Metastatic Breast Cancer Presenting as a Hilar Mass

Abstract

A 62-year-old woman with history of lobular cancer of the left breast, status post mastectomy was referred for evaluation of elevated liver function tests. She had complaints of worsening abdominal pain, 15-pound weight loss, itching and decreased appetite. Laboratory studies revealed total bilirubin 0.8 mg/dl, AST of 138 IU/L, ALT of 146 IU/L and alkaline phosphatase 828 IU/L. Ca 19-9 was slightly elevated at 78 U/ml and CEA was normal. Abdominal MRI was performed which revealed 33 mm x 27 mm hilar soft tissue mass, suspicious for cholangiocarcinoma, encasing the proximal common bile duct with porta hepatis and left para-aortic lymph node enlargement. Endoscopic ultrasound confirmed the presence a 24 mm x 20 mm irregular hypoechoic mass lesion seen in the hilum region of the liver. Dilatation of the biliary tree was seen upstream from the mass lesion. A single lymph node was visualized in the perihilar area adjacent to the hilar mass. The ultrasound image of node appeared with hypoechoic center and hyperechoic outer area. The node measured 26mm on the long axis and 17mm on the short axis, suspicious for malignant involvement. Fine needle aspiration was performed from the perihilar node and pathology revealed ER/PR positive, Her-2 neu negative, metastatic breast lobular carcinoma. The patient was referred to oncology and started on chemotherapy. Breast cancer is the most common malignancy and the leading cause of death in women. It metastasizes via hematogenous spread preferentially to bone, lungs, and the brain. Metastatic breast cancer can involve the extrahepatic ducts via direct extension of liver metastasis into the intrahepatic ducts and into the extrahepatic ducts. However, very few cases demonstrate hematogenous spread targeting the extrahepatic biliary tree without hepatic involvement. The largest case series published by Popp et al in the 1970s followed 7 women who underwent surgery for biliary obstruction from metastatic breast cancer. 6 of the 7 cases were due to bile duct compression from lymph node metastases; only one patient had direct metastasis to the biliary duct. This case illustrates, a rare case of metastatic breast cancer presenting as a hilar mass. In patients with breast cancer history who develop worsening abdominal pain and signs of biliary outflow tract obstruction, it is important to consider the biliary tree as a location for possible recurrence of metastatic disease.Figure: Diffuse mild intrahepatic biliary duct dilation is noted to the level of hepatic hilum. There is a 3.3 x 2.7 cm mass in the hepatic hilum.Figure: Histological appearance of biopsied perihilar node revealing ER positive, PR positive, HER2 Neu negative metastatic breast lobular cancer.