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Friederike Mackensen, Viviane Grewing, Stephan Schulz, Christina Beisse, Frederik Marmé; Evolution of optic neuropathy in a patient with breast cancer: a personal journey. Invest. Ophthalmol. Vis. Sci. 2016;57(12):5096.
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© ARVO (1962-2015); The Authors (2016-present)
Triple negative breast cancer (TNBC) is the least frequent type of BC. It can metastasize among other organs to the choroid. There are only two to three cases of unilateral carcinomatous optic nerve (ON) involvement published. We want to present a case of bilateral blindness that presented as ON swelling in cranial hypertension (CH).
Chart review of a single case. The author (FM) presents her own story. Evaluation of OCT pictures (Spectralis OCT, Heidelberg Engineering).
A 39 year old female (FM) was diagnosed with TNBC, BRCA2 positive, regional lymph nodes positive in 08/13. Chemotherapy was followed by surgery and radiation with a satisfying response. 06/14 bone metastasis were discovered. Immune therapy (IT) (Nivolumab, Ipilimumab) was initiated but was not able to prevent bone marrow carcinomatosis and stopped in favor of chemotherapy with eribuline until 12/14 with good partial remission. Upon progression of disease the patient was treated with four cycles of PEI (Cisplatin, Ifosfamid, Etoposid) again resulting in a good partial response. In 06/15 another form of IT was started (Pembrolizumab) and tumor vaccination. In 07/15 the patient developed symptoms of CH including attacks of blurry vision. OCT and funduscopy showed ON swelling. Lumbal punction revealed leptomeningeal disease. MRI findings did not show solid meningeosis. Treatment with intrathecal MTX was started and led to improvement. IT was continued. After four intrathecal cycles, vision decreased to light perception. Impairment of left nerve XII and nerve III were seen. Funduscopy showed vital ON and OCT normal nerve fiber layers (NFL). MRI showed solid meningeosis, ON compression by tumor cells, ON inflammation and ballooning of the pituitary. Steroids were given with no result. High dose systemic MTX (3mg/m2) and Olaparib were started. This led to clinical (nerve III, XII) and radiologic improvement but vision stayed unchanged. OCT showed no more NFL on the left eye and only rest in the right. Funduscopy mirrored this by ON pallor in the left eye and partial vitality in the right.
ON compression by metastasized breast cancer cells is rare and bilateral simultaneous involvement has not been published. We think treating doctors have to be aware of the possibility to diagnose it early and maybe treat more aggressively at a time point when vision could still be preserved.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
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