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Peritumoral Fatty Infiltration of the Liver Associated with Venous Drainage from Metastatic Liver Tumor

¹ Fukuiken Saiseikai Hospital Fukui 918-8503, Japan
² University of Kanazawa Kanazawa 920-8641, Japan

A 54-year-old woman underwent distal gastrectomy for advanced gastric carcinoma. Five months after surgery, sonography showed multiple liver tumors, each with a highly echoic rim. In addition to a diffuse fatty infiltration of the liver, unenhanced CT revealed five liver tumors, each of which measured 1.0–1.8 cm in diameter (mean, 1.2 cm). Each tumor displayed a peritumoral hypoattenuating band that was thought to be fatty infiltration (Fig. 3A). On arterial phase CT, all tumors showed rim enhancement, and metastases from gastric carcinoma were suspected, although the patient also had hepatitis C.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —54-year-old woman with metastatic liver tumors from gastric carcinoma and peritumoral fatty infiltration. Unenhanced CT scan shows 1.8-cm-diameter tumor with peritumoral hypoattenuating band.

The level of carcinoembryonic antigen was elevated at 15 ng/dL, but levels of -fetoprotein and protein induced by vitamin K antagonist II were normal. The patient had no history of alcoholism or diabetes mellitus. The serum triglyceride level was normal, and the total cholesterol level was slightly low (142 mg/dL).

On angiography, all tumors showed rim enhancement. CT during arterial portography showed multiple nodular perfusion defects including a peritumoral hypoattenuating band around each tumor (Fig. 3B). Early phase images of single-level dynamic CT during hepatic arteriography showed a hyperattenuating rim within the peritumoral hypoattenuating band around each tumor (Fig. 3C). On late phase images, the peritumoral hypoattenuating bands were gradually enhanced by direct drainage from the tumors (Fig. 3D).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —54-year-old woman with metastatic liver tumors from gastric carcinoma and peritumoral fatty infiltration. CT during arterial portogram shows portal perfusion defect, including tumor and peritumoral hypoattenuating band. Another tumor is also seen in lateral segment of liver.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3C. —54-year-old woman with metastatic liver tumors from gastric carcinoma and peritumoral fatty infiltration. Image from single-level dynamic CT during hepatic arteriography obtained 4 sec after contrast administration shows hyperenhancing tumor with central necrosis.

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3D. —54-year-old woman with metastatic liver tumors from gastric carcinoma and peritumoral fatty infiltration. Image from single-level dynamic CT during hepatic arteriography obtained 20 sec after contrast administration shows rim enhancement corresponding to peritumoral fatty infiltration.

The patient refused needle biopsy, and the diagnosis of metastatic liver tumor from gastric carcinoma was established clinically. The patient began arterial hepatic infusion chemotherapy, but on 6-month follow-up CT, the size of tumors had increased, and both the diffuse fatty infiltration and the peritumoral hypoattenuating bands had disappeared. The patient died of tumor progression 17 months after the discovery of the liver metastases.

Locally decreased portal blood flow causes focal fatty liver infiltration in some cases [1, 2] and focal sparing of normal parenchyma by fatty infiltration in others [3, 4]. The reason these converse conditions develop in the same variant blood supply is unknown. In our patient, the portal vein perfusion defect seen on CT during arterial portography included the area of peritumoral fatty infiltration and corresponded to late peritumoral enhancement on single-level dynamic CT during hepatic arteriography. This finding suggested that the portal blood did not enter the area of peritumoral fatty infiltration and that this area received blood that had passed through the tumor sinusoids. We speculate that decreased portal blood flow due to tumor draining may cause peritumoral fatty infiltration, although it usually causes peritumoral sparing of normal parenchyma by fatty liver infiltration [4].

To our knowledge, there have been no previous reports about peritumoral fatty infiltration in the liver. We believe that this lack of documentation indicates that the condition is rare and that factors in addition to regionally decreased portal blood flow must be present for peritumoral fatty liver infiltration to occur. It may be that this condition is transient and may be affected by nutritional conditions. Other researchers [2] have reported that fatty liver infiltration distal to a liver metastasis from an insulin-producing islet cell tumor could possibly be caused by insulin production and decreased portal blood flow. In our patient, however, a specific cause could not be found other than slight malnutrition.

References

1. Kawamori K, Matsui O, Takahashi S, Kadoya M, Takashima T, Miyayama S. Focal hepatic fatty infiltration in the posterior edge of the medial segment associated with aberrant gastric venous drainage: CT, US, and MR findings. J Comput Assist Tomogr1996; 20:356 –359[Medline]
2. Hoshiba K, Demachi H, Miyata S, et al. Fatty infiltration of the liver distal to a metastatic liver tumor. Abdom Imaging 1997;22:496 –498[Medline]
3. Matsui O, Kadoya M, Takahashi S, et al. Focal sparing of segment IV in fatty livers shown by sonography and CT: correlation with aberrant gastric venous drainage. AJR1995; 164:1137 –1140[Abstract/Free Full Text]
4. Gabata T, Kadoya M, Matsui O, et al. Peritumoral spared area in fatty liver: correlation between opposed-phase gradient-echo MR imaging and CT arteriography. Abdom Imaging2001; 26:384 –389[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Miyayama, S. Articles by Matsui, O. Search for Related Content PubMed PubMed Citation Articles by Miyayama, S. Articles by Matsui, O. Social Bookmarking                      What's this?