Sir,
We read with interest the article published in your journal ‘Failure of intravitreal bevacizumab in the treatment of choroidal metastasis’.1
We agree that intravitreal bevacizumab as the primary treatment of choroidal metastases might not always be efficacious in controlling the disease and should not delay treatment that is more radical.
As the authors mentioned, choroidal metastases are associated with significant exudation; the choriocapillaris and Bruch’s membrane are intact, and this may hinder the passage of the bevacizumab molecule through the retina.
Hence, we suggest another alternative, which is the use of systemic Bevacizumab, in association with chemotherapy in the treatment of choroidal metastasis. Systemic administration of bevacizumab could be superior to intravitreal injections due to its greater potential to concentrate in the metastatic tissue via the rich choroidal blood supply, regardless of the blood–retina barrier.
Systemic bevacizumab is nowadays an approved therapy for metastatic cancers originating from lung, ovaries, cervix, colon, brain, kidney and even the breast.2 Combining systemic bevacizumab with chemotherapy seems to be an interesting modality of treatment in choroidal metastasis.
Two studies (Kourie et al3 and George et al4) have recently published two cases of lung cancer with chroidal metastases successfully treated with systemic bevacizumab and chemotherapy. Obviously, further studies are warranted to confirm the IV superiority of Bevacizumab compared with intravitreal delivery in this setting.
References
Maudgil A, Sears KS, Rundle PA, Rennie IG, Salvi SM . Failure of intravitreal bevacizumab in the treatment of choroidal metastasis. Eye (Lond) 2015; 29 (5): 707–711.
Pazdur R FDA approval for bevacizumab. National Cancer Institute website http://www.cancer.gov/about-cancer/treatment/drugs/fda-bevacizumab.
Kourie HR, Antoun J, Schakal A, Nasr E, Sahyoun M, Kattan J . Complete disappearance of choroidal metastasis from lung adenocarcinoma treated with bevacizumab and chemotherapy. Case Rep Ophthalmol Med 2015; 2015: 142408.
George B, Wirostko WJ, Connor TB, Choong NW . Complete and durable response of choroid metastasis from non-small cell lung cancer with systemic bevacizumab andchemotherapy. J Thorac Oncol 2009; 4 (5): 661–662.
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Kourie, H., Antoun, J. & Kattan, J. Comment on ‘Failure of intravitreal bevacizumab in the treatment of choroidal metastasis’. Eye 29, 1628–1629 (2015). https://doi.org/10.1038/eye.2015.174
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DOI: https://doi.org/10.1038/eye.2015.174