2391 When Breast Cancer Comes Back With Vengeance: Death Within Three Weeks Secondary to Acute Liver Failure

Abstract

INTRODUCTION: Breast cancer (BC) is the most common cancer in women in the developed and developing world. Here we report a patient with treated stage II HER2+ BC presenting with abnormal liver enzymes and jaundice, found to have innumerable hepatic lesions consistent with metastatic BC, with rapid progression to acute liver failure(ALF). CASE DESCRIPTION/METHODS: A 63-year-old female with history of stage II HER2+ BC who underwent six cycles of neoadjuvant chemotherapy, lumpectomy, radiation, letrozole for four years, presented with one week of abdominal distension, dark urine, pale stools, and jaundice. She denied a history of hepatitis, intravenous drug use, or herbal supplement use but used marijuana and was a former smoker and heavy alcohol user. Six years prior to admission, two tubulovillous adenomas, 1.0 × 1.0 × 0.8 cm and 1.5 × 1.5 × 1.2 cm were resected. Surveillance colonoscopy, six months later, revealed a tubular adenoma, 0.2 × 0.2 × 0.2 cm and a tubulovillous adenoma, 1.2 × 1.2 × 1.2 cm. She missed her repeat surveillance colonoscopy. Physical examination was notable for jaundice, scleral icterus, hepatomegaly, and abdominal distension. Workup included negative hepatitis panel, platelet count 121,000/uL, total bilirubin 14.2mg/dL, direct bilirubin 10.7mg/dL, alkaline phosphatase 1367 IU/L, aspartate aminotransferase 621 U/L, alanine aminotransferase 252 U/L, albumin 1.5 g/dL, prothrombin time 14.7 seconds, activated partial thromboplastin time 41.5 seconds, international normal ratio 1.2, CA 15-3 3900 U/mL, CA 19-9 7200 U/mL, and CEA 844 U/mL. CT Abdomen/Pelvis revealed innumerable hepatic metastases, hepatomegaly, and small volume ascites (image 1). She underwent IR-guided biopsy of a hepatic lesion, confirmed as metastatic HER2 equivocal BC. Within one week, she became encephalopathic and died whilst deciding between hospice and systemic chemotherapy. DISCUSSION: BC represents about 30% of all cancer diagnoses in women each year. Of those diagnosed at early stages, 20-30% will relapse with metastatic BC. HER2+ BC has a higher risk of relapse than other subtypes, and is more likely to spread to the brain, liver, bone, and lung. This patient’s hepatic involvement was concerning for metastatic BC or colon cancer, based on past tubulovillous adenomas and missed surveillance colonoscopy. Within three weeks of presentation, she died. This case highlights the fulminant progression of HER2+ BC causing ALF due to tumor infiltration of liver parenchyma with cessation of synthetic capacity.