The relationship between the presence of a malignancy and the death of a patient is often obscure. Sometimes the clinician, more frequently the pathologist, can point to a single mechanism of death. One can mention hypercalcemia, acute cerebral edema surrounding a brain metastasis, or bilateral ureteral obstruction with uremia. However, it appears that death is most frequently due to a remote mechanism, such as infection, hemorrhage, or infarction.1
Even more subtle mechanisms are now being discovered. For example, the presence of hepatic metastases was of interest to the clinician only as a poor prognostic factor or a contraindication to surgery. Massive replacement of liver parenchyma by metastasis is not usually considered crucial to patient survival but only as a source of discomfort.
Recently, hepatic involvement has been recognized as an infrequent cause of death. Eras et al described hepatic coma in 7.2% of all patients with metastatic liver disease,