Chemotherapy induced liver abnormalities: an imaging perspective

Abstract

Treating patients undergoing chemotherapy who display findings of liver toxicity, requires a solid understanding of these medications. It is important for any clinician to have an index of suspicion for liver toxicity and be able to recognize it, even on imaging. Cancer chemotherapy has evolved, and newer medications that target cell biology have a different pattern of liver toxicity and may differ from the more traditional cytotoxic agents. There are several hepatic conditions that can result and keen clinical as well as radiographic recognition are paramount. Conditions such as sinusoidal obstructive syndrome, steatosis, and pseudocirrhosis are more commonly associated with chemotherapy. These conditions can display clinical signs of acute hepatitis, liver cirrhosis, and even liver failure. It is important to anticipate and recognize these adverse reactions and thus appropriate clinical action can be taken. Often times, patients with these liver manifestations can be managed with supportive therapies, and liver toxicity may resolve after discontinuation of chemotherapy.

Keywords: Chemotherapy; Hepatic Necrosis; Hepatic toxicity; Hepatitis; Pseudocirrhosis; Steatosis.

Figure 1

Hepatic sinusoidal obstructive syndrome. Fifty six-year-old female with metastatic colon cancer. Chemotherapy with FOLFOX (Folinic Acid, 5 Flurouracil & Oxaliplatin) regimen was performed. This may lead to sinusoidal congestion, damage to the hepatic sinusoids with features of portal hypertension, splenomegaly and resultant thrombocytopenia. Coronal contrast enhanced CT (A) and axial contrast enhanced CT (B) demonstrate an enlarged spleen (arrow).

Figure 2

Hepatic sinusoidal obstructive syndrome. Fifty six-year-old male patient with acute myeloid leukemia on high dose chemotherapy after bone marrow transplantation. (A) Axial contrast enhanced CT images show mottled enhancement of the liver representing congestion due to veno-occlusive disease and hepatic vein thrombus (arrow). (B) There is a multilevel thrombus in IVC (arrow).

Figure 3

Pseudocirrhosis. Fifty six-year-old female underwent multiple cycles of chemotherapy for metastatic liver disease from breast cancer. Coronal (A) and axial (B) contrast enhanced CT images of the abdomen show a macronodular liver with fibrosis following completion of therapy. Patient had features of early hepatic decompensation.

Figure 4

Pseudocirrhosis. Forty seven-year-old female patient with previous history of chemotherapy for metastatic breast cancer. Axial (A) and sequential coronal (B and C) contrast enhanced CT images of the abdomen show a worsening of macronodular liver contour with enlarged spleen, consistent with pseudocirrhosis and signs of liver failure.

Figure 5

Steatosis patterns. All images are axial and coronal contrast enhanced CT. A and B demonstrate diffuse hepatic steatosis with focal sparing (white arrows), common pattern. C and D demonstrate diffuse steatosis without focal sparing, common pattern. E and F demonstrate geographic fatty change (white arrows), less common pattern.

Figure 6

Acute Hepatitis. Twenty nine-year-old female with lymphoma on cyclophosphamide and doxorubicin chemotherapy among other agents. Post treatment course was complicated by increase in liver enzymes. (A) Axial contrast enhanced CT images shows decreased hepatic attenuation with mild peri-portal edema consistent with acute hepatitis. (B) After three months, findings of hepatitis were resolved.

Figure 7

Hepatic Necrosis. Twenty-year-old female with acute myeloid leukemia, on COAP regimen (cyclophosphamide, oncovin, arabinosyl cytosine and prednisone). Post treatment course was complicated by increase in liver enzymes. (A) The pretreatment image shows no abnormality in liver (B) (C) After chemotherapy, coronal (B) and axial (C) contrast enhanced CT images demonstrate focal liver necrosis vs peliosis-centrilobular hemorrhagic necrosis of the liver (arrows).

Figure 8

Sixty two-year-old female after bone marrow transplantation. Coronal contrast enhanced CT demonstrates a filling defect in the portal vein (white arrow) compatible with portal vein thrombosis.