The liver is a common site for metastatic disease (Metastatic liver disease is 20 times more common than primary liver malignancy )because of it is rich, dual blood supply (the liver receives blood via the hepatic artery and portal vein) and hormonal mileu . The liver is the second most commonly involved organ by metastatic disease, after the lymph nodes.
The most common site of primary tumor is the gastro intestinal tract (colon, stomach and pancreas). The other common primary sites are the eye, breast, and lung. Neuroblastoma , Wilms tumor, or leukemias are common primary sites in children.
Metastatic liver disease is usually asymptomatic . Other patients present with right upper quadrant tenderness, abdominal swelling, jaundice , anorexia , weight loss and fever . Liver is hardened with irregular edges on palpation. Splenomegaly may be appreciated secondary to metastasis .
Imaging : Clues to metastatic liver lesions are (1) multiple lesions and (2) predominant involvement of the right lobe . Ultrasound is the imaging of choice for initial evaluation. Contrast CT and MRI provide more detailed information of the size, number and extent of metastatic lesions. Liver biopsy is indicated in situations of unknown primary tumor .
Chemotherapy is the treatment of choice for metastatic disease . Surgical options are limited in metastatic liver lesions . Cure rates are dependent on the growth characteristics of the primary tumor .
metastatic carcinoma is a metatstatic malignant neoplasm of the liver caused by a primary carcinoma elsewhere resulting in a mass or multiple masses characterised by space occupying lesions divided into types by cell origin pathogenesis new cell growth continues aggressively with no regard to the body at large and relatively unabated structural disorder space occupying lesion or lesions functional disorder usually of no functional significance until liver extensively involved clinical presentation local pain weight loss jaundice mild hepatomegaly systemic anorexia diagnostic studies include LFT’S US, CT, MRI treatment is commonly by chemotherapy
The Battleground – Tumor vs Healthy Tissue The histopathology of a surgically resected hepatic metastasis from a primary colon carcinoma shows a mucinous secreting tumor at the bottom of the image labeled “advancing tumor”. The cellular detail is not well seen in the low power view but the columnar epithelial nature, hyperchromicity, and bizarre appearance of squatter tissue in the liver are recognized as malignant characteristics. The white spaces in between the cellular structure, represents mucin in the tumor. The edge of the tumor shows a rounded and aggressive push into the liver where the injured liver in the battlefield is recognized as compressed normal liver with linear areas of hemorrhage· evidenced by a curvilinear line at 11 and 12 oclock of· increased area of redness representing ·extravascular red cells (“layer of “injured liver”). The uppermost layer represents the normal liver which at this time looks healthy but is in jeopardy. The radial red spokes seen at the edge of the tumor are artifacts of preparation but are indicators of the direction of the battle. ·liver cancer metastasis malignant tumor battlefield mucinous secreting adenocarcinoma colon primary histopathology destruction hemorrhageCourtesy Ashley Davidoff MD copyright 2009 all rights reserved 5star 03028b01.81s
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Liver Metastases liver bone vertebra fx mass space occupying disease dx liver metastases metastasis dx primary lung carcinoma malignancy cancer CTscan Davidoff MD 46587.800
The post mortem specimen (a) shows a 2cms primary duodenal carcinoma (white arrow) with extensive nodular hepatic metastases occupying 80% of the liver. (b) In image c, the metastasis reflects an overall a blue hue caused by the increased nuclear presence. The image reveals an irregular and advancing threat on the normal liver. The higher power in d, shows a rind of compressed liver that is in the process of destruction and hemorrhage (red patches) in the tumor, in the border, as well as in the normal liver. This image is reminiscent of an advancing enemy in a battlefield with victory apparent for the aggressor. code liver duodenum adenocarcinoma metastases metastasis cancer malignant space occupation pressure atrophy death grosspathology histopathology Courtesy Ashley Davidoff MD copyright 2009 all rights reserved 02643c03.8s
PANCREATIC METSASTASES TO THE LIVER primary adenocarcinoma of the pancreas complicated by metastasis metastatic disease to the liver imaging radiology CTscan neoplasm malignant tumor cancer Courtesy Ashley Davidoff MD code pancreas pancreatic body fx mass code liver fx multiple nodules and masses code dx primary adenoca 40343c
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The liver on the left is normal except for gallstones in the gallbladder.· Gallstones are squatters but they usually do not have aggressive tendencies unless they block the outflow of bile.· The liver shown in the right image is from a patient who succumbed to metastatic pancreatic carcinoma.· The normal liver cells have been displaced and have been overridden by metastatic squatters.· The metastases have contributed to the demise of the patient by their relentless displacement of normal tissue, causing progressive impairment of function.·The liver shown in the right image is from a patient who succumbed to metastatic pancreatic carcinoma.· The normal liver cells have been displaced and have been overridden by metastatic squatters.· The metastases have contributed to the demise of the patient by their relentless displacement of normal tissue, causing progressive impairment of function.·
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Normal Liver –·(left) ·and Cancer in the Liver (right)
This unfortunate patient presented in pregnancy with metastatic disease to the liver showing rounded discrete metastases in the liver on CTscan (a) confirmed at autopsy to be metastatic pancreatic carcinoma. The lesions in the liver (b) show a bile tinged green halo caused by local cholestasis caused by space occupation and obstruction. In c and d, the metastatic tumor (m) is seen to the left of the images, the middle layer of bile stained injured liver cells caused by cholestsais (ch) is seen as a subtle orange tinged section (c). The bile tinged layer (ch) is digitally enhanced in orange in d. Therelatively normal liver tissue (l) is seen to the right and is enhanced in with pink (d). code liver malignant cancer pancreatic primary pancreas bile tinge cholestasis space occupation bile stain CTscan grosspathology histopathology Courtesy Ashley Davidoff MD copyright 2009 all rights reserved 02891c03.8s
45220 liver fx large hepatic mass dx colonic rectosigmoid carcinoma with hepatic metatsasis s/p stent placement CTscan Courtesy Ashley Davidoff MD 45220 45221 45222
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Normal Liver and Single Group of Cancer Cells Microscopic events described in the macroscopic examples above.· The left image shows normal liver cords at high power, · normal liver cords 13445 liver hepatocytes normal nodule Davidoff MD
The lower image shows slightly lower power of the liver cords in pink, and a blue, rounded, space occupying metastasis. ·· · 11440 liver hepatocytes normal metastasis adenocarcinoma histopathology nodule Davidoff MD
This specimen is from a biopsy of the liver. The medium power view of malignant adenocarcinoma shows groups of columnar cells arranged in rosettes in a bed of malignant stromal tissue and surrounded by normal liver. Although the nuclii in this case are not particulalrly enlarged the cytoplasm is basophilic, and the appearance is of a “squatter” in the liver, ie tissue that does not belong, is consistent with metastatic adenocarcinoma malignant cancer liver hepatic adenocarcinoma histopathology Courtesy Barbara Banner MD copyright 2009 all rights reserved GW question 5star
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liver colon large bowel liver fx hepatic mass fx fine stippled calcifications calcified mass dx metastattic mucin secreting adenocarcinoma of colon carcinoma metastasis CTscan Courtesy Ashley Davidoff MD 18370
liver CTscan imaging radiology mass dystrophic calcification calcified neoplasm mass metastasis malignant carcinoma adenocarcinoma cancer tumor 39484
51 year old male with history of rectal carcinoma with extensive hepatic metastases. (orange) The metastases surround gallbladder and by space occupation result in venous and lymphatic congestion causing a thickened edematous gallbladder wall (orange) with a small lumen (green) Tthe portal triad shows surrounding edema (white arrow). This is called periportal tracking which is another sign of venous and lymphatic engorgement. The metastases are calcified confirming the mucinous nature of the tumor. calcified metastasis in gallbladder fossa edema of the wall lymphatics contracted gallbladder CTscan copyright 2008 Courtesy Ashley Davidoff MD gallbladder liver portal triad 82313c01.8s
The gross and histopathological specimens are from the autopsy of a patient who died of breast carcinoma that was metastatic to the liver. The right lobe of the liver shows two patterns of metastases. In the posterior aspect of the liver there is diffuse disease, and in the anterior aspect there are innumerable nodules of varying sizes. The left lobe is relatively spared, and the pattern is of a nodular nature. The low power histopathological section shows a diffuse infiltrate of hyperchromatic malignant nuclii in the bottom of the image and relatively normal liver in the upper portion. code liver metastases metastasis breast primary cancer malignant space occupation infiltration infiltrative pattern right lobe left lobe grosspathology histopathology Courtesy Ashley DAvidoff MD copyright 2009 all rights reserved GW question 03034c.8s
The series is from a patient who died of metastatic adenocarcinoma. In image a, the ultrasound shows diffuse increased echogenicity in the dome of the right lobe of the liver that suggests diffuse infiltration of metastatic disease. the liver at autopsy showed a combination of diffuse infiltration and discrete nodules. It seems that the discrete nodules in this case become confluent to become infiltrative disease. The histolopathology in d shows discrete metastatic deposits of glandular type metastases separated by spaces within the lesion of mucus consistent with metastatic mucinous adenocarcinoma in a bed of malignant stroma. The distinct blueness and “badness of the malignant tissue is reflective of the hyperchromicity of the nuclii and their dominance in the cell. code liver metastases metastasis discrete diffuse ultrasound grosspathology histopathology Courtesy Ashley Davidoff MD copyright 2009 all rights reserved GW question The series is from a patient who died of metastatic adenocarcinoma. In image a, the ultrasound shows diffuse increased echogenicity in the dome of the right lobe of the liver that suggests diffuse infiltration of metastatic disease. the liver at autopsy showed a combination of diffuse infiltration and discrete nodules. It seems that the discrete nodules in this case become confluent to become infiltrative disease. The histolopathology in d shows discrete metastatic deposits of glandular type metastases separated by spaces within the lesion of mucus consistent with metastatic mucinous adenocarcinoma in a bed of malignant stroma. The distinct blueness and “badness of the malignant tissue is reflective of the hyperchromicity of the nuclii and their dominance in the cell. code liver metastases metastasis discrete diffuse ultrasound grosspathology histopathology Courtesy Ashley Davidoff MD copyright 2009 all rights reserved GW question
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US Liver Metastases
39473 Courtesy Philips Medical Systems liver imaging radiology USscan
The ultrasound of the liver is from a 72 year old patient with metastatic breast carcinoma. There is a region overlaid in green ) that is hyperechoic and diffuse without clear nor rounded borders. No obvious mass or nodule can be defined. This finding represents the less common infiltrating metastatic pattern characteristically, but not exclusively observed in patients with breast carcinoma. code liver cancer malignancy malignant carcinoma metastasis infiltrating infiltrative US USscan ultrasound Courtsy Ashley DAvidoff MD copyright 2009 all rights reserved 24012c01.8s
CYSTIC METASTASES from CARCINOID + fx mass + complex cystic solid metastasis dx carcinoid tumor + imaging radiology CTscan C- mass neoplasm malignant metastasis carcinoma cancer tumor Courtesy Ashley Davidoff MD 20912
20912 liver + fx mass + complex cystic solid metastasis dx carcinoid tumor + imaging radiology CTscan C- mass neoplasm malignant metastasis carcinoma cancer tumor Courtesy Ashley Davidoff MD
The autopsy series is from an elderly female who died with metastatic ovarian carcinoma. The CTscan (a) shows a focal hypodensity at the edge of the right lobe of the liver that was shown to be a metastasis. There is ascites around the spleen. Image b shows a white patch on the liver capsule in the region of the CT finding. Image c shows metastatic disease on the diaphragm characterized by a white rind of malignant tissue. (orange arrow). The histipathology shows three layers of tissue with normal liver at the bottom, the capsule in the middle and the matastatic deposit on the edge of the capsule. liver capsule ovary metastasis malignant primary cancer metastases transpertoneal spread of disease diaphragm Courtesy Ashley Davidoff MD copyright 2009 all rights reserved GW question 02996c02.8s
liver + lymph nodes lymphatics+ lymphatic drainage portal triad + fx normal + anatomy + imaging radiology CTscan 24776 R W c
liver + capsule + spleen fx mass nodule + fx calcification + calcified dx pseudomyxoma peritonei + imaging radiology CTscan 22993
56 year old male with gastric carcinoma and T2 weighted MRI that shows diffuse infiltration of metastic disease (areas of increased water (white) are abnormal and the darker areas are normal liver. The liver is almost totally replaced by diffuse metastases. The histopathology shows an infiltrative patternof dark tissue caused by hyperchromatic nuclii and diminished basophilic cytoplasm. The pink cells in between represent the normal liver. code liver metastases metastasis stomach primary gastric metastases to liver hepatic infiltrative malignant malignancy cancer MRI T 2 weighted image histopathology Courtesy Ashley Davidoff MD copyright 2009 all rights reserved 03146c.8s
51 M hepatic bare area liver abdomen ascites fx mass fx stippled calcification calcified fx psammomatous psamomatous calcifications dx metastattic mucinous adenocarcinoma of the rectum CTscan soft tissue windows Davidoff MD 22359 22357.800
diaphragm liver porta hepatis gastrohepatic ligament Glissons capsule + fx calcification + primary ovary + metastasis + imaging radiology CTscan neoplasm malignant carcinoma tumor cancer 16868
The images show a series of 4 images that reveal a metastaic lesion in the liver from a primary colon carcinoma. The lesion is about 2.5cms in size, has rounded pseudopod like advancing edges (best seen in image b – CT and image C MRI), is situated in the superior aspect of the right lobe of the liver and appears to have a complex nature. The through transmission seen in the ultrasound (a), the low density seen in the CT(b) and brightness on T2 (d) suggest complex fluid. The bright central region and bright lobulated rim on T1 (c) suggest mucin and or hemorrhage. liver hepatic mass a= US through transmission b= CT hypodense lesion c = T1 weighted cental intensity rim and matrix of low intensity periphery hyperintense d = T2 weighting = T2 bright fx metastattic colon carcinoma mucin secreting adenocarcinoma with central hemorrhage peripheral hemorrhage USscan CTscan MRIscan Davidoff MD copyright 2009 all rights reserved 03028c01
The images show a series of 4 images that reveal a metastaic lesion in the liver from a primary colon carcinoma. The lesion is about 2.5cms in size, has rounded pseudopod like advancing edges (best seen in image a – T1 weighted MRI), is situated in the superior aspect of the right lobe of the liver and appears to have a complex nature. The brightness on T2 weighted series (d) and white area in the histopathology (d) suggest water content made up from mucus. The bright central region and bright lobulated rim on T1 (a) suggest mucin and or hemorrhage. The gross pathology shows central necrosis with hemorrhage (c) and the histopathology shows mucinous tumor with hemorrhage at the the advancing edge. liver hepatic mass a= MRI T1 weighted – T1 weighted cental intensity rim and matrix of low intensity periphery hyperintense b= MRI T2 weighted lesion is wet c = gross pathology shows central necrosis and hemorrhage and peripheral hemnorrhage d = histopathology advancing mucin secreting tumor with destroyed liver and hemorrhage fx metastattic colon carcinoma mucin secreting adenocarcinoma with central hemorrhage peripheral hemorrhage MRIscan liver hepatic mass histopathology grosspathology Courtesy Davidoff MD all rights reserved copyright 2009 03028c02
Liver metastases Impinging on the IVC resulting in Budd Chiari Syndrome Courtesy Ashley Davidoff MD code pancreas + fx mass endocrine tumor + code liver capsule fx mass dx metastasis code IVC fx stent dx obstruction Budd Chiari imaging radiology CTscan neoplasm tumor carcinoma cancer 16844
Tumor Thrombus in the Hepatic Vein liver hepatic vein fx tumor thrombus lung fx consolidation dx infiltrative adenocarcinoma of the lung with metastases to the liver and adrenal and invasion of the hepatic veins malignancy cancer Davidoff MD 46581 46588 46587
The collage consists of a CT scan (a) showing a focal well circumscribed low density liver lesion. Biopsy of this lesion yielded the histopathological specimen (b) that shows hyperchromatic nuclii and spindle shaped cells consistent with metastatic leiomyosarcoma. The cytological aspirate (c) shows spindle shaped nuclii with pleomorphism and hyperchromicity. code malignant cancer sarcoma histopathology CTscan Courtesy Ashley Davidoff MD copyright 2009 all rights reserved 03057c01.8s
This series is from a patient who died with diffuse histiocytic lymphoma and DIC. The CT scan (a) shows hepatosplenomegaly with a low density liver suggestive of steatosis. The grosspathology specimen shows an enlarged liver with punctate hemorrhages. The low power histopathology shows a diffuse inflitration of dark nuclii reminiscent of a malignant infiltration, and the high power shows fatty vacuoles within the cytoplasm of the hepatocytes and an infiltrate of histiocytic appearing cells with increased nuclear cytoplasmic ratio (d). liver fatty change steatosis malignant cancer histiocytic lymphoma DIC metastases metastasis CTscan grosspathology histopathology Courtesy Ashley Davidoff MD copyright 2009 all rights reserved GW question 03172c01.8s
Liver Metastases Before and After Therapy liver metastatic small lung carcinoma with diffuse metatstattic disease to the liver )hepatic metastases metastasis before and after treatment 6weeks post chemotherapy successful result size change character change CTscan Davidoff MD 5star 70248c01
Carcinoma – Extending into the Liver via the Gallbladder Fossa
Direct Invasion into the Liver and Bile Duct Obstruction The CTscan of this patient shows a normal sized gallbladder (green) associated with a 4-5cms mass (orange) adjacent to the gallbladder, and extending from the gallbladder fossa. There is asssociated biliary obstruction (dark green tubes)· This case represents invasive gallbladder carcinoma with bile duct obstruction. Images c and d show the almost universal association of gallstones in patients with carcinoma.···In this case the stones (white) are in the centre of the gallbladder. (green) ·16254c03.8s gallbladder anterior wall liver invasion space occupatopn obstruction bile ducts aggressive gallbladder carcinoma complicated by direct invasion metastasis liver windows narroe windws tumor settings gallbladder fossa GBF CTscan Courtesy Ashley Davidoff copyright 2008
Dystrophic Calcification – Carcinoma of the Gallbladder Extending into the Gallbladder Fossa The non-contrast CT of the 75year old female patient, shows dystrophic calcification·in a mass that seems to be part of the wall of the gallbladder.· The·mass extends into the liver.· These findings are consistent with an inoperable gallbladder mucinous adenocarcinoma, metastatic to the liver by direct extension.· Calcification of adenocarcinomas is usually found in the mucinous variant of the disease. 24404c.8s 75 female gallbladder calcification adjacent mass in the liver local invasion into the gallbladder fossa dystrophic calcification probably mucinous adenocarcinoma of the gallbladder carcinoma stones cholelithiasis hydronephrosis
Carcinoma – Extending into the Liver via the Gallbladder Fossa and Additional Metastases
Local Invasion and Separate Liver Mestastasis The CTscan in this patient shows two calcified gallstones in the gallbladder (green), with a mass like malignant abnormality extending into the liver on either side (yellow) and a remote metastasis (orange) which is deforming the liver edge. 17280c02b01.8s gallbladder liver mass local invasion cholelithiasis metastasis carcinoma primary gallbladder gallbladder fossa Courtesy Ashley Davidoff MD copyright 2008
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