Liver Metastases : Treatment & Prognosis

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Treatment & Prognosis::The prognosis depends upon the extent of replacement of liver parenchyma by metastases. The greater the tumor burden, the worse the prognosis. Only about 50% of patients are alive 3 months after presentation and less than 10% survive for a year or more. The treatment is mainly aimed at palliation. The prognosis has improved lately with advancements in surgical techniques for resection, availability of new chemotherapeutic agents, and the use of regional therapies.

Colorectal Cancer: Patients with isolated liver metastases from colo-rectal cancers should undergo resection. Long-term disease-free survival or even cure has been achieved in many such cases. Liver has remarkable capacity to undergo hypertrophy and up to 80% of the liver can be resected as long as vascular perfusion and biliary and venous drainage is intact in the remnant liver. Rapid hypertrophy can restore normal liver function within weeks. Patient who are unable to tolerate or refuse surgery may be offered radiofrequency ablation of tumor.

Neuroendocrine Tumors: Hepatic metastases of neuroendocrine tumors may sometimes cause Carcinoid syndrome. The patients often experience dramatic relief of symptoms after resection of metastatic foci. Hepatectomy followed by liver transplantion with or without chemotherapy has been attempted in a small number of advanced cases. The failure rate is unacceptably high.

This autopsy photograph shows liver metastases from squamous cell carcinoma (SCC) of lung. Metastatic SCC is uncommonly seen in the liver. The primary sites include lung, esophagus, head and neck, genital tract, and anorectal region. The determination of primary site rests on accurate clinical history as immunohistochemical studies are unhelpful.

About the Disease

Metastasis is the most common malignancy in non-cirrhotic livers in the Western countries. About 40%-50% of patients dying from cancer have liver metastases. Liver is highly susceptible due to dual blood supply (hepatic and portal) and fenestrations in sinusoidal epithelium which allow tumor cells to escape into the parenchyma. Primary sites in adults: pancreas, stomach, colon, lung, breast, kidney, malignant melanomas, and soft tissue sarcomas. Malignancies of gall bladder, extrahepatic bile ducts, stomach, and pancreas can spread to liver by direct extension. Primary sites in children: neuroblastoma, Wilms tumor, and rhabdomyosarcoma. Presentation ranges from no symptoms to fulminant hepatic failure. Patients may develop malaise, anorexia, weight loss, abdominal pain, and obstructive jaundice. Diagnosis can be accurately made in most cases by CT- or ultrasound guided-FNA and needle core biopsies. Metastases form multiple, discrete expansive masses or ill-defined infiltrative areas. Larger nodules undergo necrosis and fibrosis producing umbilication. Liver may be greatly enlarged with an irregular surface. Malignancies of breast, stomach, lung, pancreas, and lymphomas may produce miliary involvement. Metastases are quite rare in cirrhotic livers. Microscopic features are those of the primary tumor. Metastatic adenocarcinomas may invade bile ducts and show intrabiliary growth mimicking cholangiocarcinoma. Prognosis is poor in most cases (with some exceptions). Most patients die within 1 year of presentation. Resection of isolated liver metastases from colo-rectal cancers can produce long-term disease-free survival or even cure in some cases. Patients with liver metastases from neuroendocrine tumors and Carcinoid syndrome get dramatic relief from symptoms after resection of metastatic foci. References: 1. Iacobuzio-Donahue, C. A. & Montgomery E. (2012). Gastrointestinal and Liver Pathology - 2nd Edition. Philadelphia, PA. Elsevier Saunders. 2. Feldman, M., Friedman, L. S., & Brandt, L. J. (2016). Sleisenger & Fordtran's Gastrointestinal & Liver Disease - 10th Edition. Philadelphia, PA. Elsevier Saunders. 3. Goldblum, J. R. et al (2018). Rosai and Ackerman's Surgical Pathology - 11th Edition. Philadelphia, PA. Elsevier.4. DeVita, V. T., Lawrence, T. S., & Rosenberg, S. A. (2019). Cancer - Principles & Practice of Oncology - 11th Edition. Wolters Kluwer.

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