Fulminant Hepatic Failure Caused by Diffuse Intrasinusoidal Metastatic Liver Disease: A Case Report

Carcinomatous cirrhosis as radiographically occult liver metastases of breast cancer: A systematic literature review

In the present study, we aimed to clarify features of carcinomatous cirrhosis from breast cancer presenting as refractory transudate ascites and acute liver failure. In our systematic literature review, we identified 26 studies and 31 cases including our case of this rare condition. Our patient was a 49-year-old woman with a history of ascites and liver failure for the past 4 years and currently being treated for invasive ductal breast cancer. On radiography, she had occult liver metastases that were confirmed using laparoscopic liver biopsy. In the 31 cases, data on the reported year, age, type of primary breast cancer, time from breast cancer diagnosis, presence of ascites and/or varices, liver biopsy, diagnostic modalities, outcomes, and survival were documented and analyzed. All cases were reported during 1984-2020, with a mean patient age of 52.9 years. Eighteen patients (58.1%) were diagnosed with ductal breast cancer. Twenty-two patients (70.9%) had ascites. All patients had gradual progression to liver dysfunction. The following tests were performed: computed tomography (77.4%); ultrasound (58.0%); liver biopsy (100%); postmortem biopsy (35.5%), transjugular liver biopsy (32.3%), and laparoscopic liver biopsy (3.2%). Outcomes were reported for 29 patients, of whom 24 (82.3%) died after 1 day to 16 months. Invasive ductal carcinoma was the most common histological type; however, invasive lobular carcinoma was more frequent (32.3%) than its reported incidence in the breast. Carcinomatous cirrhosis has poor prognosis at relatively rash and is difficult to diagnose with usual modalities. It may be associated with E-cadherin loss or CD44 pronouncement.

Radiographically Occult Carcinomatous Spread of Breast Cancer to the Liver: A Challenging Case

Metastatic carcinomatosis to the liver is a pattern of malignant infiltration that tends to provoke hepatic fibrosis. It is a rare complication of multiple solid tumor types and often seen in the absence of discrete tumor mass in the liver. We report a case of a 69-year-old woman with metastatic ductal carcinoma of the breast who presented with rising serum tumor markers and mildly cirrhotic contour of the liver on a CT scan. An early diagnosis of occult spread to the liver was made by means of a percutaneous liver biopsy showing desmoplastic response to invasive breast cancer cells found diffusely in the liver. This case highlights a rare pattern of metastatic spread of breast cancer as well as predisposing and prognostic features.

Acute Liver Failure as the Initial Manifestation of Hepatic Infiltration by a Solid Tumor: Report of 5 Cases and Review of the Literature

Background

Acute liver failure is a rare complication of metastatic liver disease with a high mortality. Recognition of malignant infiltration of the liver as the cause of acute liver failure could be a diagnostic challenge.

Patients

The medical files of 5 patients with acute liver failure due to metastatic liver disease collected over a 4-year period (1997–2000) in our department were reviewed.

Results

No patient had a past history of cancer. The interval from jaundice to encephalopathy ranged from 7 to 12 days (median, 10). Physical examination revealed hepatomegaly and deep jaundice in all patients. AST elevation ranged from 147 to 1870 IU/L (median, 716 IU/L) and ALT elevation from 74 to 556 IU/L (median, 138 IU/L). All patients died within 4–14 days (median, 7) of admission. None had papillary edema or decerebrate posture before death. Four patients had concurrent renal impairment. Liver imaging studies in 2 of the 5 patients were nondiagnostic and the malignant liver infiltration was confirmed postmortem. Liver histology in all cases showed massive tumoral infiltration of the hepatic sinusoids with diffuse replacement of hepatocytes. The primary tumors were colon, gastric, small cell lung, pancreas and cancer of unknown origin.

Conclusions

Malignant infiltration of the liver should be taken into account in the differential diagnosis of rapidly progressive liver failure. Although effective chemotherapy has improved the survival of patients with metastatic liver disease, there has been no change in the course and outcome of acute liver failure due to malignant infiltration of the liver over the last 2 decades. A proper diagnosis by liver biopsy is mandatory to prevent such patients from being considered for liver transplant.

T2 breast cancer presenting with diffuse liver metastases and hepatic failure following fertility treatment. Cautionary report

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Metastatic breast cancer presenting with liver failure is rare.

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This case had fertility treatments with clomiphene for an undisclosed duration before presenting with a T2 tumour with diffuse hepatic metastases.

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The extent of metastases was not consistent with the duration of the t2 tumour of 3months.

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The rapidity of progression and demise within a week of presentation is remarkable.

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This would be a cautionary report emphasizing the need for increased screening and surveillance during fertility treatments.

Background

Diffuse hepatic metastases with hepatic failure as a presentation of a T2 breast cancer is rare. This is also remarkable seeing our case had been on fertility treatments before presentation. There are no documented reports of breast cancer patient on fertility treatment presenting with diffuse hepatic metastases and liver failure.

Case summary

A 41 year old Para 1 Nigerian woman being managed for secondary infertility with an extended use of clomiphene presented with a 3 months history of a left breast lump, nipple bleeding and later, yellowness of eyes, right hypochondrial pain malaise and drowsiness. Abdominal USS showed an enlarged liver with diffuse metastatic nodules. Liver function tests showed persistently elevating liver enzymes and serum bilirubin. Serology showed Hepatitis B negative. She was diagnosed with a T2 left invasive ductal carcinoma, Er−, Pr+ Her2+ with deteriorating liver function from diffuse hepatic metastases She had chemotherapy but succumbed barely a week of presentation.

Conclusion

Breast cancer screening for patients before fertility treatments and continual surveillance while on such treatment is highly recommended.

Characterization of the syndrome of acute liver failure caused by metastases from breast carcinoma

AIM

To characterize syndrome of acute liver failure (ALF) from metastatic breast cancer to promote premortem diagnosis. Up to now, only 25 % of the reported 32 cases of this syndrome were diagnosed premortem.

METHODS

Cases identified by computerized literature review and review of files maintained by senior investigator.

RESULTS

Among 32 cases, average age at presentation was 47.9 ± 9.9 years. Common signs include jaundice, hepatomegaly, shifting dullness, and bilateral leg edema. Mean serum level of AST was 296.4 ± 204.0 U/L, ALT, 183.2 ± 198.9 U/L; alkaline phosphatase, 641.5 ± 610.1; and total bilirubin, 8.6 ± 8.3 mg/dL. Twenty-seven patients (84 %) have known prior breast cancer (mean diagnosis = 4.1 + 4.8 years earlier). Abdominal ultrasound findings (N = 10) include hepatomegaly in three cases, heterogeneous/multifocal hepatic lesions in three, ascites in three, and other in two. Abdominal CT findings (N = 16) include heterogeneous/multifocal hepatic lesions in six cases, ascites in five, hepatomegaly in three, cirrhosis in three, fatty liver in two, other in two. Hepatic metastases may not be suspected when abdominal CT shows no hepatic lesions. The diagnosis is made postmortem in 24 cases and antemortem in eight, with a statistically significant trend of increasing premortem diagnosis since 2000 (0 % before 2000 vs. 50 % after 2000; p = .001, 95 %--ORCI ≥ 2.86, Fisher's exact test). A new case of ALF from breast cancer is reported with notable features: abdominal CT revealed no discrete hepatic lesions despite widespread hepatic metastases demonstrated by liver biopsy; hepatic metastases occurred 21 years after original breast primary; and original diagnosis of lobular breast cancer in primary lesion was corrected to mixed ductal and lobular carcinoma, based on immunohistochemistry, performed 21 years afterward.

CONCLUSIONS

This review characterizes the clinical presentation and natural history of this syndrome to promote liver biopsy for premortem diagnosis and appropriate therapy.

Rapid liver enlargement and hepatic failure secondary to radiographic occult tumor invasion: two case reports and review of the literature

Introduction

Unfamiliarity with certain clinical presentations, as illustrated in these cases, can lead to delayed diagnoses that in turn cause increased morbidity, prolonged hospitalization, and the need for autopsy.

Case presentation

In Case 1, a 63-year-old Caucasian woman presented with hepatic enlargement and insufficiency which progressed and resulted in her death over a period of less than 2 weeks. The patient underwent a detailed workup included magnetic resonance imaging and computed tomography scan of her liver, which did not reveal the source of her liver enlargement. Due to her progressive liver enlargement and insufficiency, she developed a life-threatening esophageal variceal bleeding during her hospital stay which further delayed the attainment of her diagnosis. She finally underwent a videoscopic laparotomy and liver biopsy which revealed complete replacement and filling in of the liver sinuous with Indian filing lobular breast cancer. The patient died shortly after her diagnosis and before she could be discharged.

In Case 2, a 68-year-old Caucasian woman with non-small-cell lung cancer was admitted to our Oncology in-patient service with a presentation of rapid hepatic insufficiency and severe liver enlargement. Like the patient in Case 1, during her hospitalization, this patient underwent a thorough radiographic evaluation, including computed tomography and magnetic resonance imaging, to identify the source of her symptoms. Radiographic imaging showed only hepatomegaly and no discrete focal lesions. As the multiple imaging studies over a period of a week did not reveal a clear cause for her symptoms, she finally underwent an interventional radiology core biopsy which showed complete replacement of her liver with non-small-cell lung cancer. Her condition rapidly progressed due to continued liver enlargement and she died due to frank liver failure before her diagnosis was affirmed and she could be discharged.

Conclusion

Both of these cases illustrate the potential difficulties in diagnosing liver-infiltrative malignancy and the need for a high index of clinical suspicion for occult infiltrative malignancy in the liver to determine the appropriate therapeutic intervention, including further treatment of malignancy, palliative care, or determination of candidacy for liver transplantation. Because the diagnosis for the cause of symptoms and hepatomegaly was elucidated only by liver biopsy which occurred much later in their hospital course, both patients died while in the hospital instead of at home or in a hospice. Moreover, these delays in diagnosis and development of morbidities due to the progressing liver failure further prevent any possibility of early initiation of palliative treatment. Initial recognition of this type of presentation can lead to a prompt diagnostic biopsy and diagnosis. Giving the patient a correct diagnosis is one of the fundamental goals of oncology: a goal that, as illustrated in literature review, is not always achieved. Although treatment options in such cases often may be limited, prompt discharge from the hospital and/or admission into a hospice program can potentially afford the patient the best quality of life and help protect the patient’s dignity.

Massive infiltration of liver by metastatic adenocarcinoma: a rare cause of acute hepatic failure

Acute liver cell failure can occur by diffuse infiltration of malignant cells in liver parenchyma. The malignant cells might be either primary hepatocellular carcinoma or metastatic liver disease. Mostly, CT abdomen with intravenous contrast fails to detect liver malignancy. We report a case of liver metastasis masquerading as fulminant hepatic failure.

Fulminant Liver Failure in a Patient Affected by Polycystic Liver Disease and Liver Metastases from Breast Carcinoma

Background

Polycystic liver disease (PLD) is a rare, congenital, benign condition characterized by the presence of multiple bile-duct-derived epithelial cysts in the liver parenchyma. The disease is usually asymptomatic, but cyst growth can result in complications such as ascites, esophageal varices, jaundice and hepatic failure. The exact mechanism leading to cyst growth is unclear, but estrogenic stimulation and paracrine action of vascular endothelial growth factor (VEGF) are thought to play a role in the growth of cyst epithelium.

Case report

We report a case of acute liver failure in a young woman with PLD and liver metastases from breast carcinoma.

Results

No data are available in the literature about metastatic liver involvement in PLD patients affected by breast cancer. The prognosis of patients with liver metastases is generally poor but fulminant liver failure is a very rare occurrence. Estrogen stimulation seems to be a risk factor for breast cancer and severe PLD. In the reported case, the presence of either the cysts or the metastatic lesions may have resulted in more extensive liver damage.

Conclusions

The adoption of drugs selected in relation to their hepatic toxicity together with careful monitoring of liver function is warranted in the management of breast cancer patients affected by PLD, in order to reduce the risk of liver failure.

Metastatic prostatic carcinoma presenting as fulminant hepatic failure

A 68-year-old male presented with progressive abdominal pain, dyspnea, weight loss, and dysuria. Lab work revealed elevated creatine phosphokinase levels, prostate-specific antigen level (approximately 60 ng/mL), and elevated liver enzymes. He was admitted to the intensive care unit for worsening respiratory distress and confusion. He continued to deteriorate, and his bilirubin peaked at 8.5 mg/dL. The patient subsequently died, and an autopsy revealed extensive hepatic necrosis with diffuse intravascular and intraparenchymal permeation of metastatic prostatic carcinoma. Fulminant hepatic failure remains a rare presentation of metastatic prostatic carcinoma, with a rapidly progressive course toward hepatic coma and death. A high index of suspicion is needed to investigate the possibility of palliative chemotherapy.

[Ascites due to portal hypertension from breast cancer- related metastatic liver infiltration]

Ascites in patients with breast cancer is uncommon. We report the case of a 70-year-old woman with breast cancer and ascites caused by portal hypertension due to metastatic liver infiltration. There was no evidence of peritoneal carcinomatosis and the prothrombin index was normal. Portal hypertension was confirmed by increased hepatic venous pressure gradient. Histological examination of a liver biopsy obtained by the transjugular route demonstrated infiltration by malignant cells from the breast tumor. This case shows that, infiltration of the liver by metastases from breast cancer may lead to ascites due to portal hypertension, even in the absence of hepatic failure.

Radiographically occult, diffuse intrasinusoidal hepatic metastases from primary breast carcinomas: a clinicopathologic study of 3 autopsy cases

CONTEXT

Liver metastases usually present as radiographically detectable mass lesions that do not significantly compromise liver function. Rarely, metastatic carcinoma can diffusely infiltrate hepatic sinusoids, a pattern of metastasis that may be missed on imaging studies, and can result in liver failure.

OBJECTIVE

To describe the clinicopathologic features of 3 cases of diffuse intrasinusoidal hepatic metastases from primary breast carcinomas identified at autopsy.

DESIGN

Clinical histories and radiographic, macroscopic, and microscopic appearances of the livers were compared. Sampled liver tissue was stained with antibodies to E-cadherin, smooth muscle actin, and CD44.

RESULTS

Two of 3 cases had a history of infiltrating ductal carcinoma of the breast and presented with new-onset liver failure, but no hepatic metastases were identified on radiologic imaging. An additional case had no history of carcinoma, presented with a severe thrombocytopenic thrombotic purpura-like syndrome, and metastatic carcinoma of the breast was diagnosed only at autopsy. The livers in all 3 cases at autopsy were homogeneous, firm, and tan-yellow, and contained no large metastatic lesions. Microscopically, poorly differentiated carcinoma diffusely infiltrated hepatic sinusoids. Antibodies to smooth muscle actin stained activated hepatic stellate cells lining involved sinusoids. Cell surface adhesion molecules, E-cadherin or CD44, were not detected in any hepatic metastases.

CONCLUSION

Diffuse intrasinusoidal hepatic metastases of breast carcinoma can occupy a large percentage of the hepatic volume, yet remain occult both radiographically and macroscopically. This type of metastatic spread can present as cryptogenic liver failure. The 3 cases we studied were associated with an absence of E-cadherin and CD44 expression.

Multifocal intraportal invasion of breast carcinoma diagnosed by laparoscopy-assisted liver biopsy

Hepar lobatum carcinomatosum (HLC) is defined as an acquired hepatic deformity consisting of an irregularly lobulated hepatic contour caused by intravascular infiltration of metastatic carcinoma. To date, only nine cases of HLC have been reported in the literature. We report a case of a 68-year-old woman showing hepatic metastasis of breast carcinoma in radiologically unidentified form. Initially, she received left partial mastectomy for breast cancer but solid hepatic metastases were identified in S₂ and S₆, 9 mo after surgery. Then, they responded to chemotherapy and radiologically disappeared. After radiological disappearance of the liver tumors, the patient's blood chemistry showed abnormal liver function. A CT scan demonstrated heterog-eneous enhancement effect in the liver in the late phase, suggesting uneven hepatic blood supply. Hepatic deformity was not obvious. Laparoscopy revealed a slightly deformed liver surface with multiple indentations and shallow linear depressions. Furthermore, a wide scar was observed on the surface of S2 possibly at the site where the metastatic tumor existed before chemotherapy. Liver biopsy from the wide scar lesion showed intraportal tumor thrombi with desmoplastic change. Because of its similarity to the histology of the original breast cancer, we concluded that the hepatic functional abnormalities and slightly deformed liver surface were derived from the circulatory disturbance caused by microscopic tumor thrombi. Besides, since the wide scar was located at the site of the pre-existing tumor, it is probable that chemotherapy was an important cause of fibrous scarring as a result of tumor regression. These morphologic findings are compatible with those of HLC. Laparoscopy-assisted liver biopsy was useful to make definite diagnosis, even though the hepatic deformity was radiologically undetectable.

Metastatic liver disease and fulminant hepatic failure: presentation of a case and review of the literature

Although liver metastases are commonly found in cancer patients, fulminant hepatic failure (FHF) secondary to diffuse liver infiltration is rare. Furthermore, clinical presentation and laboratory findings are obscure and far from being pathognomonic for the disease. We report a case of a patient who died in the intensive care unit of our hospital from multiple organ failure syndrome secondary to FHF, as a result of liver infiltration from poorly differentiated small cell lung carcinoma. We also present the current knowledge about the clinical picture, laboratory findings and physical history of neoplastic liver-metastasis-induced FHF.