Original article
Brief communication
Malignant Infiltration of the Liver Presenting as Acute Liver Failure

https://doi.org/10.1016/j.cgh.2014.09.040Get rights and content

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.

Section snippets

Methods

Between January 1998 and February 2012, there were 1910 adult patients with ALF of all etiologies who were enrolled in the Acute Liver Failure Study Group registry from a total of 23 sites. All patients showed some degree of encephalopathy and coagulopathy (prothrombin time >15 s, or INR > 1.5) in the absence of pre-existing cirrhosis, with an illness of fewer than 26 weeks' duration.1 Cases of ALF secondary to malignancy were identified in 27 of 1910 patients (1.4%).

Informed consent was

Patient Demographics

The patient group was relatively young, with a mean age of 47.1 years. Eighteen patients were women (Table 1). Common etiologies were leukemia/lymphoma in 11 (41%) and breast cancer in 8 (30%). The remaining etiologies were colon cancer (2), and 1 each of signet ring adenocarcinoma, uterus, prostate, thyroid, pancreas, and small-cell lung cancer. All tumors were metastatic with no liver or biliary primary tumors leading to ALF.

Clinical Features

The time between the onset of symptoms and admission to the hospital

Discussion

The diagnosis of ALF secondary to malignancy can be challenging and may elude clinicians initially, particularly in patients with no previous cancer history. The 2 most common etiologies of malignant infiltration of the liver we observed were lymphoma and breast cancer, similar to prior studies and to general trends for common malignancies. Notably, there were no melanomas, endocrine tumors (eg, Apudomas), or primary hepatic malignancies. There were only 2 patients with colon cancer.

Common

Conclusions

Clinicians must have a high index of suspicion when approaching a case of ALF of indeterminate etiology. Hepatomegaly may be one of the only clues. Imaging often is nondiagnostic. Early liver biopsy in indeterminate cases must be considered because it can indicate the direction of future care: avoidance of needless transplantation and enabling more appropriate end-of-life care, or more aggressive steps in some circumstances. There may be a role for OLT in very select patients with ALF secondary

Acknowledgments

The authors would like to thank Dr Henry D. Appelman (Department of Pathology, University of Michigan Health System, Ann Arbor, MI) for the preparation of photomicrographs for this article.

The Acute Liver Failure Study Group sites for 2010–2012 were as follows: UT Southwestern Medical Center; University of Washington; University of California–San Francisco; Northwestern University; University of California–Los Angeles; University of Michigan; Yale University; University of Alabama Birmingham;

References (20)

There are more references available in the full text version of this article.

Cited by (44)

  • Systemic Non-infectious Hepatitis

    2023, Comprehensive Guide to Hepatitis Advances
  • Acute hepatitis and acute liver failure: Pathologic diagnosis and differential diagnosis

    2019, Seminars in Diagnostic Pathology
    Citation Excerpt :

    Despite the fact that the liver is the most common site for metastasis, neoplasm-associated ALF is rare. In a study of 27 patients,102 the most commonly associated malignancies are lymphoma or leukemia (33%), breast cancer (30%), and colon cancer (7%). Twenty-four patients (89%) died within 3 weeks of ALF.

  • Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis

    2020, Journal of Clinical and Experimental Hepatology
    Citation Excerpt :

    In patients with lymphoma, a greater elevation of lactate dehydrogenase is observed compared with serum transaminases. Consideration of an underlying malignant process and potential infiltration should also be considered in acute presentations of BCS.175 Consensus Statement: Etiology, Rare Causes

View all citing articles on Scopus

Conflicts of interest The authors disclose no conflicts.

Funding The Acute Liver Failure Study Group was supported by a grant from the National Institute for Diabetes and Digestive and Kidney Diseases (U01-DK-58369) to the University of Texas Southwestern Medical Center at Dallas.

View full text