Evaluation of liver lesions

Inflammatory Hepatocellular Adenoma Mimicking Focal Nodular Hyperplasia That Grew during Pregnancy and Changed Its Appearance on Magnetic Resonance Imaging after Delivery

We reported a notable case of inflammatory hepatocellular adenoma that grew during pregnancy, consequently changing its appearance on magnetic resonance imaging remarkably. A 5-months-pregnant 35-year-old woman presented with a 37-mm liver nodule that had been diagnosed as focal nodular hyperplasia 3 years earlier. She had never used oral contraceptives. After 2 months, the nodule grew to 57 mm. The patient delivered a full-term infant without complications. Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging performed after delivery revealed markedly different findings compared with the first images. A liver biopsy was performed, and the tumor was diagnosed as inflammatory hepatocellular adenoma.

Primary hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma associated with azathioprine immunosuppression: a case report

BACKGROUND

Hepatic masses are relatively common findings, and the diagnostic approach often begins by identifying patient and mass characteristics that are risk factors for malignancy. Chronic immunosuppression is a known risk factor for various malignancies, and azathioprine in particular has been reported in association with solid and hematologic malignancies, including diffuse large B-cell lymphoma.

CASE PRESENTATION

A 46-year-old white woman presented to clinic with several weeks of gastrointestinal symptoms and was found to have a hepatic mass on imaging. Her history was notable for neuromyelitis optica spectrum disorder on chronic immunosuppression with azathioprine. It was initially thought to be an inflammatory adenoma. On 6-month follow-up imaging, the mass had grown rapidly in size and was surgically resected. Further workup determined the mass to be an iatrogenic immunodeficiency-associated Epstein-Barr virus-positive diffuse large B-cell lymphoma confined to the liver. Azathioprine was discontinued and the patient underwent treatment with rituximab with no evidence of recurrence 2 years after the initiation of treatment.

CONCLUSIONS

This case report describes the first time hepatic Epstein-Barr virus-positive diffuse large B-cell lymphoma has been reported with azathioprine, which highlights the unique sequelae of chronic immunosuppression, including atypical hematologic malignancies, and the importance of considering chronic immunosuppression in the diagnostic evaluation of a hepatic mass.

An Extreme Case of Liver Adenomatosis: Are They All the Same?

Hepatocellular adenoma (HCA) is a rare and benign liver tumor that affects predominantly young and middle-aged women, especially between 30–40 years old. Liver adenomatosis (LA) is defined as the presence of 10 or more HCA. There are authors that report eight different subtypes of HCA, that correlates with clinical and histopathological features, being the inflammatory subtype the most common. We present a case of a 32-year-old Caucasian woman with a history of self-limited episodes of right abdominal pain and an abdominal ultrasound with multiple hypoechogenic liver nodules, suspected of metastasis. She was taking combined oral contraceptive for 6 years. Magnetic Resonance Imaging (MRI) disclosed around 40 nodules, suggestive of HCA. Liver biopsy confirmed HCA, inflammatory subtype. Oral contraceptive was stopped and control MRI 6 months later disclosed reduction of nodules’ dimensions. Management of patients with LA should be based on the size of the largest tumor, as clinical presentation and risk of bleeding or malignancy do not differ between patients with single or multiple HCAs. However, even with biopsy, there is a risk of missampling, raising concern about the real risk of bleeding and malignant potential in patients with different subtypes coexisting in the same liver.

KETOgenic diet therapy in patients with HEPatocellular adenoma: study protocol of a matched interventional cohort study

INTRODUCTION

Hepatocellular adenoma (HCA) is an uncommon, solid and benign liver lesion, mainly occurring in women using oral contraceptives. Patients are advised to stop using oral contraceptives (OC) and, as overweight is frequently observed, dietary restrictions. Metabolic changes are assumed to play a role and it has been suggested that diet may help to reduce tumour size. A low-calorie ketogenic diet (LCKD) has been shown to induce weight loss and multiple metabolic changes, including the reduction of portal insulin concentrations, which downregulates hepatic growth hormone receptors. Weight reduction and an LCKD can potentially reduce the size of HCAs.

METHODS AND ANALYSIS

We designed a matched, interventional cohort study to determine the effect of an LCKD on the regression of HCA. The study population consists of female subjects with an HCA, 18-50 years of age, body mass index>25 kg/m², who are entering a surveillance period including cessation of OC. A historical control group will be matched. The intervention consists of an LCKD (approximately 35 g carbohydrate/1500 kcal/day) for 3 months, followed by a less strict LCKD for 3 months (approximately 60 g carbohydrate/1500 kcal/day). Main study endpoint is the diameter of the HCA after 6 months, as compared with the historic control group. Secondary endpoints include adherence, quality of life, change in physical activity, liver fat content, body weight, body composition and resting energy expenditure.

ETHICS AND DISSEMINATION

The medical ethical committee has approved the study protocol, patient information files and consent procedure and other study-related documents and procedures.

TRIAL REGISTRATION NUMBER

NL75014.078.20; Pre-results. https://www.trialregister.nl/trial/9092.

Brevundimonas diminuta coinfection as source of pyogenic liver abscess

Brevundimonas diminuta, a non-fermenting gram-negative bacterium, is emerging as an important multidrug resistant opportunistic pathogen. It has been described in cases of bacteremia, pleuritis, keratitis and peritoneal dialysis-associated peritonitis. We describe, for the first time, a case of pyogenic liver abscess caused by coinfection of B. diminuta and Streptococcus anginosus, and briefly review pyogenic liver abscesses and the literature regarding B. diminuta.

Deep learning for differentiation of benign and malignant solid liver lesions on ultrasonography

PURPOSE

The ability to reliably distinguish benign from malignant solid liver lesions on ultrasonography can increase access, decrease costs, and help to better triage patients for biopsy. In this study, we used deep learning to differentiate benign from malignant focal solid liver lesions based on their ultrasound appearance.

METHODS

Among the 596 patients who met the inclusion criteria, there were 911 images of individual liver lesions, of which 535 were malignant and 376 were benign. Our training set contained 660 lesions augmented dynamically during training for a total of 330,000 images; our test set contained 79 images. A neural network with ResNet50 architecture was fine-tuned using pre-trained weights on ImageNet. Non-cystic liver lesions with definite diagnosis by histopathology or MRI were included. Accuracy of the final model was compared with expert interpretation. Two separate datasets were used in training and evaluation, one with all lesions and one with lesions deemed to be of uncertain diagnosis based on the Code Abdomen rating system.

RESULTS

Our model trained on the complete set of all lesions achieved a test accuracy of 0.84 (95% CI 0.74-0.90) compared to expert 1 with a test accuracy of 0.80 (95% CI 0.70-0.87) and expert 2 with a test accuracy of 0.73 (95% CI 0.63-0.82). Our model trained on the uncertain set of lesions achieved a test accuracy of 0.79 (95% CI 0.69-0.87) compared to expert 1 with a test accuracy of 0.70 (95% CI 0.59-0.78) and expert 2 with a test accuracy of 0.66 (95% CI 0.55-0.75). On the uncertain dataset, compared to all experts averaged, the model had higher test accuracy (0.79 vs. 0.68, p = 0.025).

CONCLUSION

Deep learning algorithms proposed in the current study improve differentiation of benign from malignant ultrasound-captured solid liver lesions and perform comparably to expert radiologists. Deep learning tools can potentially be used to improve the accuracy and efficiency of clinical workflows.

Giant intrahepatic venous malformation with localized intravascular coagulopathy. Follow-up and treatment during pregnancy

Intrahepatic lesions in adults, commonly named hepatic hemangioma, should be called Intrahepatic Venous Malformations (IHVM), or Giant Intrahepatic Venous Malformations (GIHVM) when larger than 10 cm according to the ISSVA classification (International society study group for vascular anomalies). Localized coagulation disorders (LIC) in patients with venous malformations are quite commonly associated in venous malformations, they result in decreased fibrinogen (< 2g/l) and elevated d-dimers (> 1500 ng/ml) and might be responsible of intralesional thrombotic, pain or bleeding episodes.We report a case report of a 41 y/o patient that presented with right hypochondrium pain episodes discovering an unknown GIHVM on ultrasound imaging with a prior history of uterine bleeding episodes and multiples miscarriages.On laboratory work up the patient presented an associated localized Intravascular Coagulation (LIC) with the GIHVM. As the patient desire to become pregnant was important our multidisciplinary clinic allowed a pregnancy with close clinical, biological and imaging monitoring and follow up. Early initiation of low molecular weighted heparin (LMWH) successfully allowed an uncomplicated term pregnancy and delivery. Intrahepatic lesion stability was achieved and prevented progression from LIC to diffuse intravascular coagulation disorder (DIC)..

Endoscopic ultrasound in chronic liver disease

Endoscopic ultrasound (EUS) is a minimally invasive diagnostic and therapeutic modality with a number of established as well as evolving uses in patients with chronic liver disease. Compared to other diagnostic tools such as cross-sectional imaging or conventional endoscopy, EUS has been shown to increase diagnostic sensitivity and therapeutic success for many clinical scenarios and applications with a low rate of adverse events. In this review, we discuss and focus on the current and growing role of EUS in the evaluation and/or treatment of hepatobiliary masses, hepatic parenchymal disease, portal hypertension, esophageal and other varices, and indeterminate biliary strictures.

Long-term Evolution of Hepatocellular Adenomas at MRI Follow-up

Background Hepatocellular adenomas (HCAs) are rare benign liver tumors. Guidelines recommend continued surveillance of patients diagnosed with HCAs, but these guidelines are mainly based on small studies or expert opinion. Purpose To analyze the long-term evolution of HCAs, including solitary and multiple lesions, and to identify predictive features of progression with MRI. Materials and Methods In a retrospective study, patients diagnosed with pathologically proven solitary or multiple HCAs between January 2004 and December 2015 were included; β-catenin-mutated HCAs and HCAs with foci of malignancy were considered to be at risk for progression. MRI examinations were analyzed, and tumor evolution was evaluated by using Response Evaluation Criteria in Solid Tumors, version 1.1. Student t, Mann-Whitney, χ², Fisher exact, and McNemar tests were used, as appropriate. Results In total, 118 patients (mean age, 40 years ± 10 [standard deviation]; 108 women) were evaluated, including 41 with a solitary HCA (mean age, 40 years ± 14; 36 women) and 77 with multiple HCAs (mean age, 40 years ± 10; 72 women). At a median follow-up of 5 years, 37 of 41 (90%) patients with a solitary HCA and 55 of 77 (71%) patients with multiple HCAs showed stable or regressive disease. After resection of solitary HCAs, new lesions appeared in only two of 29 (7%) patients, both of whom had HCAs at risk of progression. In patients with multiple HCAs, hepatocyte nuclear factor 1α-inactivated HCAs showed a higher rate of progression compared with inflammatory HCAs (11 of 26 [42%] vs seven of 37 [19%], P = .04) despite lower use (28 of 32 patients [88%] vs 45 of 45 patients [100%]; P = .03) and shorter duration (mean, 12.0 years ± 7.5 vs 19.2 years ± 9.2; P = .001) of oral contraceptive intake. Conclusion Long-term MRI follow-up showed that 78% of hepatocellular adenomas had long-term stability or regression. After resection of solitary hepatocellular adenomas, new lesions occurred only in hepatocellular adenomas at risk of progression. Patients with multiple hepatocellular adenomas were more likely to show progressive disease, with hepatic nuclear factor 1α-inactivated hepatocellular adenomas being the most common subtype showing progression. © RSNA, 2020 Online supplemental material is available for this article.

Hepatitis B-associated hepatocellular carcinoma in a young Haitian man: a review of screening guidelines

Hepatocellular carcinoma (HCC) is a terminal, yet preventable, outcome of untreated infection with hepatitis B virus (HBV). HBV is endemic in many areas of Latin America and the Caribbean, including Haiti. Haitians have the highest incidence of liver cancer among Caribbean immigrants. Unfortunately, many of these patients are not screened, despite current guidelines. As HBV is treatable, screening of high-risk populations is crucial to early intervention and prevention of poor outcomes. We highlight the case of a young Haitian male immigrant who presented with unintentional weight loss and epigastric pain and found to have HCC associated with HBV. Despite chemotherapy, the patient died 15 months after diagnosis. Increased awareness of HBV among patients from high-incidence countries may result in early recognition of this disease and reduced morbidity and mortality from devastating complications.

Performance of Contrast-Enhanced Sonography Versus MRI With a Liver-Specific Contrast Agent for Diagnosis of Hepatocellular Adenoma and Focal Nodular Hyperplasia

OBJECTIVE. The purpose of this article is to compare contrast-enhanced sonography (CEUS) with sulfur hexafluoride with MRI with the liver-specific contrast agent gadobenate dimeglumine in the diagnosis of hepatocellular adenoma (HCA) and focal nodular hyperplasia (FNH) in a cohort of consecutive patients. MATERIALS AND METHODS. Patients referred to a tertiary center for hepatobiliary disease who had suspected HCA or FNH on MRI performed with an extracellular gadolinium-based contrast agent underwent a prospective workup including CEUS and MRI with a liver-specific contrast agent. Diagnosis was definite when the findings of CEUS and MRI with a liver-specific contrast agent were concordant; histopathologic examination (HPE) was performed for cases with discordant findings. Descriptive statistics and the association between categoric variables were presented as numbers and percentages and were assessed using the Fisher exact test. The primary analysis was patient based. Sensitivity, specificity, and AUC and predictive values for the diagnosis of HCA and FNH were calculated separately for CEUS and MRI with a liver-specific contrast agent. RESULTS. A total of 181 patients were selected for the first analysis. Findings from CEUS and MRI with a liver-specific contrast agent were concordant for 132 patients (73%) and discordant for 49 (27%). HPE was performed for 26 of the 49 patients with discordant findings (53%), with findings indeterminate for two of these patients, the findings of MRI with a liver-specific contrast agent correct for 21 of the remaining 24 patients (87.5%), and the findings of CEUS correct for three of these 24 patients (12.5%) (p < 0.05). For further analysis, 156 patients with concordant findings or HPE-proven cases were included. For CEUS, the sensitivity and specificity for the diagnosis of HCA and FNH were 85% and 87%, respectively; the ROC AUC value was 0.856; and the positive predictive value and negative predictive value were 79% and 90%, respectively. For MRI with a liver-specific contrast agent, the sensitivity and specificity were 95% each, the ROC AUC value was 0.949, and the positive predictive value and negative predictive value were 92% and 97%, respectively, for the diagnosis of HCA and FNH. CONCLUSION. The findings of CEUS and MRI with a liver-specific contrast agent showed fair agreement for the diagnosis of HCA and FNH. MRI with a liver-specific contrast agent is diagnostically correct significantly more often than CEUS in cases with discordant findings that are HPE proven.

Endoscopic Ultrasound for the Diagnosis and Staging of Liver Tumors

Endoscopic ultrasound examination may provide complementary information to cross-sectional imaging in lesions of the liver, portal vein, and surrounding lymph nodes. With fine needle aspiration, endoscopic ultrasound examination is a powerful tool for the diagnosis of focal liver lesions and has usefulness in the evaluation of indeterminate liver lesions. Endoscopic ultrasound examination may influence hepatocellular cancer staging and Endoscopic ultrasound examination with fine needle aspiration of locoregional nodes and portal vein thromboses changes management. Contrast-enhanced endoscopic ultrasound examination and endoscopic ultrasound examination elastography are likely to expand the usefulness of endoscopic ultrasound examination in evaluating liver malignancy with technologic improvements.

Non-invasive evaluation of a liver mass in a patient post splenectomy

INTRODUCTION

Numerous conditions may cause liver lesions, solitary or multiple, benign or malignant. It can be crucial to establish the correct diagnosis. Splenosis is a rare condition that may result from the spillage of cells from the splenic pulp following abdominal trauma, accidental lesions to the spleen during operation or elective splenectomy. These splenic 'implants', which are often multiple, can be located anywhere in the peritoneal cavity, although they are most often found in the left upper quadrant of the abdomen. They may be confused with neoplasms or endometriosis, and may rarely be the cause of small bowel obstruction.

CASE PRESENTATION

A 35-year-old man presented with a hepatic mass, and malignancy was suspected. After extensive investigation, it was diagnosed as splenosis using Tc-99m-labelled heat-denaturated red blood cells scintigraphy, without the need for liver biopsy. We consider this the most effective method for diagnosing splenosis.

CONCLUSION

When splenosis is suspected, Tc-99m-labelled heat-denaturated red blood cells scintigraphy can be used to confirm the diagnosis, and may avoid invasive investigation.

Clinical and epidemiological characteristics of pyogenic liver abscess in people 65 years or older versus people under 65: a retrospective study

BACKGROUND

To analyse the clinical, epidemiological, microbiological and prognostic differences of pyogenic liver abscess (PLA) in older (≥ 65 years of age) versus younger patients (< 65 years).

METHODS

Multicentre, retrospective cohort study in all patients with PLA admitted to two Spanish hospitals from January 2000 to January 2014. Cases were divided into two age groups (< 65 years and ≥65 years) for comparison of clinical, epidemiological and microbiological characteristics as well as treatment.

RESULTS

Of 98 patients analysed, 40 patients were younger than 65, and 58 were aged 65 or older. Significant associations in the older group were found with female sex (adjusted odds ratio [ORa] 9.0; 95% CI 1.4, 56), non-cryptogenic origin (ORa 14.5; 95% CI 1.6, 129), absence of chronic liver disease (ORa 14; 95% CI 1.3, 155), Escherichia coli infection (ORa 7.7; 95% CI 1.03, 58), and incidence of complications (ORa 2.3; 95% CI 1.04, 5.4). Mortality was 8.2% overall, although all deaths occurred in the older group (8/58; 13.8%) (p = 0.02).

DISCUSSION

Our results are in consonance with other published studies. Older patients with PLA tend to present more anomalies in the biliary tract (Kai et. al, World J Gastroenterol 18: 2948-295, 2012, Rahimian et. al, Clin Infect Dis 39:1654-9, 2004, Seeto, Medicine (Baltimore) 75:99-113, 1996, Kao et.al, Aliment Pharmacol Ther 36:467-76, 2012, Lai et. al, Gastroenterology 146:129-37, 2014), while younger patients are more often male and present more commonly with previous liver disease (especially related to alcohol) and cryptogenic PLA.

CONCLUSION

In patients aged 65 or older, PLA was more common in women and in those with a history of biliary disease, and E. coli was the most frequent bacterium. Mortality was also higher in the older group.

A giant cavernous hemangioma of the liver extending into the pelvis

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A 66-year-old male with a giant liver mass (37 cm) extending in the pelvis.

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Diagnosis—cavernous hemangioma, symptomatic and growing (uncommon presentation).

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Surgical treatment offered—resection/left trisectionectomy performed.

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Indications for treatment and surgical approaches (including enucleation) discussed.

Introduction

Giant cavernous hemangiomas are the most common tumors of the liver, ocurring in up to 20% of the general population. Given their benign course, asymptomatic nature and slow growth rate, treatment is rarely indicated. The case presented herein is unique as it describes an uncommon presentation of this common tumor and the circumstances in which surgical treatment is beneficial.

Presentation of case

We present a case of a 66 year-old patient with prostate cancer referred for evaluation of a massive 37 cm giant liver hemangioma, extending into the pelvis and in the planned field of radiation for prostate cancer, exhibiting rapid growth, and associated with significant symptomatology. Given these clinical characteristics, the patient was offered surgery and underwent a left trisectionectomy with an uneventful recovery. The patient's symptoms resolved and he was able to complete radiation to the pelvis.

Discussion

In the context of an unusual presentation, this case presentation reviews the typical clinical and imaging characteristics of giant liver hemangiomas and expands on the current indications for treatment, emphasizing the role of enucleation and resection for patients meeting appropriate indications.

Conclusion

Although liver hemangiomas are extremely common, surgical treatment is rarely required. With appropriate indications, and when enucleation is not feasible or ideal, major liver resection is a safe alternative approach with excellent outcomes when performed in the right setting.

Rare benign tumors of the liver: still rare?

Background

Benign liver tumors are common. They do not spread to other areas of the body, and they usually do not pose a serious health risk. In fact, in most cases, benign liver tumors are not diagnosed because patients are asymptomatic. When they are detected, it’s usually because the person has had medical imaging tests, such as an ultrasound (US), computed tomography (CT) scan, or magnetic resonance imaging (MRI), for another condition.

Materials and methods

A search of the literature was made using cancer literature and the PubMed, Scopus, and Web of Science (WOS) database for the following keywords: “hepatic benign tumors”, “hepatic cystic tumors”, “polycystic liver disease”, “liver macroregenerative nodules”, “hepatic mesenchymal hamartoma”, “hepatic angiomyolipoma”, “biliary cystadenoma”, and “nodular regenerative hyperplasia”.

Discussion and conclusion

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in some areas of the world; there is an increasing incidence worldwide. Approximately 750,000 new cases are reported per year. More than 75 % of cases occur in the Asia-Pacific region, largely in association with chronic hepatitis B virus (HBV) infection. The incidence of HCC is increasing in the USA and Europe because of the increased incidence of hepatitis C virus (HCV) infection. Unlike the liver HCC, benign tumors are less frequent. However, they represent a chapter always more interesting of liver disease. In fact, a careful differential diagnosis with the forms of malignant tumor is often required in such a way so as to direct the patient to the correct therapy. In conclusion, many of these tumors present with typical features in various imaging studies. On occasions, biopsies are required, and/or surgical removal is needed. In the majority of cases of benign hepatic tumors, no treatment is indicated. The main indication for treatment is the presence of significant clinical symptoms or suspicion of malignancy or fear of malignant transformation.

Cat-scratch disease presenting as multiple hepatic lesions: case report and literature review

Although infectious diseases are the most prevalent cause of fevers of unknown origin (FUO), this diagnosis remains challenging in some pediatric patients. Imaging exams, such as computed tomography (CT) are frequently required during the diagnostic processes. The presence of multiple hypoattenuating scattered images throughout the liver associated with the history of cohabitation with cats should raise the suspicion of the diagnosis of cat-scratch disease (CSD), although the main etiologic agent of liver abscesses in childhood is Staphylococcus aureus. Differential diagnosis by clinical and epidemiological data with Bartonella henselae is often advisable. The authors report the case of a boy aged 2 years and 9 months with 16-day history of daily fever accompanied by intermittent abdominal pain. Physical examination was unremarkable. Abdominal ultrasound performed in the initial work up was unrevealing, but an abdominal CT that was performed afterwards disclosed multiple hypoattenuating hepatic images compatible with the diagnosis of micro abscesses. Initial antibiotic regimen included cefotaxime, metronidazole, and oxacillin. Due to the epidemiology of close contact with kittens, diagnosis of CSD was considered and confirmed by serologic tests. Therefore, the initial antibiotics were replaced by clarithromycin orally for 14 days followed by fever defervescence and clinical improvement. The authors call attention to this uncommon diagnosis in a child presenting with FUO and multiple hepatic images suggestive of micro abscesses.

Characterization of the syndrome of acute liver failure caused by metastases from breast carcinoma

AIM

To characterize syndrome of acute liver failure (ALF) from metastatic breast cancer to promote premortem diagnosis. Up to now, only 25 % of the reported 32 cases of this syndrome were diagnosed premortem.

METHODS

Cases identified by computerized literature review and review of files maintained by senior investigator.

RESULTS

Among 32 cases, average age at presentation was 47.9 ± 9.9 years. Common signs include jaundice, hepatomegaly, shifting dullness, and bilateral leg edema. Mean serum level of AST was 296.4 ± 204.0 U/L, ALT, 183.2 ± 198.9 U/L; alkaline phosphatase, 641.5 ± 610.1; and total bilirubin, 8.6 ± 8.3 mg/dL. Twenty-seven patients (84 %) have known prior breast cancer (mean diagnosis = 4.1 + 4.8 years earlier). Abdominal ultrasound findings (N = 10) include hepatomegaly in three cases, heterogeneous/multifocal hepatic lesions in three, ascites in three, and other in two. Abdominal CT findings (N = 16) include heterogeneous/multifocal hepatic lesions in six cases, ascites in five, hepatomegaly in three, cirrhosis in three, fatty liver in two, other in two. Hepatic metastases may not be suspected when abdominal CT shows no hepatic lesions. The diagnosis is made postmortem in 24 cases and antemortem in eight, with a statistically significant trend of increasing premortem diagnosis since 2000 (0 % before 2000 vs. 50 % after 2000; p = .001, 95 %--ORCI ≥ 2.86, Fisher's exact test). A new case of ALF from breast cancer is reported with notable features: abdominal CT revealed no discrete hepatic lesions despite widespread hepatic metastases demonstrated by liver biopsy; hepatic metastases occurred 21 years after original breast primary; and original diagnosis of lobular breast cancer in primary lesion was corrected to mixed ductal and lobular carcinoma, based on immunohistochemistry, performed 21 years afterward.

CONCLUSIONS

This review characterizes the clinical presentation and natural history of this syndrome to promote liver biopsy for premortem diagnosis and appropriate therapy.