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Metastatic Liver Disease (Secondary Liver Cancer)

Definition:
Metastatic liver disease, also called secondary liver cancer, occurs when malignant cells from a primary tumor in another organ spread (metastasize) to the liver. Unlike primary liver cancer (such as hepatocellular carcinoma), metastatic liver tumors originate outside the liver and reach it via the bloodstream, lymphatic system, or direct extension.


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Epidemiology:

The liver is the most common site of metastasis for many cancers because of its dual blood supply (portal vein and hepatic artery) and rich capillary network.

Common primary sites include:

Colorectal carcinoma (most frequent)

Pancreatic cancer

Breast cancer

Lung cancer

Melanoma

Gastric cancer




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Pathophysiology:

Tumor cells detach from the primary lesion, enter circulation, and lodge in hepatic sinusoids.

Growth within the liver is facilitated by:

The liver’s rich vascular supply

Local growth factors and immune microenvironment


Lesions may appear as single, multiple, or diffuse nodules within the liver parenchyma.



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Clinical Features:

Symptoms may be absent in early stages but can include:

Right upper quadrant abdominal pain or discomfort

Hepatomegaly (enlarged liver)

Jaundice (in advanced disease with biliary obstruction)

Weight loss and fatigue

Ascites (with peritoneal involvement or portal hypertension)

Anorexia, nausea, and general malaise



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Diagnosis:

1. History and Physical Examination – identifying symptoms and risk factors with known primary malignancy.


2. Laboratory Tests:

Liver function tests (often abnormal but nonspecific)

Elevated alkaline phosphatase and γ-GT common

Tumor markers (e.g., CEA for colorectal, CA 19-9 for pancreatic) may help.



3. Imaging:

Ultrasound (initial detection)

CT scan or MRI (characterization and staging)

PET-CT (for identifying occult primaries or systemic spread)



4. Biopsy:

Image-guided core needle biopsy if diagnosis is uncertain.





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Prognosis:

Prognosis depends on:

Primary cancer type

Number and size of liver metastases

Presence of extrahepatic spread

Response to systemic therapy


Without treatment, prognosis is generally poor.



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Treatment:

Treatment aims at both controlling the systemic disease and managing liver involvement. Options include:

1. Surgical Resection (Hepatectomy):

Best option in selected patients (especially colorectal metastases).

Criteria: adequate liver reserve, no uncontrolled extrahepatic disease.



2. Liver Transplantation:

Rare and limited to very selected cases (mainly experimental in metastatic colorectal cancer).



3. Locoregional Therapies:

Radiofrequency ablation (RFA)

Microwave ablation

Transarterial chemoembolization (TACE)

Selective internal radiation therapy (SIRT/Yttrium-90).



4. Systemic Therapy:

Chemotherapy (e.g., FOLFOX, FOLFIRI for colorectal cancer)

Targeted therapies (e.g., anti-EGFR, anti-VEGF agents)

Immunotherapy (in certain primaries like melanoma or lung cancer).



5. Palliative Care:

For advanced disease not suitable for aggressive therapy.

Focus on symptom control (pain, jaundice, ascites, nutritional support).





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Key Points:

Metastatic liver disease is far more common than primary liver cancer.

Most patients have multiple lesions and advanced disease at diagnosis.

Multidisciplinary management (oncology, hepatology, surgery, radiology) is essential.

Advances in surgical and systemic treatments have improved survival, especially for colorectal cancer metastases.