Metastatic Breast Cancer Presenting as Painless Jaundice

Abstract

Jaundice carries with it a wide-ranging differential diagnosis, including etiologies relating to infection, autoimmune, toxins, malignancy, and metabolic derangements. We present a case involving a female with history of breast cancer and relapse-free interval of 15 years who presented with an initial complaint of painless jaundice and was unfortunately diagnosed with metastatic disease involving the liver, bone, and lymph nodes. A 56-year-old female presented to the emergency department for evaluation of painless jaundice, first noticed by family members one day prior to arrival. The patient has a history of breast cancer at age 36, treated with chemotherapy, radiation, and right mastectomy. Physical exam revealed jaundice and scleral icterus and a firm, non-tender liver, palpable beyond the costal border with a negative Murphy's sign. Laboratory findings were consistent with a cholestatic process. A right upper quadrant abdominal ultrasound revealed a 4.1 x 3.6 cm poorly defined mass in the right lobe of the liver, common bile duct measuring 8.6 mm, and intrahepatic ductal dilatation, suggestive of distal common bile duct obstruction. A follow up MRCP showed extensive hepatic metastases with innumerable liver lesions of varying shape and size. The patient underwent an ERCP, where a pancreatic duct stent was deployed but the common bile duct could not be cannulated. The patient subsequently underwent a hepatic lesion biopsy and placement of an internal/external biliary drainage catheter by Interventional Radiology secondary to complete, abrupt obstruction of the distal common bile duct. Biopsy results were positive for primary mammary malignancy. A review of the literature revealed only a select number of cases where patients presented with painless jaundice deemed secondary to metastatic breast cancer. This is the first such case in which the patient already had a known diagnosis of breast cancer, irrespective of prior treatment. In patients with malignant obstruction, biliary stenting has been shown to improve jaundice and deliver improved quality of life. In conclusion, in patients with known malignancy, the development of jaundice may indicate hepatic or biliary metastasis with bile duct obstruction. While a multidisciplinary approach to treatment is necessary, biliary stenting to relieve obstruction is a viable option for palliation.1364_A.tif Figure 1: Papanicolaou stain, (A, 40x) showing numerous large atypical atypical cells with high nuclear to cytoplasmic ratios. H&E stain (B, 10x) of the core biopsy showing this infiltrate within the liver parenchyma. Additional immunohistochemical stains show these cells are positive for GATA3 (C, 10x), GDCDFP-15 (D, 10x), mammaglobin (E, 10x), and ER (F, 10x).1364_B.tif Figure 2: MRI of abdomen: axial image showing extensive hepatic metastases with innumerable liver lesions of varying shape and size.