Pseudocirrhosis

Pseudocirrhosis is a radiologic term describing morphologic changes of the liver that resemble cirrhosis, often seen in patients with hepatic metastases, especially from breast cancer, after chemotherapy. Unlike true cirrhosis, it is not due to chronic liver disease or fibrosis resulting from typical causes like viral hepatitis or alcohol, but rather is secondary to malignancy or its treatment.

1. Cause and Etiology

Primary Cause:

Most commonly associated with metastatic breast cancer, especially after chemotherapy.
It can also be seen with other malignancies: pancreatic, colon, gastric, esophageal, neuroendocrine tumors, and lymphoma.

Mechanisms (Etiologic Contributors):

Chemotherapy-induced hepatic injury: including sinusoidal obstruction, regenerative nodules, and hepatic fibrosis.
Desmoplastic reaction from infiltrative metastatic tumors.
Tumor regression with fibrosis mimicking cirrhotic nodularity.
Capsular retraction due to scarring.
Vascular changes and nodular regenerative hyperplasia.

In essence, pseudocirrhosis is a consequence of tumor biology and treatment-related hepatic remodeling rather than classic etiologies of cirrhosis.

2. Pathophysiology

Pseudocirrhosis evolves through a combination of hepatic tumor infiltration, chemotherapy effects, and secondary fibrotic responses, which include:

Nodular regenerative hyperplasia (NRH): widespread transformation of hepatic parenchyma into regenerative nodules without fibrosis.
Sinusoidal obstruction syndrome (SOS): injury to the hepatic sinusoidal endothelium, leading to vascular congestion and fibrosis.
Peritumoral fibrosis: induced by regressing metastases.
Hepatic capsular retraction: from desmoplastic response to tumor.
Volume loss of liver segments: from ischemia or regressive changes.
Portal hypertension may develop from compression or remodeling of hepatic vasculature despite the absence of diffuse fibrosis.

3. Epidemiology

Incidence is not precisely known, but among breast cancer patients with liver metastases, pseudocirrhosis may occur in up to 50% of those undergoing systemic chemotherapy.
More common in:

Women, at to breast cancer.
Patients receiving multiple cycles of chemotherapy, especially agents like paclitaxel, capecitabine, or gemcitabine.

4. Clinical Presentation

Pseudocirrhosis may be:

Asymptomatic and discovered on surveillance imaging.
Or may present with signs similar to true cirrhosis:

Symptoms/Signs:

Ascites
Splenomegaly
Esophageal varices
Hepatic dysfunction (in advanced cases)
Portal hypertension
Jaundice (rare and late)

Importantly, liver function may remain relatively preserved until late stages, unlike true cirrhosis.

5. Imaging Features

CT and MRI:

Liver surface nodularity
Capsular retraction
Segmental volume loss, especially of the right lobe
Enlarged caudate lobe
Atrophy-hypertrophy complex
Ascites
Splenomegaly and portosystemic collaterals in advanced cases
Decreased size of metastases (post-chemotherapy) with fibrotic response

Ultrasound:

Irregular liver surface
Signs of portal hypertension
Heterogeneous echotexture

Key Point: These imaging features mimic cirrhosis but are found in patients without a chronic liver disease history.

6. Treatment

There is no specific treatment for pseudocirrhosis itself, but management depends on:

a) Treatment of Underlying Malignancy:

Systemic chemotherapy continuation or modification
Palliative care if advanced

b) Management of Complications (as in cirrhosis):

Ascites: sodium restriction, diuretics (spironolactone, furosemide), paracentesis
Portal hypertension: beta-blockers, variceal band ligation if bleeding
Hepatic encephalopathy, if present: lactulose, rifaximin

c) Adjustment of Hepatic Dosing for Chemotherapy

Modified dosing to reduce hepatotoxicity

7. Prognosis

Prognosis depends primarily on the underlying malignancy, particularly metastatic breast cancer.
Pseudocirrhosis itself does not represent end-stage liver disease, but the development of portal hypertension or liver failure worsens the prognosis.
Median survival after diagnosis of pseudocirrhosis is variable, often less than a year if complications occur and the malignancy is not well controlled.
Patients may become ineligible for further chemotherapy due to hepatic dysfunction.

Summary Table

Category	Details
Cause/Etiology	Metastatic cancer (esp. breast), chemotherapy-induced hepatic remodeling
Pathophysiology	NRH, sinusoidal obstruction, peritumoral fibrosis, vascular remodeling
Epidemiology	Common in metastatic breast cancer (up to 50%); more in women
Clinical Presentation	Ascites, splenomegaly, varices, preserved LFTs early
Imaging	Nodular contour, segmental atrophy, capsular retraction, ascites
Treatment	Treat malignancy, manage portal hypertension, and liver dysfunction
Prognosis	Depends on the underlying cancer; it worsens with portal hypertension or failure

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Case study: A 52-Year-Old Woman Presenting with Abdominal Pain
Pseudocirrhosis

Clinical History and Imaging Findings

A 52-year-old woman with a prior history of breast cancer presented to the emergency department with complaints of abdominal pain.
Contrast-enhanced abdominal CT was performed.

Quiz 1

On axial CT images using a soft tissue window, the liver shows nodular contours.
(1) True (2) False
Axial CT images using a bone window demonstrate diffuse sclerosis of the osseous structures, suggesting metastasis.
(1) True (2) False
This phenomenon commonly occurs in hepatic metastases treated with chemotherapy.
(1) True (2) False
This imaging pattern is associated with a favorable prognosis.
(1) True (2) False
Explanation: This phenomenon is associated with a poor prognosis.
What does this imaging finding suggest?
(1) Cirrhosis
(2) Pseudocirrhosis
(3) Hemochromatosis
(4) Hepatic steatosis

Findings and Diagnosis
Findings: Axial CT images in a soft tissue window show nodular hepatic contours. Axial CT in a bone window reveals diffuse osseous sclerosis suggestive of skeletal metastases.

Diagnosis: Pseudocirrhosis

Discussion: Pseudocirrhosis
Pseudocirrhosis refers to morphologic changes of the liver contour seen in metastatic malignancies, mimicking true cirrhosis. It is most frequently observed in patients with hepatic metastases from breast cancer undergoing systemic chemotherapy, often regimens including 5-fluorouracil (5-FU). However, similar appearances may be seen with liver metastases from other primary malignancies such as pancreatic carcinoma, colorectal cancer, medullary thyroid carcinoma, and esophageal cancer.

Pseudocirrhosis can develop rapidly, with imaging changes becoming evident within 1 to 3 months. It is distinguished from true cirrhosis by the absence of bridging fibrosis between regenerating nodules. Nevertheless, pseudocirrhosis may be associated with complications such as ascites, portal hypertension, and splenomegaly. Due to these potential sequelae, pseudocirrhosis is often linked to a poor clinical prognosis.

References

(1) Ozaki K, Higuchi S, Kimura H, Gabata T. Liver metastases: Correlation between imaging features and Pathomolecular Environments. Radiographics. 2022;42(7):1994-2013.

(2) Sadlik G, Anderson RC, Lei X, Cen SY, Duddalwar VA, Fong TL. Pseudocirrhosis: A case series with clinical and radiographic correlation and review of the literature. Dig Dis Sci. 2024;69(3):1004-1014.

(3) Oilai C, Douek ML, Rhoane C, et al. Clinical features of pseudocirrhosis in metastatic breast cancer. Breast Cancer Res Treat. 2019;177(2):409-417.

(4) Engelman D, Moreau M, Lepida A, Zaouak Y, Paesmans M, Awada A. Metastatic breast cancer and pseudocirrhosis: An unknown clinical entity. ESMO Open. 2020;5(3):e000695.

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