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Liver Metastasis

Liver Cancer Metastatic

Liver metastasis develops due to the spread of malignant tumors from their primary sites in the gastrointestinal tract, breast, lung, and pancreas. The extension of melanomas and neuroendocrine tumors may also result in this disease. Clinical manifestations can be non-specific and imaging studies like ultrasonography, computed tomograms, and magnetic resonance imaging are required to detect the disease while biopsy with histopathology is necessary to confirm the diagnosis.


Presentation

Liver metastasis occurs secondary to the spread of melanomas, renal cell carcinoma, neuroendocrine tumors and the primary cancers involving various sites of the body. Of these, the commonest is the colon, followed by non-colorectal locations such as breast, lungs, pancreas, etc. [1]. 95% of uveal melanomas metastasize to the liver versus 15% of cutaneous melanomas [2] [3] [4] [5] and liver metastasis has been reported in approximately 44% of neuroendocrine tumors [6] [7] [8].

In a majority of the patients, the metastases are multiple with concomitant spread to other sites [9] [10] while a small percentage of patients develop solitary lesions. 75% of the patients have involvement of bilateral lobes of the liver. The incidence and pattern of the metastases depend on the age, sex, primary site of the tumor, duration, and histopathology. Primary liver cancer is less common as compared to liver metastasis.

In the initial stages of the disease, patients with liver metastasis are asymptomatic. Subsequently, they develop non-specific symptoms like anorexia, weight loss, fever, night sweats, cachexia and right upper quadrant pain. On palpation, hard, tender hepatomegaly may be noted. Jaundice is rare in the early stages and is typically seen in the presence of bile duct obstruction. Ascites develops with peritoneal seeding of the tumor and in advanced stages, there is hyperbilirubinemia with hepatic encephalopathy.

Weight Loss
  • Patients with a primary cancer are suspected of having liver metastasis if they present with weight loss and a palpable, enlarged and hard liver.[symptoma.com]
  • Liver metastases are suspected in patients with weight loss and hepatomegaly or with primary tumors likely to spread to the liver.[msdmanuals.com]
  • When this happens, the following symptoms may occur: loss of appetite weight loss dark-colored urine abdominal swelling or bloating jaundice , a yellowing of the skin or the whites of the eyes pain in the right shoulder pain in the upper right abdomen[healthline.com]
Thyroid Nodule
  • Positron emission tomography-computed tomography documented a lesion in his liver in addition to a metabolically active thyroid nodule.[ncbi.nlm.nih.gov]
Abdominal Pain
  • A 50-year-old woman complained of abdominal pain beneath the xiphoid process for 1 day. Physical checkup revealed tenderness at the right upper abdomen. A fecal occult blood test was positive.[ncbi.nlm.nih.gov]
Diarrhea
  • A 72-year-old man was referred to our hospital complaining of abdominal discomfort, diarrhea, and weakness over the last month. Colorectal liver metastases concurrent intrahepatic cholangiocarcinoma (ICC).[ncbi.nlm.nih.gov]
  • My feeling is that the chemo can be very harmful, but theoretically less harmful than the cancer, so the diarrhea shouldn't be a surprise.[cancercompass.com]
  • However, in our patient when paclitaxel 100 mg weekly had been used with pegylated adriamycin as a third line chemotherapy, patient develop severe grade IV diarrhea and his performance status deteriorated very fast from which he could not recover.[npplweb.com]
  • Side effects, which can be severe, include fatigue and diarrhea. Hormonal therapy Hormonal therapy can slow or stop the growth of certain types of tumors that rely on hormones to grow, such as breast and prostate cancer.[healthline.com]
Hepatic Mass
  • However, an immunohistological study of the hepatic mass indicated metastasis derived from cancer of the ascending colon. These findings were consistent with total necrosis of a liver metastasis of colorectal cancer.[ncbi.nlm.nih.gov]
  • "Biopsy considerations in the diagnosis of hepatic masses.". Clin Gastroenterol Hepatol 5 (5): 541-4. doi : 10.1016/j.cgh.2007.02.028. PMID 17478344.[librepathology.org]
  • FLC characteristically manifests as a 10-20 cm large hepatic mass in adolescents or young adults. The typical risk factors for HCC such as cirrhosis, elevated alphafetoprotein, viral hepatitis, alcohol abuse are absent.[radiologyassistant.nl]
Flushing
  • The bypass circuit is composed of a venous Delcath 16F polyethylene catheter with one large fenestrated lumen and 3 accessory lumens, flushed bypass tubing, 2 filters, and the internal jugular central venous return line.[hrjournal.net]
  • These hormones could cause characteristic patterns of symptoms, like flushing, diarrhea, and palpitation. NETs are comparatively uncommon, with an incidence range from 2.5 to 5.3 per 100,000 ( 1 ).[atm.amegroups.com]
Meningism
  • Primary meningeal melanocytic tumors have genetic similarities with uveal melanomas, including GNAQ or GNA11 mutations.[ncbi.nlm.nih.gov]
Personality Change
  • Breast cancer cells that have spread to the brain cause persistent, progressively worsening headache, visual changes, seizures, nausea, vomiting, vertigo, behavioral and personality changes and increased intracranial pressure.[breast-cancer.ca]

Workup

Patients with a primary cancer are suspected of having liver metastasis if they present with weight loss and a palpable, enlarged and hard liver. Routine laboratory tests like a complete blood count and liver function tests may be inconclusive in the early stages although alkaline phosphatase, gamma-glutamyl transpeptidase, and lactate dehydrogenase levels may be elevated.

Plain X-ray chest is performed as a routine in patients with a known primary cancer to exclude pulmonary lesions.

Radiological tests such as ultrasonography, computed tomogram (CT) and magnetic resonance imaging (MRI) are required to detect the metastasis. CT with contrast is the study of choice to diagnose the disease with MRI being more sensitive as compared to CT and positron emission tomography (PET) [11]. However, Kinkel et al, have reported that fluorodeoxyglucose (FDG) PET scan is the most sensitive imaging modality to detect liver metastases, especially if the primary tumor is located in the colon, and upper gastrointestinal tract [12]. Liver angiography is indicated in vascular metastasis, especially if, embolization is being considered as a therapeutic modality.

Histopathological evaluation of a liver biopsy specimen obtained under image guidance is usually required for confirmation of the diagnosis.

Treatment

  • Stereotactic body radiation therapy (SBRT) is reported as a well-tolerated treatment modality, which offers a long-term tumor control.[ncbi.nlm.nih.gov]

Prognosis

  • Therefore, D-dimer may help predict recurrence and prognosis in patients with CRLM.[ncbi.nlm.nih.gov]

Etiology

  • The epidemiology, etiology, clinical diagnosis and treatment of the disease remain challenging, because case reports of the disease are few in number.[ncbi.nlm.nih.gov]

Epidemiology

  • The epidemiology, etiology, clinical diagnosis and treatment of the disease remain challenging, because case reports of the disease are few in number.[ncbi.nlm.nih.gov]
  • Colorectal Cancer Epidemiology: Incidence, Mortality, Survival, and Risk Factors. Clin Colon Rectal Surg. 2009 November; 22(4): 191–197.[bead.btg-im.com]
  • References Govindan R, Page N, Morgensztern D, Read W, Tierney R, Vlahiotis A, Spitznagel EL, Piccirillo J: Changing epidemiology of small-cell lung cancer in the United States over the last 30 years: analysis of the surveillance, epidemiologic, and end[karger.com]
  • .: Small bowel cancer in the United States: changes in epidemiology, treatment, and survival over the last 20 years. Ann surg 2009; 249: 63-71. 30.[degruyter.com]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology of RILD is not well understood. Pathologically, venoocclusive disease, similar to that seen following bone marrow translation, is seen.[aboutcancer.com]

Prevention

  • Tailoring microwave ablation device protocols to tumor type might prevent incomplete ablations.[ncbi.nlm.nih.gov]

References

Article

  1. Page AJ, Weiss MJ, Pawlik TM. Surgical management of non-colorectal cancer liver metastases. Cancer. 2014 Oct;120(20):3111–3121
  2. Leiter U, Meier F, Schittek B, Garbe C. The natural course of cutaneous melanoma. J Surg Oncol. 2004;86(4):172-178.
  3. Gragoudas E, Egan K, Seddon J, et al. Survival of patients with metastases from uveal melanoma. Ophthalmology. 1991;98:3831-39;
  4. Eskelin S. The development and early diagnosis of primary and disseminated uveal melanoma. Acta Ophthalmol Scand. 2003;81:546-547.
  5. Eskelin S, Pyrhönen S, Summanen P, Prause JU, Kivelä T. Screening for metastatic malignant melanoma of the uvea revisited. Cancer. 1999;85:1151-1159.
  6. Patel J, Didolkar M, Pickren J, Moore R. Metastatic pattern of malignant melanoma: a study of 216 autopsy cases. Am J Surg. 1978;135:807-810.
  7. Tan MC, Jarnagin WR. Surgical management of non-colorectal hepatic metastasis. J Surg Oncol. 2014;109:8-13.
  8. Chamberlain RS, Canes D, Brown KT, et al. Hepatic neuroendocrine metastases: does intervention alter outcomes? J Am Coll Surg. 2000;190:432-445.
  9. Pagani O, Senkus E, Wood W, et al. International guidelines for management of metastatic breast cancer: can metastatic breast cancer be cured? J Natl Cancer Inst. 2010;102:456-463.
  10. Pivot X, Asmar L, Hortobagyi G, et al. A retrospective study of first indicators of breast cancer recurrence. Oncology. 2000;58:185-190.
  11. Sahani DV, Bajwa MA, Andrabi Y, Bajpai S, Cusack JC. Current status of imaging and emerging techniques to evaluate liver metastases from colorectal carcinoma. Ann Surg. 2014 May;259(5):861-72.
  12. Kinkel K, Lu Y, Both M. Detection of hepatic metastases from cancers of the gastrointestinal tract by using noninvasive imaging methods (US, CT, MR imaging, PET): a meta-analysis. Radiology. 2002 Sep;224(3):748-56.

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Last updated: 2019-07-11 21:46