Tumori, 90: 525-527, 2004
CYSTIC LIVER METASTASES FROM LUNG ADENOCARCINOMA: A CASE REPORT Fabrizio Romano, Andrea Porta, Roberto Caprotti, Fabio Uggeri, Matteo Conti, and Franco Uggeri Department of Surgery, San Gerardo Hospital, Monza, II University of Milan Bicocca, Milan, Italy
Cystic hepatic metastases arising from lung cancer are rare. We herein describe a case of a 71-year-old women admitted to our hospital for abdominal pain 6 months after the resection of a lung adenocarcinoma. Two cystic lesions of the liver were discovered at abdominal ultrasonography and computerized tomography scan. An ERCP excluded a biliary adenoma or adenocarcinoma, and an ultrasound-guided liver biopsy was negative for malignant cells. For persistence of symptoms
and lack of a diagnosis, the patient underwent an exploratory laparotomy, a surgical biopsy with a diagnosis of adenocarcinoma, and a consequent right hepatectomy. After 2 years of follow-up, the patient is well and disease free. Although cystic liver metastasis are rare and a differential diagnosis difficult, the malignant nature should always be considered in the differential diagnosis of hepatic cysts to offer the patient the best treatment.
Key words: cystic components, liver metastasis, lung adenocarcinoma.
Introduction
Neoplastic cystic lesions of the liver include biliary cystadenoma or cystoadenocarcinoma and metastatic lesions from the pancreas, ovary1, kidney2, prostate3 and colon4. Unusual lesions, such as mesothelioma5 or sarcoma6, are rarely reported. Secondary cystic degeneration of primary or metastatic liver tumors is believed to be due to spontaneous intratumoral hemorrhage, which is recognized in hepatic adenoma, hepatocellular carcinoma and metastatic leiomyosarcoma 7. Cystic liver metastasis, although not frequent, usually arises from colorectal cancers, whereas lesions from other neoplasms such as lung cancer are very rare and, to the best of our knowledge, only one case has been reported in the literature8. Diagnosis of such lesions is often difficult, even after an accurate instrumental diagnosis and eventually biopsies, but otherwise essential to offer the best treatment option to the patient. We herein describe a case of two large symptomatic metastatic cystic lesions of the liver deriving from a previously treated lung adenocarcinoma.
appetite, with a subsequent weight loss of 5 kg. She had no nausea, vomiting, dysphagia or odynophagia. Laboratory tests were within normal values. The patient underwent abdominal ultrasound and computerized tomography (CT) scan, which demonstrated 2 cystic masses within the right lobe of the liver (maximum diameter of 7.1 and 1 cm, respectively). The ultrasound images showed 2 hypoechoic heterogeneous lesions with a hyperechoic border. Abdominal CT scan (Figure 1) confirmed the cystic nature of the lesions with the presence of 2 low-density masses with homogeneous at-
Case report
A 71-year-old woman underwent a right superior lobectomy of the lung after neoadjuvant chemoradiotherapy in February 2001. Preoperative workup was negative for metastatic diffusion. The tumor was an adenocarcinoma pathologically staged as pT2N0M0. Six months later the woman was admitted to the hospital because she developed increasing pain in the right upper abdominal quadrant which irradiated to the epigastrium and was associated with a marked decrease in
Figure 1 - CT abdominal scan showing a 7 cm cystic lesion of the right lobe of the liver with slight enhancement of the peripheral zone.
Correspondence to: Fabrizio Romano, MD, Department of Surgery (Chirurgia I), San Gerardo Hospital, II University of Milan Bicocca, Via Donizetti 106, 20052 Monza, Italy. Tel +39-039-2333456/2332393/2333449; fax +39-039-2333600; e-mail
[email protected] Received August 28, 2003; accepted December 19, 2003.
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tenuation and slight enhancement in the peripheral zone. Owing to the suspicion of the metastatic nature of the lesions, although tumor markers were negative, the patient underwent ultrasound-guided biopsy of the larger mass with the evacuation of a brown fluid. Histologic examination was negative for malignant cells. In the hypothesis of biliary cystoadenoma, an endoscopic retrograde cholangiopancreatography (ERCP) was performed and showed a dislocation of the right intrahepatic biliary tree, without infiltration or communication with the cystic mass. Liver arteriography, performed to evaluate eventual vascular invasion and to plan surgery (Figure 2), showed 2 avascular lesions with thick edges suspicious for secondary masses. The right portal branch was unidentifiable because of compression and/or infiltration. Owing to the persistence of symptoms and for the lack of a diagnosis, the patient underwent to an exploratory laparotomy. A biopsy of the cystic wall was performed, and frozen examination showed the presence of an adenocarcinoma. A right hepatectomy was thus performed. The definitive histologic diagnosis was metastasis from undifferentiated lung adenocarcinoma with necrotic and hemorrhagic areas. The tumor was present in the periphery of the lesions. Carcinoma cells lined/underlay part of the internal wall. The postoperative course was uneventful, and patient was well and disease free after 2 years of follow-up.
Figure 2 - Hepatic angiography showing an avascular lesion with a thick edge suspicious for secondary masses.
F ROMANO, A PORTA, R CAPROTTI ET AL
Discussion
Cystic liver metastasis are a rare entity and usually derive from colorectal4, and rarely from pancreatic9 and gastric10 cancer. Some secondary localizations from rare tumors, such as neuroectodermal neoplasms, have been reported11. Recently, cystic changes in hepatic metastasis from gastrointestinal stromal tumors treated with Gleevec have been observed12. Moreover, some primary rare cystic liver lesions have been reported, such as benign cystic mesothelioma of the liver and a cystic variant of embryonal sarcoma of the liver. Otherwise, the literature lacks reports of metastatic cystic lesion from lung adenocarcinoma. A cerebral13 and only an hepatic metastatic tumor have been reported8. The cause of the cystic change in these secondary liver tumors is not well understood. It is generally believed that the hemorrhage and necrosis usually present in these lesions indicate that the tumor has grown rapidly, outstripping/depleting its blood supply14. Our case, in which a 7-cm lesion developed within 6 months (time development of a 7 cm lesion), supports this hypothesis. Furthermore, a degeneration by apoptosis was considered in a case of cavernous hemangioma15. Differential diagnosis is a concern and major considerations include biliary cystadenoma, cystadenocarcinoma and benign tumors. Intrahepatic bile duct dilatation distal to the tumor, septicemia/septation and a thick cyst wall are features, even if not always present, of cystoadenocarcinoma16. A connection with the intrahepatic biliary system or hilar bile duct compression may lead to a diagnosis17, and ERCP and cholangio-magnetic resonance imaging are helpful diagnostic tools. In our case, ERCP did not identify infiltration or communications between the cystic mass and biliary tree. In some cases, it may be difficult to differentiate metastases that appear cystic from benign tumors such as cysts. Serum CEA, ultrasound and CT scan may provide only limited information for differentiation18. An enhanced cyst wall and enhanced septa on CT may provide helpful findings, because they can reflect viable cancerous tissue. In our patient, CT scan showed a slight enhancement in the peripheral zone of the lesion, leading to the suspicious of a malignant nature of the cysts. Although ultrasound-guided liver biopsy was negative for neoplastic cells and owing to persistent symptoms and lack of a certain diagnosis, a surgical biopsy was performed which permitted the diagnosis and offered the patient the appropriate treatment. Even though metastatic cystic hepatic lesions deriving from lung cancer are very rare and the differential diagnosis is not easy, the malignant nature should be always suspected especially if the mass grows quickly. The correct diagnosis leads to the best treatment for the patient.
References 1. Doty JE, Thompkins RK: Management of cystic disease of the liver. Surg Clin North Am, 69: 285-295, 1989. 2. Forbes A, Lyon IMM: Cystic disease of the liver and biliary tract. Gut, S: 116-122, 1991.
3. Demarquary JF, Caroli-Bosc FX, Hastier P: Metastases hepatiques multiples et isolee d’allure kystique d’un adenocarcinome prostatique. Gastroenterol Clin Biol, 20: 511-512, 1996.
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4. Sugawara Y, Yamamoto J, Yamasaki S, Shimada K, Kosuge T, Sakamoto M: Cystic liver metastases from colorectal cancer. J Surg Oncol, 74: 148-152, 2000. 5. Flemming P, Becker T, Klempnauer J, Hogemann D, Kreft A, Kreip HH: Benign cystic mesothelioma of the liver. Am J Surg Pathol, 26: 1523-1527, 2002. 6. Shah SR, Joshi P, Bhaduri AS, Bharelao RA: Cystic variant of embryonal sarcoma of the liver. Indian J Gastroenterol, 21: 35-36, 2002. 7. Federle MP, Filly RA, Moss AA: Cystic hepatic neoplasms: complementary role of CT and sonography. AJR, 136: 345348, 1981. 8. Mizuguchi M, Nishi K, Tachibana H, Ohka T, Kurumaya H, Fujimara M, Matsuda T: Adenosquamous cell carcinoma of the lung with multiple cystic metastases in the liver. Nihon Kyobu Shikkan Gakkai Zasshi, 35: 306-310, 1997. 9. Bradea C, Fortu L, Andrei A, Mihaila D, Niculescu D, Daniil C, Florescu C: Case of cystic metastasis of the liver. Rev Med Chir Soc Med Nat Iasi, 105: 570-572, 2001. 10. Ito T, Nishida H, Kawada T, Senjyu S, Nanbu K, Nishikawa J: A case of gastric adenosquamous carcinoma with cystic hepatic metastases. Nippon Shokakibyo Gakkai Zasshi, 90: 1445-1449, 1993. 11. Shah BK, McHugh K: Cystic liver metastases from extracra-
12. 13. 14.
15.
16. 17. 18.
nial primitive neuroectodermal tumour: a case report. Pediatr Radiol, 30: 834-836, 2000. Chen MY Bechtold RE, Savage PD: Cystic changes in hepatic metastases from gastrointestinal stromal tumors (GISTs) treated with Gleevec. Am J Roentgenol, 179: 1059-1062, 2002. De Shields MS, Ruether J: Lung carcinoma presenting as multiple cystic lesions in the brain. Del Med J, 70: 77-80, 1998. Aoki K, Takayasu K, Muramatsu Y: Spontaneous massive hemorrhage within a malignant tumor of the liver: diagnostic features in sonography and CT. Jpn J Clin Oncol, 21: 366371, 1991. Hanazaki, Koide N, Kajikawa S, Ushiyama T, Watanabe T, Amano J: Cavernous hemangioma of the liver with giant cyst formation: degeneration by apoptosis? J Gastroenterol Hepatol, 16: 352-355, 2001. Szubert A, Bialek P, Biejat Z, Uryszek M, Zajac L, Polanski JA: Liver adenocarcinoma, case report. Med Sci Monit, 7S: 292-293, 2001. Hara H, Morita S, Sako S, Dohi T, Iwamoto M, Inoue H, Tanigawa N: Hepatobiliary cystadenoma combined with multiple liver cysts: report of a case. Surg Today, 31: 651-654, 2001. Wooten WB, Korobkin M, Callen PW: Ultrasonography of necrotic hepatic metastases. AJR, 131: 843-846, 1978.
