CT of the liver in patients with metastatic breast carcinoma treated by chemotherapy: findings simulating cirrhosis

The Clinical Features and Outcomes of Pseudocirrhosis in Breast Cancer

Pseudocirrhosis is a diffuse nodularity of the liver that radiologically mimics cirrhosis but is a distinct pathological process. It is seen almost exclusively in patients with liver metastases and may represent a response to systemic treatment. Data on the risk factors for pseudocirrhosis and outcomes are limited. In total, 170 patients with a diagnosis of breast cancer and pseudocirrhosis in a 10-year period were identified and retrospectively analysed. Data were collected on baseline patient characteristics, treatments received, and outcomes. Median time between diagnosis of liver metastases and diagnosis of pseudocirrhosis was 17.1 months (range, 0-149 months). In total, 89.4% of patients received chemotherapy between their diagnosis of breast cancer liver metastases and their diagnosis of pseudocirrhosis, most commonly a taxane (74.7%) or capecitabine (67.1%), and the median treatment lines received was 3. Median OS from first diagnosis of pseudocirrhosis was 7.6 months (95% CI: 6.1-9.6 months) and was longer in patients with HER2+ disease at 16.7 months (95% CI: 6.4-32.9 months), which was statistically significant. In our study, pseudocirrhosis occurred in the presence of liver metastases and was associated with a poor prognosis. HER2+ patients with pseudocirrhosis had a better prognosis than other subtypes, but we did not identify other significant predictors of survival. Chemotherapy was not a prerequisite for pseudocirrhosis development, although the majority of patients had received at least one line of chemotherapy before pseudocirrhosis was diagnosed.

Liver surface depressions in the presence of diaphragmatic muscular bands on trans-illumination

Traditional descriptions of liver anatomy refer to a smooth, convex surface contacting the diaphragm. Surface depressions are recognized anatomic variants. There are many theories to explain the cause of the depressions. We discuss the theory that these are caused by hypertrophic muscular bands in the diaphragm.

Pseudocirrhosis: A Case Series with Clinical and Radiographic Correlation and Review of the Literature

BACKGROUND AND AIMS

Pseudocirrhosis is a poorly understood acquired morphologic change of the liver that occurs in the setting of metastatic malignancy and radiographically resembles cirrhosis. Pseudocirrhosis has been primarily described in metastatic breast carcinoma, with few case reports arising from other primary malignancies. We present 29 cases of pseudocirrhosis, including several cases from primary malignancies not previously described.

METHODS

Radiologic, clinical, demographic, and biomedical data were collected retrospectively and analyzed. We compared clinical and radiologic characteristics and outcomes between patients with pseudocirrhosis arising in metastatic breast cancer and non-breast primary malignancies.

RESULTS

Among the 29 patients, 14 had breast cancer and 15 had non-breast primaries including previously never reported primaries associated with pseudocirrhosis, melanoma, renal cell carcinoma, appendiceal carcinoid, and cholangiocarcinoma. Median time from cancer diagnosis to development of pseudocirrhosis was 80.8 months for patients with primary breast cancer and 29.8 months for non-breast primary (p = 0.02). Among all patients, 15 (52%) had radiographic features of portal hypertension. Radiographic evidence of portal hypertension was identified in 28.6% of breast cancer patients, compared to 73.3% of those with non-breast malignancies (p = 0.03).

CONCLUSION

Pseudocirrhosis has most commonly been described in the setting of metastatic breast cancer but occurs in any metastatic disease to the liver. Our study suggests that portal hypertensive complications are more common in the setting of non-breast primary cancers than in metastatic breast cancer. Prior exposure to multiple chemotherapeutic agents, and agents known to cause sinusoidal injury, is a common feature but not essential for the development of pseudocirrhosis.

Clinical characteristics and outcomes in patients with metastatic breast cancer and pseudocirrhosis: a single center retrospective cohort study

PURPOSE

Pseudocirrhosis is a term used to describe changes in hepatic contour that mimic cirrhosis radiographically, but lack the classic pathologic features of cirrhosis. This radiographic finding is frequently found in patients with metastatic breast cancer (MBC), but the risk factors and clinical consequences are poorly understood.

METHODS

In this retrospective study, we identified patients with MBC and pseudocirrhosis who were treated at a single center from 2002 to 2021. We used chart extraction and radiology review to determine demographic characteristics, treatment history, imaging features, and complications of pseudocirrhosis.

RESULTS

120 patients with MBC and pseudocirrhosis were identified with the following BC subtypes: hormone receptor (HR) positive, HER2 negative (n = 99, 82.5%), HR+/HER2+ (n = 14, 11.7%), HR- /HER2+ (n = 3, 2.5%), and triple negative (TNBC; n = 4, 3.3%). All patients had liver metastases and 82.5% (n = 99) had > 15 liver lesions. Thirty-six patients (30%) presented with de novo metastatic disease. Median time from MBC diagnosis to pseudocirrhosis was 29.2 months. 50% of patients had stable or responding disease at the time of pseudocirrhosis diagnosis. Sequelae of pseudocirrhosis included radiographic ascites (n = 97, 80.8%), gastric/esophageal varices (n = 68, 56.7%), splenomegaly (n = 26, 21.7%), GI bleeding (n = 12, 10.0%), and hepatic encephalopathy (n = 11, 9.2%). Median survival was 7.9 months after pseudocirrhosis diagnosis. Radiographic ascites was associated with shorter survival compared to no radiographic ascites (42.8 vs. 76.2 months, p =  < 0.001).

CONCLUSIONS

This is the largest case series of patients with MBC and pseudocirrhosis. Nearly all patients had HR+ MBC and extensive liver metastases. Survival was short after pseudocirrhosis and prognosis worse with radiographic ascites.

Clinical Outcomes of Metastatic Breast Cancer in Patients Having Imaging Liver Pseudocirrhosis with or without Evident Varices

BACKGROUND

Pseudocirrhosis is an imaging finding of malignancies with liver metastasis with or without clinical liver cirrhosis-related portal hypertension (pHTN). This study defined evident pHTN by the presence of esophageal or gastric varices and compared patients' outcomes of metastatic breast cancer with imaging-diagnosed pseudocirrhosis with or without varices.

METHODS

The medical records from patients with metastatic breast cancer and pseudocirrhosis between 2005 and 2017 were retrospectively analyzed. Survival outcomes were compared based on endoscopic evidence of esophageal or gastric varices.

RESULTS

Among 106 patients with pseudocirrhosis, 33 (31%) had de novo stage IV disease, and 66 (62%) had hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative breast cancer. Eighty-one (76%) had initial metastases in both hepatic lobes, and 32 (30%) had esophageal or gastric varices. The median overall survival (OS) was 5 and 13 months in patients with and without varices (P = .002). The median OS in patients with HER2-positive, HR-positive/HER2-negative, and triple-negative subtype was 16, 9, and 2 months, respectively (P = .001). Patients with varices usually had cirrhotic complications, including gastrointestinal bleeding, hyperbilirubinemia, hyperammonemia, and coagulopathy. Despite their challenging clinical conditions, 7 patients with varices had OS exceeding 1 year. In multivariate analysis, evident varices (P = .007) and triple-negative subtype (P = .013) were associated with poor OS.

CONCLUSIONS

Patients with pseudocirrhosis and evident varices had a significantly shorter median OS, and were usually associated with clinical cirrhosis-related complications. To maximize OS, early identification and meticulous supportive care are warranted.

Pseudocirrhosis and portal hypertension in patients with metastatic cancers: a systematic review and meta-analysis

Pseudocirrhosis is a clinical and radiological entity mimicking liver cirrhosis in patients without a history of chronic liver disease. We performed a systematic review and meta-analysis of the current literature to evaluate the state-of-the-art and investigate the epidemiology and clinical features of pseudocirrhosis. We searched PubMed, Web of Science and Scopus for literature published until February 28, 2022. We included in the final analysis 62 articles (N = 389 patients): 51 case reports (N = 64 patients), 5 case series (N = 35 patients) and 6 observational studies (N = 290 patients). About 80% of patients included in the case reports and case series had breast cancer. Most patients had at least one clinical sign of portal hypertension and ascites was the most common clinical manifestation of portal hypertension. The median time from pseudocirrhosis to death was 2 months (IQR 1-7 months). Alkylating agents and antimitotics were the most common classes of anticancer drugs reported in our study population. Notably, about 70% of patients received three or more anticancer drugs. Finally, pseudocirrhosis is a condition that occurs in patients with hepatic metastases and may have a negative impact on survival and clinical management of patients because of the potential development of portal hypertension and its complications.

Liver metastases - An unusual cause of portal hypertension: A case report

Introduction

Portal hypertension is a rare complication of liver metastases. The study highlights that clinician should be aware of conditions mimicking cirrhosis with similar clinical presentation and imaging findings.

Case presentation

We present the case of a 29-year-old non-alcoholic lady who presented to our hospital with a history of two months of progressive, painless abdominal distension and progressively increasing yellowish discoloration of the eyes. Physical examination, laboratory investigations, and imaging tests led to a diagnosis of multiple metastases from breast carcinoma to the liver leading to portal hypertension after exclusion of other causes of portal hypertension. However, after three weeks of presentation to the hospital, the patient died before any therapeutic measures were initiated to address breast carcinoma.

Clinical discussion

Liver metastasis from primary breast carcinoma rarely presents with clinical symptoms of portal hypertension. Although portal hypertension secondary to pseudocirrhosis, predominantly linked to ongoing chemotherapy for known cancers, has been previously described in case studies, our case had an unusual presentation leading to diagnostic uncertainty.

Conclusion

Our case highlights the rare cause of liver metastasis secondary to breast carcinoma, which presented as portal hypertension.

Noncirrhotic Portal Hypertension after Trastuzumab Emtansine in HER2-positive Breast Cancer as Determined by Deep Learning-measured Spleen Volume at CT

Background Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate approved for use in human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Case reports have suggested an association between T-DM1 and portal hypertension. Purpose To evaluate the association of T-DM1 therapy with spleen volume changes and portal hypertension on CT scans and clinical findings compared with lapatinib and capecitabine therapy. Materials and Methods Patients with HER2-positive breast cancer who were administered at least two cycles of T-DM1 or lapatinib and capecitabine (controls) in a tertiary institution from 2001 to 2020 and who underwent CT before initial treatment and at least once during treatment were retrospectively enrolled. Spleen volume changes and the signs of portal hypertension (gastroesophageal varix [GEV], spontaneous portosystemic shunt [SPSS], and ascites) were evaluated at contrast-enhanced CT. Patients were followed until treatment ended or for 2 years after the start of treatment. Spleen volume changes were measured with a deep learning algorithm and evaluated by using a linear mixed model. The incidences of splenomegaly and portal hypertension were compared between the T-DM1 and control groups by using a χ² test or Fisher exact test. Results The T-DM1 group included 111 patients (mean age, 54 years ± 11 [SD]; 111 women) and the control group included 122 patients (mean age, 50 years ± 9; 121 women). Spleen volume progressively increased with T-DM1 therapy but was constant in the control group (104% ± 5 vs -1% ± 6 at the 33rd treatment cycle, respectively; P < .001). Incidences of splenomegaly (46% [51 of 111] vs 3% [four of 122] of patients; P < .001), GEV (11% [12 of 111] vs 1% [one of 122] of patients; P < .001), and SPSS (27% [30 of 111] vs 1% [one of 122] of patients; P < .001) were higher in the T-DM1 group than in the control group. Conclusion Trastuzumab emtansine therapy was associated with noncirrhotic portal hypertension at CT, with higher incidences of splenomegaly, gastroesophageal varix, and spontaneous portosystemic shunt than those with lapatinib and capecitabine therapy. © RSNA, 2022 Online supplemental material is available for this article.

Transjugular intrahepatic portosystemic shunt for the management of symptomatic malignant pseudocirrhosis

BACKGROUND

Pseudocirrhosis is defined by radiologic changes of the liver parenchyma secondary to metastatic disease and/or cancer treatments, and portends a high rate of morbidity and mortality from sequelae of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension; however, TIPS is relatively contraindicated in the setting of hepatic metastases. The study aims to determine the technical efficacy and clinical outcomes of patients undergoing TIPS for symptomatic pseudocirrhosis.

METHODS

Retrospective analysis of patients with hepatic malignancy who underwent TIPS between 2008 and 2020 at a single tertiary care center. Patients with imaging findings of pseudocirrhosis and without history of primary liver malignancy or confounding causes of cirrhosis were included. West Haven scores assessing hepatic encephalopathy were obtained from chart review. Technical success was defined as successful TIPS creation with reduction in the portosystemic gradient (PSG). Clinical success was defined as resolution of variceal bleeding and/or ascites.

RESULTS

Nine patients (4 female/5 male), average (± SD) age 61.2±9.5 years with metastatic pseudocirrhosis were included for analysis. Primary malignancy was colorectal adenocarcinoma (n=5), neuroendocrine tumor (n=3), and malignant endothelial hemangioendothelioma (n=1). Average Model for End Stage Liver Disease (MELD-Na) score was 15.7±3.7. Technical success was 8/9 (89%) with average PSG reduced from 23.5±11.0 to 6.5±2.8 mmHg (P=0.001). Clinical success was 6/9 (67%). Two patients required TIPS revision after initial clinical success. Mild-moderate HE occurred in 6/9 patients post TIPS (67%), with a highest West Haven score of 2. Time from TIPS to death for acute variceal bleeding and ascites was 4.9±4.2 and 12±16.5 months, respectively. Cause of death was disease progression (n=5), variceal bleeding (n=1), or unavailable (n=2).

CONCLUSIONS

TIPS in the setting of malignant pseudocirrhosis can be created safely with similar clinical outcomes to TIPS performed for benign disease. Rates of low-grade hepatic encephalopathy may be higher amongst patients undergoing TIPS for pseudocirrhosis.

Imaging of the chemotherapy-induced hepatic damage: Yellow liver, blue liver, and pseudocirrhosis

The liver is the major drug-metabolizing and drug-detoxifying organ. Many drugs can cause liver damage through various mechanisms; however, the liver response to injury includes a relatively narrow spectrum of alterations that, regardless of the cause, are represented by phlogosis, oxidative stress and necrosis. The combination of these alterations mainly results in three radiological findings: vascular alterations, structural changes and metabolic function reduction. Chemotherapy has changed in recent decades in terms of the drugs, protocols and duration, allowing patients a longer life expectancy. As a consequence, we are currently observing an increase in chemotherapy-associated liver injury patterns once considered unusual. Recognizing this form of damage in an early stage is crucial for reconsidering the therapy regimen and thus avoiding severe complications. In this frontier article, we analyze the role of imaging in detecting some of these pathological patterns, such as pseudocirrhosis, “yellow liver” due to chemotherapy-associated steatosis-steatohepatitis, and “blue liver”, including sinusoidal obstruction syndrome, veno-occlusive disease and peliosis.

Pseudocirrhosis after chemotherapy for gastric cancer with diffuse liver metastases: A case report

Pseudocirrhosis is a rare but important complication of metastatic cancer. We herein present the case of a patient with pseudocirrhosis occurring after a complete response to chemotherapy for metastatic gastric cancer was achieved. A 72-year-old man was diagnosed with gastric adenocarcinoma with multiple liver metastases. The patient's general condition was good, with an Eastern Cooperative Oncology Group performance status of 1. Chemotherapy with oxaliplatin and S-1 was initiated and, after four cycles, the patient noticed sudden abdominal distension. Despite the marked regression of the liver metastases, massive ascites, segmental atrophy and esophageal varices developed, findings consistent with pseudocirrhosis. The patient achieved complete response for the primary and metastatic lesions. Following endoscopic ligation of the varices, he underwent subsequent chemotherapy with S-1 only and management of his ascites for 6 months. At 12 months after initial chemotherapy, the patient appeared to be disease-free. In conclusion, clinicians should be aware of the possibility of pseudocirrhosis in cases of cancer metastasis to the liver, including metastatic gastric cancer.

Imaging of chemotherapy-induced liver toxicity: an illustrated overview

Chemotherapy is a potential cause of focal and diffuse hepatobiliary lesions. Many of these lesions may be demonstrated on imaging, especially computed tomography and MRI. Some of these lesions, especially those of steatosis and sinusoidal obstruction syndrome, are associated with a worse prognosis and risk of hepatic failure in the context of surgical management. Notably, some chemotherapy-induced hepatic alterations, such as sinusoidal obstruction syndrome, pseudocirrhosis and focal hepatopathies, may be mistakenly interpreted as signs of cancer progression, misguiding the therapeutic planning for patients receiving chemotherapy.

Unveiling the unreal: Comprehensive imaging review of hepatic pseudolesions

Hepatic pseudolesions are defined as non-neoplastic focal abnormalities of the liver which can mimic or conceal true liver lesions. It is particularly common in liver due to its unique dual blood supply and the existence of multilevel anastomosis between them. Because of the recent advances in CT and MRI technology, they are being increasingly encountered in daily practice. Broadly they can be categorised in to (1) Focal parenchymal abnormalities like focal fatty change, focal fat sparing, focal confluent fibrosis, segmental hypertrophy and regenerative nodules, (2) Perfusion abnormalities which include transient hepatic parenchymal enhancement in portal vein obstruction, third inflow, intrahepatic shunts, hepatic arterial occlusion and hepatic venous obstruction, (3) Imaging pitfalls like parenchymal compression, unenhanced vessels and pseudolipoma. It is essential for the radiologists to be familiar with the typical and atypical imaging features of pseudolesions to avoid mistaking them for sinister pathologies and also to avoid overlooking underlying hidden pathologies.

Metastatic breast cancer and pseudocirrhosis: an unknown clinical entity

PURPOSE

Pseudocirrhosis is a radiological term used to describe rapid changes in the contour of liver invaded by metastases and treated with chemotherapy. Our primary objectives were to analyse the clinical and biological characteristics of those patients with breast cancer and to assess the prevalence of complications generally associated with decompensated cirrhosis. We have also assessed associated treatments and response.

METHODS

This retrospective study included all women with metastatic breast cancer to the liver who had imaging protocols describing diffuse liver contour abnormalities during systemic treatment between 2003 and 2018 in our centre. The following were identified: neoplastic characteristics, complications presented, treatments administered and response.

RESULTS

48 patients were included. There was a trend towards an increased proportion of luminal cancers (88.2%, n=30, p=0052) when compared with our hospital cancer registry. Most patients (97.9%, n=47) had a widespread liver invasion, 58.3% (n=28) had ascites on physical examination; 90% (n=18) of ascites were classified as transudate. Nearly 23% (n=11) of patients had oesophageal varices and 6.5% (n=3) had an episode of variceal rupture. At the time of the appearance of liver contour abnormalities, the most frequently used molecules were: 5-fluorouracil (22.9%; n=11) and cisplatin (18.8%; n=9). A partial response was observed in 52.1% (n=25) of patients.

CONCLUSION

This is the largest reported series of patients with pseudocirrhosis. Many patients developed complications related to portal hypertension and liver failure, similar to those observed in decompensated cirrhosis. Luminal subtypes could be over-represented. In our series, pseudocirrhosis appears to develop at the expense of extensive liver disease burden and most often under 5-fluorouracil, or its derivatives, with or without cisplatin, possibly following a response to treatment.

Pseudocirrhosis due to liver metastasis from lung adenocarcinoma

Pseudocirrhosis is a radiological diagnosis of cirrhosis without histological evidence and occurs as a complication of liver metastases from solid tumors. A 50-year-old man without any previous history of liver disease was diagnosed with adenocarcinoma of the left upper lung lobe and liver metastasis. After chemotherapy, the liver metastases shrank; however, over time, the liver shrank and showed cirrhosis-like morphological changes. His performance status deteriorated due to ascites and leg edema, and chemotherapy was terminated. Physicians treating lung adenocarcinoma with liver metastases should be aware that pseudocirrhosis is a rare but important complication that can worsen performance status (PS) and hinder treatment continuation.

Pseudocirrhosis in Breast Cancer - Experience From an Academic Cancer Center

Background

Pseudocirrhosis is characterized by radiological changes in the liver that resemble cirrhosis, but with more rapid onset and progression. Though reported most frequently in patients with metastatic breast cancer, little is known about its prognostic factors and impact on breast cancer outcomes.

Methods

In this observational study, we reviewed abdominal CT and/or MRI scan reports of all patients with invasive breast cancer diagnosed at our center, during a ten-year period, to identify patients with pseudocirrhosis. Exclusion criteria included lack of baseline imaging, pre-existing cirrhosis, hepatitis B or C, other chronic liver diseases, or heavy alcohol use. Routine descriptive statistical measures were used. Survival distributions were estimated using Kaplan-Meier method, and Cox regression was used for multivariate analysis. Two-tailed p < 0.05 was considered significant.

Results

Eighty-six patients were included - all were females, median age was 57.5 years, and 90% were Caucasian; 86% of primary tumors were hormone-receptor positive and 17% were HER2 positive. Most patients (98%) had metastatic disease with liver involvement (94%), and were heavily pre-treated - 97% with chemotherapy, 85% with hormonal therapy, and 19% with anti-HER2 agents. Median interval from breast cancer diagnosis to pseudocirrhosis was 75.4 months (IQR 35.2-115.3 months). Thirty-six percentage of patients had ≥1 signs of portal hypertension and 49% had ≥1 signs of hepatocellular failure. Pseudocirrhosis led to permanent discontinuation of chemotherapy, endocrine therapy, and all systemic therapies in 29%, 31%, and 20% patients, respectively. Median overall survival from diagnosis of pseudocirrhosis was 10.0 months (95%CI 5.2-14.8 months). On multivariate analysis, coagulopathy, hyperbilirubinemia, hypoalbuminemia, and cancer progression were independently predictive of mortality.

Conclusions

In this largest series, to date, of breast cancer with pseudocirrhosis, the latter was often complicated by portal hypertension and hepatocellular failure, and markedly impacted breast cancer management. Survival was shorter for patients who developed hepatocellular failure.

Pseudocirrhosis caused by lung adenocarcinoma with diffuse liver metastasis: An autopsy case report

We describe a rare case of a 64-year-old man with lung adenocarcinoma with lymph node and bone metastases who developed pseudocirrhosis. Initial examination revealed a hepatic disorder of unknown cause with narrowing of the portal vein and a low-density area surrounding the portal veins in computed tomography (CT) imaging. Diffuse liver metastasis was diagnosed after percutaneous liver biopsy. During chemotherapy, liver atrophy and irregular liver surface appearance were confirmed with CT. Eventually, the disease progressed to death, and an autopsy was performed. The autopsy demonstrated exacerbation of diffuse liver metastases and cirrhosis-like findings.

Transitional Cell Carcinoma and Pseudocirrhosis— A Case Report and Review of the Literature

Pseudocirrhosis is the occurrence of capsular retraction in patients with metastatic liver disease, usually of breast origin. It usually appears in these patients following chemotherapy and may result from shrinkage of the tumor, with scarring and nodular regeneration. In this article, we describe the first case of pseudocirrhosis, following treatment of transitional cell carcinoma metastatic to the liver. Portal vein thrombosis, a rare complication in pseudocirrhosis, was also detected in this patient.

Hepatic surface grooves in Trinidad and Tobago

PURPOSE

Hepatic surface grooves (HSGs) are prominent depressions on the antero-superior surface of the liver. We sought to document the prevalence of HSGs in an Eastern Caribbean population.

METHODS

We observed all consecutive autopsies performed at a facility in Trinidad and Tobago and recorded the presence, number, location, width, length and depth of any HSG identified. Each liver was then sectioned to document intra-parenchymal abnormalities.

RESULTS

Sixty Autopsies were observed. There were HSGs in 9 (15%) cadavers (5 females and 4 males), at an average age of 66 years (range 48-83, Median 64, SD ± 10.4). The HSGs were located on the diaphragmatic surface of the right hemi-liver in 8 (89%) cadavers, left medial section in 4 (44%), left lateral section in 3 (33%) and coursing along Cantlie's plane in 3 (33%) cadavers. Eight (89%) cadavers with HSGs had other associated anomalies: accessory inferior grooves (5), parenchymal nutmeg changes (5), abnormal caudate morphology (4), hyperplastic left hemi-liver (3), lingular process (2), bi-lobar gallbladder (1) and/or abnormal ligamentous attachments (1).

CONCLUSIONS

Approximately 15% of unselected Afro-Caribbean persons in this Eastern Caribbean population have HSGs. Every attempt should be made to identify HSGs on pre-operative imaging because they can alert the hepatobiliary surgeon to: (1) associated anatomic anomalies in 89% of cases, (2) associated hepatic congestion in 56% of persons, (3) increased risk of bleeding during liver resections and (4) increased technical complexity of liver resections. The association between HSGs, cardiovascular complications, hepatic congestion and nutmeg liver prompted us to propose a new aetiologic mechanism for HSG formation, involving localized hyperplasia at growth zones due to upregulation of beta-catenin levels.

Morphometric changes and imaging findings of diffuse liver disease in relation to intrahepatic hemodynamics

Diffuse hepatic diseases have a variety of etiologies, with each showing characteristic morphometric changes. These changes are closely related to micro- and macro-level intrahepatic hemodynamics, in addition to the specific underlying pathophysiology. Short-term disorders in intrahepatic hemodynamics caused by each pathophysiological condition are compensated for by the balance of blood perfusion systems using potential trans-sinusoidal, transversal, and transplexal routes of communication (micro-hemodynamics), while long-term alterations to the intrahepatic hemodynamics result in an increase in total hepatic vascular resistance. Blood flow disorders induced by this increased vascular resistance elicit hepatic cellular necrosis and fibrosis. These changes should be uniformly widespread throughout the whole liver. However, morphometric changes do not occur uniformly, with shrinkage or enlargement not occurring homogeneously. Against this background, several macro-intrahepatic hemodynamic effects arise, such as asymmetrical and complicating morphometric structures of the liver, intricate anatomy of portal venous flow and hepatic venous drainage, and zonal differentiation between central and peripheral zones. These hemodynamic factors and pathophysiological changes are related to characteristic morphometric changes in a complicated manner, based on the combination of selective atrophy and compensatory hypertrophy (atrophy-hypertrophy complex). These changes can be clearly depicted on CT and MR imaging.

Infiltrative non-mass-like hepatocellular carcinoma initially presenting with isolated malignant portal vein thrombosis: A case report and review of the literature

Hepatocellular carcinoma (HCC) shows a rising incidence and mortality rates worldwide. HCC is divided into several distinct subtypes, both morphologically and histopathologically. Among these subtypes, infiltrative HCC may be the most challenging subtype to diagnose, given its characteristic myriad of tumor nodules blended with normal hepatocytes without a distinct mass-like lesion. Herein, we report an unusual case of an infiltrative HCC initially presenting with isolated malignant portal vein thrombosis and provide a brief review of the literature regarding the infiltrative HCC subtype. Additionally, we demonstrate how sonoelastography could aid in detecting the appropriate biopsy area in the infiltrative HCC subtype. To our knowledge, there have not been previously reported cases describing the use of sonoelastography in the evaluation of the appropriate area for the targeted liver biopsy.

Recurrent metastatic breast cancer presenting with portal hypertension and pseudocirrhosis

We present a case of a 63-year-old woman with an acute history of abdominal distension and shortness of breath. She had no risk factors for liver disease though her prior medical history was positive for breast carcinoma, in remission for 14 years. Examination and investigations were initially consistent with decompensated cirrhosis, thought to be due to subclinical autoimmune hepatitis. Imaging revealed hepatic contour irregularity, atrophy of the liver parenchyma and numerous lesions highly suggestive for multifocal hepatocellular carcinoma. Surprisingly, tissue histology revealed no evidence of cirrhosis, but recurrence of breast cancer which had mimicked cirrhosis. Pseudocirrhosis may be indistinguishable from true cirrhosis without histopathology. It has previously been linked to chemotherapy-induced hepatic injury and nodular regenerative hyperplasia, although our case illustrates an uncommon pathophysiology. Pseudocirrhosis often represents a poor prognosis even with a good baseline performance status, and early involvement of palliative care specialists may be advisable.

CT and MR imaging of chemotherapy-induced hepatopathy

Chemotherapy-induced hepatopathy includes a wide variety of parenchymal and vascular hepatic changes on imaging, including diffuse or focal hepatopathies (i.e. hepatitis, steatosis, fibrosis, pseudocirrhosis, or sinusoidal obstruction). These changes can profoundly alter the hepatic parenchyma on imaging and result in both false negative and false-positive diagnoses of hepatic metastases and lead to errors in patient management strategies. It is therefore important for radiologists to have a comprehensive knowledge of the imaging patterns that may develop following chemotherapy. The purpose of this review is to explore the broad spectrum of hepatic parenchymal and vascular chemotherapy-induced changes on CT and MR imaging.

Clinical features of pseudocirrhosis in metastatic breast cancer

PURPOSE

Pseudocirrhosis has been demonstrated to mimic cirrhosis radiographically, but studies evaluating the pathophysiology and clinical features are lacking. To better understand the incidence, risk factors, clinical course, and etiology of pseudocirrhosis, we performed a retrospective analysis of consecutively treated patients with metastatic breast cancer (MBC).

METHODS

Of 374 patients treated for MBC from 2006 to 2012, 199 had imaging available for review. One radiologist evaluated computed tomography scans for evidence of pseudocirrhosis. Features of groups with and without pseudocirrhosis were compared by Kaplan-Meier product-limit survival estimates and log-rank tests. Wilcoxon Rank-Sum testing evaluated if patients more heavily treated were more likely to develop pseudocirrhosis. Univariate and multivariate Cox proportional hazard models investigated factors associated with mortality.

RESULTS

Pseudocirrhosis developed in 37 of 199 patients (19%). Of the patients with liver metastases, 55% developed pseudocirrhosis. Liver metastases were demonstrated in 100% of patients with pseudocirrhosis. Survival in the subset with liver metastases favored those without pseudocirrhosis, 189 versus 69 months (p = 0.01). The number of systemic regimens received were higher in patients with pseudocirrhosis (p = 0.01). Ascites was demonstrated in 68%, portal hypertension in 11%, and splenomegaly in 8% of patients with pseudocirrhosis.

CONCLUSIONS

Pseudocirrhosis does not occur in the absence of liver metastases, can manifest as hepatic decompensation, and appears to be associated with poorer survival amongst patients with hepatic metastases. Higher cumulative exposure to systemic therapy may be causative, instead of the previously held belief of pseudocirrhosis as an adverse effect of a particular systemic agent/class.

Diagnostic value/performance of radiological liver imaging during chemoterapy for gastrointestinal malignancy: a critical review

This article reviews the main toxic effect, complications and relative imaging findings of the liver that may appear during the oncologic follow up among patients affected by gastrointestinal malignancy. Awareness of the causative chemotherapeutic agent and regimens, pathophysiology and relative characteristic imaging findings of hepatic injuries is critical in order to obtain an accurate diagnosis especially when these parenchymal lesions are focal. An accurate synergic radiological diagnosis with Computed Tomography (CT) and Magnetic Resonance (MR) techniques may induce a potential termination of ineffective/toxic chemotherapy during early phases of treatment, changing the therapeutic plan in order to avoid first unnecessary liver biopsy and then invasive treatment as hepatic resection if not required.

Metastatic Carcinomatosis Cirrhosis: A Rare Pattern of Metastasis

Metastatic carcinomatosis cirrhosis is a pattern of metastasis in which malignancy infiltrates the liver and provokes hepatic fibrosis. It is an especially rare complication of several malignancies, including breast cancer. We report a case of a 61-year-old woman with lobular carcinoma of the breast who presented with confusion and rising serum tumor markers without evidence of disease recurrence on imaging. She subsequently developed clinical evidence of hepatic dysfunction and a liver biopsy revealed diffuse infiltration of the liver by breast carcinoma with surrounding fibrous tissue deposition, consistent with metastatic carcinomatosis cirrhosis. This case highlights a rare and clinically significant pattern of metastasis and is the first to describe lobular carcinoma of the breast causing metastatic carcinomatosis cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Portal Hypertension-Induced Refractory Ascites Due to Metastatic Carcinomatous Liver Disease

Three patients with a medical history of breast carcinoma and metastatic carcinomatous liver disease associated with severe portal hypertension and refractory ascites are presented. Transjugular intrahepatic portosystemic shunt creation was considered as a palliative treatment option and a valuable alternative to regular paracenteses in these patients. In 2 of the 3 patients, the refractory ascites was controlled for several months without need for paracentesis, and subsequently transjugular intrahepatic portosystemic shunt may provide valuable palliation and ascites control in patients with refractory ascites due to breast cancer-induced pseudocirrhosis.

Unintended Consequences of Systemic and Ablative Oncologic Therapy in the Abdomen and Pelvis

Human cancers are genetically complex and diverse. Although advances in oncologic therapy aim to define and target unique steps in carcinogenesis, oncologists often rely on less discriminate anticancer therapies that have consequences for normal tissues. Even many of the so-called targeted therapies currently employed can adversely affect normal cells, leading to complications that necessitate dose reductions or cessation of specific therapies. This article explores the unintended consequences of currently employed systemic and ablative anticancer therapies that might manifest at imaging examinations of the abdomen and pelvis, including cytotoxic, molecular targeted, and immunologic agents; ablation; and hematopoietic stem cell transplant. Each of these treatments can have both major and minor unintended effects in the targeted organ(s), in local or adjacent structures, or at distant sites. Timely detection and reporting of adverse consequences of anticancer therapies by the astute imager can result in critical treatment modifications and/or lifesaving interventions; therefore, knowledge of these unintended effects is paramount for radiologists interpreting the results of imaging examinations in cancer patients. ^©RSNA, 2018.

Hepatic morphology abnormalities: beyond cirrhosis

The diagnosis of cirrhosis can be reached on the basis of established hepatic morphological changes. However, some other conditions can mimic cirrhosis. The aim of this pictorial essay is to review the CT and MRI appearances of hepatic morphology abnormalities in the cirrhotic liver and other diseases, describing pathologic conditions that can mimic cirrhosis, with useful tips for the differential diagnosis. Mimickers of cirrhosis include congenital hepatic fibrosis, Caroli disease, Budd-Chiari Syndrome, hepatoportal sclerosis, cavernous transformation of the portal vein, pseudocirrhosis from metastatic disease, acute liver failure, post-therapeutic morphologic changes in the liver, and infective conditions including schistosomiasis and oriental cholangiohepatitis. Recognizing the hepatic morphological changes in images can help radiologists to diagnose cirrhosis and other diseases in early stages.

Pseudocirrhosis after chemotherapy in breast cancer, case reports

Pseudocirrhosis is a rare hepatic complication of chemotherapy, which is morphological changes in hepatic contour that closely mimic cirrhosis. Like in classic cirrhosis, portal hypertension is common in patients with this condition. The mechanism of pseudocirrhosis is unknown to date. We report three cases of pseudocirrhosis arising in the setting of regression of breast cancer liver metastases. All the cases underwent systemic chemotherapy, and all had remarkable responses. Their hormone receptor statuses were all positive and Her2/neu statuses were all negative. They were all treated with cytotoxic chemotherapeutic agent and also hormone therapy. This report suggests clinicians should have pseudocirrhosis in mind when hormone therapy and cytotoxic chemotherapy are jointly administered.

Cirrhosis and LI-RADS

Chronic liver disease, irrespective of cause, can eventually lead to cirrhosis, which is the primary risk factor for developing hepatocellular carcinoma (HCC). In patients with cirrhosis or appropriate risk factors, HCC can be diagnosed by imaging with high specificity using liver imaging reporting and data system v2017, obviating the need for histologic confirmation. Confident recognition of cirrhosis by conventional imaging alone can be challenging, as radiologists are not always provided with the requisite information to determine if the patient has cirrhosis or other risk factors for HCC. Moreover, cirrhosis-associated abnormalities may impair the diagnostic accuracy of imaging for HCC. This article addresses the diagnosis of cirrhosis by non-invasive imaging and the implications of cirrhosis for imaging interpretation and accuracy.

Causes of hepatic capsular retraction: a pictorial essay

Abstract

Hepatic capsular retraction refers to the loss of the normal convex hepatic contour, with the formation of an area of flattening or concavity. This can result from myriad causes, including intrinsic hepatic conditions such as cirrhosis, biliary obstruction, benign tumours, malignancy and infections, as well as extrahepatic causes such as trauma. This article aims to provide familiarity with this wide spectrum of conditions, including mimics of hepatic capsular retraction, by highlighting the anatomic, pathologic and imaging features that help distinguish these entities from one another.

Teaching Points

• Hepatic capsular retraction can occur due to various intrinsic or extrinsic hepatic causes.

• Hepatic capsular retraction is observed in both benign and malignant conditions.

• Recognising associated imaging features can help elicit causes of hepatic capsular retraction.

Minimising the impact of errors in the interpretation of CT images for surveillance and evaluation of therapy in cancer

Radiological error is inevitable and usually multifactorial. Error can be secondary to radiologist-specific causes, including cognitive and perceptive errors or ambiguity of report, or system-related causes, including inadequate, misleading, or incorrect clinical information, poor imaging technique, excessive workload, and poor working conditions. In this paper, we discuss a systematic approach to reduce errors in oncological radiology reporting, thus reducing risk to the patient. Rather than attempt to discuss all types of error, we concentrate on the most important and commonly occurring errors that we have encountered over 20 years of practice, based on weekly discrepancy reviews of our practice and independent reviews of clinical and research imaging from other institutions. This review focuses on computed tomography (CT) reporting for staging, surveillance, and response assessment of cancer patients, but the messages apply to all imaging methods.

Pseudocirrhosis: A Case Series and Literature Review

Pseudocirrhosis describes morphological changes of the liver that closely mimic cirrhosis, without the typical histopathological changes seen in cirrhosis. It most commonly occurs in patients with metastatic breast cancer, although it has been reported in other malignancies as well. Like in cirrhosis, portal hypertension is often seen in patients with pseudocirrhosis. Pseudocirrhosis is a rare but important complication of metastatic cancer. In this case series and literature review, we describe 6 patients with hormone-receptor-positive metastatic breast cancer. We report the significant morbidity associated with pseudocirrhosis in the course of treatment in patients with metastatic breast cancer.

Non-focal liver signal abnormalities on hepatobiliary phase of gadoxetate disodium-enhanced MR imaging: a review and differential diagnosis

Gadoxetate disodium (Gd-EOB-DTPA) is a linear, non-ionic paramagnetic MR contrast agent with combined extracellular and hepatobiliary properties commonly used for several liver indications. Although gadoxetate disodium is commonly used for detection and characterization of focal lesions, a spectrum of diffuse disease processes can affect the hepatobiliary phase of imaging (i.e., when contrast accumulates within the hepatocytes). Non-focal signal abnormalities during the hepatobiliary phase can be seen with multiple disease processes such as deposition disorders, infiltrating tumors, vascular diseases, and post-treatment changes. The purpose of this paper is to review the different processes which result in non-focal signal alteration during the hepatobiliary phase and to describe imaging patterns that may order a differential diagnosis and facilitate patient management.

Pseudocirrhosis in Gastric Cancer with Diffuse Liver Metastases after a Dramatic Response to Chemotherapy

We present the first reported case of pseudocirrhosis arising after a dramatic response to chemotherapy in metastatic gastric cancer. A 74-year-old man was diagnosed with gastric adenocarcinoma having multiple liver metastases. His general condition was poor, with an Eastern Cooperative Oncology Group performance status of 3, inadequate oral intake, and jaundice (total bilirubin 2.8 mg/dl). Chemotherapy with oxaliplatin, l-leucovorin, and 5-fluorouracil (modified FOLFOX-6) was initiated. After four treatment cycles, he experienced a marked regression of liver metastases; however, he developed massive ascites with a lobular liver surface and segmental atrophy, which were consistent with pseudocirrhosis. Chemotherapy was continued along with ascites management. Thereafter, ascites disappeared, and a complete response of the metastatic lesions was achieved at 11 months after initial treatment. He had no evidence of disease progression at 30 months after initial chemotherapy. This report suggests clinicians should recognize this entity, even in gastric cancer metastatic to the liver.

Chemotherapy induced liver abnormalities: an imaging perspective

Treating patients undergoing chemotherapy who display findings of liver toxicity, requires a solid understanding of these medications. It is important for any clinician to have an index of suspicion for liver toxicity and be able to recognize it, even on imaging. Cancer chemotherapy has evolved, and newer medications that target cell biology have a different pattern of liver toxicity and may differ from the more traditional cytotoxic agents. There are several hepatic conditions that can result and keen clinical as well as radiographic recognition are paramount. Conditions such as sinusoidal obstructive syndrome, steatosis, and pseudocirrhosis are more commonly associated with chemotherapy. These conditions can display clinical signs of acute hepatitis, liver cirrhosis, and even liver failure. It is important to anticipate and recognize these adverse reactions and thus appropriate clinical action can be taken. Often times, patients with these liver manifestations can be managed with supportive therapies, and liver toxicity may resolve after discontinuation of chemotherapy.

Pseudocirrhosis of breast cancer metastases to the liver treated by chemotherapy

Pseudocirrhosis refers to a condition that shows changes in hepatic contour that mimic cirrhosis radiographically in the absence of the typical histopathological findings of cirrhosis. This condition has been observed in patients with cancer metastatic to the liver, both in those who have undergone prior systemic chemotherapy and those who have not. Pseudocirrhosis may cause difficulty in interpretation of the response to chemotherapy and hepatic decompression and complication of portal hypertension have a negative effect on the prognosis. We report on a case of breast cancer with liver metastases that showed cirrhotic changes during disease progression. Progression of liver metastases was confirmed by F18 fluorodeoxyglucose positron emission tomography/computed tomography (PET-CT). We also performed ultrasound-guided liver biopsy and confirmed tumor infiltration with severe desmoplastic fibrosis. This case suggests the pathogenesis of pseudocirrhosis through histopathological findings and the role of PET-CT in evaluation of the response to chemotherapy in patients with pseudocirrhosis.

Yttrium-90 radioembolization of liver tumors: what do the images tell us?

Transarterial radioembolization (TARE) with yttrium 90 microspheres is an increasingly popular therapy for both primary and secondary liver malignancies. TARE entails delivery of β-particle brachytherapy and embolization of the tumor vasculature. The consequent biological sequelae are distinct from those of other transarterial therapies for liver tumors, as reflected in the often baffling post-treatment imaging features. As the clinical use of TARE is increasing, more diverse post-treatment radiological findings are encountered with variable overlap among treatment response, residual disease, reactionary changes and complications. Thus, post-TARE image interpretation is challenging. This review provides a comprehensive description of the different findings seen in post-treatment scans, with the aim of facilitating appropriate radiological interpretation of post-TARE pathologic changes, notwithstanding their existing limitations.

Medullary thyroid cancer and pseudocirrhosis: case report and literature review

Pseudocirrhosis is a rare form of liver disease that can cause clinical symptoms and radiographic signs of cirrhosis; however, its histologic features suggest a distinct pathologic process. In the setting of cancer, hepatic metastases and systemic chemotherapy are suspected causes of pseudocirrhosis. Here, we present a patient with medullary thyroid carcinoma metastatic to the liver who developed pseudocirrhosis while on maintenance sunitinib after receiving 5-fluorouracil, leucovorin, and oxaliplatin (folfox) in combination with sunitinib. Cirrhotic change in liver morphology was accompanied by diffusely infiltrative carcinomatous disease resembling the primary tumor. We discuss the diagnosis of pseudocirrhosis in this case and review the literature regarding pseudocirrhosis in cancer.

[Perfusion computed tomography for diffuse liver diseases]

CLINICAL/METHODICAL ISSUE

Perfusion computed tomography (CT) has its main application in the clinical routine diagnosis of neuroradiological problems.

STANDARD RADIOLOGICAL METHODS

Polyphase multi-detector spiral computed tomography is primarily used in liver diagnostics.

METHODICAL INNOVATIONS

The use of perfusion CT is also possible for the diagnostics and differentiation of diffuse hepatic diseases.

PERFORMANCE

The differentiation between cirrhosis and cirrhosis-like parenchymal changes is possible. It also helps to detect early stages of malignant tumors.

ACHIEVEMENTS

However, there are some negative aspects, particularly that of radiation exposure.

PRACTICAL RECOMMENDATIONS

This paper summarizes the technical basics and possible applications of perfusion CT in cases of diffuse liver disease and weighs up the advantages and disadvantages of the examinations.