Complete response to radiation therapy of orbital metastasis from hepatocellular carcinoma

Abstract

The incidence of hepatocellular carcinoma (HCC) is increasing in the United States, and 50%-75% of patients with HCC will develop metastatic disease. Orbital metastases from HCC are extremely rare. We report the case of a 52-year-old male with known metastatic HCC, who presented with severe proptosis and diplopia. An orbital mass was identified on magnetic resonance imaging (MRI) and confirmed to have hypermetabolic activity on positron emission tomography/computed tomography. He received a palliative course of external beam radiation therapy to the right orbit. Intensity modulated radiation therapy (IMRT) was used to allow sparing of critical normal tissues in close proximity to the tumor. One month after completion of IMRT to 58 Gray in 30 fractions delivered over 6 wk, the patient had a complete clinical, radiologic (MRI) and symptomatic response. The patient continues to have local control in the orbit 1.7 years after therapy completion. All critical normal structures were kept below the tolerance dose using IMRT, and no toxicities were observed.

Keywords: Eye neoplasms; Hepatocellular carcinoma; Intensity modulated radiation therapy; Metastasis; Palliative therapy.

Figure 1

Axial (A) and coronal (B) T2 weighted MRI of the brain demonstrating the large soft tissue mass in the superior and lateral aspect of the right orbit (white arrows) prior to radiation treatment and resolution of mass on follow-up MRI 12 mo after treatment on axial (C) and coronal images (D).

Figure 2

Three-dimensional contours for treatment planning demonstrate the gross target volume (GTV) encompassing the tumor (red contour) and the planning target volume (PTV, black contour) on initial (A) and boost (B) CT images. Doses from the initial 7 field intensity modulated radiation (IMRT) plan (A) are represented as color wash according to the scale shown in the figures, representing the range of 95% through 20% of dose coverage. The 7 field IMRT plan for the coned-down field (B) shows even tighter dose coverage and greater sparing of the right optic nerve (pink contour).