Pathology of Liver Metastases

Compressed sensing with deep learning reconstruction: Improving capability of gadolinium-EOB-enhanced 3D T1WI

PURPOSE

The purpose of this study was to determine the utility of compressed sensing (CS) with deep learning reconstruction (DLR) for improving spatial resolution, image quality and focal liver lesion detection on high-resolution contrast-enhanced T1-weighted imaging (HR-CE-T1WI) obtained by CS with DLR as compared with conventional CE-T1WI with parallel imaging (PI).

METHODS

Seventy-seven participants with focal liver lesions underwent conventional CE-T1WI with PI and HR-CE-T1WI, surgical resection, transarterial chemoembolization, and radiofrequency ablation, followed by histopathological or >2-year follow-up examinations in our hospital. Signal-to-noise ratios (SNRs) of liver, spleen and kidney were calculated for each patient, after which each SNR was compared by means of paired t-test. To compare focal lesion detection capabilities of the two methods, a 5-point visual scoring system was adopted for a per lesion basis analysis. Jackknife free-response receiver operating characteristic (JAFROC) analysis was then performed, while sensitivity and false positive rates (/data set) for consensus assessment of the two methods were also compared by using McNemar's test or the signed rank test.

RESULTS

Each SNR of HR-CE-T1WI was significantly higher than that of conventional CE-T1WI with PI (p < 0.05). Sensitivities for consensus assessment showed that HR-CE-MRI had significantly higher sensitivity than conventional CE-T1WI with PI (p = 0.004). Moreover, there were significantly fewer FP/cases for HR-CE-T1WI than for conventional CE-T1WI with PI (p = 0.04).

CONCLUSION

CS with DLR are useful for improving spatial resolution, image quality and focal liver lesion detection capability of Gd-EOB-DTPA enhanced 3D T1WI without any need for longer breath-holding time.

Discovery of novel DNA methylation biomarker panels for the diagnosis and differentiation between common adenocarcinomas and their liver metastases

Differentiation between adenocarcinomas is sometimes challenging. The promising avenue for discovering new biomarkers lies in bioinformatics using DNA methylation analysis. Utilizing a 2853-sample identification dataset and a 782-sample independent verification dataset, we have identified diagnostic DNA methylation biomarkers that are hypermethylated in cancer and differentiate between breast invasive carcinoma, cholangiocarcinoma, colorectal cancer, hepatocellular carcinoma, lung adenocarcinoma, pancreatic adenocarcinoma and stomach adenocarcinoma. The best panels for cancer type exhibit sensitivity of 77.8-95.9%, a specificity of 92.7-97.5% for tumors, a specificity of 91.5-97.7% for tumors and normal tissues and a diagnostic accuracy of 85.3-96.4%. We have shown that the results can be extended from the primary cancers to their liver metastases, as the best panels diagnose and differentiate between pancreatic adenocarcinoma liver metastases and breast invasive carcinoma liver metastases with a sensitivity and specificity of 83.3-100% and a diagnostic accuracy of 86.8-91.9%. Moreover, the panels could detect hypermethylation of selected regions in the cell-free DNA of patients with liver metastases. At the same time, these were unmethylated in the cell-free DNA of healthy donors, confirming their applicability for liquid biopsies.

Circulating microRNA Panels for Detection of Liver Cancers and Liver-Metastasizing Primary Cancers

Malignant liver tumors, including primary malignant liver tumors and liver metastases, are among the most frequent malignancies worldwide. The disease carries a poor prognosis and poor overall survival, particularly in cases involving liver metastases. Consequently, the early detection and precise differentiation of malignant liver tumors are of paramount importance for making informed decisions regarding patient treatment. Significant research efforts are currently directed towards the development of diagnostic tools for different types of cancer using minimally invasive techniques. A prominent area of focus within this research is the evaluation of circulating microRNA, for which dysregulated expression is well documented in different cancers. Combining microRNAs in panels using serum or plasma samples derived from blood holds great promise for better sensitivity and specificity for detection of certain types of cancer.

Liver metastases: The role of magnetic resonance imaging

The liver is one of the organs most commonly involved in metastatic disease, especially due to its unique vascularization. It's well known that liver metastases represent the most common hepatic malignant tumors. From a practical point of view, it's of utmost importance to evaluate the presence of liver metastases when staging oncologic patients, to select the best treatment possible, and finally to predict the overall prognosis. In the past few years, imaging techniques have gained a central role in identifying liver metastases, thanks to ultrasonography, contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI). All these techniques, especially CT and MRI, can be considered the non-invasive reference standard techniques for the assessment of liver involvement by metastases. On the other hand, the liver can be affected by different focal lesions, sometimes benign, and sometimes malignant. On these bases, radiologists should face the differential diagnosis between benign and secondary lesions to correctly allocate patients to the best management. Considering the above-mentioned principles, it's extremely important to underline and refresh the broad spectrum of liver metastases features that can occur in everyday clinical practice. This review aims to summarize the most common imaging features of liver metastases, with a special focus on typical and atypical appearance, by using MRI.

Discrimination of Liver Metastases of Digestive System Neuroendocrine Tumors From Neuroendocrine Carcinoma by Computed Tomography-Based Radiomics Analysis

OBJECTIVE

The aim of the study is to investigate the value of computed tomography (CT) radiomics features to discriminate the liver metastases (LMs) of digestive system neuroendocrine tumors (NETs) from neuroendocrine carcinoma (NECs).

METHODS

Ninety-nine patients with LMs of digestive system neuroendocrine neoplasms from 2 institutions were included. Radiomics features were extracted from the portal venous phase CT images by the Pyradiomics and then selected by using the t test, Pearson correlation analysis, and least absolute shrinkage and selection operator method. The radiomics score (Rad score) for each patient was constructed by linear combination of the selected radiomics features. The radiological model was constructed by radiological features using the multivariable logistic regression. Then, the combined model was constructed by combining Rad score and the radiological model into logistic regression. The performance of all models was evaluated by the receiver operating characteristic curves with the area under curve (AUC).

RESULTS

In the radiological model, only the enhancement degree (odds ratio, 8.299; 95% confidence interval, 2.070-32.703; P = 0.003) was an independent predictor for discriminating the LMs of digestive system NETs from those of NECs. The combined model constructed by the Rad score in combination with the enhancement degree showed good discrimination performance, with AUCs of 0.893, 0.841, and 0.740 in the training, testing, and external validation groups, respectively. In addition, it performed better than radiological model in the training and testing groups (AUC, 0.893 vs 0.726; AUC, 0.841 vs 0.621).

CONCLUSIONS

The CT radiomics might be useful for discrimination LMs of digestive system NECs from NETs.

Circulating Tumor DNA Methylation Biomarkers for Characterization and Determination of the Cancer Origin in Malignant Liver Tumors

Malignant liver tumors include primary malignant liver tumors and liver metastases. They are among the most common malignancies worldwide. The disease has a poor prognosis and poor overall survival, especially with liver metastases. Therefore, early detection and differentiation between malignant liver tumors are critical for patient treatment selection. The detection of cancer and the prediction of its origin is possible with a DNA methylation profile of the tumor DNA compared to that of normal cells, which reflects tissue differentiation and malignant transformation. New technologies enable the characterization of the tumor methylome in circulating tumor DNA (ctDNA), providing a variety of new ctDNA methylation biomarkers, which can provide additional information to clinical decision-making. Our review of the literature provides insight into methylation changes in ctDNA from patients with common malignant liver tumors and can serve as a starting point for further research.

MR elastography is a good response parameter for microwave ablation liver tumors

OBJECTIVES

To determine the response of hepatic tissue to percutaneous microwave ablation (MWA) of liver tumors via MR elastography in a clinical setting using MRI and MR elastography.

METHODS

51 Patients (28 m, 23f) underwent MWA of liver tumors (HCC: 20, metastasis: 31) and received MRI and MR elastography immediately before and 24 h after MWA. Retrospective analysis included pre- and post-ablative tumor extent, T1/T2 mapping and stiffness values as well as the duration and energy dose of the MWA session.

RESULTS

Total liver stiffness increased by 4.3% from 3.31 kPa to 3.45 kPa (p = 0.036). Total liver stiffness post-MWA significantly correlated with the duration of the MWA session (r = 0.369, p = 0.008). The higher the baseline tumor stiffness was, the more energy had to be applied in MWA (r = 0.391, p < 0.001) and the longer the duration of the session (r = 0.391, p = 0.007). Healthy parenchyma stiffness increased by 3.5% from 3.55 kPa to 3.68 kPa (p = 0.142) and was strongly influenced by the cumulative energy (r = 0.436, p < 0.001), the duration (r = 0.458, p < 0.001) and the energy intensity (r = 0.458, p < 0.001) of MWA. 43 patients had a technically successful ablation result (margin ≥ 5 mm). Those with successful ablation had increased ablation margin stiffness (5.3 kPa vs. 4.6 kPa, p = 0.26) and had received higher ablation intensity than those with unsuccessful ablation (5.73 kJ/min vs. 5.03 kJ/min, p = 0.002).

CONCLUSION

Additional MRE may be used before and after MWA to assess treatment response and collateral tissue damage after MWA. Baseline tumor stiffness helps finding the appropriate MWA parameters.

Immunohistochemical staining reveals differential expression of ACSL3 and ACSL4 in hepatocellular carcinoma and hepatic gastrointestinal metastases

Long-chain fatty acyl CoA synthetases (ACSLs) activate fatty acids by CoA addition thus facilitating their intracellular metabolism. Dysregulated ACSL expression features in several cancers and can affect processes such as ferroptosis, fatty acid β-oxidation, prostaglandin biosynthesis, steroidogenesis and phospholipid acyl chain remodelling. Here we investigate long chain acyl-CoA synthetase 3 (ACSL3) and long chain acyl-CoA synthetase 4 (ACSL4) expression in liver malignancies. The expression and subcellular localisations of the ACSL3 and ACSL4 isoforms in hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA) and hepatic metastases were assessed by immunohistochemical analyses of multiple tumour tissue arrays and by subcellular fractionation of cultured HepG2 cells. The expression of both enzymes was increased in HCC compared with normal liver. Expression of ACSL3 was similar in HCC and hepatic metastases but lower in healthy tissue. Increased ACSL3 expression distinguished HCC from CCA with a sensitivity of 87.2% and a specificity of 75%. ACSL4 expression was significantly greater in HCC than in all other tumours and distinguished HCC from normal liver tissue with a sensitivity of 93.8% and specificity of 93.6%. Combined ACSL3 and ACSL4 staining scores distinguished HCC from hepatic metastases with 80.1% sensitivity and 77.1% specificity. These enzymes had partially overlapping intracellular distributions, ACSL4 localised to the plasma membrane and both isoforms associated with lipid droplets and the endoplasmic reticulum (ER). In conclusion, analysis of ACSL3 and ACSL4 expression can distinguish different classes of hepatic tumours.

Liver Metastases and Histological Growth Patterns: Biological Behavior and Potential Clinical Implications-Another Path to Individualized Medicine?

Colorectal cancer is a major health burden and despite the recent advances in healthcare and screening programs, a great percentage of patients already present metastases once their disease is found. In those cases, liver surgery has an essential role, but even with neoadjuvant chemotherapy there is a high rate of intrahepatic recurrence. New prognostic factors are needed in order to decide the best surgical approach considering the biological behavior of the tumors in order to tailor the used therapies, moving towards individualized medicine/treatment. However, the majority of the factors described in literature are expensive, time consuming, and difficult to apply on a daily basis. Histological growth patterns have emerged over the past few years as a reproducible characteristic, an easy to apply one, and with very low costs since it only needs the standard Haematoxylin and Eosin stained slides of observation. In this article, we provide a review of the histological growth patterns of liver metastases and their prognostic significance, biological meaning, and therapeutic importance.

Insight on ALPPS - Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy - mechanisms: activation of mTOR pathway

BACKGROUND

ALPPS procedure has been introduced to increase the volume of future liver remnant. The mechanisms underlying the accelerated regeneration observed with ALPPS are unknown. It was hypothesized that AMPK/mTOR is activated as an integrating pathway for metabolic signals leading to proliferation and cell growth. Our aim was to analyze increase in liver volume, proliferation parameters and expression of AMPK/mTOR pathway-related molecules in patients undergoing ALPPS.

METHODS

A single center prospective study of patients undergoing ALPPS was performed from 2013 to 2015. Liver and serum samples, clinical laboratory results and CT-scan data were obtained. ELISA, Ki-67 immunostaining and qRT-PCR were performed in deportalized and remnant liver tissue in both stages of the procedure.

RESULTS

11 patients were enrolled. Remnant liver volume increased 112 ± 63% (p < 0.05) in 9.1 ± 1.6 days. Proliferation-related cytokines IL-6, TNF-α, HGF and EGF significantly increased, while higher Ki-67 immunostaining and cyclin D expression were observed in remnant livers after ALPPS. mTOR, S6K1, 4E-BP1, TSC1 and TSC2 expression were significantly increased in remnant livers at second stage, while AMPK and Akt increased only in deportalized liver samples.

CONCLUSION

Rapid liver regeneration with ALPPS might be associated with hepatocyte proliferation induced by mTOR pathway activation.

Hepatic endometrial stromal sarcoma

Endometrial stromal sarcomas are rare tumors that may recur or metastasize many years after their initial presentation. Though most recurrences are within the pelvis, distant metastases can occur, and are most common to the lungs. Metastases to the liver are extremely rare. Herein we report two cases of endometrial stromal sarcoma with metastases to the liver without a prior history of endometriosis, accompanied by their histology, immunohistochemistry, and molecular analysis in the context of a relevant literature review.

A Comprehensive Evaluation of Special AT-rich Sequence-binding Protein 2 (SATB2) Immunohistochemical Staining in Mucinous Tumors From Gastrointestinal and Nongastrointestinal Sites

Special AT-rich sequence-binding protein 2 (SATB2) is an accurate marker for conventional colorectal carcinoma (CRC), although its sensitivity and specificity in mucinous tumors from the colon and other sites remains unknown. The objective of this study is to evaluate the accuracy of SATB2 expression detected by immunohistochemical assay, as a marker of primary CRC in mucinous adenocarcinomas. SATB2 immunohistochemical stains were performed on whole sections from 63 conventional CRCs (controls), 47 mucinous CRCs (mCRC), and 182 noncolorectal mucinous tumors. SATB2 intensity was scored as 1 to 3 based on the estrogen receptor/progesterone receptor grading system, and the percent positive cells was scored in broad categories as follows: 0 (negative)≤5%, 1=5% to 49%, 2≥50%. An optimal sensitivity/specificity pairing (83% and 95%, respectively) was achieved in the mCRCs when the additive intensity and percent score was ≥3 (ie, intensity score+percent score=total score). Defining this total score (histologic score/"H score") as a "positive" result, the sensitivity of SATB2 for conventional CRC was 98% (62/63) versus 83% (39/47) for mCRCs (P=0.02); whereas 5% (9/182) of all noncolorectal mucinous tumors were considered positive. SATB2 especially demonstrated reduced specificity when applied to mucinous gastroesophageal and breast carcinomas, which showed significant expression in 27% and 9% of cases, respectively. In summary, SATB2 is a less sensitive marker of colorectal origin in mCRC compared with conventional CRC and shows significantly reduced specificity in mucinous gastroesophageal and breast primaries.

Making the Case: Intra-arterial Therapy for Less Common Metastases

Intra-arterial therapies have high antitumor activity for both primary and secondary hepatic malignancies. Selective infusions allow increased delivery of cytoreductive therapy to the tumor bed while sparing the normal hepatic parenchyma. These therapies are now often applied in the outpatient setting or with short overnight hospital stays and have a growing role in the treatment of liver-dominant disease from metastatic colorectal cancer and from neuroendocrine tumors. Less commonly, intra-arterial therapies are applied to treat secondary hepatic malignancies from breast cancer, melanoma, pancreatic adenocarcinoma, and soft-tissue sarcomas. The available data are limited and generally retrospective observational cohort series of single institutions. The purpose of this article is to summarize the recent literature on outcomes for intra-arterial therapy in nonsurgical patients. Multi-institutional registries and prospective data are greatly needed, as intra-arterial therapies are increasingly applied in these patients to stop progression of chemorefractory tumors.

Utility of FNAC in Conjunction with Cell Block for Diagnosing Space-Occupying Lesion (SOL) of Liver with Emphasis on Differentiating Hepatocellular Carcinoma from Metastatic SOL: Analysis of 61 Cases

OBJECTIVES

To study the cytological patterns of fine-needle aspiration cytology (FNAC) obtained from space-occupying lesions (SOLs) of the liver with an aim to differentiate primary hepatocellular carcinoma from metastatic deposits and to evaluate the added advantage and efficacy of studying cell blocks in conjunction with smears for enhancing diagnostic accuracy.  .

METHODS

This prospective study took place over two years (September 2007 to 2009) and included 61 patients with cases of liver SOLs that were clinically or radiologically suspicious for malignancy and who were referred for computed tomography or ultrasonography-guided FNAC. Smears were prepared from the aspirated material, and any remainder was used to make the cell block (n = 55). A final diagnosis was made after evaluating the smears and cell block sections.  .

RESULTS

On cytomorphology, a diagnosis of moderately differentiated hepatocellular carcinoma (HCC) and metastatic carcinoma was made in 10 (18.2%) and 25 (45.5%) cases, respectively, and were confirmed using cell block sections. In cases where it was difficult to differentiate between well-differentiated HCC and regenerative nodules, and between poorly differentiated HCC and poorly differentiated metastatic carcinoma, a final diagnosis was made with the help of cell blocks sections. Cell blocks assisted in reaching a final diagnosis in 16 (29.1%) cases. Cases that were diagnosed using cytomorphology were confirmed by the cell block method. In these 39 (70.9%) cases we were able to render a diagnosis with much more confidence.  .

CONCLUSION

In our experience, difficulties in diagnosing SOL liver are attributed to differentiation of the tumor. Cell block preparation gives an additional advantage as architectural details can be studied that help to reach an accurate diagnosis in problematic and challenging cases. Thus, we strongly recommend the use of the cell block technique in conjunction with cytosmears for the purpose of diagnosis.

An Oral Salmonella-Based Vaccine Inhibits Liver Metastases by Promoting Tumor-Specific T-Cell-Mediated Immunity in Celiac and Portal Lymph Nodes: A Preclinical Study

Primary tumor excision is one of the most widely used therapies of cancer. However, the risk of metastases development still exists following tumor resection. The liver is a common site of metastatic disease for numerous cancers. Breast cancer is one of the most frequent sources of metastases to the liver. The aim of this work was to evaluate the efficacy of the orally administered Salmonella Typhi vaccine strain CVD 915 on the development of liver metastases in a mouse model of breast cancer. To this end, one group of BALB/c mice was orogastrically immunized with CVD 915, while another received PBS as a control. After 24 h, mice were injected with LM3 mammary adenocarcinoma cells into the spleen and subjected to splenectomy. This oral Salmonella-based vaccine produced an antitumor effect, leading to a decrease in the number and volume of liver metastases. Immunization with Salmonella induced an early cellular immune response in mice. This innate stimulation rendered a large production of IFN-γ by intrahepatic immune cells (IHIC) detected within 24 h. An antitumor adaptive immunity was found in the liver and celiac and portal lymph nodes (LDLN) 21 days after oral bacterial inoculation. The antitumor immune response inside the liver was associated with increased CD4⁺ and dendritic cell populations as well as with an inflammatory infiltrate located around liver metastatic nodules. Enlarged levels of inflammatory cytokines (IFN-γ and TNF) were also detected in IHIC. Furthermore, a tumor-specific production of IFN-γ and TNF as well as tumor-specific IFN-γ-producing CD8 T cells (CD8⁺IFN-γ⁺) were found in the celiac and portal lymph nodes of Salmonella-treated mice. This study provides first evidence for the involvement of LDLN in the development of an efficient cellular immune response against hepatic tumors, which resulted in the elimination of liver metastases after oral Salmonella-based vaccination.

Role of glypican-3 immunocytochemistry in differentiating hepatocellular carcinoma from metastatic carcinoma of the liver utilizing fine needle aspiration cytology

PURPOSE

Evaluation of the sensitivity and specificity of glypican3 (GPC3) in differentiating hepatocellular carcinoma (HCC) from metastatic carcinomas of the liver in cell block material.

PATIENTS AND METHODS

Sixty cell blocks were prepared from liver FNAs performed in the radiodiagnosis department, National Cancer Institute, in the period between August 2011 and May 2012. Cases diagnosed as hepatocellular carcinoma, or metastatic carcinoma were included in the study. Cell block sections were stained with anti GPC-3. Sensitivity, specificity, and positive and negative predictive values, of GPC3 were calculated. The final diagnosis was based on the triple approach of clinical data, radiological findings, as well as cytomorphologic features aided by GPC-3 results.

RESULTS

70% of cases were diagnosed as HCC, and 30% as metastatic carcinomas. 95.2% of HCC cases expressed GPC3. Poorly differentiated cases showed the highest GPC3 sensitivity (100%), followed by moderately differentiated cases (96.5%), while well differentiated cases expressed GPC3 in 90% of cases. 83.3% of metastatic carcinomas were negative for GPC3. In this study, sensitivity of GPC-3 in HCC was 95.2%, specificity was 83.3%, positive and negative predictive values were 93% and 88.2% respectively, and total accuracy was 91.7%.

CONCLUSION

Immunocytochemical staining for GPC3 in cell block material is a highly sensitive and specific method capable of distinguishing HCC from the vast majority of metastatic carcinomas of the liver.

Aromatase in human liver and its diseases

Estrogens play important roles in the cell proliferation and invasion of estrogen-dependent human neoplasms. Aromatase overexpression has been also reported in hepatitis and hepatocellular carcinoma (HCC) compared with normal liver but its details in these hepatic disorders have remained unclear. Therefore, in this study, we first immunolocalized aromatase using immunohistochemistry in patients with liver cirrhosis, steatosis, hepatitis, HCC, and metastasis liver carcinoma (MLC) in order to study the detailed status of intrahepatic aromatase. Aromatase immunoreactivity was predominantly detected in nonneoplastic hepatocytes around tumor cells. We then evaluated the effects of an interaction between hepatocytes and carcinoma cells upon aromatase mRNA expression, using HepG2 as a substitute model of hepatocytes by coculture systems. Aromatase mRNA levels in HepG2 were significantly increased by coculture with all carcinoma cell lines examined. We also evaluated alternative splicing of aromatase exon 1 but the same splicing variant was used in HepG2 cells regardless of carcinoma cell lines employed in the coculture system. These findings obtained in HepG2 indicated that carcinoma cells, whether metastatic or primary, induced aromatase expression in adjacent normal hepatocytes possibly through the soluble aromatase inducible factors in human hepatic microenvironments.

Distinct claudin expression profiles of hepatocellular carcinoma and metastatic colorectal and pancreatic carcinomas

Tight junction proteins, including claudins, are often dysregulated during carcinogenesis and tumor progression. Moreover, the claudin expression pattern usually varies between different tumor entities. We aimed to investigate claudin expression profiles of primary and metastatic liver malignancies. We analyzed claudin-1, -2, -3, -4, and -7 expression by quantitative immunohistochemistry and real-time RT-PCR, respectively. Twenty hepatocellular carcinomas (HCCs) and liver metastases of 20 colorectal adenocarcinomas (CRLMs) and 15 pancreatic adenocarcinomas (PLMs) were studied together with paired surrounding non-tumorous liver samples and 5 normal liver samples. Strong claudin-3 and -7 immunohistochemical positivities were detected in CRLM samples, each with significantly stronger staining when compared with HCC and PLM groups. Claudin-1 protein was found highly expressed in CRLM, in contrast to lower expression in PLM and HCC. CRLMs and PLMs also were strongly positive for claudin-4, while being virtually undetectable in HCC. Claudin-2 showed strong positivity in non-tumorous liver tissue, whereas significantly weaker positivity was observed in all tumors. Differences in mRNA expression were mostly similar to those found by immunohistochemistry. In conclusion, HCC and both CRLM and PLM display distinct claudin expression profiles, which might provide better understanding of the pathobiology of these lesions and might be used for differential diagnosis.

Cytopathologic diagnosis of liver mass lesions

The liver is a common site for metastatic malignancies, particularly from the gastrointestinal tract. It also may be involved by primary neoplasms, both benign and malignant. Cytopathologic examination of mass lesions of the liver with pertinent use of ancillary studies is a useful method of establishing a correct diagnosis for patient management. The authors reviewed the literature for articles pertaining to cytologic characteristics of specific tumor types, utility of immunohistochemical markers and pertinent molecular studies, differential diagnoses and pitfalls.

Acute liver failure associated with diffuse liver infiltration by metastatic breast carcinoma: A case report

Diffuse parenchymal metastasis is an unusual pattern of liver metastasis that is capable of causing liver failure. In the present study, the authors describe malignant infiltration of the liver by primary breast carcinoma in an autopsy of a 49-year-old female who had a rapid onset of liver failure and died after three weeks. Ultrasonography and computed tomography (CT) scans of the abdomen, as well as macroscopic examination, failed to detect liver metastasis; while microscopic examination revealed diffuse tumor cells with a loss of E-cadherin expression infiltrating into the liver parenchyma. The prognosis of liver failure associated with malignant infiltration is extremely poor; the survival time of patients is extremely low. Liver biopsy may be the most efficient technique for confirming the diagnosis during the patient’s life.

Meta-analysis of gadoxetic acid disodium (Gd-EOB-DTPA)-enhanced magnetic resonance imaging for the detection of liver metastases

Objective

To determine the accuracy of MR imaging with Gd-EOB-DTPA for the detection of liver metastases.

Materials and Methods

PUBMED, EMBASE, the Web of Science, and the Cochrane Library were searched for original articles published prior to February 2012. The criteria for the inclusion of articles were as follows: reported in the English language; MR imaging with Gd-EOB-DTPA was performed to detect liver metastases; histopathologic analysis (surgery, biopsy), intraoperative observation (manual palpatation, intraoperative ultrasonography), and/or follow-up US was the reference standard; and data were sufficient for the calculation of true-positive or false-negative values. The methodological quality was assessed by using the quality assessment of diagnostic studies instrument. The data were extracted to calculate sensitivity, specificity, predictive value, diagnostic odds ratio, and areas under hierarchical summary receiver operating characteristic (HSROC) curve to perform heterogeneity test and threshold effect test, as well as publication bias analysis and subgroup analyses.

Results

From 229 citations, 13 were included in the meta-analysis with a total of 1900 lesions. We detected heterogeneity between studies and evidence of publication bias. The methodological quality was moderate. The pooled weighted sensitivity with a corresponding 95% confidence interval (CI) was 0.93 (95% CI: 0.90, 0. 95), the specificity was 0.95 (95% CI: 0.91, 0.97), the positive likelihood ratio was 18.07 (95% CI: 10.52, 31.04), the negative likelihood ratio was 0.07 (95% CI: 0.05, 0.10), and the diagnostic odds ratio was 249.81 (95% CI: 125.12, 498.74). The area under the receiver operator characteristic curve was 0.98 (95% CI: 0.96, 0.99).

Conclusion

MR imaging with Gd-EOB-DTPA is a reliable, non-invasive, and no-radiation-exposure imaging modality with a high sensitivity and specificity for detection of liver metastases. Nonetheless, it should be applied cautiously, and large scale, well-designed trials are necessary to assess its clinical value.

Triple malignancy in a single patient including a cervical carcinoma, a basal cell carcinoma of the skin and a neuroendocrine carcinoma from an unknown primary site: A case report and review of the literature

Introduction

The occurrence of multiple primary cancers is rare. Only a few cases and patient reviews of an association of triple malignancy have been reported.

Case presentation

We report here a case of a 78-year-old Moroccan woman presenting initially with a synchronous double malignancy, the first in her cervix and the second in her skin. Our patient was treated with radiation therapy for both tumors and remained in good control for 17 years, when she developed a metastatic disease from a neuroendocrine carcinoma of an unknown primary site.

Conclusions

Although the association of multiple primary cancers can be considered a rare occurrence, improving survival in cancer patients has made this situation more frequent.

Pathologic evaluation of unknown primary cancer

The pathologic approach to metastases of unknown primary cancer (UPC) is stepwise and uses the clinical context, morphology, and, where necessary, immunohistochemistry (IHC). This review covers the initial approach to a UPC biopsy; the diagnosis of malignancy and broad tumor typing into carcinoma, melanoma, lymphoma, or sarcoma; and further subtyping of carcinoma into germ cell (broadly included), squamous, neuroendocrine, and solid organ including liver and renal, and adenocarcinomas. Finally, for adenocarcinoma, the prediction of primary tumor site, including lung, pancreas, stomach, colon, ovary, prostate, and breast, is discussed. For each tumor type, the morphologic features are presented alongside established useful IHC markers, with a description of their staining patterns and common diagnostic dilemmas. Optimal tissue handling and IHC interpretation, quality assurance, and limitations also are discussed. The target readership is oncologists, but other clinicians and trainee pathologists also may find the content of use.

Immunocytochemical diagnosis of hepatocellular carcinoma and identification of carcinomas of unknown primary metastatic to the liver on fine-needle aspiration cytologies

BACKGROUND

Difficulties with cytologic diagnoses on fine-needle aspiration cytology (FNAC) of the liver can be overcome by the application of immunocytochemical panels applied on smears. The aim of the current study was to analyze the performance of a panel of monoclonal antibodies to differentiate hepatocellular carcinoma (HCC) from metastatic carcinoma (MC) or regenerative nodules, and to identify the to date unknown primary sites of carcinomas that had metastasized to the liver.

METHODS

In a validating cohort study, 108 FNACs coin lesions in the liver were routinely evaluated applying immunocytochemistry as an ancillary method. All patients had confirmatory histologic and/or clinical follow-up. A total of 23 HCCs were analyzed for the distinction from MC or regenerative nodules applying a panel of HepPar1, alpha-fetoprotein, BerEP4, CD31, CD68, and Ki-67. A total of 85 cases of unknown primary tumor metastatic to the liver were used to identify the tumor sites applying a panel of CK5/6, CK7, CK20, CA 125, thyroid transcription factor-1 (TTF-1), and Cdx2.

RESULTS

Typing accuracy to differentiate HCC from MC or regenerative nodules was 100% and 90.3%, respectively, to identify the primary tumor site of MC. In 23 cases, the site of the primary tumor remained clinically unknown.

CONCLUSIONS

The application of immunocytochemical panels on the same slide used for microscopic diagnosis is a useful tool in the routine assessment of FNACs of the liver to discriminate HCCs from MC or regenerative nodules and for the identification of primary sites of MC. Their performance should be confirmed in a larger series of cases.