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Letters to the Editor |
Department of Radiology, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9RH, England. e-mail: j.healy@ic.ac.uk
Editor:
We read with interest the article by Dr Nascimento and colleagues in the October issue of Radiology (1) in which they described two patients who had diffuse desmoplastic breast carcinoma metastases to the liver, which simulated cirrhosis at magnetic resonance (MR) imaging. We wish to report a similar case in which a liver-specific contrast agent facilitated identification of metastatic disease.
A 47-year-old woman with a history of lymph node–positive stage II infiltrating ductal carcinoma of the left breast, treated with excision plus adjuvant mitomycin, carboplatin, 5-fluorouracil chemotherapy and tamoxifen in 1992, underwent surveillance contrast material–enhanced computed tomography (CT) in 1998. The scan showed a diffusely abnormal liver most likely representative of macronodular cirrhosis. Findings from follow-up CT in August 1999 and CT plus ultrasonography (US) in October 1999 also demonstrated cirrhosis with macronodular regeneration. No risk factors for liver cirrhosis were identified other than the previous methotrexate therapy. Findings from liver function tests were only mildly abnormal, and there were no clinical signs of decompensation or US features of portal venous hypertension.
Findings from hepatic MR imaging in December 1999 demonstrated a nodular liver contour plus several subtle focal lesions with low signal intensity on TI-weighted images (Figure, part a) and high signal intensity on T2-weighted images. Delayed T1-weighted images obtained 24 hours after the infusion of mangafodipir trisodium (Teslascan; Nycomed Amersham, UK) clearly demonstrated rim enhancement of the lesions suspicious for metastases (Figure, part b). US-guided biopsy of the liver in an area where rim-enhancing lesions had been demonstrated helped to confirm the diagnosis of metastatic breast carcinoma. At histologic examination, some fibrosis was also present around the two metastatic deposits sampled in the biopsy specimen, but the liver architecture appeared normal.
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REFERENCES
Department of Radiology, Thomas Jefferson University Hospital, 132 S 10th St, 1096 Main Bldg, Philadelphia, PA 19107* e-mail: donald.mitchell@mail.tju.edu
Alessandra B. Nascimento, MD
Blumenau, Santa Catarina, Brazil
We thank Dr Burkill and colleagues for their interest in our article in which we described two patients with diffuse desmoplastic breast carcinoma metastasis to the liver that mimicked cirrhosis at MR imaging (1). We agree with their suggestion that administration of mangafodipir trisodium may increase the contrast enhancement between liver parenchyma and tumor and that this might help depict advanced metastatic carcinoma in cases such as these. However, we wish to draw attention to some probable differences between the two patients in our report and the case that they illustrate in figure 1.
We believe that the woman Drs Burkill and colleagues described had pseudocirrhosis, a phenomenon of posttreatment metastatic breast cancer, described by Young et al (2), whereby regions of retracted tumor tissue and scarring delineate areas of regeneration, producing an appearance that resembles macronodular cirrhosis. In patients with pseudocirrhosis, there may or may not be foci of residual tumor. The distinction between these patients and ours is that in pseudocirrhosis, the intervening liver tissue between fibrous bands is essentially intact, without substantial fibrosis or disturbed architecture. Dr Burkill and colleagues describe their patient as having minimal fibrosis adjacent to the metastatic deposits but normal architecture. This should be distinguished from the two cases that we described, where the liver architecture was diffusely abnormal, in a pattern resembling cirrhosis, with dense areas of fibrosis and scattered foci of tumor, with little recognizable liver tissue. Because of the advanced hepatic destruction, both of the patients in our report presented with abnormal liver function test findings and other signs of liver disease. The gross distortion of the liver typical of pseudocirrhosis, with prominent areas of capsular retraction and bulging areas of regeneration, was not seen in either of these two cases.
It is interesting to speculate whether administration of mangafodipir trisodium might have improved our understanding of these patients’ liver disease prior to biopsy. Presumably, since there was indeed little liver parenchyma present, enhancement would have been minimal. Perhaps we would have been able to recognize some areas of the liver with partial preservation of parenchyma, if there were any, as areas of increased signal intensity on postcontrast images. Unfortunately, we do not have the opportunity to confirm any of these speculations.
In conclusion, we thank Dr Burkill and colleagues for reminding us that alternative contrast agents, although used less commonly than the more familiar gadolinium chelates, can be used to distinguish liver parenchyma from other tissues in a variety of clinical settings.
REFERENCES
This article has been cited by other articles:
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  F. M. Fennessy, K. J. Mortele, T. Kluckert, A. Gogate, S. Ondategui-Parra, P. Ros, and S. G. Silverman Hepatic Capsular Retraction in Metastatic Carcinoma of the Breast Occurring with Increase or Decrease in Size of Subjacent Metastasis Am. J. Roentgenol., March 1, 2004; 182(3): 651 - 655. [Abstract] [Full Text] [PDF]
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