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WSU Medical School
Wayne State University
CASE: A 45 year-old-female with history of clinically stage IA ER/PR/Her-2 Negative moderately differentiated ductal carcinoma of right breast presented with abdominal pain, abdominal distension, jaundice, and scleral icterus three weeks after laparoscopic cholecystectomy due to acute cholecystitis. Intraoperatively her liver was noted to be cirrhotic and an intraoperative biopsy was done. Upon discharge after surgery her total bilirubin remained elevated. On presentation she showed signs of acute liver failure and coagulopathy with a bilirubin of 10.5, INR was elevated to 2.8, and AST/ALT downtrending. Clinically she continued to have increased abdominal pain and distension, jaundice, and scleral icterus. Intraoperative biopsy pathology showed fragments of benign liver cyst with granulomatous inflammation. During her hospital course she continued to display worsening liver function with elevated AST/ALT, total bilirubin, alkaline phosphatase, and INR. Post-surgical complications including bile leak, viral, autoimmune, and granulomatous causes of acute liver failure were excluded. Further evaluation with transjugular hepatic biopsy was done due to limited diagnostic value of previous biopsy, and revealed cirrhosis. Immunohistochemical staining was positive for GATA-3 immunostain and CK-7 stain, revealing adenocarcinoma most consistent with primary breast carcinoma. DISCUSSION: Acute Liver Failure (ALF) is defined as sudden liver dysfunction manifesting as coagulopathy and any degree of encephalopathy in a patient without preexisting cirrhosis with illness lasting less than 26 weeks' duration. As much as 20-40% of ALF is due to unclear causes. Hepatic metastases have been identified in up to 40% of adults with malignant tumors. In the case of breast cancer metastases,the liver is considered to among the common sites of metastasis, along with lungs and bone. However, most metastases present in the form of a discrete mass, and patients do not usually present with liver disease. Isolated liver metastases from breast cancer is rare and only seen in 5-12% of breast cancer patients. Prior studies have shown that isolated liver involvement prognosis improves if patients have hormone positive cancer, normal liver function, good performance status, and have had a long Disease Free Interval (DFI). Resection of liver metastasis is indicated of helical CT or MRI demonstrates well-circumscribed mass that can be excised without further damaging liver function. Diffuse liver metastasis is very rare and difficult to diagnose as they are not identifiable on routine radiologic diagnostic studies. There are multiple case reports of occult metastatic breast cancer in the liver presenting with acute liver failure, in patients with a history of known and treated breast cancer. The majority of these cases are only identified as metastasis from breast cancer primary upon autopsy, as the prognosis for such a presentation of metastatic breast cancer is appalling. In few reported cases, early diagnosis and treatment resulted in some improvement beyond the 18-24 months expected prognosis in metastatic breast cancer. CONCLUSION: Our patient presents a challenging case in which liver function and performance status was poor prior to diagnosis of metastasis. Helical CT also demonstrated a unique presentation of cirrhotic liver with vastly diffuse metastatic lesions, with no circumscribed mass seen. The findings of this case emphasize the unique presentations of metastatic breast cancer in patients who are in remission, necessitating a broader differential diagnosis at time of presentation.
Mohammed, Saara; Sankar, Keerthana; Al Saheli, Zaid; and Willens, David E., "Occult Breast Cancer Metastasis Presenting as Acute Liver Failure" (2019). Case Reports. 117.