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British Journal of Radiology (2005) 78, 1098-1103
© 2005 British Institute of Radiology
doi: 10.1259/bjr/16104611
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A pictorial review of the varied appearance of atypical liver metastasis from carcinoma of the breast

H Roach, MRCP, FRCR1, E Whipp, MA, FRCR2, J Virjee, FRCR1 and M P Callaway, MRCP, FRCR1

1 Department of Clinical Radiology, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW and 2 Department of Oncology, Bristol Oncological Centre, Horfield Road, Bristol BS2 8ED, UK



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  		Figure 1. Small liver metastasis. (a) Standard liver ultrasound in a patient with a history of carcinoma of the breast. No focal abnormality was detected. (b) Following the injection of microbubble contrast media, a small 7 mm hypoechoic focus can be identified in the parenchymal phase of liver enhancement. (c) Standard T1 weighted MR. There is a small low signal lesion in the posterior aspect of the right lobe of the liver. (d) Standard T2 weighted MR. The lesion can just be identified on this sequence. (e) T2 fat saturation breath hold MR. The small lesion now has an increased signal. (f) A sub-10 mm liver metastasis (arrow) is clearly visible on this T2 weighted post-iron oxide MR image of the liver. Post-iron oxide (Endorem; Guerbet, Paris) MR is the most sensitive non-invasive method of identifying liver metastasis.

 


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  		Figure 2. Small hypervascular metastasis. (a) A hypoechoic lesion can be seen on this conventional ultrasound adjacent to the portal vein. No Doppler flow from within the lesion has been demonstrated. (b) The lesion is very difficult to identify on this portal venous phase CT despite being approximately 1 cm in diameter. However, increased attenuation in the region of the arrows and a poorly defined focal abnormality, are identifiable.

 


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  		Figure 3. Hypervascular metastasis. (a) There is a large part-solid, part-cystic lesion in the mid portion of the right lobe of the liver demonstrated on ultrasound. This lesion was identified 8 years following the original mastectomy on routine follow up. (b) The liver is now imaged using a continuous low mechanical index harmonic package following the injection of 2.4 ml of Sonovue (Bracco, Milan, Italy). This image was obtained during the arterial phase of enhancement. There is a hypervascular solid rim to the lesion. This rim became hypoechoic during the sinusoidal phase, a feature of malignancy. The lesion was biopsied, and this confirmed adenocarcinoma of the same cell type as the primary breast carcinoma.

 


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  		Figure 4. Changes mimicking cirrhosis. (a) There is a single metastasis in the right lobe of the liver, arrowed, on this contrast enhanced CT. The size and shape of the liver is, however, normal. (b) There is considerable morphological change in the size and shape of the liver on this post-chemotherapy CT obtained 12 months after the original scan. The right lobe is irregular with hypertrophy of the left and caudate lobe. These appearances are similar to those of background cirrhosis. A non-focal liver biopsy was performed into the right lobe and this demonstrated diffuse metastatic adenocarcinoma.

 


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  		Figure 5. Fulminant hepatic failure. (a) This patient presented with fulminant liver failure with rapid deterioration of liver function. The liver was enlarged with some non-specific patchy abnormality and gross ascites. (b) Several axial sections through this liver demonstrate intrahepatic portal hypertension with recanalization of the umbilical vein arrowed. This demonstrates a diffuse process, and a transjugular liver biopsy demonstrated diffuse metastatic adenocarcinoma. The inferior vena cava (IVC) is also compressed by the rapidly enlarging liver. The patient died 2 days later.

 


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  		Figure 6. Development of lobar atrophy. (a) On this unenhanced CT of the liver there is an area of low attenuation at the junction of segments 2, 3 and 4. This area is wedge shaped, suggesting it is vascular in nature. A biopsy of this region confirmed metastatic adenocarcinoma. (b) During the portal venous phase of contrast enhancement this area of abnormality is no longer visible. There is a small area of low density within the periphery of this wedge shape region. The portal vein is patent. (c) 15 months later, despite several courses of chemotherapy, there is almost complete atrophy of the left lobe of the liver. There is extensive ascites present. The left portal vein was not identified, but the main portal vein remained patent.

 


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  		Figure 7. (a, b) Capsular retraction. A large single metastasis developed 8 years after the resection of the primary segment 4 of the liver. There is considerable distortion of the liver surface with marked capsular retraction. This feature is more common in large metastasis

 




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