Small-cell carcinoma of the lung manifesting as acute hepatic failure

Acute liver failure secondary to malignant infiltration: A single center experience

Acute liver failure (ALF) requires early and very precise treatment decisions for a diagnosis that is not often easy and may lead to erroneous decisions. Accordingly, we undertook a review of ALF secondary to malignant infiltration given the rarity of the condition, plus its singularity and therapeutic implications. This review should aid in establishing future frameworks for action. Analyze cases of ALF secondary to malignant infiltration in our center during the last 5 years and review the literature. We undertook a retrospective review of all cases of ALF due to malignant infiltration in our center between January 2015 and December 2019. Data were recorded on demographic characteristics, clinical presentation, type of tumor, diagnostic techniques used, treatment and evolution. We also undertook a literature review on the subject and compared the results. AFL secondary to malignant infiltration was diagnosed in five patients, four women and one man with a median age 58 years. The most common clinical presentation was jaundice. Three cases were due to infiltration by hematological tumors (non-Hodgkin lymphoma and histiocytosis), one a cholangiocarcinoma and one lung cancer. In all cases a liver biopsy was required for diagnosis, this being conclusive in four cases; diagnosis in the non-conclusive case was by analysis of the hepatectomy sample after transplantation. Three patients died due to AFL in a mean of 13.8 days, another died 5 months after diagnosis as a consequence of the tumor while the patient with a diagnosis of non-Hodgkin lymphoma and transplant recipient remains alive after a follow-up of 6 years and after receiving chemotherapy. AFL due to malignant infiltration is a very unusual condition but with a high rate of mortality. It requires a rapid and precise diagnosis given the relevant treatment options.

Acute Liver Failure Due to Severe Hepatic Metastasis of Small-cell Lung Cancer Producing Adrenocorticotropic Hormone Complicating Ectopic Cushing Syndrome

A 72-year-old man was admitted to a general hospital with progressive liver dysfunction, hypokalemia, hyperglycemia, and nodules in the lung and liver and then transferred to our institution on the seventh hospital day. Plasma levels of adrenocorticotropic hormone (ACTH), cortisol, and neuron-specific enolase concentrations were extremely high. He developed acute liver failure, his consciousness and general condition deteriorated rapidly, and he died on Day 11. At the postmortem examination, he was found to have extensive metastases from small-cell lung cancer, including advanced hepatic metastases. This is the first reported case of acute liver failure caused by metastases derived from an ACTH-producing pulmonary small-cell carcinoma.

Sudden onset acute liver failure in a patient with clinically occult small cell lung carcinoma: autopsy report and review of the medical literature

Liver metastases are commonly found in advanced cancer patients; however, acute liver failure secondary to diffuse liver infiltration is rare. Small cell lung carcinoma accounts for 15% of lung carcinomas. We describe the ninth case of small cell lung carcinoma massively metastatic to the liver, reported in the scientific literature, with sudden clinical onset and death after a few days. An autopsy was performed to understand the cause of death.

Unusual acute liver failure from small cell carcinoma of the lung

A 75-year-old woman with a 50-pack-year history of tobacco abuse presented with abdominal pain, encephalopathy and elevated liver enzymes. Serologic evaluation for viral hepatitis, drug levels and chronic liver disease panel was negative. Computed tomography (CT) scan of the abdomen showed hepatomegaly and a large area of decreased attenuation in the lateral segment of the left lobe of the liver which was also demonstrated on the magnetic resonance cholangiopancreatography. CT of the chest was significant for a 1.4 cm left peripheral lingular nodule. Hepatic mass biopsy revealed small cell carcinoma (SCC), favoring lung primary. She had persistent liver failure with encephalopathy, coagulopathy and elevated liver enzymes during her hospital stay. Acute liver failure (ALF) is characterized by liver damage, encephalopathy and coagulopathy in patients without any prior history of liver disease. Although malignant infiltration has been described as a cause of ALF, SCC of the lung is an uncommon etiology.

Acute Liver Failure as the Initial Manifestation of Hepatic Infiltration by a Solid Tumor: Report of 5 Cases and Review of the Literature

Background

Acute liver failure is a rare complication of metastatic liver disease with a high mortality. Recognition of malignant infiltration of the liver as the cause of acute liver failure could be a diagnostic challenge.

Patients

The medical files of 5 patients with acute liver failure due to metastatic liver disease collected over a 4-year period (1997–2000) in our department were reviewed.

Results

No patient had a past history of cancer. The interval from jaundice to encephalopathy ranged from 7 to 12 days (median, 10). Physical examination revealed hepatomegaly and deep jaundice in all patients. AST elevation ranged from 147 to 1870 IU/L (median, 716 IU/L) and ALT elevation from 74 to 556 IU/L (median, 138 IU/L). All patients died within 4–14 days (median, 7) of admission. None had papillary edema or decerebrate posture before death. Four patients had concurrent renal impairment. Liver imaging studies in 2 of the 5 patients were nondiagnostic and the malignant liver infiltration was confirmed postmortem. Liver histology in all cases showed massive tumoral infiltration of the hepatic sinusoids with diffuse replacement of hepatocytes. The primary tumors were colon, gastric, small cell lung, pancreas and cancer of unknown origin.

Conclusions

Malignant infiltration of the liver should be taken into account in the differential diagnosis of rapidly progressive liver failure. Although effective chemotherapy has improved the survival of patients with metastatic liver disease, there has been no change in the course and outcome of acute liver failure due to malignant infiltration of the liver over the last 2 decades. A proper diagnosis by liver biopsy is mandatory to prevent such patients from being considered for liver transplant.

Distribution patterns of the metastases of the lung carcinoma in relation to histological type of the primary tumor: An autopsy study

INTRODUCTION:

Lung cancer is among leading causes of death worldwide. Different histological types of the lung carcinoma show significant differences in behavior.

OBJECTIVES:

The aim of this study is to determine the distribution patterns of metastases of different lung cancer histological types in autopsied individuals.

METHODS:

Protocols from all autopsies performed at the Institute of Pathology from 2008 till 2014 were reviewed retrospectively, and information on individuals' age, sex, histological type of primary lung cancer, presence and location of metastases, and causes of death were recorded.

RESULTS:

More than 90% of the individuals with lung cancer metastases were older than 50 years (mean age: 64.5 ± 10.3), with two-fold male predominance. The most frequent histological type in both sexes was adenocarcinoma (48%). Although, in general, hematogenous metastases were mostly found in the liver and adrenal glands, various histological types of lung cancer show specific dissemination patterns. Metastases in adrenal glands derived mostly from adenocarcinoma and large-cell carcinoma. Metastases in the intestines most frequently originated from large-cell carcinoma (P = 0.01). Metastatic complications and bronchopneumonia were the most frequent causes of death.

CONCLUSIONS:

While, overall, the most frequent hematogenous metastases occur in the liver and adrenal glands, various histological types of lung cancer show specific dissemination patterns. Knowing distribution of metastases is essential for making algorithms of treatment, as well as for improving clinical assessment of the patients with unclear clinical findings and suspicion on occult primary lung cancer.

Acute Warfarin Toxicity as Initial Manifestation of Metastatic Liver Disease

Near complete infiltration of the liver secondary to metastasis from the head and neck cancer is a rare occurrence. The prognosis of liver failure associated with malignant infiltration is extremely poor; the survival time of patients is extremely low. We present a case of acute warfarin toxicity as initial manifestation of metastatic liver disease. Our patient is a 64-year-old woman presenting with epigastric pain and discomfort, found to have unrecordable International Normalized Ratio. She rapidly deteriorated with acute respiratory failure requiring mechanical ventilation, profound shock requiring high dose vasopressor infusion, severe coagulopathy, worsening liver enzymes with worsening of lactic acidosis and severe metabolic abnormalities, and refractory to aggressive supportive care and died in less than 48 hours. Autopsy revealed that >90% of the liver was replaced by tumor masses.

Diffuse Liver Metastasis of Small-Cell Lung Cancer Presenting as Acute Liver Failure and Diagnosed by Transjugular Liver Biopsy: A Rare Case in Whom Nodular Lesions Were Detected by Enhanced CT Examination

Small-cell lung cancer (SCLC) is a subgroup of lung cancer with a high frequency of liver metastasis, which is a predictor of poor prognosis. Diffuse liver metastases of SCLC with no visible nodular lesions in the liver when examined using computed tomography (CT) are relatively rare; however, a few cases with rapid progression to acute liver failure that were diagnosed after death have been reported. In this paper, we report a 63-year-old man with diffuse liver metastases of SCLC that were histologically diagnosed using a transjugular liver biopsy while the patient was alive, even though no lesions were visible during a contrast-enhanced CT examination.

Unique morphologic and clinical features of liver predominant/primary small cell carcinoma--autopsy and biopsy case series

Liver predominant small cell carcinoma is rare but often presents as hyperacute liver failure with unknown primary and is a medical emergency. We present 2 autopsy and 7 biopsy cases of liver predominant small cell carcinoma and demonstrate that these patients present with liver failure and identifiable hepatomegaly but lack discrete lesions on imaging as well as no mass lesions identified in other organs including lung. Compared with the multiple nodules of metastatic small cell carcinoma in the liver, unique morphologic feature of liver predominant/primary small cell carcinoma in autopsy and biopsy specimens was a diffuse infiltration of small blue neoplastic cells predominantly in the sinusoidal space in the liver parenchyma. Before diagnosing liver predominant/primary small cell carcinoma, other infiltrating small blue cell neoplasms including lymphoma and peripheral neuroectodermal tumor need to be ruled out through immunohistochemistry. We, therefore, demonstrate that liver biopsy together with a rapid panel of immunostains is necessary to firmly establish a diagnosis of liver predominant small cell carcinoma and allow clinicians to immediately implement potentially lifesaving chemotherapy.

Fulminant hepatic failure and hepatomegaly caused by diffuse liver metastases from small cell lung carcinoma: 2 autopsy cases

Fulminant hepatic failure (FHF) is defined as a liver disease that causes encephalopathy within 8 weeks of onset in the absence of pre-existing liver disease. Although liver metastases are commonly found in cancer patients, FHF secondary to diffuse liver infiltration is rare. Here, we report the rare autopsy cases of patients with small cell lung carcinoma (SCLC) and secondary FHF. These patients presented with remarkable hepatomegaly and a near complete replacement of the liver parenchyma with metastatic tumor. Neoplastic involvement of the liver should be considered in the differential diagnosis of FHF.

Metastatic small-cell lung cancer presenting as fulminant hepatic failure

We report a case of a 75-year-old woman with fulminant hepatic failure due to metastatic small-cell lung cancer (SCLC). The patient was hospitalised for the management of rapidly progressive hepatic failure. Thoracic radiology identified a widened mediastinum, and prior to hospitalisation she had received antibiotics for a urinary tract infection. Consequently, her hepatic failure was deemed to be due to either sarcoidosis with hepatic involvement or an antibiotic-related adverse event and was treated with prednisolone. However, the patient's clinical condition continued to deteriorate and a liver biopsy was obtained. Histopathology and immunohistochemistry tests demonstrated almost complete parenchymal replacement with metastatic SCLC. The patient was considered to be too unwell to receive chemotherapy and hence received best supportive care instead, and died shortly thereafter.

[Acute hepatic failure as the presenting manifestation of a metastatic lung carcinoma to liver]

Liver failure as a result of neoplasia is a rare event before the terminal stage of the illness. We report a 66-year-old man who presented with clinical features of acute liver failure as the initial manifestation of a small-cell lung carcinoma. Liver was enlarged without ascitis. Abdominal CT-scan revealed a massive hepatomegaly with multiple low-density wedge-shaped lesions. The patient developed stage 3 hepatic encephalopathy and died on day 4. The diagnosis was obtained with post-mortem study. A Medline search of acute liver failure due to small-cell carcinoma identified only 17 cases already published, with a universally poor prognosis.

[A case of fulminant hepatic failure secondary to hepatic metastasis of small cell lung carcinoma]

Although liver metastasis is commonly found in cancer patients, fulminant hepatic failure secondary to diffuse cancer infiltration into the liver is rare. Liver metastasis-induced fulminant hepatic failure has been reported in patients with primary cancer of the gastrointestinal tract, breast and uroepithelium, and in patients with melanoma and hematologic malignancy. Small cell lung cancer is so highly invasive that hepatic metastasis is common, but rapid progression to fulminant hepatic failure is extremely rare. We report here on a case of a patient who died because of rapid progression to fulminant hepatic failure as a result of hepatic metastasis of small cell lung carcinoma.

Diffuse malignant infiltration of the liver manifesting as a case of acute liver failure

BACKGROUND

A 54-year-old male with a history of coronary artery disease, diabetes mellitus and 120 pack years of tobacco abuse presented to the emergency room with right upper quadrant abdominal pain, decreased appetite and dark urine.

INVESTIGATIONS

Laboratory investigations, chest radiograph, portal duplex, CT of the abdomen and pelvis, liver serologies and autopsy.

DIAGNOSIS

Fulminant hepatic failure secondary to metastatic small-cell lung carcinoma.

MANAGEMENT

Supportive care.

Fulminant hepatic failure resulting from small-cell lung cancer and dramatic response of chemotherapy

Prompt treatment in tumor-associated encephalopathy may prolong survival. We describe a 69-year-old male patient who was presented with fulminant hepatic failure, secondary to small-cell lung carcinoma with rapidly progressing encephalopathy. Both symptoms remitted following chemotherapy, suggesting swift diagnosis and administration of chemotherapy to be effective in treatment of fulminant hepatic failure and encephalopathy.

Acute hepatic failure and multi-system organ failure secondary to replacement of the liver with metastatic melanoma

Background

Metastatic malignant melanoma to the liver resulting in fulminant hepatic failure is a rare occurrence.

Case presentation

A 46 year old man presented to hospital with massive hepatomegaly, elevated liver enzymes and increased lactate three weeks following resection of a malignant melanoma from his shoulder (Clark level 5). Initially stable, he decompensated 24 to 48 hours subsequent to presentation with respiratory failure requiring mechanical ventilation, distributive shock requiring high dose vasopressor infusion, coagulopathy refractory to plasma infusion, progressive rise in liver enzymes and severe metabolic abnormalities including hyperkalemia, acidosis, hyperphosphatemia, hyperuricemia and hypocalcemia. Refractory to aggressive physiologic support he received palliation. Autopsy revealed >80% liver infiltration by metastatic malignant melanoma.

Conclusion

We report a case of fulminant hepatic failure secondary to metastatic malignant melanoma infiltration of the liver.

Metastatic liver disease and fulminant hepatic failure: presentation of a case and review of the literature

Although liver metastases are commonly found in cancer patients, fulminant hepatic failure (FHF) secondary to diffuse liver infiltration is rare. Furthermore, clinical presentation and laboratory findings are obscure and far from being pathognomonic for the disease. We report a case of a patient who died in the intensive care unit of our hospital from multiple organ failure syndrome secondary to FHF, as a result of liver infiltration from poorly differentiated small cell lung carcinoma. We also present the current knowledge about the clinical picture, laboratory findings and physical history of neoplastic liver-metastasis-induced FHF.

Diffuse hepatic intravascular carcinomatous embolization resulting in fatal liver failure: a clinicopathologic study of 4 cases

The authors report four cases in which patients died of acute or fulminant hepatic failure resulting from massive intravascular metastatic carcinomatous embolization, a rarely reported manifestation of metastatic disease. Neoplasms were high grade carcinomas. Tumor emboli were present within portal branches ranging 0.12-2.9 mm in diameter and were free floating or attached to the vascular wall, with or without varying degrees of superimposed organization. In one case, intravascular tumor necrosis was prominent and appeared as granular casts with superimposed dystrophic calcification and/or entrapped foamy histiocytes. There were associated geographical areas of parenchymal (4 cases) and tumor (1 case) ischemic necrosis with a multifocal and regional topographic distribution. An associated predominant pattern of intrasinusoidal tumor infiltration (with or without fibrosis) was present in 3 cases, whereas the fourth case had underlying micronodular cirrhosis, providing ancillary evidence for preexisting altered intrahepatic microcirculation. The literature on fatal hepatic failure resulting from neoplasia is reviewed with a reassessment of its pathobiological significance.

Prospective study of intratumoral microvessel density, p53 expression and survival in colorectal cancer

Adjuvant treatment of patients with colorectal cancer is hampered by a lack of reliable prognostic factors in addition to the clinicopathological staging system. A poorly defined but considerable fraction of Astler-Coller stage B patients will experience tumour recurrence, and some of the stage C patients will probably survive for a prolonged time after surgery without adjuvant treatment. Assessing parameters related to tumour angiogenesis has provided valuable prognostic information in different tumour types. The formation of new microvessels is part of the malignant phenotype in the majority of tumours. Alterations in tumour-suppressor genes, such as the p53 gene, or oncogenes, such as the ras gene, have been found to be responsible for changing the local balance of pro- and antiangiogenic factors in favour of the former. In this prospective study, intratumoral microvessel density (IMD) was assessed by immunostaining tissue sections for CD31 and counting individual microvessels in selected and highly vascular regions in specimens of 145 colorectal cancer patients. p53 protein overexpression was semiquantitatively determined after immunohistochemistry. In both uni- and multivariate analysis, high IMD was significantly associated with shorter survival in the patients undergoing surgery with curative intent (Astler-Coller stages A-C). p53 added prognostic power to IMD, both in Astler-Coller stage B and stage C patients. An association between IMD and mode of metastasis was also noted. High IMD was strongly associated with the incidence of haematogenous metastasis during follow-up, but not with the presence of lymphogenic metastasis observed at surgery. This study confirms the results of previous retrospective analyses of IMD and survival in colorectal cancer and warrants a clinical validation by randomizing stage B tumour patients with high IMD and p53 overexpression between adjuvant treatment or not.

Fulminant hepatic failure secondary to malignant melanoma: case report and review of the literature

Malignant melanoma has a propensity to metastasize widely to many organs, involving the liver in up to one-third of cases. Fulminant hepatic failure is an unusual presentation of hepatic neoplasms, whether primary or metastatic. We describe a case of malignant melanoma with liver metastases that rapidly progressed to fulminant hepatic failure and death. Striking elevations of liver tests, particularly lactate dehydrogenase, were seen. Liver biopsy showed diffuse intrasinusoidal infiltration with melanoma cells. In patients with malignant melanoma, raised serum lactate dehydrogenase levels may suggest hepatic involvement, with extreme elevations possibly predictive of liver failure.

Massive liver necrosis associated with hyperamylasemia

In North America, massive liver necrosis is due mainly to viral infection or exposure to hepatotoxins. We report an unusual case of massive liver necrosis due to diffuse liver infiltration by small cell carcinoma of the lung. The unusual presentation included hyperamylasemia due to ectopic amylase production by the tumor. In this era of liver transplantation it is important to consider malignancy in the differential diagnosis of fulminant or acute liver failure prior to liver transplantation.