A Necrotic Liver Mass

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• Answer to the Clinical Challenges and Images in GI: Image 3: Compression of the Inferior Vena Cava by Metastatic Papillary Serous Carcinoma of the Fallopian Tube
• References
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Question: A 54-year-old woman presented with a mass in the upper abdomen that had gradually increased in size over the past 3 months. Initially, she did not seek medical attention because she did not like doctors. Her past medical history was unremarkable, with no family history of liver disease, regular alcohol consumption, use of intravenous drugs, or having received a blood transfusion. She was postmenopausal. A screening colonoscopy, mammogram, and Papanicolaou smear had recently been performed and were normal. Worsening abdominal swelling and the onset of bilateral lower extremity prompted evaluation.

Physical examination revealed a visibly protuberant mass in the right upper abdomen that was firm, nontender, and without an audible bruit. The liver span was approximately 20 cm. There were no stigmata of chronic liver disease and bilateral pitting edema of the lower extremities was present. Pertinent laboratory data showed a normal complete blood count, alkaline phosphatase of 615 U/L (normal, 41–108); AST, 107 U/L (normal, 8–43); ALT, 87 U/L (normal, 7–45); and total bilirubin, 0.5 mg/dL (normal, 0.1–1.0). Her CA-125 level was elevated at 969 U/mL (normal, <35 U/mL) and her alpha-fetoprotein level was normal. Contrast-enhanced computed tomography showed a large, necrotic liver mass with central necrosis (Figures A and B). A biopsy of the mass revealed moderately differentiated adenocarcinoma (Figure C). What is the likely explanation for her lower extremity edema and what is the origin of this liver mass?

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Answer to the Clinical Challenges and Images in GI: Image 3: Compression of the Inferior Vena Cava by Metastatic Papillary Serous Carcinoma of the Fallopian Tube 

Figure D shows the liver mass compressing the inferior vena cava (arrow) leading to increased venous hydrostatic pressure in the lower extremities with resultant edema. The patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, resection of a mass in the left uterosacral ligament, bilateral pelvic, and para-aortic lymphadenectomy, omentectomy, and extended right hepatectomy. The resected liver specimen weighed 4.6 kg. Histopathologic examination revealed a primary serous carcinoma of the fallopian tube (Figure E) with widespread metastases. The primary tumor and metastases were positive for p53 and WT-1, providing further support for a müllerian primary. Recent evidence suggests that a significant proportion of pelvic serous carcinomas originate from the fallopian tube epithelium.¹

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Metastases to the liver are common. Two explanations for the high frequency of liver metastases include the dual blood supply to the liver and fenestrations of the sinusoidal endothelium allowing malignant cells easy access to the hepatic parenchyma.² The primary malignancies that most commonly metastasize to the liver include colon, gastric, pancreatic, lung, and breast carcinomas. This case illustrates how symptoms and signs attributable to liver metastases can be the initial manifestation of a primary tumor.

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References 

1. Salvador S, Gilks B, Kobel M, et al. The fallopian tube: primary site of most pelvic high-grade serous carcinomas. Int J Gynecol Cancer. 2009;19:58–64
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2. Dingemans KP, Roos E. Ultrastructural aspects of the invasion of the liver by cancer cells. In:  Weiss L,  Gilbert HA editor. Liver metastasesm. Boston: CK Hall; 1982;p. 51
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