Reversible Nodular Regenerative Hyperplasia/Sinusoidal Obstruction Syndrome Due to Oxaliplatin Toxicity

Abstract

Case Report: A 61-year-old female with a history of stage IIIB adenocarcinoma of colon status post laparoscopic-assisted resection of the sigmoid and left colon, who was started on adjuvant chemotherapy with Oxaliplatin and Capecitabine, noted to be with elevated liver enzymes two months later. Initially, ALT was 56 U/L and AST was 63 U/L and these elevations were persistent for another two months. Then she had CT abdomen for further evaluation. CT scan showed multiple linear nodular hypodensities within the liver most noticeable on the delayed images along with hypodensity within the dome of the liver concerning for metastases. CT scan of the abdomen done prior to the chemotherapy initiation for staging was unremarkable. As the lesions were seen only on the delayed images of CT abdomen, the non-contrast CT scan used for the liver biopsy did not actually find the nodular lesions, so specimen was obtained from liver parenchyma instead of the nodular lesion indeed. Liver biopsy showed mild steatosis with no significant fibrosis. Later, MRI of the abdomen (Image 1) performed, which showed linear nodular patchy low signal throughout the liver consistent with sinusoidal obstruction syndrome and nodular regenerative hyperplasia concerning for Oxaliplatin toxicity. The patient was taken off Oxaliplatin for three months and then a follow-up MRI of the abdomen (Image 2) showed significant improvement in previously noted diffuse liver disease due to Oxaliplatin hepatotoxicity.Figure 1Figure 2Discussion: Oxaliplatin-based chemotherapy is most commonly used in the setting of colorectal cancer and its associated metastatic disease. In patients with colorectal hepatic metastases, Oxaliplatin increases the surgical amenability of the formerly unresectable lesions by shrinking the size, consequently increasing the long-term survival. Sinusoidal Obstruction syndrome is noted as a complication of Oxaliplatin chemotherapy with nodular regenerative hyperplasia (NRH) being the most notable degree of injury in this disease spectrum. This pattern mimics as metastatic liver lesions on imaging. Although it is still controversial, NRH causes portal hypertension and adversely affects the surgical outcome of the liver resection by escalating the risk of perioperative bleeding and postoperative liver failure. Therefore, we suggest clinicians consider oxaliplatin-induced liver injury, in patients presenting with liver nodules and obtain appropriate imaging to delineate this entity from metastasis.