Imaging Liver Complications of Cancer Therapy

  • Sharon Z. Adam
  • Michal Mauda-Havakuk
  • Ravit Geva
  • Arye Blachar
Part of the Medical Radiology book series (MEDRAD)


The liver is often affected by the different therapies used to treat malignancies. Hepatic complications can result from systemic chemotherapeutic therapy, external beam irradiation of the liver, transarterial therapies using chemotherapeutic agents or radiation-emitting particles, and ablative techniques.

Systemic chemotherapeutic agents often cause steatosis and steatohepatitis and less frequently cirrhosis, pseudocirrhosis, hepatic veno-occlusive disease, and focal benign lesions such as nodular regenerative hyperplasia, focal nodular hyperplasia, and peliosis hepatis. When administered transarterially, there can be accidental embolization of other organs, tumor rupture, periportal edema, biliary damage, abscess formation, and hepatic infarction.

Radiation therapy can cause radiation-induced liver disease when administered externally or transarterially. When it is administered transarterially, inadvertent embolization of the cystic artery can occur, resulting in gallbladder ischemia.

Percutaneous ablative techniques (radiofrequency ablation, microwave ablation, ethanol injection, cryoablation, and laser interstitial thermotherapy), due to their invasive nature, may cause similar complications. These include abscess formation, biliary and vascular injury, hepatic infarction, and hepatic insufficiency. When noninvasive high-intensity focused ultrasound is used, complications are less common, mainly thermal damage to adjacent tissues and possibly thermal biliary damage.


Focal Nodular Hyperplasia Liver Stiffness Transient Elastography Cystic Artery Sinusoidal Obstruction Syndrome 


  1. Barie PS, Eachempati SR (2010) Acute acalculous cholecystitis. Gastroenterol Clin North Am 39(2):343–357, x. doi: 10.1016/j.gtc.2010.02.012
  2. Behrns KE, Tsiotos GG, DeSouza NF, Krishna MK, Ludwig J, Nagorney DM (1998) Hepatic steatosis as a potential risk factor for major hepatic resection. J Gastrointest Surg 2(3):292–298CrossRefPubMedGoogle Scholar
  3. Bertot LC, Sato M, Tateishi R, Yoshida H, Koike K (2011) Mortality and complication rates of percutaneous ablative techniques for the treatment of liver tumors: a systematic review. Eur Radiol 21(12):2584–2596. doi: 10.1007/s00330-011-2222-3 CrossRefPubMedGoogle Scholar
  4. Berzigotti A, Castera L (2013) Update on ultrasound imaging of liver fibrosis. J Hepatol 59(1):180–182. doi: 10.1016/j.jhep.2012.12.028 CrossRefPubMedGoogle Scholar
  5. Brancatelli G, Federle MP, Ambrosini R, Lagalla R, Carriero A, Midiri M, Vilgrain V (2007) Cirrhosis: CT and MR imaging evaluation. Eur J Radiol 61(1):57–69. doi: 10.1016/j.ejrad.2006.11.003 CrossRefPubMedGoogle Scholar
  6. Brennan IM, Ahmed M (2013) Imaging features following transarterial chemoembolization and radiofrequency ablation of hepatocellular carcinoma. Semin Ultrasound CT MR 34(4):336–351. doi: 10.1053/j.sult.2013.04.004 CrossRefPubMedGoogle Scholar
  7. Cefalo MG, Maurizi P, Arlotta A, Scalzone M, Attina G, Ruggiero A, Riccardi R (2010) Hepatic veno-occlusive disease: a chemotherapy-related toxicity in children with malignancies. Paediatr Drugs 12(5):277–284. doi: 10.2165/11531840-000000000-00000 CrossRefPubMedGoogle Scholar
  8. Cha DI, Lee MW, Rhim H, Choi D, Kim YS, Lim HK (2013) Therapeutic efficacy and safety of percutaneous ethanol injection with or without combined radiofrequency ablation for hepatocellular carcinomas in high risk locations. Korean J Radiol 14(2):240–247. doi: 10.3348/kjr.2013.14.2.240 PubMedCentralCrossRefPubMedGoogle Scholar
  9. Chen J, Talwalkar JA, Yin M, Glaser KJ, Sanderson SO, Ehman RL (2011) Early detection of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease by using MR elastography. Radiology 259(3):749–756. doi: 10.1148/radiol.11101942 PubMedCentralCrossRefPubMedGoogle Scholar
  10. Clark TW (2006) Complications of hepatic chemoembolization. Semin Interv Radiol 23(2):119–125. doi: 10.1055/s-2006-941442 CrossRefGoogle Scholar
  11. Clouet M, Boulay I, Boudiaf M, Soyer P, Nemeth J, Kiselman R, Rymer R (1999) Imaging features of nodular regenerative hyperplasia of the liver mimicking hepatic metastases. Abdom Imaging 24(3):258–261CrossRefPubMedGoogle Scholar
  12. Curley SA, Marra P, Beaty K, Ellis LM, Vauthey JN, Abdalla EK, Scaife C, Raut C, Wolff R, Choi H, Loyer E, Vallone P, Fiore F, Scordino F, De Rosa V, Orlando R, Pignata S, Daniele B, Izzo F (2004) Early and late complications after radiofrequency ablation of malignant liver tumors in 608 patients. Ann Surg 239(4):450–458PubMedCentralCrossRefPubMedGoogle Scholar
  13. DeLeve LD, Shulman HM, McDonald GB (2002) Toxic injury to hepatic sinusoids: sinusoidal obstruction syndrome (veno-occlusive disease). Semin Liver Dis 22(1):27–42. doi: 10.1055/s-2002-23204 CrossRefPubMedGoogle Scholar
  14. Donadon M, Di Tommaso L, Roncalli M, Torzilli G (2013) Multiple focal nodular hyperplasias induced by oxaliplatin-based chemotherapy. World J Hepatol 5(6):340–344. doi: 10.4254/wjh.v5.i6.340 PubMedCentralPubMedGoogle Scholar
  15. Dubel GJ, Soares GM (2008) Regional infusion-radioembolization. Surg Oncol Clin N Am 17(4):957–985, xii. doi: 10.1016/j.soc.2008.04.008
  16. Eichler K, Zangos S, Gruber-Rouh T, Vogl TJ, Mack MG (2012) Magnetic resonance-guided laser-induced thermotherapy in patients with oligonodular hepatocellular carcinoma: long-term results over a 15-year period. J Clin Gastroenterol 46(9):796–801. doi: 10.1097/MCG.0b013e3182641806 CrossRefPubMedGoogle Scholar
  17. Erturk SM, Mortele KJ, Binkert CA, Glickman JN, Oliva MR, Ros PR, Silverman SG (2006) CT features of hepatic venoocclusive disease and hepatic graft-versus-host disease in patients after hematopoietic stem cell transplantation. AJR Am J Roentgenol 186(6):1497–1501. doi: 10.2214/ajr.05.0539 CrossRefPubMedGoogle Scholar
  18. Golowa YS, Cynamon J, Reinus JF, Kinkhabwala M, Abrams M, Jagust M, Chernyak V, Kaubisch A (2012) Value of noncontrast CT immediately after transarterial chemoembolization of hepatocellular carcinoma with drug-eluting beads. J Vasc Interv Radiol 23(8):1031–1035. doi: 10.1016/j.jvir.2012.04.020 CrossRefPubMedGoogle Scholar
  19. Hillaire S, Bonte E, Denninger MH, Casadevall N, Cadranel JF, Lebrec D, Valla D, Degott C (2002) Idiopathic non-cirrhotic intrahepatic portal hypertension in the West: a re-evaluation in 28 patients. Gut 51(2):275–280PubMedCentralCrossRefPubMedGoogle Scholar
  20. Horita T, Tsutsumi A, Takeda T, Yasuda S, Takeuchi R, Amasaki Y, Ichikawa K, Atsumi T, Koike T (2002) Significance of magnetic resonance imaging in the diagnosis of nodular regenerative hyperplasia of the liver complicated with systemic lupus erythematosus: a case report and review of the literature. Lupus 11(3):193–196CrossRefPubMedGoogle Scholar
  21. Iannaccone R, Federle MP, Brancatelli G, Matsui O, Fishman EK, Narra VR, Grazioli L, McCarthy SM, Piacentini F, Maruzzelli L, Passariello R, Vilgrain V (2006) Peliosis hepatis: spectrum of imaging findings. AJR Am J Roentgenol 187(1):W43–W52. doi: 10.2214/ajr.05.0167 CrossRefPubMedGoogle Scholar
  22. Iwasa S, Mayahara H, Tanaka T, Ito Y (2013) Ring-enhancing lesion associated with radiation-induced liver disease. J Clin Oncol 31(14):e243–e244. doi: 10.1200/jco.2012.46.7217 CrossRefPubMedGoogle Scholar
  23. Jia Z, Tian F, Jiang G (2013) Ruptured hepatic carcinoma after transcatheter arterial chemoembolization. Curr Ther Res Clin Exp 74:41–43. doi: 10.1016/j.curtheres.2012.12.006 PubMedCentralCrossRefPubMedGoogle Scholar
  24. Jung SE, Cho SH, Jang JH, Han JY (2011) High-intensity focused ultrasound ablation in hepatic and pancreatic cancer: complications. Abdom Imaging 36(2):185–195. doi: 10.1007/s00261-010-9628-2 CrossRefPubMedGoogle Scholar
  25. Karcaaltincaba M, Haliloglu M, Akpinar E, Akata D, Ozmen M, Ariyurek M, Akhan O (2007) Multidetector CT and MRI findings in periportal space pathologies. Eur J Radiol 61(1):3–10. doi: 10.1016/j.ejrad.2006.11.009 CrossRefPubMedGoogle Scholar
  26. Khan AZ, Morris-Stiff G, Makuuchi M (2009) Patterns of chemotherapy-induced hepatic injury and their implications for patients undergoing liver resection for colorectal liver metastases. J Hepatobiliary Pancreat Surg 16(2):137–144. doi: 10.1007/s00534-008-0016-z CrossRefPubMedGoogle Scholar
  27. Kim SW, Rhim H, Park M, Kim H, Kim YS, Choi D, Lim HK (2009) Percutaneous radiofrequency ablation of hepatocellular carcinomas adjacent to the gallbladder with internally cooled electrodes: assessment of safety and therapeutic efficacy. Korean J Radiol 10(4):366–376. doi: 10.3348/kjr.2009.10.4.366 PubMedCentralCrossRefPubMedGoogle Scholar
  28. Kim AY, Rhim H, Park M, Lee MW, Kim YS, Choi D, Lim HK (2011) Venous thrombosis after radiofrequency ablation for hepatocellular carcinoma. AJR Am J Roentgenol 197(6):1474–1480. doi: 10.2214/ajr.11.6495 CrossRefPubMedGoogle Scholar
  29. Kooby DA, Fong Y, Suriawinata A, Gonen M, Allen PJ, Klimstra DS, DeMatteo RP, D’Angelica M, Blumgart LH, Jarnagin WR (2003) Impact of steatosis on perioperative outcome following hepatic resection. J Gastrointest Surg 7(8):1034–1044CrossRefPubMedGoogle Scholar
  30. Lam MG, Louie JD, Iagaru AH, Goris ML, Sze DY (2013) Safety of repeated yttrium-90 radioembolization. Cardiovasc Intervent Radiol 36(5):1320–1328. doi: 10.1007/s00270-013-0547-9 CrossRefPubMedGoogle Scholar
  31. Lawrence TS, Robertson JM, Anscher MS, Jirtle RL, Ensminger WD, Fajardo LF (1995) Hepatic toxicity resulting from cancer treatment. Int J Radiat Oncol Biol Phys 31(5):1237–1248. doi: 10.1016/0360-3016(94)00418-k CrossRefPubMedGoogle Scholar
  32. Lawrence DA, Oliva IB, Israel GM (2012) Detection of hepatic steatosis on contrast-enhanced CT images: diagnostic accuracy of identification of areas of presumed focal fatty sparing. AJR Am J Roentgenol 199(1):44–47. doi: 10.2214/ajr.11.7838 CrossRefPubMedGoogle Scholar
  33. Liang P, Wang Y, Yu X, Dong B (2009) Malignant liver tumors: treatment with percutaneous microwave ablation–complications among cohort of 1136 patients. Radiology 251(3):933–940. doi: 10.1148/radiol.2513081740 CrossRefPubMedGoogle Scholar
  34. Livraghi T, Meloni F, Solbiati L, Zanus G (2012) Complications of microwave ablation for liver tumors: results of a multicenter study. Cardiovasc Intervent Radiol 35(4):868–874. doi: 10.1007/s00270-011-0241-8 CrossRefPubMedGoogle Scholar
  35. Mahamid J, Miselevich I, Attias D, Laor R, Zuckerman E, Shaoul R (2005) Nodular regenerative hyperplasia associated with idiopathic thrombocytopenic purpura in a young girl: a case report and review of the literature. J Pediatr Gastroenterol Nutr 41(2):251–255CrossRefPubMedGoogle Scholar
  36. Mahgerefteh SY, Sosna J, Bogot N, Shapira MY, Pappo O, Bloom AI (2011) Radiologic imaging and intervention for gastrointestinal and hepatic complications of hematopoietic stem cell transplantation. Radiology 258(3):660–671. doi: 10.1148/radiol.10100025 CrossRefPubMedGoogle Scholar
  37. Maor Y, Malnick S (2013) Liver injury induced by anticancer chemotherapy and radiation therapy. Int J Hepatol 2013:815105. doi: 10.1155/2013/815105 PubMedCentralCrossRefPubMedGoogle Scholar
  38. Maturen KE, Feng MU, Wasnik AP, Azar SF, Appelman HD, Francis IR, Platt JF (2013) Imaging effects of radiation therapy in the abdomen and pelvis: evaluating “innocent bystander” tissues. Radiographics 33(2):599–619. doi: 10.1148/rg.332125119 CrossRefPubMedGoogle Scholar
  39. Miyake K, Hayakawa K, Nishino M, Morimoto T, Mukaihara S (2005) Effects of oral 5-fluorouracil drugs on hepatic fat content in patients with colon cancer. Acad Radiol 12(6):722–727. doi: 10.1016/j.acra.2005.02.010 CrossRefPubMedGoogle Scholar
  40. Mortele KJ, Ros PR (2001) Cystic focal liver lesions in the adult: differential CT and MR imaging features. Radiographics 21(4):895–910. doi: 10.1148/radiographics.21.4.g01jl16895 CrossRefPubMedGoogle Scholar
  41. Murthy R, Nunez R, Szklaruk J, Erwin W, Madoff DC, Gupta S, Ahrar K, Wallace MJ, Cohen A, Coldwell DM, Kennedy AS, Hicks ME (2005) Yttrium-90 microsphere therapy for hepatic malignancy: devices, indications, technical considerations, and potential complications. Radiographics 25(Suppl 1):S41–S55. doi: 10.1148/rg.25si055515 CrossRefPubMedGoogle Scholar
  42. Nawawi O, Hazman M, Abdullah B, Vijayananthan A, Manikam J, Mahadeva S, Goh K (2010) Transarterial embolisation of hepatocellular carcinoma with doxorubicin-eluting beads: single centre early experience. Biomed Imaging Interv J 6(1):e7. doi: 10.2349/biij.6.1.e7 PubMedCentralCrossRefPubMedGoogle Scholar
  43. Okamoto D, Nishie A, Asayama Y, Tajima T, Ishigami K, Kakihara D, Nakayama T, Ohga S, Yoshitake T, Shioyama Y, Honda H (2014) Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MR finding of radiation-induced hepatic injury: relationship to absorbed dose and time course after irradiation. Magn Reson Imaging. doi: 10.1016/j.mri.2014.02.019 Google Scholar
  44. Parikh AA, Gentner B, Wu TT, Curley SA, Ellis LM, Vauthey JN (2003) Perioperative complications in patients undergoing major liver resection with or without neoadjuvant chemotherapy. J Gastrointest Surg 7(8):1082–1088CrossRefPubMedGoogle Scholar
  45. Peterson JL, Vallow LA, Johnson DW, Heckman MG, Diehl NN, Smith AA, Tzou KS, Paz-Fumagalli R, Kim S, Ko SJ, Daugherty LC, Kim GP, Brown N, Mori KW, Buskirk SJ (2013) Complications after 90Y microsphere radioembolization for unresectable hepatic tumors: an evaluation of 112 patients. Brachytherapy 12(6):573–579. doi: 10.1016/j.brachy.2013.05.008 CrossRefPubMedGoogle Scholar
  46. Qayyum A, Lee GK, Yeh BM, Allen JN, Venook AP, Coakley FV (2007) Frequency of hepatic contour abnormalities and signs of portal hypertension at CT in patients receiving chemotherapy for breast cancer metastatic to the liver. Clin Imaging 31(1):6–10. doi: 10.1016/j.clinimag.2006.09.028 CrossRefPubMedGoogle Scholar
  47. Qian J (2011) Interventional therapies of unresectable liver metastases. J Cancer Res Clin Oncol 137(12):1763–1772. doi: 10.1007/s00432-011-1026-9 CrossRefPubMedGoogle Scholar
  48. Reissfelder C, Brand K, Sobiegalla J, Rahbari NN, Bork U, Schirmacher P, Buchler MW, Weitz J, Koch M (2014) Chemotherapy-associated liver injury and its influence on outcome after resection of colorectal liver metastases. Surgery 155(2):245–254. doi: 10.1016/j.surg.2013.07.022 CrossRefPubMedGoogle Scholar
  49. Richardson P, Guinan E (1999) The pathology, diagnosis, and treatment of hepatic veno-occlusive disease: current status and novel approaches. Br J Haematol 107(3):485–493CrossRefPubMedGoogle Scholar
  50. Robinson PJ (2009) The effects of cancer chemotherapy on liver imaging. Eur Radiol 19(7):1752–1762. doi: 10.1007/s00330-009-1333-6 CrossRefPubMedGoogle Scholar
  51. Robinson S, Manas DM, Pedley I, Mann D, White SA (2011) Systemic chemotherapy and its implications for resection of colorectal liver metastasis. Surg Oncol 20(2):57–72. doi: 10.1016/j.suronc.2009.10.002 CrossRefPubMedGoogle Scholar
  52. Rubbia-Brandt L, Lauwers GY, Wang H, Majno PE, Tanabe K, Zhu AX, Brezault C, Soubrane O, Abdalla EK, Vauthey JN, Mentha G, Terris B (2010) Sinusoidal obstruction syndrome and nodular regenerative hyperplasia are frequent oxaliplatin-associated liver lesions and partially prevented by bevacizumab in patients with hepatic colorectal metastasis. Histopathology 56(4):430–439. doi: 10.1111/j.1365-2559.2010.03511.x CrossRefPubMedGoogle Scholar
  53. Saif MW, Shahrokni A, Cornfeld D (2007) Gemcitabine-induced liver fibrosis in a patient with pancreatic cancer. JOP 8(4):460–467PubMedGoogle Scholar
  54. Schreiner SA, Gorman B, Stephens DH (1998) Chemotherapy-related hepatotoxicity causing imaging findings resembling cirrhosis. Mayo Clin Proc 73(8):780–783. doi: 10.4065/73.8.780 CrossRefPubMedGoogle Scholar
  55. Shakil AO, Jones BC, Lee RG, Federle MP, Fung JJ, Rakela J (2000) Prognostic value of abdominal CT scanning and hepatic histopathology in patients with acute liver failure. Dig Dis Sci 45(2):334–339CrossRefPubMedGoogle Scholar
  56. Singh D, Das CJ, Baruah MP (2013) Imaging of non alcoholic fatty liver disease: a road less travelled. Indian J Endocrinol Metab 17(6):990–995. doi: 10.4103/2230-8210.122606 PubMedCentralCrossRefPubMedGoogle Scholar
  57. Thatishetty AV, Agresti N, O’Brien CB (2013) Chemotherapy-induced hepatotoxicity. Clin Liver Dis 17(4):671–686, ix–x. doi: 10.1016/j.cld.2013.07.010
  58. Torrisi JM, Schwartz LH, Gollub MJ, Ginsberg MS, Bosl GJ, Hricak H (2011) CT findings of chemotherapy-induced toxicity: what radiologists need to know about the clinical and radiologic manifestations of chemotherapy toxicity. Radiology 258(1):41–56. doi: 10.1148/radiol.10092129 CrossRefPubMedGoogle Scholar
  59. Vauthey JN, Pawlik TM, Ribero D, Wu TT, Zorzi D, Hoff PM, Xiong HQ, Eng C, Lauwers GY, Mino-Kenudson M, Risio M, Muratore A, Capussotti L, Curley SA, Abdalla EK (2006) Chemotherapy regimen predicts steatohepatitis and an increase in 90-day mortality after surgery for hepatic colorectal metastases. J Cin Oncol 24(13):2065–2072. doi: 10.1200/jco.2005.05.3074 CrossRefGoogle Scholar
  60. Vogl TJ, Farshid P, Naguib NN, Zangos S (2013) Thermal ablation therapies in patients with breast cancer liver metastases: a review. Eur Radiol 23(3):797–804. doi: 10.1007/s00330-012-2662-4 CrossRefPubMedGoogle Scholar
  61. Wagnetz U, Jaskolka J, Yang P, Jhaveri KS (2010) Acute ischemic cholecystitis after transarterial chemoembolization of hepatocellular carcinoma: incidence and clinical outcome. J Comput Assist Tomogr 34(3):348–353. doi: 10.1097/RCT.0b013e3181caaea3 CrossRefPubMedGoogle Scholar
  62. Worthy SA, Elliott ST, Bennett MK (1994) Low-reflectivity periportal collar on hepatic ultrasound. Br J Radiol 67(803):1050–1051CrossRefPubMedGoogle Scholar
  63. Yajima Y, Narui T, Ishii M, Abe R, Ohtsuki M, Goto Y, Endo S, Yamada K, Ito M (1982) Computed tomography in the diagnosis of fatty liver: total lipid content and computed tomography number. Tohoku J Exp Med 136(3):337–342CrossRefPubMedGoogle Scholar
  64. Young ST, Paulson EK, Washington K, Gulliver DJ, Vredenburgh JJ, Baker ME (1994) CT of the liver in patients with metastatic breast carcinoma treated by chemotherapy: findings simulating cirrhosis. AJR Am J Roentgenol 163(6):1385–1388. doi: 10.2214/ajr.163.6.7992734 CrossRefPubMedGoogle Scholar
  65. Zech CJ, Seiderer J, Reinisch W, Ochsenkuhn T, Schima W, Diebold J, Wrba F, Reiser MF, Schoenberg SO (2007) Thioguanin-induced nodular regenerative hyperplasia of the liver-ROC analysis of different MR techniques. Eur Radiol 17(7):1898–1905. doi: 10.1007/s00330-006-0544-3 CrossRefPubMedGoogle Scholar
  66. Zegel HG, Kurtz AB, Perlmutter GS, Goldberg BB (1981) Ultrasonic characteristics of bilomas. J Clin Ultrasound 9(1):21–24CrossRefPubMedGoogle Scholar
  67. Zhou YF (2011) High intensity focused ultrasound in clinical tumor ablation. World J Clin Oncol 2(1):8–27. doi: 10.5306/wjco.v2.i1.8 PubMedCentralCrossRefPubMedGoogle Scholar
  68. Zorzi D, Laurent A, Pawlik TM, Lauwers GY, Vauthey JN, Abdalla EK (2007) Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases. Br J Surg 94(3):274–286. doi: 10.1002/bjs.5719 CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • Sharon Z. Adam
    • 1
    • 2
  • Michal Mauda-Havakuk
    • 1
  • Ravit Geva
    • 3
  • Arye Blachar
    • 1
    • 4
  1. 1.Department of RadiologyTel Aviv Sourasky Medical CenterTel AvivIsrael
  2. 2.Department of Diagnostic RadiologyNorthwestern University Feinberg School of MedicineChicagoUSA
  3. 3.Department of OncologyTel Aviv Sourasky Medical CenterTel AvivIsrael
  4. 4.Computed Tomography and Magnetic Resonance Imaging DivisionThe Tel Aviv University Sackler School of MedicineTel AvivIsrael

Personalised recommendations