Diffuse hepatic intravascular carcinomatous embolization resulting in fatal liver failure: A clinicopathologic study of 4 cases

The authors report four cases in which patients died of acute or fulminant hepatic failure resulting from massive intravascular metastatic carcinomato us embolization, a rarely reported manifestation of metastatic disease. Neo plasms were high grade carcinomas. Tumor emboli were present within portal branches ranging 0.12-2.9 mm in diameter and were free floating or attached to the vascular wall, with or without varying degrees of superimposed orga nization. In one case, intravascular tumor necrosis was prominent and appea red as granular casts with superimposed dystrophic calcification and/or ent rapped foamy histiocytes. There were associated geographical areas of paren chymal (4 cases) and tumor (1 case) ischemic necrosis with a multifocal and regional topographic distribution. An associated predominant pattern of in trasinusoidal tumor infiltration (with or without fibrosis) was present in 3 cases, whereas the fourth case had underlying micronodular cirrhosis, pro viding ancillary evidence for preexisting altered intrahepatic microcircula tion. The literature on fatal hepatic failure resulting from neoplasia is r eviewed with a reassessment of its pathobiological significance.