Original articleBrief communicationMalignant Infiltration of the Liver Presenting as Acute Liver Failure
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;
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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.