Chemotherapy-related hepatotoxicity causing imaging findings resembling cirrhosis

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.

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.

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.

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.

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.

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.

The effects of cancer chemotherapy on liver imaging

Chemotherapy changes the appearance of liver tumours and may also affect the liver parenchyma. Tumours respond with changes in size, outline, and internal architecture. The accuracy of liver CT for detecting metastases is reduced after chemotherapy. Histologic studies have shown that some metastases which become invisible on follow-up CT are completely sterile at later resection, but most 'disappearing' lesions still contain active tumour. Hepatic steatosis becomes much more common after chemotherapy. Diffuse fatty change may conceal metastases on US and CT, whilst focal steatosis may mimic tumour. Chemical-shift MRI will distinguish fat from tumour. Fatty change is usually reversible, unless the liver receives a 'second hit' of damage from other causes. Sinusoidal obstructive syndrome (SOS), nodular regenerative hyperplasia, veno-occlusive disease and peliosis are manifestations of microvascular injury which can result from chemotherapy. SOS, the most common of these, is undetectable on US and CT, but can be shown on SPIO-enhanced MRI. Although SOS causes no symptoms in most patients, it may cause increased bleeding from the friable liver at surgery, and greater risk of peri-operative adverse events. Rarer complications of chemotherapy include pseudo-cirrhosis and sclerosing cholangitis.

Pseudocirrhosis in a pancreatic cancer patient with liver metastases: A case report of complete resolution of pseudocirrhosis with an early recognition and management

We report a case of pseudocirrhosis arising in the setting of regression of liver metastases from pancreatic cancer. A 55-year-old asymptomatic woman presented to our clinic with newly diagnosed metastatic pancreatic cancer with extensive liver metastases. She underwent systemic chemotherapy with gemcitabine and oxaliplatin (GEMOX). After 8 cycles of therapy, she had a remarkable response to the therapy evidenced by decline of carcinoembryonic antigen (CEA) and CA19 by > 50% and nearly complete resolution of hepatic metastases in computed tomography (CT) scan. Shortly after, she developed increasing bilateral ankle edema and ascites, associated with dyspnea, progressive weight gain, and declining performance status. Gemcitabine and oxaliplatin were discontinued as other causes of her symptoms such as congestive heart disease or venous thrombosis were ruled out. CT scan 6 mo after the initiation of GEMOX revealed worsening ascites with a stable pancreatic mass. However, it also revealed a lobular hepatic contour, segmental atrophy, and capsular retraction mimicking the appearance of cirrhosis. She was managed with aggressive diuresis and albumin infusions which eventually resulted in a resolution of the above-mentioned symptoms as well as complete resolution of pseudocirrhotic appearance of the liver and ascites in CT scan. This case demonstrates that pancreatic cancer patients can develop pseudocirrhosis. Clinicians and radiologist should be well aware of this entity as early recognition and management can lead to a near complete recovery of liver function and much improved quality of life as illustrated in this case.

Cirrhosis-like radiological pattern in patients with breast cancer

INTRODUCTION

Hepatic toxicity of breast cancer therapy is well known, usually consisting of elevation in the serum levels of hepatic enzymes or fatty infiltration of the liver. The chemotherapeutic agents most commonly linked to hepatotoxic effects are methotrexate, anthracyclines, taxanes and cyclophosphamide. There are few reports of patients with liver metastasis having radiological findings mimicking cirrhosis, both in the presence or the absence of prior systemic chemotherapy. Hepatotoxicity of antineoplastic drugs and cellular necrosis induced by response of liver metastases to chemotherapy may play a critical role in its physiopathology.

MATERIALS AND METHODS

This article reports a series of ten women with breast cancer (nine with liver metastasis) treated with chemotherapy or hormonotherapy.

RESULTS

They had low risk factors for hepatic disease, but developed a cirrhosis-like appearance in the computed tomography scan. The patient without liver metastasis is the second of this kind described in the literature. Relatively few reports have documented clinical sequelae of portal hypertension. In our series, three patients had oesophageal bleeding varices needing be hospitalised. To our knowledge, these are the first cases reported in the literature.

CONCLUSIONS

This suggests that some manifestations of portal hypertension may develop in association with the cirrhosis- like pattern induced by breast cancer therapy.

Frequency of hepatic contour abnormalities and signs of portal hypertension at CT in patients receiving chemotherapy for breast cancer metastatic to the liver

PURPOSE

This study aimed to determine the frequency of hepatic contour abnormalities and signs of portal hypertension at serial CT in patients receiving chemotherapy for breast cancer metastatic to the liver.

MATERIALS AND METHODS

We retrospectively identified 91 women with breast cancer metastatic to the liver who received chemotherapy and underwent serial CT at our institution between 1998 and 2002. Two readers independently categorized hepatic contour abnormalities on the final CT examination as none, limited retraction, widespread retraction, or diffuse nodularity. Readers also recorded the development of hepatic atrophy or enlargement, ascites, portosystemic collateral veins, and splenomegaly. Interpretative discrepancies were resolved by consensus. Portal hypertension was defined as the presence of at least two of the following CT signs: simple ascites, portosystemic collateral veins, and splenomegaly.

RESULTS

After a median follow-up interval of 15 months (range, 1-46), hepatic contour abnormalities were seen in 68 of 91 patients (75%) and consisted of limited retraction (n = 42), widespread retraction (n = 10), or diffuse nodularity (n = 16). Portal hypertension was found in 1 of 23 patients without contour abnormalities, in 1 of 42 patients with limited retraction, in none of 10 patients with widespread retraction, and in 6 of 16 patients with diffuse nodularity (P < .01).

CONCLUSION

Hepatic contour abnormalities commonly develop at serial CT in patients undergoing chemotherapy for breast cancer metastatic to the liver and may be accompanied by signs of portal hypertension; the latter are particularly, but not exclusively, associated with the development of diffuse hepatic nodularity.

Hepatic capsular retraction in metastatic carcinoma of the breast occurring with increase or decrease in size of subjacent metastasis

OBJECTIVE

We evaluated the prevalence and significance of hepatic capsular retraction in hepatic metastases from breast cancer and correlated these with metastatic number, size, change in size over time, breast tumor histopathology, chemotherapeutic regimen, and tumor-receptor status.

MATERIALS AND METHODS

Abdominal CT scans of 200 consecutive women with breast carcinoma (mean age, 57 years; range, 33-81 years), obtained over a 7-month period, were retrospectively reviewed. Fifty-eight women had hepatic metastases. Two hundred seventy-two CT scans, including present and prior examinations (mean [+/- SD], 4.6 +/- 2 per patient), were evaluated. The number and diameter of liver metastases at all examinations, chemotherapeutic agents used, histopathologic diagnosis of breast tumor, and tumor-receptor status were compared in patients with and without capsular retraction. Descriptive analyses of the variables and comparisons of means and proportions as well as correlations were conducted.

RESULTS

Hepatic capsular retraction was observed in 29 patients with hepatic metastases (50%). Retraction ranged from 1 to 10 mm in depth. Patients with capsular retraction had significantly larger metastases than those without retraction (p < 0.05). The associations between retraction and increase in size of the subjacent metastasis and between retraction and decrease in size were statistically significant (p < 0.05). Capsular retraction was independent of the number of hepatic metastases, histopathologic diagnosis, tumor-receptor status, and chemotherapeutic regimen.

CONCLUSION

Hepatic capsular retraction is common in patients with hepatic metastases from breast cancer and is associated with larger metastases and both increase and decrease in subjacent lesion size. It is unrelated to lesion number, histopathology, receptor status, or chemotherapeutic regimen.

Post-treatment malignant liver lesions. MR imaging

MR imaging is very accurate in the diagnosis and staging of tumors and in surgical planning. MR imaging is also an excellent method for evaluation of the liver after surgical resection, systemic or local tumor therapies, and liver transplantation. It permits early recognition of complications and the presence of recurrent tumor, providing an opportunity to repeat treatment or use alternative treatment. Surgical resection remains the standard therapy for treating liver metastases. The relatively small number of patients who are candidates for curative resection have provided impetus for the implementation and improvement of other techniques. The variety of techniques and the sensitivity for contrast enhancement have made MR imaging an ideal method to follow the response of tumors to various treatment approaches. The appearance of tumor recurrence and the response to treatment are relatively consistently shown on MR images; however, the time course of change in lesion appearance has not been fully elucidated, particularly in the setting of chemotherapy. Evaluating the response to chemotherapy is rendered complex because of the longer duration of the therapy, the types of response that various chemotherapeutic agents engender, the method of action of this therapy and the time of imaging in relation to therapy. The various local therapies share some general principles of action, and many have similar MR imaging findings. Some local therapies are effective only with certain malignancies (e.g., alcohol therapy and HCC), whereas other therapies are more limited because of the size of the tumor kill zone (e.g., interstitial laser therapy). We are in the early stages of using MR imaging to guide local therapies and to monitor response during treatment in real time. This appears to be an important future direction for MR imaging. The role of MR imaging in liver transplantation involves pre- and postoperative investigation of both donors (in the case of living-related transplantation) and recipients. These issues are described further in the section on MR imaging of liver transplantation.

Diffuse desmoplastic breast carcinoma metastases to the liver simulating cirrhosis at MR imaging: report of two cases

Two patients with breast carcinoma, without a prior diagnosis of liver lesions, had proved desmoplastic hepatic metastases that resembled cirrhosis at magnetic resonance (MR) imaging. The cirrhotic appearance of the livers may have resulted from the hepatotoxic effects of chemotherapy and/or hepatic infiltration by the metastatic tumor itself. Despite its high soft-tissue contrast, MR imaging may fail to depict extensive metastases from breast carcinoma, especially when they simulate other diseases (eg, cirrhosis). Correlation of MR imaging findings with clinical history is mandatory.

Delayed effects of tamoxifen in hepatocarcinogenesis-resistant Fischer 344 rats as compared with susceptible strains

The anti-oestrogenic drug tamoxifen has been under investigation as a breast cancer chemopreventive agent for at least a decade. However, its use for this purpose is still debatable since it is able to induce liver tumours in rats via a mechanism involving metabolic activation to a DNA adduct-forming electrophilic intermediate. The metabolic activation and adduct-forming properties of tamoxifen are now well characterized but less is known about its ability to induce hepatic cell proliferation, which is also essential for the carcinogenic process. The effects of tamoxifen on liver weight and cell proliferation were compared in female Fischer 344 (F344), Wistar and Lewis rats given the drug in the diet for up to 26 weeks. The onset and duration of hepatic cell proliferation varied between the strains of rat. In Wistar and Lewis but not F344 rats there was a marked increase in hepatocellular proliferation during the first 4 weeks of tamoxifen administration. In the Wistar strain this was associated with an increase in DNA adduct levels; no such increase was observed in the F344 strain. The onset of the proliferative response was delayed until the 13 week time point in the F344 strain. By the 13 and 26 week time points, cell proliferation in tamoxifen-treated Wistar and Lewis rat liver had returned to normal, but the amount of apoptotic activity in these livers was elevated. This suggests that excess cells generated during the proliferative phase of tamoxifen treatment were being eliminated by apoptosis. In the F344 strain, however, increased proliferative activity was associated with relatively low apoptotic activity at the 26 week time point, suggesting that the delayed proliferative response had yet to be balanced by apoptotic deletion. This is consistent with the fact that tamoxifen-induced hepatocellular tumours develop very late, towards the end of the lifespan, in this strain. The cell proliferative activity of tamoxifen in the Wistar rat liver was compared with that of a non-mutagenic analogue, toremifene. Tamoxifen induced increased cell cycle activity in the livers of rats following gavage dosing at all sampling times (1-12 weeks), whereas toremifene had no effect on the incidence of cycling in hepatic cells, demonstrating that the hepatic cell proliferation is not a general response to anti-oestrogen treatment. These observations suggest that the rate of promotion of liver tumours by tamoxifen is a function of the rate, time of onset and duration of increased cell replication. The susceptibility of rat strains to the hepatocarcinogenic effects of tamoxifen appears to depend upon the balance between initiation via DNA adduct formation, promotion via increased cell proliferation and cell deletion via apoptosis. Our findings suggest that an early proliferative response to tamoxifen is important in this process.