Orbital Lesion as the First Presentation of Hepatocellular Carcinoma: Lessons Learned From 2 Cases

Purpose: To demonstrate 2 cases where orbital lesion was the initial sign of late-stage hepatocellular carcinoma. Methods: Sixty-three-year-old and 62-year-old otherwise healthy females were studied with history of protruded eyes since 3 months before. In the first case, the right eye was protruded accompanied by vision impairment and double vision. The left eye orbit was involved in the second case, with eye protrusion to inferior site and restricted ocular motility to all directions without visual acuity disturbance. Computed tomography (CT) scan of both cases showed homogenous contrast enhancing mass with distinct edge, bridging the orbital wall (the sphenoid bone in the first case and the frontal bone in the second one) with intracranial involvement. Incisional biopsy of both cases revealed malignant tumor with poor differentiation of unknown origin. Further investigation with immunohistochemical examination showed positive results in Hepar1 and AE1/3 marker and pointed to hepatocellular carcinoma metastases. Abdominal CT-scan was performed later in both cases and showed an irregular surface of the liver with a rough parenchymal structure and multiple nodules of varying sizes suspiciously due to liver malignancies. Multidisciplinary management was then planned with hemato-oncology, neurology, and neurosurgery departments. Results: Both cases were diagnosed with hepatoma stage IVB. Conclusions: Orbital signs and symptoms of hepatic pathology are rarely considered early in the diagnosis of disease. Although rare, this type of malignancy can be found with orbital lesions as the initial presentation in 30% of cases. An awareness of the potential for these manifestations brings some concern to the ophthalmologist and oncologist.