Pseudocirrhosis in a pancreatic cancer patient with liver metastases: A case report of complete resolution of pseudocirrhosis with an early recognition and management

Abstract

We report a case of pseudocirrhosis arising in the setting of regression of liver metastases from pancreatic cancer. A 55-year-old asymptomatic woman presented to our clinic with newly diagnosed metastatic pancreatic cancer with extensive liver metastases. She underwent systemic chemotherapy with gemcitabine and oxaliplatin (GEMOX). After 8 cycles of therapy, she had a remarkable response to the therapy evidenced by decline of carcinoembryonic antigen (CEA) and CA19 by > 50% and nearly complete resolution of hepatic metastases in computed tomography (CT) scan. Shortly after, she developed increasing bilateral ankle edema and ascites, associated with dyspnea, progressive weight gain, and declining performance status. Gemcitabine and oxaliplatin were discontinued as other causes of her symptoms such as congestive heart disease or venous thrombosis were ruled out. CT scan 6 mo after the initiation of GEMOX revealed worsening ascites with a stable pancreatic mass. However, it also revealed a lobular hepatic contour, segmental atrophy, and capsular retraction mimicking the appearance of cirrhosis. She was managed with aggressive diuresis and albumin infusions which eventually resulted in a resolution of the above-mentioned symptoms as well as complete resolution of pseudocirrhotic appearance of the liver and ascites in CT scan. This case demonstrates that pancreatic cancer patients can develop pseudocirrhosis. Clinicians and radiologist should be well aware of this entity as early recognition and management can lead to a near complete recovery of liver function and much improved quality of life as illustrated in this case.

Pseudocirrhosis caused by regorafenib in an advanced rectal cancer patient with multiple liver metastases

“…In the present case, the patient survived after severe regorafenib-induced hepatic injury. The course of treatment in the present as well as another case (12) suggests that pseudocirrhosis with a mild elevation of aminotransferase levels during chemotherapy may be reversed by discontinuation of the chemotherapeutic agents. In such cases, where the chemotherapeutic agents administered are potent enough to induce liver injury and reversible pseudocirrhosis, potent antitumor effects may also be expected.…”

“…Although the precise mechanism underlying the development of pseudocirrhosis remains unknown, the response to systemic chemotherapeutic agents may induce cirrhotic changes with tumor shrinkage following chemotherapy. Previous reports (10)(11)(12) have indicated that pseudocirrhosis may be associated with nodular regenerative hyperplasia (NRH) caused by chemotherapy-induced hepatic injury. NRH is characterized by widespread transformation of nor mal liver parenchyma into hyperplastic regenerative nodules without bridging fibrosis, a characteristic that distinguishes this entity from liver cirrhosis (15).…”

“…Previous studies on breast cancer reported that multiple liver metastases worsened when atrophic changes occurred in the liver (10,11). Kang et al (12) reported a reversible change in a pancreatic cancer patient with multiple liver metastases, who received 8 cycles of chemotherapy with gemcitabine and 5-fluorouracil. When liver atrophy was observed during treatment, the values of the liver enzymes were elevated, while the level of carbohydrate antigen 19-9 was markedly decreased.…”

Medullary Thyroid Cancer and Pseudocirrhosis: Case Report and Literature Review

“…The most frequently reported cause of pseudocirrhosis is metastatic breast cancer treated with chemotherapy [4][5][6][7][8][9][10][11][12][13][14] , which commonly presents with diffuse nodular changes of the liver surface on ct imaging 15 . However, the liver can also become nodular and resemble cirrhosis after hepatic metastasis in pancreatic, esophageal, and small-cell lung cancer [16][17][18] . To our knowledge, pseudocirrhosis has not been reported in metastatic mtc.…”

“…Sinusoidal dilatation is a common adverse event with oxaliplatin that can cause noncirrhotic portal hypertension in patients with stage iii or iv colorectal cancer 21,22 . In a report of pseudocirrhosis in the setting of metastatic pancreatic cancer, the liver appeared normal after discontinuation of gemcitabine and oxaliplatin, but that change was also accompanied by primary tumor regression and reduction in the CA19-9 tumour marker, suggesting that metastatic disease may have 16 . In general, there is little to no evidence that adverse effects from folfox can mimic cirrhosis.…”