PICTURES IN DIGESTIVE PATHOLOGY

 

Orbital metastasis from hepatocellular carcinoma

 

 

Luis Téllez-Villajos, Maite Maroto-Castellanos, José Luis Lledó-Navarro, Sergio López-Durán, Víctor Moreira-Vicente and Agustín Albillos-Martínez

Department of Gastroenterology. Hospital Universitario Ramón y Cajal. Universidad de Alcalá de Henares. Alcalá de Henares, Madrid. Spain

 

 

Case report

A 70 year-old woman with personal history of hepatitis C virus compensated cirrhosis. Three years before she was diagnosed with HCC in segment VI of the right hepatic lobe. She was first treated with radiofrequency and then she required three sessions of adriamycin-lipiodol transarterial chemoembolization. The computed tomography (CT) practiced four months later revealed a 38 mm hypodense lesion in segment VI, without radiological evidence of tumor activity. The patient presented with four weeks of occasional diplopia and right proptosis. Physical examination showed exophthalmos, conjunctival hyperemia and limited lateral mobilization of the right eye with normal visual acuity. Orbital CT after intravenous contrast revealed a solid, well-defined, hyperdense lesion, located in the right temporal fossa, which destroyed the greater wing of the right zygomatic bone and the ipsilateral orbital wall, penetrating the orbit and displacing anteriorly the lateral rectus muscle and the eyeball. The administration of contrast showed an increase in density of 20 HU and the presence of a nutrient vessel dependent of the ipsilateral carotid artery. This finding was confirmed by magnetic resonance imaging (MRI). Biopsy was performed through an incision in the superior sulcus, and the histological examination revealed the presence of tumor cells with an immunohistochemistry consistent with metastasis from a hepatocellular carcinoma. Tc-99m scintigraphy was performed, showing osteogenic response in right orbital region, consistent with secondary deposit. At follow-up, the patient referred significant pain in right orbital and therefore she received palliative radiotherapy. Four months later, after ten sessions of radiotherapy the patient is still alive with adequate pain control but a limited daily life (ECOG 3).

 

Discussion

Orbital metastases are uncommon, representing the 3-7% of orbital masses. They usually appear in advanced tumor stages. The most common neoplasm associated to this kind of metastases are lung, followed by prostate in men and breast cancer in women (1,2). Orbital metastases of hepatocellular carcinoma are very rare (3-5). However, we should be aware of ophthalmological symptoms and face bone pain, with the purpose of an early detection of these metastases, when surgical treatment may be an option.

 

 

References

1. Ahmad SM, Esmaeli B. Metastatic tumors of the orbit and ocular adnexa. Curr Opin Ophthalmol 2007;18:405-13.         [ Links ]

2. Demirci H, Shields CL, Shields JA, et al. Orbital tumors in the older adult population. Ophthalmology 2002;109:243-8.         [ Links ]

3. Gupta R, Honavar SG, Vemuganti GK. Orbital metastasis from hepatocellular carcinoma. Surv Ophthalmol 2005;50:485-9.         [ Links ]

4. Quick AM, Bloomston M, Kim EY, et al. Complete response to radiation therapy of orbital metastasis from hepatocellular carcinoma. World J Gastroenterol 2009;15:6000-3.         [ Links ]

5. Eldesouky MA, Elbakary MA, Shalaby OE, et al. Orbital metastasis frrom hepatocellular carcinoma: Report of 6 cases. Ophthal Plast Reconstr Surg 2013;Nov 5. (Epub ahead of print).         [ Links ]