End-Stage Acute Hepatic Failure as Clinical Presentation of Liver Metastases from Breast Cancer

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.

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.

[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.