Wright Center for Graduate Medical Education Scranton, PA
Award: ACG Presidential Poster Award
Sunny Kumar, MD1, Rahul Kumar, MD2, Avinash Nankani, MBBS3, Deepak Kumar, MBBS, MD4, Jyoti Yadav, MD5, Fnu Aakash, MD6, Hany Eskarous, MD5, Aman Ali, MD7 1Wright Center for Graduate Medical Education, Scranton, PA; 2North Central Bronx Hospital, Bronx, NY; 3Dow University of Health Sciences, Karachi, Sindh, Pakistan; 4Northwell Health, Port Jefferson, NY; 5The Wright Center for Graduate Medical Education, Scranton, PA; 6Florida State University, Cape Coral, FL; 7Wilkes-Barre General Hospital, Scranton, PA Introduction: Small cell lung carcinoma (SCLC) is a rapidly progressive neuroendocrine malignancy that frequently metastasizes to the liver. Hepatic involvement may present with hepatomegaly, jaundice, transaminitis, and portal hypertension. Infiltrative liver metastases can radiographically mimic vascular disorders such as Budd-Chiari syndrome, leading to diagnostic uncertainty. This case highlights the importance of integrating imaging, tumor markers, and liver biopsy for definitive diagnosis.
Case Description/
Methods: A 61-year-old female with coronary artery disease, hypertension, diabetes, and a heavy smoking history presented with abdominal pain, jaundice, nausea, and unintentional weight loss. Laboratory findings revealed AST 775 U/L, ALT 121 U/L, ALP 565 U/L, and total bilirubin 7.8 mg/dL. Abdominal CT (Computed Tomography) demonstrated hepatomegaly with nodularity, colonic wall thickening, and a right middle lobe lung opacity. MRI (Magnetic Resonance Imaging) showed segmental hepatic lesions with perfusion abnormalities and suggested hepatic outflow obstruction. Doppler ultrasound confirmed patent hepatic and portal veins, ruling out Budd-Chiari syndrome.
Further evaluation of Chest CT revealed right hilar lymphadenopathy, pulmonary nodules, and middle lobe opacities suspicious for neoplasm. MRI Pelvis revealed a complex ovarian mass and osseous lesions concerning for metastatic disease. Tumor markers were elevated: CA 125, CA 19-9, and CEA (Carcinoembryonic Antigen), with normal AFP (Alpha-Fetoprotein). Heparin initiated for presumed Budd-Chiari was discontinued. A trans jugular liver biopsy revealed a hepatic venous pressure gradient of 12 mmHg and histopathology consistent with metastatic small cell carcinoma. Immunohistochemistry was positive for pan-cytokeratin, CK7, CD56, synaptophysin, chromogranin, and TTF-1, confirming pulmonary origin. The Ki-67 proliferation index was 100%. Discussion: This case demonstrates an unusual hepatic presentation of metastatic SCLC, initially raising concern for Budd-Chiari syndrome. Hepatic metastases may mimic hepatic venous outflow obstruction radiographically due to sinusoidal compression. However, Doppler ultrasound remains a key tool in excluding vascular obstruction. The definitive diagnosis relied on liver biopsy and immunohistochemical staining, with TTF-1 and neuroendocrine markers supporting lung origin. Prompt recognition is critical, as SCLC has a poor prognosis and requires early oncologic intervention.
Figure: Image 1:The liver is enlarged, right lobe measuring (24.6 cm), heterogeneous parenchymal enhancement and signal intensities, associated with perfusion changes. Hepatic features are suggestive of Budd-Chiari syndrome.
Figure: Image 2: Right hilar lymphadenopathy and pulmonary hilar mass.
Disclosures: Sunny Kumar indicated no relevant financial relationships. Rahul Kumar indicated no relevant financial relationships. Avinash Nankani indicated no relevant financial relationships. Deepak Kumar indicated no relevant financial relationships. Jyoti Yadav indicated no relevant financial relationships. Fnu Aakash indicated no relevant financial relationships. Hany Eskarous indicated no relevant financial relationships. Aman Ali indicated no relevant financial relationships.
Sunny Kumar, MD1, Rahul Kumar, MD2, Avinash Nankani, MBBS3, Deepak Kumar, MBBS, MD4, Jyoti Yadav, MD5, Fnu Aakash, MD6, Hany Eskarous, MD5, Aman Ali, MD7. P1715 - Metastatic Small Cell Lung Carcinoma Presenting With Hepatic Nodularity and Transaminitis Mimicking Budd-Chiari Syndrome, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
