Malignant infiltration of the liver presenting as acute liver failure

Abstract

There have been few reports of acute liver failure (ALF), with encephalopathy and coagulopathy, caused by infiltration of the liver by malignant cells. We describe a case series of 27 patients with ALF caused by malignancy. We examined a large, multicenter ALF registry (1910 patients; mean age, 47.1 ± 13.9 y) and found only 27 cases (1.4%) of ALF attributed to malignancy. Twenty cases (74%) presented with abdominal pain and 11 presented with ascites. The most common malignancies included lymphoma or leukemia (33%), breast cancer, (30%), and colon cancer (7%); 90% of the patients with lymphoma or leukemia had no history of cancer, compared with 25% of patients with breast cancer. Overall, 44% of the patients had evidence of liver masses on imaging. Diagnosis was confirmed by biopsy in 15 cases (55%) and by autopsy for 6 cases. Twenty-four patients (89%) died within 3 weeks of ALF.

Keywords: Acute Liver Failure; Liver Transplantation; Malignancy.

Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

A 47-year old female presented with ALF. A transjugular liver biopsy demonstrated A) In the center of the field, there is a plug of metastatic carcinoma that is filling and obstructing a sinusoid (Hematoxylin and Eosin, 200X). B) At the lower center, there is a zone of acute hemorrhagic necrosis containing necrotic liver cell debris and blood (Hematoxylin and eosin, 200X). The pattern of necrosis suggests an acute interference of incoming blood flow from the portal venule or hepatic artery, presumably embolic in nature from the metastatic breast cancer. (Photomicrographs courtesy of Henry D. Appelman, MD). C) Dynamic contrast enhanced MRI images of the same 47-year-old female with metastatic breast cancer to the liver at month 18 of follow-up following her ALF episode. The liver has a nodular surface contour consistent with “pseudo-cirrhosis” from partially treated malignant infiltration and a small focus of hypointensity indicative of residual tumor. The patient developed esophageal varices during follow-up that required band ligation.

Figure 1

A 47-year old female presented with ALF. A transjugular liver biopsy demonstrated A) In the center of the field, there is a plug of metastatic carcinoma that is filling and obstructing a sinusoid (Hematoxylin and Eosin, 200X). B) At the lower center, there is a zone of acute hemorrhagic necrosis containing necrotic liver cell debris and blood (Hematoxylin and eosin, 200X). The pattern of necrosis suggests an acute interference of incoming blood flow from the portal venule or hepatic artery, presumably embolic in nature from the metastatic breast cancer. (Photomicrographs courtesy of Henry D. Appelman, MD). C) Dynamic contrast enhanced MRI images of the same 47-year-old female with metastatic breast cancer to the liver at month 18 of follow-up following her ALF episode. The liver has a nodular surface contour consistent with “pseudo-cirrhosis” from partially treated malignant infiltration and a small focus of hypointensity indicative of residual tumor. The patient developed esophageal varices during follow-up that required band ligation.

Figure 1

A 47-year old female presented with ALF. A transjugular liver biopsy demonstrated A) In the center of the field, there is a plug of metastatic carcinoma that is filling and obstructing a sinusoid (Hematoxylin and Eosin, 200X). B) At the lower center, there is a zone of acute hemorrhagic necrosis containing necrotic liver cell debris and blood (Hematoxylin and eosin, 200X). The pattern of necrosis suggests an acute interference of incoming blood flow from the portal venule or hepatic artery, presumably embolic in nature from the metastatic breast cancer. (Photomicrographs courtesy of Henry D. Appelman, MD). C) Dynamic contrast enhanced MRI images of the same 47-year-old female with metastatic breast cancer to the liver at month 18 of follow-up following her ALF episode. The liver has a nodular surface contour consistent with “pseudo-cirrhosis” from partially treated malignant infiltration and a small focus of hypointensity indicative of residual tumor. The patient developed esophageal varices during follow-up that required band ligation.