Pseudocirrhosis in Breast Cancer - Experience From an Academic Cancer Center

ESR Essentials: assessing the radiological response of liver metastases to systemic therapy-practice recommendations by the European Society of Gastrointestinal and Abdominal Radiology

The liver is a common site for metastatic spread, especially in advanced colorectal, breast, and pancreatic cancers. Imaging evaluation of liver metastases after systemic treatments like chemotherapy, targeted therapy, or immunotherapy is essential to distinguish treatment response from disease progression. The widely used response evaluation criteria in solid tumours (RECIST 1.1) focus on lesion size changes to evaluate treatment response. However, newer therapies, mainly targeted therapy and immunotherapy, often induce changes beyond size reduction, such as tumour necrosis, fibrosis, cystic transformation, calcifications, and modifications at the liver-tumour interface. These morphological and enhancement changes can be evaluated on CT and MRI and may better reflect the biological response in specific clinical settings. Overall, RECIST 1.1 criteria are recommended for assessing the radiological response of liver metastases after systemic treatment. The use of alternative radiological criteria validated on CT (such as Chun or Choi criteria) is recommended in specific clinical settings (e.g. metastatic colorectal cancer or metastatic gastrointestinal stromal tumours). Additionally, CT and MR modifications that reflect fibrosis, necrosis, calcifications, and haemorrhage can serve as ancillary indicators of tumoural response. These alternative criteria and radiological findings should be systematically assessed, particularly in liver metastases with minimal size changes, to better identify responders. KEY POINTS: RECIST 1.1 is the standard for evaluating tumour response in solid tumours and is recommended for the assessment of liver metastases after systemic therapy. CT attenuation, enhancement, and liver/tumour interface may correlate better with tumoural response compared to size reduction. CT and MR changes suggesting necrosis, fibrosis, calcifications, and haemorrhage can be used as additional indicators of tumoural response.

Analysis of clinical and imaging characteristics of pseudocirrhosis in breast cancer liver metastasis

BACKGROUND

Pseudocirrhosis that may be triggered by the treatment of breast cancer liver metastasis often begins insidiously and progresses rapidly. This complicates the accurate assessment of tumor growth or regression. Without timely intervention, patients are at significant risk of death due to acute liver failure or bleeding from ruptured varices.

OBJECTIVE

This study aims to explore the clinical and radiological characteristics of pseudocirrhosis, providing a theoretical basis for clinicians to facilitate early diagnosis and treatment, thereby reducing the misdiagnosis rate and mortality associated with this condition.

METHODS

This study conducted a retrospective analysis of clinical data and CT and MRI images from 32 patients (the pseudocirrhosis group) with pathologically confirmed breast cancer liver metastasis and radiological features of pseudocirrhosis, and 28 patients (the control group) with breast cancer liver metastasis without pseudocirrhosis, at the First Affiliated Hospital of Zhejiang University from November 2012 to January 2024. All patients were female, with an average age of 58.3 ± 8.3 years in the pseudocirrhosis group and 56.5 ± 7.8 years in the control group. In the pseudocirrhosis group, 27 patients underwent CT scans and 23 underwent routine MRI examinations. In the control group, 24 patients underwent CT scans and 20 underwent routine MRI examinations. Image analysis included the number of lesions, morphology, enhancement patterns, degree of liver capsule retraction, presence of portal hypertension, gastric varices, ascites, and abnormal nodules, as well as an analysis of patients' chemotherapy regimens, prothrombin time (PT), albumin, and cholinesterase levels.

RESULTS

In our study, liver metastases in both the pseudocirrhosis group and the control group were multiple and round-shaped, with enhanced lesions exhibiting moderate to marked ring or nodular enhancement. Among the 32 cases in the pseudocirrhosis group, one patient presented with multiple liver metastases and the development of pseudocirrhosis at initial diagnosis, while the remaining 31 patients developed pseudocirrhosis following chemotherapy or combined therapy. No abnormal nodules, were observed in either group aside from the metastatic tumors. In the pseudocirrhosis group, portal vein thickening was observed in 2 cases (6.3 %), ascites in 18 cases (56.3 %), splenomegaly in 11 cases (34.4 %), and gastric varices in 3 cases (9.4 %). The liver capsule retraction was classified as diffuse in 14 cases (43.7 %), extensive in 10 cases (31.3 %), and limited in 8 cases (25.0 %). Among the 24 patients with available laboratory data, the prothrombin time (PT) was normal in 21 cases (65.6 %) and prolonged in 3 cases (9.4 %), albumin levels were normal in 14 cases (58.3 %) and decreased in 10 cases (41.3 %), and cholinesterase levels were normal in 23 cases (95.8 %) with a decrease in 1 case (4.2 %). The control group showed no signs of portal hypertension or its decompensated manifestations; among the 26 patients with available data, albumin levels were normal in 18 cases (69.2 %) and decreased in 8 cases (30.8 %); PT was normal in 24 cases (92.3 %) and prolonged in 2 cases (7.7 %); cholinesterase levels were normal in 27 cases (96.4 %) with a decrease in 1 case (3.6 %).

CONCLUSION

Chemotherapy or combined therapy may be a triggering factor for the development of pseudocirrhosis in patients with breast cancer liver metastasis. In the early stages of pseudocirrhosis, liver synthetic function does not appear to be significantly affected.

The Clinical Features and Outcomes of Pseudocirrhosis in Breast Cancer

Pseudocirrhosis is a diffuse nodularity of the liver that radiologically mimics cirrhosis but is a distinct pathological process. It is seen almost exclusively in patients with liver metastases and may represent a response to systemic treatment. Data on the risk factors for pseudocirrhosis and outcomes are limited. In total, 170 patients with a diagnosis of breast cancer and pseudocirrhosis in a 10-year period were identified and retrospectively analysed. Data were collected on baseline patient characteristics, treatments received, and outcomes. Median time between diagnosis of liver metastases and diagnosis of pseudocirrhosis was 17.1 months (range, 0-149 months). In total, 89.4% of patients received chemotherapy between their diagnosis of breast cancer liver metastases and their diagnosis of pseudocirrhosis, most commonly a taxane (74.7%) or capecitabine (67.1%), and the median treatment lines received was 3. Median OS from first diagnosis of pseudocirrhosis was 7.6 months (95% CI: 6.1-9.6 months) and was longer in patients with HER2+ disease at 16.7 months (95% CI: 6.4-32.9 months), which was statistically significant. In our study, pseudocirrhosis occurred in the presence of liver metastases and was associated with a poor prognosis. HER2+ patients with pseudocirrhosis had a better prognosis than other subtypes, but we did not identify other significant predictors of survival. Chemotherapy was not a prerequisite for pseudocirrhosis development, although the majority of patients had received at least one line of chemotherapy before pseudocirrhosis was diagnosed.

Pseudocirrhosis: A Case Series with Clinical and Radiographic Correlation and Review of the Literature

BACKGROUND AND AIMS

Pseudocirrhosis is a poorly understood acquired morphologic change of the liver that occurs in the setting of metastatic malignancy and radiographically resembles cirrhosis. Pseudocirrhosis has been primarily described in metastatic breast carcinoma, with few case reports arising from other primary malignancies. We present 29 cases of pseudocirrhosis, including several cases from primary malignancies not previously described.

METHODS

Radiologic, clinical, demographic, and biomedical data were collected retrospectively and analyzed. We compared clinical and radiologic characteristics and outcomes between patients with pseudocirrhosis arising in metastatic breast cancer and non-breast primary malignancies.

RESULTS

Among the 29 patients, 14 had breast cancer and 15 had non-breast primaries including previously never reported primaries associated with pseudocirrhosis, melanoma, renal cell carcinoma, appendiceal carcinoid, and cholangiocarcinoma. Median time from cancer diagnosis to development of pseudocirrhosis was 80.8 months for patients with primary breast cancer and 29.8 months for non-breast primary (p = 0.02). Among all patients, 15 (52%) had radiographic features of portal hypertension. Radiographic evidence of portal hypertension was identified in 28.6% of breast cancer patients, compared to 73.3% of those with non-breast malignancies (p = 0.03).

CONCLUSION

Pseudocirrhosis has most commonly been described in the setting of metastatic breast cancer but occurs in any metastatic disease to the liver. Our study suggests that portal hypertensive complications are more common in the setting of non-breast primary cancers than in metastatic breast cancer. Prior exposure to multiple chemotherapeutic agents, and agents known to cause sinusoidal injury, is a common feature but not essential for the development of pseudocirrhosis.

Key CT and MRI findings of drug-associated hepatobiliary and pancreatic disorders

Obtaining an imaging diagnosis of various hepatobiliary and pancreatic disorders caused by certain drugs can often be challenging. Familiarity with these conditions may improve diagnostic accuracy and patient management. This review aimed to describe the imaging findings of drug-associated hepatobiliary and pancreatic disorders and identify suggestions for obtaining a correct diagnosis. We focused on relatively common disorders or those that can present with characteristic imaging findings, such as drug-induced acute hepatitis, sinusoidal obstruction syndrome, focal nodular hyperplasia-like lesions, hepatocellular adenoma, pseudocirrhosis, chemotherapy-associated steatohepatitis, amiodarone deposition in the liver, secondary iron overload, drug-induced pancreatitis, pancreatic enlargement after epoprostenol therapy, ceftriaxone-associated gallbladder pseudolithiasis, immune-related adverse events, and methotrexate-associated lymphoproliferative disorders.

Clinical characteristics and outcomes in patients with metastatic breast cancer and pseudocirrhosis: a single center retrospective cohort study

PURPOSE

Pseudocirrhosis is a term used to describe changes in hepatic contour that mimic cirrhosis radiographically, but lack the classic pathologic features of cirrhosis. This radiographic finding is frequently found in patients with metastatic breast cancer (MBC), but the risk factors and clinical consequences are poorly understood.

METHODS

In this retrospective study, we identified patients with MBC and pseudocirrhosis who were treated at a single center from 2002 to 2021. We used chart extraction and radiology review to determine demographic characteristics, treatment history, imaging features, and complications of pseudocirrhosis.

RESULTS

120 patients with MBC and pseudocirrhosis were identified with the following BC subtypes: hormone receptor (HR) positive, HER2 negative (n = 99, 82.5%), HR+/HER2+ (n = 14, 11.7%), HR- /HER2+ (n = 3, 2.5%), and triple negative (TNBC; n = 4, 3.3%). All patients had liver metastases and 82.5% (n = 99) had > 15 liver lesions. Thirty-six patients (30%) presented with de novo metastatic disease. Median time from MBC diagnosis to pseudocirrhosis was 29.2 months. 50% of patients had stable or responding disease at the time of pseudocirrhosis diagnosis. Sequelae of pseudocirrhosis included radiographic ascites (n = 97, 80.8%), gastric/esophageal varices (n = 68, 56.7%), splenomegaly (n = 26, 21.7%), GI bleeding (n = 12, 10.0%), and hepatic encephalopathy (n = 11, 9.2%). Median survival was 7.9 months after pseudocirrhosis diagnosis. Radiographic ascites was associated with shorter survival compared to no radiographic ascites (42.8 vs. 76.2 months, p =  < 0.001).

CONCLUSIONS

This is the largest case series of patients with MBC and pseudocirrhosis. Nearly all patients had HR+ MBC and extensive liver metastases. Survival was short after pseudocirrhosis and prognosis worse with radiographic ascites.

Pseudocirrhosis and portal hypertension in patients with metastatic cancers: a systematic review and meta-analysis

Pseudocirrhosis is a clinical and radiological entity mimicking liver cirrhosis in patients without a history of chronic liver disease. We performed a systematic review and meta-analysis of the current literature to evaluate the state-of-the-art and investigate the epidemiology and clinical features of pseudocirrhosis. We searched PubMed, Web of Science and Scopus for literature published until February 28, 2022. We included in the final analysis 62 articles (N = 389 patients): 51 case reports (N = 64 patients), 5 case series (N = 35 patients) and 6 observational studies (N = 290 patients). About 80% of patients included in the case reports and case series had breast cancer. Most patients had at least one clinical sign of portal hypertension and ascites was the most common clinical manifestation of portal hypertension. The median time from pseudocirrhosis to death was 2 months (IQR 1-7 months). Alkylating agents and antimitotics were the most common classes of anticancer drugs reported in our study population. Notably, about 70% of patients received three or more anticancer drugs. Finally, pseudocirrhosis is a condition that occurs in patients with hepatic metastases and may have a negative impact on survival and clinical management of patients because of the potential development of portal hypertension and its complications.

Interventional Management of Portal Hypertension in Cancer Patients

PURPOSE OF REVIEW

To provide an overview of the classifications and clinical hallmarks of common cancer-related conditions that contribute to the high incidence of portal hypertension in this population and provide an update on currently available interventional radiology therapeutic approaches.

RECENT FINDINGS

In the last few decades, there have been significant advancements in understanding the pathophysiology of portal hypertension. This knowledge has led to the development of safer and more effective minimally invasive approaches. The main objective is to provide alternatives to prevent life-threatening complications from clinically significant portal hypertension and to allow the continuation of cancer treatment interventions that would otherwise be stopped. Clinicians involved in cancer care should be aware of risk factors, associated complications, and management of portal hypertension in cancer patients. Interventional radiology offers minimally invasive alternatives that play a central role in improving clinical outcomes and survival of these patients, allowing the continuation of cancer treatments.

Noncirrhotic Portal Hypertension after Trastuzumab Emtansine in HER2-positive Breast Cancer as Determined by Deep Learning-measured Spleen Volume at CT

Background Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate approved for use in human epidermal growth factor receptor 2 (HER2)-positive breast cancer. Case reports have suggested an association between T-DM1 and portal hypertension. Purpose To evaluate the association of T-DM1 therapy with spleen volume changes and portal hypertension on CT scans and clinical findings compared with lapatinib and capecitabine therapy. Materials and Methods Patients with HER2-positive breast cancer who were administered at least two cycles of T-DM1 or lapatinib and capecitabine (controls) in a tertiary institution from 2001 to 2020 and who underwent CT before initial treatment and at least once during treatment were retrospectively enrolled. Spleen volume changes and the signs of portal hypertension (gastroesophageal varix [GEV], spontaneous portosystemic shunt [SPSS], and ascites) were evaluated at contrast-enhanced CT. Patients were followed until treatment ended or for 2 years after the start of treatment. Spleen volume changes were measured with a deep learning algorithm and evaluated by using a linear mixed model. The incidences of splenomegaly and portal hypertension were compared between the T-DM1 and control groups by using a χ² test or Fisher exact test. Results The T-DM1 group included 111 patients (mean age, 54 years ± 11 [SD]; 111 women) and the control group included 122 patients (mean age, 50 years ± 9; 121 women). Spleen volume progressively increased with T-DM1 therapy but was constant in the control group (104% ± 5 vs -1% ± 6 at the 33rd treatment cycle, respectively; P < .001). Incidences of splenomegaly (46% [51 of 111] vs 3% [four of 122] of patients; P < .001), GEV (11% [12 of 111] vs 1% [one of 122] of patients; P < .001), and SPSS (27% [30 of 111] vs 1% [one of 122] of patients; P < .001) were higher in the T-DM1 group than in the control group. Conclusion Trastuzumab emtansine therapy was associated with noncirrhotic portal hypertension at CT, with higher incidences of splenomegaly, gastroesophageal varix, and spontaneous portosystemic shunt than those with lapatinib and capecitabine therapy. © RSNA, 2022 Online supplemental material is available for this article.

Transjugular intrahepatic portosystemic shunt for the management of symptomatic malignant pseudocirrhosis

BACKGROUND

Pseudocirrhosis is defined by radiologic changes of the liver parenchyma secondary to metastatic disease and/or cancer treatments, and portends a high rate of morbidity and mortality from sequelae of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension; however, TIPS is relatively contraindicated in the setting of hepatic metastases. The study aims to determine the technical efficacy and clinical outcomes of patients undergoing TIPS for symptomatic pseudocirrhosis.

METHODS

Retrospective analysis of patients with hepatic malignancy who underwent TIPS between 2008 and 2020 at a single tertiary care center. Patients with imaging findings of pseudocirrhosis and without history of primary liver malignancy or confounding causes of cirrhosis were included. West Haven scores assessing hepatic encephalopathy were obtained from chart review. Technical success was defined as successful TIPS creation with reduction in the portosystemic gradient (PSG). Clinical success was defined as resolution of variceal bleeding and/or ascites.

RESULTS

Nine patients (4 female/5 male), average (± SD) age 61.2±9.5 years with metastatic pseudocirrhosis were included for analysis. Primary malignancy was colorectal adenocarcinoma (n=5), neuroendocrine tumor (n=3), and malignant endothelial hemangioendothelioma (n=1). Average Model for End Stage Liver Disease (MELD-Na) score was 15.7±3.7. Technical success was 8/9 (89%) with average PSG reduced from 23.5±11.0 to 6.5±2.8 mmHg (P=0.001). Clinical success was 6/9 (67%). Two patients required TIPS revision after initial clinical success. Mild-moderate HE occurred in 6/9 patients post TIPS (67%), with a highest West Haven score of 2. Time from TIPS to death for acute variceal bleeding and ascites was 4.9±4.2 and 12±16.5 months, respectively. Cause of death was disease progression (n=5), variceal bleeding (n=1), or unavailable (n=2).

CONCLUSIONS

TIPS in the setting of malignant pseudocirrhosis can be created safely with similar clinical outcomes to TIPS performed for benign disease. Rates of low-grade hepatic encephalopathy may be higher amongst patients undergoing TIPS for pseudocirrhosis.