Clinical features

Symptoms and signs

Hepatic metastases produce clinical manifestations in about two-thirds of cases and they generally reveal themselves through symptoms referable to the liver. Afflicted patients often present with ascites, hepatomegaly or abdominal full-

Fig. 8.77 Metastatic breast carcinoma.

ness, hepatic pain, jaundice, anorexia, and weight loss. Constitutional symptoms, such as malaise, fatigue, and fever may be present. On examination, nodules or a mass are felt in up to 50% of the cases, and a friction bruit may be heard on auscultation. Unfortunately, symptomatic presentation is associated with bulky, rapidly progressive tumours with a poor prognosis {2035}. Rarely, patients present with fulminant hepatic failure, obstructive jaundice, or intraperitoneal haemorrhage. Functioning neuroendocrine tumours produce syndromes of hormonal excess. 'Carcinomatous cirrhosis' with jaundice, ascites, and bleeding varices due to diffuse infiltration of the liver, usually by metastatic breast carcinoma, has been described {174}.

Laboratory studies

The alkaline phosphatase (ALP) and serum glutamic-oxaloacetic transaminase (SGOT) levels, although non-specific, are elevated in approximately 80% and 67% of patients respectively, and most likely represent the effects of hepatic parenchymal infiltration by tumour and of generalized wasting. Elevated lactic dehydrogenase (LDH) levels are relatively specific for the presence of metastatic melanoma. Tests of synthetic function, e.g. serum albumin levels and the prothrombin time, may be normal despite extensive metastatic involvement. Alpha-fetoprotein (AFP) levels may be slightly to moderately elevated but very high concentrations are more consistent with a diagnosis of hepatocellular carcinoma {904}. Carcinoembryonic antigen (CEA) levels, which are raised in as many as 90% of patients with metastases from colorectal carcinoma, can be useful in monitoring patients after primary tumour resection. However, CEA levels do not correlate well with prognosis {2043, 1821}.

Imaging

Ultrasound (US) can identify tumours measuring 1-2 cm in size, can differentiate solid from cystic lesions, and provide guidance for percutaneous needle biopsy. However, it provides poor anatomical definition and frequently misses smaller lesions.

Computed tomography (CT), using both contrasted and non-contrasted images, can also serve as a screening tool. The administration of intravenous contrast permits the detection of tumours as small as 0.5 cm in diameter {1763}. Most metastases display decreased vascularity in comparison to the surrounding hepatic parenchyma and appear as hypodense defects. Tumours that are hypervascular (e.g. melanoma, carcinoids and some breast cancers) or calcified (e.g. colorec-tal carcinoma) are better delineated by noncontrast views.

Magnetic resonance imaging (MRI) is more sensitive than CT in the detection of hepatic tumours and can demonstrate additional lesions, too small to be seen on CT.

Positron emission tomography (PET) can detect metastatic disease in the liver and elsewhere. Using 2-(18)fluoro-2-deoxy-D-glucose (F-18 FDG), a radiolabeled glucose analogue, PET highlights meta-bolically active tissues. Through co-registration with anatomical studies like CT or MRI, viable malignant tumours can be differentiated from benign or necrotic lesions {54}.

CT arterial portography performed pre-operatively, and intraoperative ultrasound are associated with the highest sensitivities {1796}. The former is capable of detecting lesions as small as 15 mm, although a false positive rate of

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