Case presentation
Our 18-month-old patient with recurrent oRT of the right side presented
to our hospital with rapid tumor growth and profuse bleeding from the
right orbital cavity.
Magnetic Resonance Imaging (MRI) revealed extensive tumor recurrence in
the orbit with infiltration of the adjacent bony structures of the
maxillary sinus the nasal cavity, ethmoid cells, and frontal base, as
well as intracranial extension via the right optic canal (Fig.1 A).
13 months prior to this presentation, he had undergone surgical
resection of the tumor, chemotherapy according to the European Rhabdoid
Registry (EU-RHAB) and proton radiotherapy of 54 Gray (Gy). One year
later, the first local recurrence was observed and the patient underwent
tumor resection followed by orbital exenteration.
A significant drop in hemoglobin level (75 g/l) was noted on admission,
requiring transfusions of packed red blood cells. Considering the
patient’s medical history and previous treatments, tumor location and
skin toxicity in the right maxillary and periorbital regions after
proton therapy, a combined approach consisting of transarterial
embolization and subsequent BT was chosen to achieve hemostasis and
local tumor control.
Due to the young age, the treatment was performed under general
anesthesia. Diagnostic angiography showed a predominantly medial tumor
blush via the nasal ethmoid branches and the infraorbital artery;
therefore, these vessels were embolized with precipitating hydrophobic
injectable liquid (PHIL) 25% after exclusion of collaterals,
particularly to the internal carotid artery (ICA). (Fig.2 A).
One hour later, after CT marking for BT, a total of twelve plastic tubes
and four Onco-Smarts catheters were implanted in the cheek, caudal and
lateral to the orbital cavity, to completely cover the clinical target
volume (CTV) (Fig 2.B,C,D and E). We applied a total dose of 28 Gy (7x
4Gy) over four days, 2 fractions per day with minimum intervals of 6
hours by using a 192Ir source taking into account the dose of the proton
therapy completed 7 months earlier.
The first fraction was administered on the same day of embolization and
implantation, and the remaining six sessions were conducted on the
following days without complications.
Regular wound checks showed intact skin without development of
macroscopic tumor progress and bleeding.
On 6-week follow up, MRI showed a significant decrease in the size of
the tumor in the right orbit (Fig. 1B). Unfortunately, the patient died
2 months after the procedure due to new distant metastases.