Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 1, 2011, pp. 127-129

Indian Journal of Cancer, Vol. 48, No. 1, January-March, 2011, pp. 127-129

Letter to Editor

Solitary giant cystic liver metastasis mimicking an abscess - A word of caution

V Singla¹, V Virmani¹, P Dey², N Khandelwal¹

¹ Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India
² Department of Pathology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India

Correspondence Address:
V Singla
Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
modim72@yahoo.com

Code Number: cn11030

Sir,

Solitary large cystic liver metastasis is rare and in the absence of a known primary malignancy may mimic an abscess. A 47yearold female presented to the emergency department with right upper quadrant pain, fever and chills. Physical examination demonstrated hepatomegaly with right hypochondrial tenderness. Laboratory investigations revealed normal hemoglobin of 11g/dl, raised total leukocyte count of 16400/mm ³ , and elevated serum alanine aminotransferase (ALT) as well as serum aspartate aminotransferase (AST) levels. USG of upper abdomen showed a well-defined, round to oval cystic liver lesion with low-level internal echoes and an irregular wall. CT depicted a large, solitary, rounded, hypoattenuating hepatic lesion (12-20 HU) measuring 1312 cm, having a slightly shaggy and enhancing wall [Figure - 1]. There was no abdominal lymphadenopathy or ascites. Considering the clinical, laboratory, and radiological picture, a diagnosis of liver abscess was made and ultrasound-guided pigtail drainage was done. The culture results of abscess fluid analysis showed growth of Grampositive bacteria. Subsequent sonograms demonstrated regression of the lesion and patient was discharged on oral antibiotics with percutaneous catheter in situ and was told to come for weekly followup on an outpatient basis. Follow-up sonogram after weeks revealed persistent lesion of size 1511cm despite daily drainage of approximately 35 ml of pus. CT abdomen was repeated which showed that the lesion had increased in size and thick irregular walls with peripheral enhancement, suggestive of a tumor with central necrosis [Figure - 2]. Ultrasound-guided fine needle aspiration cytology from the wall of the lesion showed many polymorphs along with discrete malignant squamoid cells indicating a metastatic squamous cell carcinoma [Figure - 3], [Figure - 4]. The diagnostic workup of the patient for primary lesion identified a bulky cervix on ultrasound, which on biopsy confirmed the diagnosis of squamous cell carcinoma. No other lesion was observed on chest CT and skeletal bone scan. This case represents a rare initial presentation of a patient of squamous cell carcinoma of uterine cervix with large isolated cystic hepatic metastases, which was misdiagnosed as liver abscess and subsequently drained percutaneously. The incidence of liver metastasis in cervical carcinoma is uncommon with a reported incidence of 2.2%. The incidence of isolated liver metastasis without involvement of other sites is still rare in cervical cancer with an incidence of 0.3%.^[1] Liver metastases are usually associated with other extrahepatic metastases with latestage carcinoma of cervix usually metastasizing to pelvic or para-aortic lymph nodes, lungs, and bones. If carcinoma cervix metastasizes to liver, it usually presents as multiple hepatic nodules of varying sizes, usually less than 10 cm in 80% of cases. ^[2] Moreover, cystic liver metastases are usually secondary to neuroendocrine tumors, ovarian and testicular carcinomas, or sarcomas.^[3] On CT, presence of septations and mural nodules is significantly higher in cystic malignancies than in abscesses. ^[4] This case illustrates the radiological similarities between hepatic abscess and other cystic lesions of liver and emphasizes that a single large metastatic lesion should also be considered in the differential diagnosis of patients with clinical setting of liver abscess.

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Copyright 2011 - Indian Journal of Cancer

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