HEPATOCELLULAR CARCINOMA METASTATIC TO UVEA Robert Wesolowski, MD,* Jeffrey Yau-Huei Chung, MD,† Arun Singh, MD,† Richard Kim, MD*
Purpose: To describe a case of uveal metastasis secondary to hepatocellular carcinoma. Methods: The authors present a 57-year-old man with known diagnosis of hepatocellular carcinoma, with progressive visual problems in his right eye. Work-up including indirect ophthalmoscopic examination, ocular ultrasonography, and brain magnetic resonance imaging revealed a dome-shaped choroidal mass abutting the optic disk with surrounding shallow exudative retinal detachment. Results: A fine-needle biopsy of the lesion confirmed the presence of malignant cells suggestive of metastatic disease from hepatocellular carcinoma. The patient was subsequently treated with brachytherapy. The patient died 3 weeks after the treatment due to pneumonia, which was felt to be unrelated to his ocular disease. Conclusion: This is a report of a very unusual case of hepatocellular carcinoma with metastasis to uveal tract. RETINAL CASES & BRIEF REPORTS 4:178 –180, 2010
From the *Department of Solid Tumor Oncology, Taussig Cancer Institute; and †Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
possible resection of the neoplastic lesions but was found not to be a candidate for this procedure. Shortly after that, he was evaluated by a liver transplant team, which did not feel that liver transplantation was an option because of portal vein thrombosis. Seven months after his initial diagnosis, the patient was treated with one course of TheraSphere administration to the left liver lobe. Restaging imaging revealed stable appearance of the masses in the posterior, inferior right lobe of the liver. However, there was an interval appearance of a large neoplastic mass occupying the left segment of the left lobe of the liver. Five months later, the patient underwent a chemoembolization procedure with cisplatin and doxorubicin at our institution. Upon admission to our inpatient chemotherapy service immediately after chemoembolization therapy, the patient had a 2-week history of progressive blurry vision and right-sided headache after hitting his right temple with a cabinet door. He subsequently noted development of left-sided facial numbness. A brain magnetic resonance imaging done by his local primary care physician before the hospitalization was reported as normal but upon review by a neuroradiologist at our institution, some swelling and inflammatory changes in the posterior globe of his right eye without evidence of bleeding or fluid collection were observed (Figure 1). Subsequently, an ophthalmologic examination showed a yellow white dome-shaped choroidal mass abutting the optic disk with surrounding shallow exudative retinal detachment (Figure 2A). Ocular ultrasonography B-scan confirmed a dome-shaped choroidal mass with overlying retinal detachment and no extrascleral extension (Figure 2B). An ultrasonography A-scan showed that the choroidal mass had low-medium internal reflectivity. The patient then underwent fine-needle biopsy of the mass, which revealed presence of malignant cells, suggestive of
T
he most common sites of metastases of hepatocellular carcinoma are the peritoneal cavity, adrenal glands, lungs, and bones.1 Metastases of hepatocellular carcinoma to the uveal tract are rare.2,3 Herein, we report a patient with hepatocellular carcinoma, who developed uveal metastasis. The patient had no evidence of any other site of metastatic disease. Case Report
A 57-year-old man, a chronic alcohol abuser, with a 3-year history of untreated hepatitis C infection, was found to have an elevated ␣ fetoprotein (AFP) of 62.3 ng/mL on routine follow-up. Abdominal magnetic resonance imaging was consistent with presence of liver cirrhosis and two suspicious masses in the posterior inferior right lobe of the liver. The patient subsequently underwent a biopsy of the larger of the two lesions, which was positive for moderately differentiated hepatocellular carcinoma. Three months after his diagnosis, the patient was seen by a general surgeon for All authors report no potential conflicts of interests. Reprint requests: Richard Kim, MD, Taussig Cancer Center, Cleveland Clinic, R35, 9500 Euclid Ave., Cleveland, OH 44195; e-mail: [email protected]
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Fig. 1. Axial T1 magnetic resonance imaging image showing some swelling and inflammatory changes in the posterior globe of the right eye.
metastatic disease from hepatocellular carcinoma (Figure 3). Restaging computed tomography scan of the chest, abdomen, and pelvis showed no other possible primary site of tumor. The patient was treated with brachytherapy (Iodine-125 radioactive episcleral plaque, 16-mm size apical dose 43.33 Gy in 74 hours). The patient died 3 weeks after therapy due to pneumonia.
Discussion Ophthalmic metastases are not uncommon. Analysis of ophthalmic biopsy specimens taken from 76 patients with ophthalmic metastases by Fahmy et al4 found that the most frequent site of involvement was the uveal tract (63%), followed by the orbit (26%) and the eyelids (10%). Shields et al5 performed a retrospective analysis of 520 cases with metastatic deposits in the uveal tract (420 patients and a total of 950 metastatic deposits). They found that the choroid was the most common site of involvement occurring in 88% of all cases followed by the iris (9%) and ciliary body (2%). In patients with choroidal metastatic deposits, the majority of tumors were found in the area between the macula and equator (80%), followed by the macula (12%) and anterior to the equator (8%).5 Metastatic breast cancer was the most common lesion found, accounting for 47% of all tumors, followed by lung cancer (21%), gastrointestinal (GI) tract tumors (4%), renal cell carcinoma (2%), skin cancer (2%), prostate (2%), and other cancers (4%).5 Because ophthalmic metastases are frequently a sign of hematogenous spread of primary disease, treatment is palliative and aims at minimizing visual loss and preserving patient’s quality of life.6 Radiotherapy is the mainstay of treatment as it is effective in controlling
Fig. 2. A, Fundus photograph of the right eye. Note yellow white domeshaped choroidal mass that is abutting the optic disk. Surrounding shallow exudative retinal detachment is also present. B, Ultrasonography B-scan showing choroidal mass (between calipers). Overlying retinal detachment is also evident (arrow). There is no extrascleral extension.
local growth of the tumor and preservation of vision.6 Chemotherapy and hormonal therapy may also be used depending upon extent of metastasis and the type of primary tumor.6 Two forms of radiotherapy are available, external fractionated radiotherapy or local brachytherapy with radionuclide such as Iodine125 or Ruthenium-106.6 Dry eyes, cataracts formation, and radiation retinopathy are common side effects of radiation therapy, and this becomes more relevant in patients who are expected to survive for longer than 1 year after therapy.6 Surgical treatment, such as enucleation is usually not recommended as a goal of therapy is not curative and enucleation is associated with a significant decline in quality of life.
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RETINAL CASES & BRIEF REPORTSℜ
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2010
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VOLUME 4
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NUMBER 2
In summary, we report an unusual case of hepatocellular carcinoma with uveal metastases that was treated with brachytherapy. Key words: brachytherapy, hepatocellular carcinoma, uveal metastases. References 1.
2. 3. 4.
5. Fig. 3. Fine-needle aspirate of the choroidal tumor demonstrating malignant cells suggestive of metastatic disease from hepatocellular carcinoma. The slide was prepared by the ThinPrep (Hologic Corp, Marlborough, MA) process (hematoxylin and eosin ⫻40).
6.
Llovet JM, Bustamante J, Castells A, et al. Natural history of untreated nonsurgical hepatocellular carcinoma. Rationale for the design and evaluation of therapeutic trials. Hepatology 1999;29:62– 67. Yeatts RP, Campbell RJ, Lie JT. Hepatocellular carcinoma metastatic to the choroid. Arch Pathol Lab Med 1982;106:256–257. Taake WH, Allen RA, Straatsma BR. Metastasis of a hepatoma to the choroid. Am J Ophthalmol 1963;56:208 –213. Fahmy P, Heegaard S, Jennsen OA, Prause JU. Metastases in the ophthalmic region in Denmark. 1969-98. A histopathological study. Acta Ophthalmol Scand 2003;81:47–50. Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265–1276. Bornfeld N. Uveal metastatic tumors. In: Singh AD, Damato BE, Pe’er J, et al, eds. Clinical Ophthalmic Oncology. Philadelphia: Saunders-Elsevier, 2007:322–327.
Purpose: To describe a case of uveal metastasis secondary to hepatocellular carcinoma. Methods: The authors present a 57-year-old man with known diagnosis of hepatocellular carcinoma, with progressive visual problems in his right eye. Work-up including indirect ophthalmoscopic examination, ocular ultrasonography, and brain magnetic resonance imaging revealed a dome-shaped choroidal mass abutting the optic disk with surrounding shallow exudative retinal detachment. Results: A fine-needle biopsy of the lesion confirmed the presence of malignant cells suggestive of metastatic disease from hepatocellular carcinoma. The patient was subsequently treated with brachytherapy. The patient died 3 weeks after the treatment due to pneumonia, which was felt to be unrelated to his ocular disease. Conclusion: This is a report of a very unusual case of hepatocellular carcinoma with metastasis to uveal tract. RETINAL CASES & BRIEF REPORTS 4:178 –180, 2010
From the *Department of Solid Tumor Oncology, Taussig Cancer Institute; and †Department of Ophthalmic Oncology, Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
possible resection of the neoplastic lesions but was found not to be a candidate for this procedure. Shortly after that, he was evaluated by a liver transplant team, which did not feel that liver transplantation was an option because of portal vein thrombosis. Seven months after his initial diagnosis, the patient was treated with one course of TheraSphere administration to the left liver lobe. Restaging imaging revealed stable appearance of the masses in the posterior, inferior right lobe of the liver. However, there was an interval appearance of a large neoplastic mass occupying the left segment of the left lobe of the liver. Five months later, the patient underwent a chemoembolization procedure with cisplatin and doxorubicin at our institution. Upon admission to our inpatient chemotherapy service immediately after chemoembolization therapy, the patient had a 2-week history of progressive blurry vision and right-sided headache after hitting his right temple with a cabinet door. He subsequently noted development of left-sided facial numbness. A brain magnetic resonance imaging done by his local primary care physician before the hospitalization was reported as normal but upon review by a neuroradiologist at our institution, some swelling and inflammatory changes in the posterior globe of his right eye without evidence of bleeding or fluid collection were observed (Figure 1). Subsequently, an ophthalmologic examination showed a yellow white dome-shaped choroidal mass abutting the optic disk with surrounding shallow exudative retinal detachment (Figure 2A). Ocular ultrasonography B-scan confirmed a dome-shaped choroidal mass with overlying retinal detachment and no extrascleral extension (Figure 2B). An ultrasonography A-scan showed that the choroidal mass had low-medium internal reflectivity. The patient then underwent fine-needle biopsy of the mass, which revealed presence of malignant cells, suggestive of
T
he most common sites of metastases of hepatocellular carcinoma are the peritoneal cavity, adrenal glands, lungs, and bones.1 Metastases of hepatocellular carcinoma to the uveal tract are rare.2,3 Herein, we report a patient with hepatocellular carcinoma, who developed uveal metastasis. The patient had no evidence of any other site of metastatic disease. Case Report
A 57-year-old man, a chronic alcohol abuser, with a 3-year history of untreated hepatitis C infection, was found to have an elevated ␣ fetoprotein (AFP) of 62.3 ng/mL on routine follow-up. Abdominal magnetic resonance imaging was consistent with presence of liver cirrhosis and two suspicious masses in the posterior inferior right lobe of the liver. The patient subsequently underwent a biopsy of the larger of the two lesions, which was positive for moderately differentiated hepatocellular carcinoma. Three months after his diagnosis, the patient was seen by a general surgeon for All authors report no potential conflicts of interests. Reprint requests: Richard Kim, MD, Taussig Cancer Center, Cleveland Clinic, R35, 9500 Euclid Ave., Cleveland, OH 44195; e-mail: [email protected]
178
HEPATOCELLULAR CARCINOMA METASTATIC TO UVEA
179
Fig. 1. Axial T1 magnetic resonance imaging image showing some swelling and inflammatory changes in the posterior globe of the right eye.
metastatic disease from hepatocellular carcinoma (Figure 3). Restaging computed tomography scan of the chest, abdomen, and pelvis showed no other possible primary site of tumor. The patient was treated with brachytherapy (Iodine-125 radioactive episcleral plaque, 16-mm size apical dose 43.33 Gy in 74 hours). The patient died 3 weeks after therapy due to pneumonia.
Discussion Ophthalmic metastases are not uncommon. Analysis of ophthalmic biopsy specimens taken from 76 patients with ophthalmic metastases by Fahmy et al4 found that the most frequent site of involvement was the uveal tract (63%), followed by the orbit (26%) and the eyelids (10%). Shields et al5 performed a retrospective analysis of 520 cases with metastatic deposits in the uveal tract (420 patients and a total of 950 metastatic deposits). They found that the choroid was the most common site of involvement occurring in 88% of all cases followed by the iris (9%) and ciliary body (2%). In patients with choroidal metastatic deposits, the majority of tumors were found in the area between the macula and equator (80%), followed by the macula (12%) and anterior to the equator (8%).5 Metastatic breast cancer was the most common lesion found, accounting for 47% of all tumors, followed by lung cancer (21%), gastrointestinal (GI) tract tumors (4%), renal cell carcinoma (2%), skin cancer (2%), prostate (2%), and other cancers (4%).5 Because ophthalmic metastases are frequently a sign of hematogenous spread of primary disease, treatment is palliative and aims at minimizing visual loss and preserving patient’s quality of life.6 Radiotherapy is the mainstay of treatment as it is effective in controlling
Fig. 2. A, Fundus photograph of the right eye. Note yellow white domeshaped choroidal mass that is abutting the optic disk. Surrounding shallow exudative retinal detachment is also present. B, Ultrasonography B-scan showing choroidal mass (between calipers). Overlying retinal detachment is also evident (arrow). There is no extrascleral extension.
local growth of the tumor and preservation of vision.6 Chemotherapy and hormonal therapy may also be used depending upon extent of metastasis and the type of primary tumor.6 Two forms of radiotherapy are available, external fractionated radiotherapy or local brachytherapy with radionuclide such as Iodine125 or Ruthenium-106.6 Dry eyes, cataracts formation, and radiation retinopathy are common side effects of radiation therapy, and this becomes more relevant in patients who are expected to survive for longer than 1 year after therapy.6 Surgical treatment, such as enucleation is usually not recommended as a goal of therapy is not curative and enucleation is associated with a significant decline in quality of life.
180
RETINAL CASES & BRIEF REPORTSℜ
●
2010
●
VOLUME 4
●
NUMBER 2
In summary, we report an unusual case of hepatocellular carcinoma with uveal metastases that was treated with brachytherapy. Key words: brachytherapy, hepatocellular carcinoma, uveal metastases. References 1.
2. 3. 4.
5. Fig. 3. Fine-needle aspirate of the choroidal tumor demonstrating malignant cells suggestive of metastatic disease from hepatocellular carcinoma. The slide was prepared by the ThinPrep (Hologic Corp, Marlborough, MA) process (hematoxylin and eosin ⫻40).
6.
Llovet JM, Bustamante J, Castells A, et al. Natural history of untreated nonsurgical hepatocellular carcinoma. Rationale for the design and evaluation of therapeutic trials. Hepatology 1999;29:62– 67. Yeatts RP, Campbell RJ, Lie JT. Hepatocellular carcinoma metastatic to the choroid. Arch Pathol Lab Med 1982;106:256–257. Taake WH, Allen RA, Straatsma BR. Metastasis of a hepatoma to the choroid. Am J Ophthalmol 1963;56:208 –213. Fahmy P, Heegaard S, Jennsen OA, Prause JU. Metastases in the ophthalmic region in Denmark. 1969-98. A histopathological study. Acta Ophthalmol Scand 2003;81:47–50. Shields CL, Shields JA, Gross NE, Schwartz GP, Lally SE. Survey of 520 eyes with uveal metastases. Ophthalmology 1997;104:1265–1276. Bornfeld N. Uveal metastatic tumors. In: Singh AD, Damato BE, Pe’er J, et al, eds. Clinical Ophthalmic Oncology. Philadelphia: Saunders-Elsevier, 2007:322–327.
