DIFFUSE SINUSOIDAL INVOLVEMENT OF LIVER BY METASTATIC RENAL CELL CARCINOMA

Abstract

A 65-yrs-old non-alcoholic gentleman, with recently diagnosed left renal cell carcinoma and known bone metastases, was treated with 2 cycles of IL-2 at 3 weeks interval, last dose given 10 days prior to admission. He presented with increasing fatigue and rising liver function tests for two weeks. On examination he had deep icterus and enlarged, firm, smooth, minimally tender liver. His laboratory values were as follows: AST 133U/L, ALT 109U/L, ALP 198U/L, GGT 378U/L, and bilirubin 16 mg/dL (direct 9.9 mg/dL). There was no evidence of sepsis. Hepatitis serology and iron studies were negative. CT scan with contrast showed enlarged liver without focal lesions or biliary dilatation. Liver biopsy revealed diffuse sinusoidal involvement of liver parenchyma by the tumor cells that were identical to the primary renal cell carcinoma and the bone marrow metastases. Renal cell carcinoma is known to cause Stauffer's Syndrome, a paraneoplastic elevation of alkaline phosphatase and other liver enzymes that are suspected to be mediated by interleukin-6. Focal hepatic metastases is also known to occur with renal cell carcinoma but diffuse sinusoidal involvement of liver by renal cell carcinoma has never been reported before. In such cases, even if imaging shows no hepatic metastases, a liver biopsy is warranted to exclude microscopic liver involvement by tumor cells. This is especially important if a potentially curative nephrectomy is being considered.