior portion of the pars corona. There is necrosis in these processes. The ciliary epithelium and pigment epithelium have been destroyed or are barely distinguishable. There is vascular congestion in the ciliary body. There is vascular congestion in the larger vessels
Fig. 2 (Cury). Case 1. High-power view of Fig ure 1, showing morphology of the metastatic bron chogenic carcinoma from the lung.
of the choroid. The lamina vitrea and pigment epithelium are intact. There is some gliosis in the nerve fiber and ganglion cell layers. Marked cystic degeneration is seen at the temporal ora serrata. The optic nerve and the papillae are not seen in the sections ex amined. The vitreous is detached posteriorly and in places is filled with a fibrinous coagulum. The lens is markedly indented in the temporal anterior quad rant. The capsule is intact, but there is pressure necrosis in the subcapsular epithelium, underlying cortex, and nucleus, and in these areas there are vacuoles. Impression. Metastatic bronchogenic carcinoma (epidermoid?) into the iris and ciliary body. Ne crosis of iris and ciliary body. Iridocyclitis. Com plicated cataract. CASE 2 (patient of Dr. Leon Weiss) This 79-year-old white man had a blind and painful right eye when first seen at the New York Eye and Ear Infirmary in June, 19S4, at which time he was admitted for an enucleation. The clinical diagnosis was amaurosis, iridocyclitis, sec ondary glaucoma, retinal detachment, and cataract. The iridocyclitis with secondary glaucoma had been uncontrolled by medication for three weeks prior to admission. The fellow eye showed retinal degen-
Fig. 3 (Cury). Case 2. Low-power view of original lesion of squamous-cell carcinoma of the lower lip.
METASTATIC CARCINOMA OF T H E IRIS erative changes, lenticular opacities, and vitreous floaters. Seven years earlier (June, 1947) squamous cell carcinoma of the lower lip was diagnosed and excised at Memorial Hospital, New York City. Periodic examinations revealed no recurrence. His last examination was in April, 1954, two months before his admission to the New York Eye and E a r Infirmary, at which time there was no systemic evidence of recurrence. Pathologic study. Gross. An eye measuring 25 by 24 mm. is presented for study. T h e eye is somewhat irregular in shape and does not show an external scleral sulcus as it is usually seen. The sections are cut somewhat eccentrically and do not show the pupillary area or pass directly through the nerve. The anterior chamber contains a reddish coagulum. The lens is oblong in shape, its center removed dur ing fixation. Microscopic. The corneal epithelium is intact. It contains vesicles in its outer layer and consider able edema of the basal layers. Bowman's mem brane and Descemet's membrane are identified. There are some bullae between Bowman's membrane and the overlying epithelium. The stroma is edematous. The endothelium is edematous and is con tinuous with an epitheliumlike membrane on the surface of the iris at the pseudo angle. A granular coagulum is adherent to its inner surface. There are peripheral anterior synechias of the iris. The iris does not show crpyts and folds. Fes tooning of the pigment epithelium is present but irregular. There are small posterior synechias be tween the pigment epithelium of the iris and the lens. The iris shows atrophy and mobilization of its pigment. There is a membrane on much of the anterior surface of the iris, especially adjacent to the pseudo angle. The cells of this membrane have the appearance of epithelial cells and are arranged
Fig. 4 ( C u r y ) . Case 2. High-power view of section from the lip.
223
Fig. 5 ( C u r y ) . Case 2. Metastatic squamous car cinoma from the lower lip on the surface of the iris and extending to the pseudo angle. in irregular layers, and in some areas penetrate the stroma of the iris. The nuclei are oval-shaped and contain numerous nucleoli. Some of the nuclei are hyperchromatic. The cytoplasm is scant in many of the cells studied. Occasional mitotic figures are seen. The ciliary body shows, mobilization of its pigment epithelium, and at the ora serrata there is a "ringschwiele." The choroid is compressed, and in portions is
Fig. 6 ( C u r y ) . Case 2. High-power view of Fig ure 5, showing metastatic squamous cell carcinoma infiltrating the stroma of the iris.
224
DAHAR CURY
infiltrated with chronic inflammatory cells. The pigment epithelium is adherent to the choroid. Some of the pigment epithelium cells have migrated into the subretinal fluid. There are numerous pathologic drusen. The retina is detached except at the optic disc and the ora serrata and shows degeneration and atrophy. Numerous macrophages containing pig ment are seen in the retina. Some foci and diffuse infiltration of chronic inflammatory cells are seen. The retina is not seen in its entirety, probably artefact of fixation, but that portion seen is sepa rated and thrown into folds. There is cystoid degen eration of the retina. The retinal elements have undergone degeneration and atrophy. The subretinal fluid is a clear eosinophilic staining coagulum which contains pigmented macrophages and a few cho lesterol clefts. The optic nerve shows complete irregularity of its nuclear columns. There is an increase in the glial elements. The vitreous body lies anteriorly. It contains more macrophages than are usually seen and shows areas of fresh hemorrhage. Behind the lens there are numerous areas which show a coarse coagulum thought to be lens substance that has apparently leaked from the hypermature lens. Numerous mac rophages and an occasional eosinophil are seen in these areas. The crystalline lens is shrunken and there is a
break in the continuity of the lens capsule pos teriorly. The lens substance shows liquefaction and in some areas stains basophilically and contains crystals. At the equator of the lens, the lens capsule is drawn upward toward the ciliary body and sur rounds several inclusions of lens substance. On the posterior surface of the lens there are collections of pigment and macrophages containing pigment. The anterior chamber contains a granular eosin ophilic coagulum. The angle is obliterated and a pseudo angle is seen. Schlemm's canal is not iden tified in the sections studied. Impression. Metastatic squamous-cell carcinoma of the iris. Separation of the retina. Secondary glaucoma. Chronic uveitis. Optic atrophy due to glaucoma. Hypermature lens with lens reaction. SUMMARY
Two additional cases of metastatic carci noma of the iris are reported in which the enucleated eye and primary site were ex amined histologically. The second case is re markable in that it resembles epithelization of the anterior surface of the iris as seen in downgrowths in the anterior chamber. 2665 Walnut Street.
REFERENCES
1. Bollack, J., Bertillon, F., and Roques, A.: Metastatic epithelioma of the iris. Ann. Ocul., 164 :336, 1927. 2. Hudson, A. C, and Lister, W.: Metastatic hypernephroma of the iris. Proc. Roy. Soc. Med., 27:1613. 1934. 3. Sanders, T. E.: Metastatic carcinoma of the iris. Am. J. Ophth., 21:646, 1938. 4. Asbury, M. K., and Vail, D.: Metastatic carcinoma of the iris. Am. J. Ophth., 23:402, 1940. 5. Sautter, H.: Some interesting findings on the iris. Klin. Monatsbl. f. Augenh., 113:44, 1948. 6. Reese, A. B.: Tumors of the Eye. New York, Hoeber, 1950. 7. Greear, J.: Metastatic carcinoma of the eye. Am. J. Ophth., 33:1015, 1950. 8. Greer, C. H.: Metastatic carcinoma of the iris. Brit. J. Ophth., 38 -.699, 1954.
221
11. Kearns, T. P., Henderson, J. W., and Haines, S. F.: Clinical orbitonometry in Graves' disease. Am. J. Ophth., 36:45-55 (Jan.) 1953. 12. Faldi, S.: Further clinical trials with Copper's orbitonometer. Gior. ital. oftal., 6:498-502 (SeptOct.) 1953. 13. Benedict, W. L.: Diseases of the orbit: Jackson memorial lecture. Am. J. Ophth., 33:1-10 (Jan.) 1950. 14. Kearns, T. P. and Wagener, H. P.: Ophthalmologic diagnosis of meningiomas of the sphenoidal ridge. Am. J. M. Sc, 226:221-228 (Aug.) 1953.
METASTATIC CARCINOMA O F T H E IRIS* DAHAR CURY,
M.D.
Huntington Park, California
The eye is an uncommon site for metastatic new growths. These growths are usual ly multiple and often bilateral. To date eight histologically verified cases confined to the iris have been reported. 1-8 Microscopic ex amination of the primary site has been re ported in three cases.4"8 It is the purpose of this paper to report two additional cases of metastatic carcinoma of the iris. In Case 1, the tumor, when first observed, clinically was confined to the iris but had extended to the adjacent ciliary body at the time of enucleation. CASE REPORTS
CASE 1 (patient of Dr. Eric Richardson) This 57-year-old white man complained of a dry, hacking cough for some months which began in the spring of 1952. A diagnosis of carcinoma of the right lung was made in June, 1952. On July 11, 1952, a right pneumonectomy was performed at St. Clare's Hospital. At the time of operation no metastases were found in the regional lymph nodes. Two weeks after the operation and while the patient was still in the hospital the left eye became inflamed and painful. A small, grayish-white mass with many newly formed blood vessels was present on the temporal surface of the iris near the pe riphery. This mass grew in size and vascularity. The intraocular pressure was increased to 60 mm. Hg (Schi^tz). The eye was removed on September 18, 1952, under local anesthesia because of intract able pain. The pathologic study of the resected lung re vealed bronchogenic carcinoma. * From the ENO Laboratory, New York Eye and Ear Infirmary, New York,
The patient died in October, 1952, four months after the diagnosis of cancer of the lung had been made. There had occurred very rapid and wide spread metastases, many of them to the bones of the skull and legs. Pathologic report. Gross. A globe of normal size and shape is submitted. Sections are eccentric and only portions of the lens and anterior chamber are visible. That portion of the anterior chamber seen is filled with a dense heavy-staining mass which has indented the lens behind. Microscopic. That portion of the cornea near the limbus is mainly seen in the sections studied. There is some vascularization in the middle and outer third. The endothelium is obscured for the most part by the mass in the anterior chamber. The epithelium is intact. The stroma is not re markable, and the angle meshwork is normal nasally. On the temporal side, the meshwork is compressed by the mass in the temporal angle. Some of the cells from this mass are seen in the Canal of Schlemm on this side. Almost the entire chamber is filled with a tumor mass which appears to have emanated from the temporal iris and anterior portion of the ciliary body. The nasal angle is the only area not filled by the mass. This region contains an albuminous coagulum in which are floating a few tumor cells and red blood cells. The temporal iris is almost completely missing, having been destroyed by the tumor. The tumor has invaded the posterior cham ber, temporally, and has exerted pressure against the lens. There is extensive necrosis throughout the tumor obscuring much of the cytology. The tumor is composed chiefly of large, uni formly faint-staining cells with prominent small nucleoli. There are numerous mitotic figures. There is a suggestion of granular formation. Several large blood spaces are seen lined by tumor cells. The tumor has caused a pressure necrosis in the medial half of the nasal iris. The iris has lost its normal crypts and folds. The stroma is marked by sanguineous extravasation and perivascular
222
DAHAR CURY
Fig. 1 (Cury). Case 1. This section shows the metastatic bronchogenic carcinoma from the lung filling the anterior chamber and infiltrating the iris. round cell infiltration. The posterior pigment layer has lost many of its festoonations and is frag mented in places, especially medially, where the iris is connected by adhesive bands to the lens behind and to remnants of the temporal iris. The temporal iris, as noted, has been destroyed by hemorrhagic necrosis due to tumor invasion. On the temporal side of the ciliary body, the tumor has invaded the anterior portion of the pars corona. There is necrosis in these processes. The ciliary epithelium and pigment epithelium have been destroyed or are barely distinguishable. There is vascular congestion in the ciliary body. There is vascular congestion in the larger vessels
Fig. 2 (Cury). Case 1. High-power view of Fig ure 1, showing morphology of the metastatic bron chogenic carcinoma from the lung.
of the choroid. The lamina vitrea and pigment epithelium are intact. There is some gliosis in the nerve fiber and ganglion cell layers. Marked cystic degeneration is seen at the temporal ora serrata. The optic nerve and the papillae are not seen in the sections ex amined. The vitreous is detached posteriorly and in places is filled with a fibrinous coagulum. The lens is markedly indented in the temporal anterior quad rant. The capsule is intact, but there is pressure necrosis in the subcapsular epithelium, underlying cortex, and nucleus, and in these areas there are vacuoles. Impression. Metastatic bronchogenic carcinoma (epidermoid?) into the iris and ciliary body. Ne crosis of iris and ciliary body. Iridocyclitis. Com plicated cataract. CASE 2 (patient of Dr. Leon Weiss) This 79-year-old white man had a blind and painful right eye when first seen at the New York Eye and Ear Infirmary in June, 19S4, at which time he was admitted for an enucleation. The clinical diagnosis was amaurosis, iridocyclitis, sec ondary glaucoma, retinal detachment, and cataract. The iridocyclitis with secondary glaucoma had been uncontrolled by medication for three weeks prior to admission. The fellow eye showed retinal degen-
Fig. 3 (Cury). Case 2. Low-power view of original lesion of squamous-cell carcinoma of the lower lip.
METASTATIC CARCINOMA OF T H E IRIS erative changes, lenticular opacities, and vitreous floaters. Seven years earlier (June, 1947) squamous cell carcinoma of the lower lip was diagnosed and excised at Memorial Hospital, New York City. Periodic examinations revealed no recurrence. His last examination was in April, 1954, two months before his admission to the New York Eye and E a r Infirmary, at which time there was no systemic evidence of recurrence. Pathologic study. Gross. An eye measuring 25 by 24 mm. is presented for study. T h e eye is somewhat irregular in shape and does not show an external scleral sulcus as it is usually seen. The sections are cut somewhat eccentrically and do not show the pupillary area or pass directly through the nerve. The anterior chamber contains a reddish coagulum. The lens is oblong in shape, its center removed dur ing fixation. Microscopic. The corneal epithelium is intact. It contains vesicles in its outer layer and consider able edema of the basal layers. Bowman's mem brane and Descemet's membrane are identified. There are some bullae between Bowman's membrane and the overlying epithelium. The stroma is edematous. The endothelium is edematous and is con tinuous with an epitheliumlike membrane on the surface of the iris at the pseudo angle. A granular coagulum is adherent to its inner surface. There are peripheral anterior synechias of the iris. The iris does not show crpyts and folds. Fes tooning of the pigment epithelium is present but irregular. There are small posterior synechias be tween the pigment epithelium of the iris and the lens. The iris shows atrophy and mobilization of its pigment. There is a membrane on much of the anterior surface of the iris, especially adjacent to the pseudo angle. The cells of this membrane have the appearance of epithelial cells and are arranged
Fig. 4 ( C u r y ) . Case 2. High-power view of section from the lip.
223
Fig. 5 ( C u r y ) . Case 2. Metastatic squamous car cinoma from the lower lip on the surface of the iris and extending to the pseudo angle. in irregular layers, and in some areas penetrate the stroma of the iris. The nuclei are oval-shaped and contain numerous nucleoli. Some of the nuclei are hyperchromatic. The cytoplasm is scant in many of the cells studied. Occasional mitotic figures are seen. The ciliary body shows, mobilization of its pigment epithelium, and at the ora serrata there is a "ringschwiele." The choroid is compressed, and in portions is
Fig. 6 ( C u r y ) . Case 2. High-power view of Fig ure 5, showing metastatic squamous cell carcinoma infiltrating the stroma of the iris.
224
DAHAR CURY
infiltrated with chronic inflammatory cells. The pigment epithelium is adherent to the choroid. Some of the pigment epithelium cells have migrated into the subretinal fluid. There are numerous pathologic drusen. The retina is detached except at the optic disc and the ora serrata and shows degeneration and atrophy. Numerous macrophages containing pig ment are seen in the retina. Some foci and diffuse infiltration of chronic inflammatory cells are seen. The retina is not seen in its entirety, probably artefact of fixation, but that portion seen is sepa rated and thrown into folds. There is cystoid degen eration of the retina. The retinal elements have undergone degeneration and atrophy. The subretinal fluid is a clear eosinophilic staining coagulum which contains pigmented macrophages and a few cho lesterol clefts. The optic nerve shows complete irregularity of its nuclear columns. There is an increase in the glial elements. The vitreous body lies anteriorly. It contains more macrophages than are usually seen and shows areas of fresh hemorrhage. Behind the lens there are numerous areas which show a coarse coagulum thought to be lens substance that has apparently leaked from the hypermature lens. Numerous mac rophages and an occasional eosinophil are seen in these areas. The crystalline lens is shrunken and there is a
break in the continuity of the lens capsule pos teriorly. The lens substance shows liquefaction and in some areas stains basophilically and contains crystals. At the equator of the lens, the lens capsule is drawn upward toward the ciliary body and sur rounds several inclusions of lens substance. On the posterior surface of the lens there are collections of pigment and macrophages containing pigment. The anterior chamber contains a granular eosin ophilic coagulum. The angle is obliterated and a pseudo angle is seen. Schlemm's canal is not iden tified in the sections studied. Impression. Metastatic squamous-cell carcinoma of the iris. Separation of the retina. Secondary glaucoma. Chronic uveitis. Optic atrophy due to glaucoma. Hypermature lens with lens reaction. SUMMARY
Two additional cases of metastatic carci noma of the iris are reported in which the enucleated eye and primary site were ex amined histologically. The second case is re markable in that it resembles epithelization of the anterior surface of the iris as seen in downgrowths in the anterior chamber. 2665 Walnut Street.
REFERENCES
1. Bollack, J., Bertillon, F., and Roques, A.: Metastatic epithelioma of the iris. Ann. Ocul., 164 :336, 1927. 2. Hudson, A. C, and Lister, W.: Metastatic hypernephroma of the iris. Proc. Roy. Soc. Med., 27:1613. 1934. 3. Sanders, T. E.: Metastatic carcinoma of the iris. Am. J. Ophth., 21:646, 1938. 4. Asbury, M. K., and Vail, D.: Metastatic carcinoma of the iris. Am. J. Ophth., 23:402, 1940. 5. Sautter, H.: Some interesting findings on the iris. Klin. Monatsbl. f. Augenh., 113:44, 1948. 6. Reese, A. B.: Tumors of the Eye. New York, Hoeber, 1950. 7. Greear, J.: Metastatic carcinoma of the eye. Am. J. Ophth., 33:1015, 1950. 8. Greer, C. H.: Metastatic carcinoma of the iris. Brit. J. Ophth., 38 -.699, 1954.