Lipid Dominant Toxic Tumor Syndrome

The aim of the study was to describe clinical features of lipid dominant toxic tumor syndrome (TTS) and report outcomes following use of intravitreal steroids.

Records of 13 patients who had lipid dominant TTS following treatment of choroidal melanoma with episcleral plaque brachytherapy (EPB) were retrospectively reviewed. Resolution of lipid exudates, subfoveal subretinal fluid, cystoid macular edema (CME), exudative detachment were main outcome measures.

Of the 13 patients who developed lipid dominant TTS, 11 (85%) had medium-sized melanomas, and 2 (15%) small-sized melanomas. The average time to onset following EPB was 22 months (range 3-48 months). Seven patients (54%) were noted to have dyslipidemia. The baseline visual acuity at the time of diagnosis of TTS was 50 ETDRS letters (range 10-85). Ophthalmic characteristics were lipid exudates centered around the tumor base in 13 (100%) patients, subfoveal subretinal fluid in 4 (31%) patients, and CME in 2 (15%) patients. Exudative detachment was absent in all (100%) patients. Regressed melanoma was present in all (100%) patients. Eight (62%) patients were treated with intravitreal steroids (4 mg triamcinolone), while 5 patients (38%) were observed. The response to intravitreal steroids was noted in 7(88%) of the treated patients, with the average time to response being 1.9 months. Features characterizing a positive response were reduction in lipid exudates centered around the tumor base (100%), reduction in subfoveal subretinal fluid (100%), and reduction in CME (50%). Cataract development was seen in 10 (83%) and ocular hypertension in 3 patients (23%). Proliferative radiation retinopathy developed in 2 (15%) patients, neovascular glaucoma developed in 1(8%) while no patients required enucleation.

The lipid dominant TTS centered around the tumor base that occurs in a radiation responsive tumor could be considered a chronic variant in the spectrum of TTS. Intravitreal steroids in selected cases reverse the course of this variant, stabilizing or improving the vision and avoiding enucleation. Our observations would need to be verified through a larger prospective study.