A Rare Case of Acute Liver Failure Secondary to Diffuse Hepatic Infiltration of Small Cell Neuroendocrine Carcinoma

Unusual Presentation of a Hepatic Neuroendocrine Tumor With Elevated CEA and CA 19-9: A Case Report

Neuroendocrine tumors (NETs) of the gastrointestinal tract (GIT) are rare malignancies, which may have unique presentations. The diagnostic process predominantly relies on immunohistochemical analysis. While tumor markers are extensively utilized in diagnosing and monitoring GI malignancies, their specific role in NETs has not been fully explored. This case describes an 83-year-old male presenting with jaundice and general weakness. Diagnostic imaging through MRI and CT angiography (CTA) revealed a nodular texture on the liver's surface suggesting cirrhosis. The presence of elevated tumor markers, specifically carcinoembryonic antigen (CEA) and cancer antigen 19-9 (CA 19-9), raised suspicions of malignancy. A subsequent liver biopsy confirmed the diagnosis of small-cell high-grade neuroendocrine carcinoma accompanied by reactive fibrosis. As per our knowledge, this case is the first recorded instance of a liver neuroendocrine tumor (NET) exhibiting elevated levels of both CEA and CA 19-9, with no abnormalities detected in the gallbladder, biliary tree, and bowel in the MRI with magnetic resonance cholangiopancreatography (MRCP) and CTA. This is an atypical presentation of a liver NET, mimicking cirrhotic liver morphology, and underscores the potential diagnostic relevance of tumor markers CEA and CA 19-9 in such cases.

Liver failure as the initial presentation in cancer of unknown primary: a case report

BACKGROUND

Liver failure is severe hepatic cellular damage caused by multiple factors that leads to clinical manifestations. Hepatic infiltration by malignancy is rarely reported as a cause of liver failure.

CASE PRESENTATION

A 51-year-old male patient was admitted to the Wuhan Union Hospital complaining of bloating and jaundice. He had been diagnosed with polymyositis ten prior and was taking oral glucocorticoids. Physical examination revealed seroperitoneum and icteric sclera; laboratory tests revealed liver dysfunction, a coagulopathy, and negative results for the common causes of liver failure. Moreover, an ascitic tap and bone marrow aspirate and trephine confirmed a metastatic, poorly differentiated adenocarcinoma. These findings indicate that malignant infiltration is the most likely cause of liver failure. Regrettably, the patient refused complete liver and lymph node biopsies and was discharged on day 31.

CONCLUSION

Clinicians should consider the possibility of malignant infiltration when approaching a case of liver failure with prodromal symptoms or imaging abnormalities, especially in patients with autoimmune diseases, such as polymyositis.

A case of neuroendocrine carcinoma with massive invasion to the liver and multiorgan causing acute liver failure

INTRODUCTION

Acute liver failure (ALF) due to a malignant neoplasm is rare. Here, we present a case of neuroendocrine carcinoma (NEC) with massive invasion to the liver and multi-organ causing ALF that resulted in a poor outcome. A 56-year-old man was referred to our hospital for ALF of unknown cause. Abdominal imaging studies revealed hepatomegaly with multiple intrahepatic lesions. The patient also showed disseminated intravascular coagulation. Despite administration of prednisolone for the ALF, he died suddenly of respiratory failure on day 3 after admission. Autopsy showed a markedly enlarged liver weighing 4,600 g with diffuse nodular lesions. The tumors had metastasized to the lungs, spleen, adrenal glands, and bone marrow. Severe pulmonary hemorrhage was also noted. Histologically, the tumors were poorly differentiated and composed of small-sized and uniform neoplastic cells, positive for chromogranin A, synaptophysin, CD56, and p53 with a Ki-67 labeling index of over 50%. As there was no primary lesion in the gastrointestinal tract, pancreas, or other organs, primary hepatic neuroendocrine carcinoma (PHNEC) was suspected.

CONCLUSION

We experienced a case of NEC causing ALF and multi-organ invasion with a rapidly deteriorating course. Liver metastasis from a neuroendocrine tumor/neoplasm is common, while a primary hepatic neuroendocrine tumor/neoplasm is extremely rare. We could not determine PHNEC; however, it was highly suspected. Further studies are needed to elucidate the pathogenesis of this rare disease.