Rare Case of Acute Liver Failure Caused by Diffuse Liver Metastases in a Patient With Non-Muscle Invasive Transitional Cell Carcinoma of the Bladder

Abstract

Introduction: Acute liver failure (ALF) secondary to infiltration of the liver by malignant cells is unusual, and hematological malignancies are the most common underlying etiology. ALF secondary to liver infiltration from transitional cell bladder cancer is extremely rare. Case Report: A 70-year-old woman with a 2008 history of non-muscle invasive (Stage T1) transitional cell cancer of bladder, treated with transurethral resection of the bladder tumor, presented to the hospital with right upper quadrant pain, fever, and vomiting. Labs showed WBC 12,000, lactate 6.2 mmol/L, and abnormal liver parameters (AST, 416 U/L; ALT, 147 U/L, total/direct bilirubin, 6.1/4 mg%, alkaline phosphatase, 268 U/L, INR, 1.5). Abdominal ultrasound showed multiple gallstones and non-dilated CBD. ERCP showed no CBD stone or evidence of cholangitis. Viral hepatitis, autoimmune serologies, and other laboratory studies for other causes of acute liver failure were negative or non-reactive. A CT scan showed numerous low attenuation masses in the liver and enlarged retroperitoneal lymph nodes, and the bladder appeared normal. A liver biopsy showed sheets of malignant cells. P63 stain was positive, suggestive of metastatic carcinoma of urothelial origin. The patient’s liver synthetic parameters continued to worsen. She developed hepatic coma and expired 6 days after presentation. Discussion: ALF secondary to infiltration of the liver by malignant cells is a well-described entity, with hematological malignancies, including lymphoma and leukemias, being the most common causes. Other metastatic malignancies that rarely can cause ALF include adenocarcinomas and melanoma. ALF secondary to liver infiltration from transitional cell bladder cancer is extremely rare, with only 3 previous cases reported, all with documented muscle invasive (Stage T2) disease. Conclusion: To our knowledge, we report the first case of ALF secondary to non-muscle invasive (Stage T1) transitional cell bladder cancer occurring 5 years after original presentation and presumptive cure.