Metastatic rectal adenocarcinoma to the liver associated with focal nodular hyperplasia

Abstract

A 45 year old female patient underwent right hemihepatectomy for metastatic rectal adenocarcinoma. Preoperative imaging demonstrated an area of focal nodular hyperplasia (FNH) in segment VIII and metastatic carcinoma in segment VI of the liver. Gross and microscopic examination of the former lesion showed features typical of FNH with an intralesional metastatic adenocarcinoma. To the best of our knowledge, this is the first reported case of metastatic adenocarcinoma located within a lesion of FNH. The possibility of a pathogenetic association behind this occurrence is discussed.A previously well 43 year old female patient underwent anterior resection for Dukes's stage C1 adenocarcinoma of the rectum. Postoperatively, she received adjuvant chemotherapy for six months. Liver ultrasonography at one year follow up demonstrated an irregular hypoechoic lesion measuring 25 mm in diameter and extensive fatty change.After referral to a liver surgeon, contrast enhanced magnetic resonance imaging (MRI) was performed. This demonstrated a 34 mm circular hypervascular mass in segment VIII of the liver (lesion A) with decreased signal on T1 and T2 weighted images, showing early and persistent enhancement. The mass contained an eccentric low attenuation area on dynamic imaging, which was suggestive of a scar within an area of focal nodular hyperplasia (FNH). A 15 mm non-enhancing spherical lesion in segment VI was demonstrated (lesion B), which did not conclusively represent a metastatic focus.After an interval of three months MRI was repeated. Lesion B had grown to 35 mm in diameter and showed irregular rim enhancement with reduced signal on T1 and T2 weighted images; features that are typical of neoplastic disease. The patient was admitted for elective right hemihepatectomy. The patient recovered without complications and was discharged. PATHOLOGY MacroscopyThe resected specimen weighed a total of 1056 g and measured 21 × 17 × 9 cm. A well circumscribed unencapsulated tumour (lesion B), which measured 2.7 × 2.2 × 2 cm, was present at 2 cm from the resection margin in liver segment VI. Lesion A measured 5 × 3 × 4 cm, and was situated in segment VIII, 6.5 cm from lesion B, so that it extended closely (0.3 cm) to the margin of resection.Lesion A had an ill defined, lobulated, flesh coloured, nodular appearance when sectioned, and contained a central scar, surrounded by irradiating fibrous septa-a picture typical of FNH. A solid white tumour measuring 1 × 1 × 0.7 cm was seen arising within the main mass of FNH ( fig 1A). More than 80% of the metastatic tumour nodule was surrounded by the FNH and the remaining outline was composed of fibrous capsule. MicroscopyMicroscopic examination of lesion A revealed nodular hyperplastic parenchyma showing thickened hepatic plates and prominent tortuous vessels of arteriolar calibre (fig 1B), consistent with FNH.

Does Focal Nodular Hyperplasia Predispose to Metastatic Growth of Renal Cell Carcinoma-A Surgical Dilemma

“…In a brief review of the literature three cases of such a co-existence have been reported before. The first one is a case of a metastatic RCC within a FNH (Wheeler, Wheeler, Diaz-Arias, & Anders, 2009), and the second is a case of metastatic rectal adenocarcinoma associated with FNH (Nisar et al, 2002). The third case which correlates to our case, refers to a patient with Von-Hippel-Lindau disease who had metastatic deposit of a primary RCC within a FNH (Dogrul et al, 2009).…”

Liver metastases within focal nodular hyperplasias

“…Very few cases of metastases superimposed to FNH have been described in the literature [1][2][3]. In our patient, all the metastases were observed only in the two FHNs, and not in the remaining liver parenchyma.…”

Focal Nodular Hyperplasia (FNH) of the Liver

“…In children, FNH was detected following hematopoietic stem cell transplantation (Masetti et al 2013). Interesting observations are also those where FNH was found within tumors showing hypervascularity; for example, FNH almost completely surrounded by metastatic renal cell carcinoma has been described, and the observers suggested that tumor-associated hyperemia may have played a pathogenic role (Nisar et al 2002). FNH developed within 1 year after blunt abdominal trauma (Savoye-Collet et al 2002).…”