Hepatic metastasis from perianal Paget’s disease without identified underlying carcinoma: a case report

Background Perianal Paget’s disease (PPD) is a rare malignancy, often associated with an underlying adenocarcinoma and a poor prognosis. Case presentation A 69-year-old female was presented with a history of perianal pruritus for 6 months and enlarged inguinal lymph nodes in the left side. Paget cells were confirmed by pathology after a wide excision of perianal skin. Radiotherapy was performed covering the bilateral inguinal lymphatic drainage area. Hepatic metastasis was found 8 months after surgery. Hepatic artery embolization (HAE) and high-intensity focused ultrasound therapy (HIFU) were performed successively. However, hepatic metastasis happened again 3 months later. Ultrasound-guided percutaneous radiofrequency ablation (PRFA) was carried out and various means of inspection could not identify the primary tumor. In the case of rapid progression of the tumor, we gave the patient chemotherapy regimens of XELOX. After 4 cycles of chemotherapy, the tumor marker went down continuously and the hepatic metastasis stayed stable. Conclusions Hepatic metastasis from perianal Paget’s disease without identified underlying carcinoma may benefit from XELOX on the basis of adenocarcinoma.

Diagnostic Benefit of High b-Value Computed Diffusion-Weighted Imaging in Patients with Hepatic Metastasis

Diffusion-weighted imaging (DWI) has rapidly become an essential tool for the detection of malignant liver lesions. The aim of this study was to investigate the usefulness of high b-value computed DWI (c-DWI) in comparison to standard DWI in patients with hepatic metastases. In total, 92 patients with histopathologic confirmed primary tumors with hepatic metastasis were retrospectively analyzed by two readers. DWI was obtained with b-values of 50, 400 and 800 or 1000 s/mm2 on a 1.5 T magnetic resonance imaging (MRI) scanner. C-DWI was calculated with a monoexponential model with high b-values of 1000, 2000, 3000, 4000 and 5000 s/mm2. All c-DWI images with high b-values were compared to the acquired DWI sequence at a b-value of 800 or 1000 s/mm2 in terms of volume, lesion detectability and image quality. In the group of a b-value of 800 from a b-value of 2000 s/mm2, hepatic lesion sizes were significantly smaller than on acquired DWI (metastases lesion sizes b = 800 vs. b 2000 s/mm2: mean 25 cm3 (range 10–60 cm3) vs. mean 17.5 cm3 (range 5–35 cm3), p < 0.01). In the second group at a high b-value of 1500 s/mm2, liver metastases were larger than on c-DWI at higher b-values (b = 1500 vs. b 2000 s/mm2, mean 10 cm3 (range 4–24 cm3) vs. mean 9 cm3 (range 5–19 cm3), p < 0.01). In both groups, there was a clear reduction in lesion detectability at b = 2000 s/mm2, with hepatic metastases being less visible compared to c-DWI images at b = 1500 s/mm2 in at least 80% of all patients. Image quality dropped significantly starting from c-DWI at b = 3000 s/mm2. In both groups, almost all high b-values images at b = 4000 s/mm2 and 5000 s/mm2 were not diagnostic due to poor image quality. High c-DWI b-values up to b = 1500 s/mm2 offer comparable detectability for hepatic metastases compared to standard DWI. Higher b-value images over 2000 s/mm2 lead to a noticeable reduction in imaging quality, which could hamper diagnosis.

Radioembolization of Secondary Hepatic Malignancies

Cancer has become the leading cause of mortality in America, and the majority of patients eventually develop hepatic metastasis. As liver metastases are frequently unresectable, the value of liver-directed therapies, such as transarterial radioembolization (TARE), has become increasingly recognized as an integral component of patient management. Outcomes after radioembolization of hepatic malignancies vary not only by location of primary malignancy but also by tumor histopathology. This article reviews the outcomes of TARE for the treatment of metastatic colorectal cancer, metastatic breast cancer, and metastatic neuroendocrine tumors, as well as special considerations when treating metastatic disease with TARE.