Liver metastases are common in many types of cancer, especially those of the gastrointestinal tract, breast, lung, and pancreas. The first symptoms of metastases are usually nonspecific (eg, weight loss, right upper quadrant discomfort); they are sometimes the first symptoms of the primary cancer. Liver metastases are suspected in patients with weight loss and hepatomegaly or with primary tumors likely to spread to the liver. Diagnosis is usually supported by an imaging test, most often ultrasonography, spiral CT with contrast, or MRI with contrast. Treatment usually involves palliative chemotherapy.
Metastatic liver cancer is more common than primary liver cancer and is sometimes the initial clinical manifestation of cancer originating in the gastrointestinal tract, breast, lung, or pancreas.
Symptoms and Signs of Metastatic Liver Cancer
Early liver metastases may be asymptomatic. Nonspecific symptoms of cancer (eg, weight loss, anorexia, fever) often develop first. The liver may be enlarged, hard, or tender; massive hepatomegaly with easily palpable nodules signifies advanced disease. Hepatic bruits and pleuritic-type pain with an overlying friction rub are uncommon but characteristic. Splenomegaly is occasionally present, especially when the primary cancer is pancreatic. Concomitant peritoneal tumor seeding may produce ascites, but jaundice is usually absent or mild initially unless a tumor causes biliary obstruction.
In the terminal stages, progressive jaundice and hepatic encephalopathy presage death.
Diagnosis of Metastatic Liver Cancer
CT with contrast or MRI with contrast
Sometimes biopsy
Photo courtesy of Patrick O’Kane, MD.
Liver metastases are suspected in patients with weight loss and hepatomegaly or with primary tumors likely to spread to the liver. If metastases are suspected, liver tests are often done, but results are usually not specific for the diagnosis. Alkaline phosphatase, gamma-glutamyl transpeptidase, and sometimes lactate dehydrogenase typically increase earlier or to a greater degree than do other test results; aminotransferase levels vary. Imaging tests have good sensitivity and specificity. Ultrasonography is usually helpful, but CT with contrast or MRI with contrast is often more accurate.
Liver biopsy guided by imaging provides the definitive diagnosis and is done if other tests are equivocal or if histologic information (eg, cell type of the liver metastasis) may help determine the treatment plan.
Treatment of Metastatic Liver Cancer
Sometimes surgical resection
Sometimes systemic chemotherapy; sometimes hepatic intra-arterial chemotherapy
Occasionally, radiation therapy for palliation
Treatment depends on the extent of metastasis.
With solitary or very few metastases due to colorectal cancer, surgical resection may prolong survival.
Depending on characteristics of the primary tumor, systemic chemotherapy may shrink tumors and prolong life but is not curative; hepatic intra-arterial chemotherapy sometimes has the same effect but with fewer or milder systemic adverse effects.
Radiation therapy to the liver occasionally alleviates severe pain due to advanced metastases but does not prolong life. Extensive disease is fatal and is best managed by palliation for the patient and support for the family (see The Dying Patient).
Hematologic Cancers and the Liver
The liver is commonly involved in advanced leukemia and related blood disorders. Liver biopsy is not needed. In hepatic lymphoma, especially Hodgkin lymphoma, the extent of liver involvement determines staging and treatment but may be difficult to assess. Hepatomegaly and abnormal liver tests may reflect a systemic reaction to Hodgkin lymphoma rather than spread to the liver, and biopsy often shows nonspecific focal mononuclear infiltrates or granulomas of uncertain significance. Treatment is directed at the hematologic cancer.
