British Journal of Radiology (2005) 78, 1098-1103
© 2005 British Institute of Radiology
doi: 10.1259/bjr/16104611
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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Introduction
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Each year in the UK around 41 000 new cases of breast cancer are diagnosed and about 13 000 patients die of breast cancer. Breast cancer is the most common single cause of death among women aged 35–54 years. Each year 1 or 2 women in every thousand will be newly diagnosed with breast cancer. 75% of these will be post-menopausal women. 1 in 9 women in the UK will develop the disease. Metastases to the liver are a common complication of this condition occurring in up to 20% [1] of patients. The liver is the most common site of intra-abdominal metastastic disease.
Whilst the vast majority of liver metastasis have a classic target appearance on ultrasound or produce an irregular area of low attenuation during the portal phase of contrast enhancement on CT, the pattern of metastatic disease can be extremely varied. This pictorial review demonstrates this variable appearance of liver lesions on a range of imaging modalities (Figure 1
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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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Unusual patterns of disease
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Lesions in the fatty liver
The benefit of Tamoxifen administration for patients with oestrogen receptor-positive breast cancer outweighs the risk of any complications of its usage. One of the complications of Tamoxifen therapy is massive hepatic steatosis, as demonstrated on unhanced CT [2, 3]. In one series, up to 43% of patients on Tamoxifen developed hepatic steatosis within the first 2 years of treatment. This pattern can be in a lobar or generalized distribution. This phenomenon can lead to a derangement of liver function tests and it is important to differentiate this condition from metastatic disease. The presence of fat can make the interpretation of liver patterns on ultrasound examination difficult, but the use of microbubble contrast media and continuous low mechanical index imaging can aid in the diagnosis of metastatic disease
Hypervascular breast liver metastases (Figures 2 and 3)
Most metastases to the liver from breast carcinoma have the typical appearance of a hypovascular lesion, best demonstrated in the portal venous phase of enhancement on contrast enhanced CT. Several series have demonstrated that up to 26% of liver metastases from carcinoma of the breast can be identified as hypervascular in the arterial phase of contrast enhancement [4].
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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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Metastatic disease mimicking cirrhosis (Figure 4)
Carcinomatous involvement of the liver mimicking cirrhosis is a rare complication of carcinoma of the breast, and although this condition was first reported in the early 1970s there remain only a few reported cases in the literature [5]. In an early case report there was evidence of associated portal hypertension. Variceal bleeding as a result of metastatic infiltration causing portal hypertension is rare, but has been reported. At autopsy, intense intrahepatic stromal fibrosis was reported with associated intravascular tumour infiltration with compression of the portal system. The morphological pattern within the liver that develops is similar to the appearances of established cirrhosis [5]. This condition is characterized by an irregular hepatic contour, segmental volume loss and enlargement of the caudate lobe. In addition, focal lesions suggestive of focal nodular regeneration have been reported [6]. In one series only 4% of these lesions were identified only on the hepatic arterial phase of enhancement.
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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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Fulminant hepatic failure (Figure 5)
Fulminant hepatic failure resulting from diffuse intrasinusoidal metastatic disease from carcinoma of the breast is a rare but recognized presentation of hepatic involvement [7–9]. This rare complication often presents with rapid onset of ascites, marked elevation of the serum bilirubin and hypoalbuminea. The imaging is often non-specific with no evidence of a focal abnormality and diffuse enlargement of the organ.
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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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This form of metastatic disease has also been reported in malignant melanoma [10], small cell carcinoma of the lung [11], gastric carcinoma [12] and Hodgkin's lymphoma [13].
Lobar atrophy (Figure 6)
Atrophy of a lobe of the liver, usually the left, can rarely occur as a result of a metastatic deposit directly invading the vascular structure leading to the lobe [14]. The development of lobar atrophy usually occurs in the setting of combined biliary and portal vein obstruction. Whilst the biliary obstruction may involve both lobes, portal vein occlusion is usually unilateral and confined to the atrophic lobe in the majority of cases (87%). In one series the most common cause for lobar atrophy was malignant infiltration [15].
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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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Capsular retraction (Figure 7)
Hepatic capsular retraction is common in patients with hepatic metastasis from breast carcinoma, occurring in up to 15% of patients with liver metastasis [16]. This appearance is usually associated with larger liver metastasis, and can occur if there is a marked change, either increase or decrease, in the size of the metastasis.
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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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Conclusion
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Metastatic carcinoma of the breast can produce a variety of appearances within the liver, affecting the morphology of the organ and even leading to fulminant hepatic failure.
Received for publication October 19, 2004.
Revision received April 25, 2005.
Accepted for publication May 16, 2005.
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References
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Introduction
Unusual patterns of disease
