EDUCATION AND IMAGING
Hepatobiliary and Pancreatic: Hepatocellular carcinoma
diagnosed by proptosis due to metastatic orbital mass
A 71-year-old man with excessive alcohol consumption
complained of a 2-week history of left proptosis. Despite progres-
sive visual deterioration for 2 years, he did not receive treatment.
His past medical and family history was unremarkable. Physical
examination showed 9-mm proptosis and a ﬁrm, solid mass at
the lateral aspect of the left orbit. Brain magnetic resonance
imaging (MRI) revealed a 31 × 28 × 31-mm vividly enhanced, left
orbital mass with high vascularity and involvement of the left
temporalis muscle (Fig. 1a), causing proptosis of the left eye.
Blood chemistry revealed the following: white blood cell count,
8480/μL; hemoglobin level, 15 g/dL; platelet count, 126 × 10
L; serum albumin level, 4.45 g/dL; serum bilirubin level,
0.82 mg/dL; serum aspartate aminotransferase level, 133 IU/L; se-
rum alanine aminotransferase level, 53 IU/L; and prothrombin
time-international normalized ratio, 1.03. Test results for serum
hepatitis B surface antigen and hepatitis C antigen were negative.
Orbital mass biopsy revealed metastatic hepatocellular carcinoma
(HCC), conﬁrmed on histology (Fig. 2a,b) and immunohistochem-
istry (Fig. 2c,d). Abdominal computed tomography showed multi-
ple huge HCC masses with central necrosis in the right lobe and
direct tumor invasion of the inferior vena cava (Fig. 1b). The serum
alpha-fetoprotein level was 8894 ng/mL (normal range: 0–15). A
total of 45 Gy radiation was administered over 15 days to relieve
the symptoms of orbital metastasis. However, the patient did not
show improvement and died within 2 months.
Orbital metastasis from HCC is rare. Only 10 patients with
orbital metastasis as the ﬁrst ocular symptom before detection of
the primary lesion have been reported. The mechanism of orbital
metastasis from HCC is unclear. Metastasis of HCC is known to
occur via the hematogenous route, mainly through the inferior vena
cava. Because the orbit does not have lymphatic vessels, metastasis
is thought to occur primarily through the bloodstream, which is
known to occur through the Batson vertebral venous plexus. The
Batson venous plexus in the epidural space does not have valves
and is connected to the pelvic veins, thoracic veins, and azygos
vein. When the pressure in the thoracic and abdominal cavity is
increased, reversal of blood ﬂow can cause cancer to spread to
the skull, sinus, and orbit through the Batson venous plexus.
Histologically, the diagnosis of HCC is based on the trabecular pat-
tern of polygonal cells with large nuclei and granular acidophilic
cytoplasm but shows similar architecture in renal cell carcinoma.
Primary tumors can be distinguished by immunohistochemical
staining for hepatocyte-speciﬁc antigen, anti-cytokeratin, alpha-
fetoprotein, and arginase-1. Palliative radiation is the only available
treatment for symptom relief in the treatment of orbital metastasis
from HCC, but the prognosis is poor and the mean survival time
is 8.1months after the diagnosis of extrahepatic metastasis from
HCC. Histological and immunohistochemical studies to determine
the primary site of cancer may be useful for evaluating treatment
and prognosis in patients with an orbital mass.
and TN Kim
Division of Gastroenterology and Hepatology, Department of
Internal Medicine, Yeungnam University College of Medicine,
Figure 2 (a and b) Diffuse cluster of polygonal cells with pale, eosinophilic
cytoplasm and vesicular nuclei (HE staining, at 100× and 200× magniﬁcation).
The cells were positively stained for hepatocyte-speciﬁc antigen (c, ×200) and
arginase-1 (d, ×200).
Figure 1 (a) Contrast MRI revealed a left orbital mass with high vascular-
ity and bone destruction on T1-weighted imaging (white arrow), causing
left eye proptosis. (b) Abdominal computed tomography revealed multiple
hepatocellular carcinoma with inferior vena cava invasion (black arrow).
Journal of Gastroenterology and Hepatology 33 (2018) 773
© 2018 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd