S2706 Metastatic Breast Cancer Presenting as Acute Liver Failure

Abstract

INTRODUCTION: Up to 20% of acute liver failure (ALF) cases have no known etiology. Of the many causes, initial presentation of metastatic carcinoma is rare, with malignant infiltration of the liver usually diagnosed postmortem. We present a case of fulminant liver failure caused by a new diagnosis of metastatic breast cancer. CASE DESCRIPTION/METHODS: A 55 year old African American female with no significant medical history presented with fatigue and jaundice for one month and one week of pruritus and lower extremity edema. On presentation, she had a MELD-Na of 38 with mild confusion, therefore prompting a rapid inpatient liver transplant evaluation for ALF. Physical exam revealed an obese female in no distress, a distended but soft abdomen with hepatomegaly, scleral icterus, and pitting edema. Further history regarding medications and family history was unrevealing other than having immigrated from Liberia in 2000, a history of a positive PPD with negative chest x-ray follow up, and not up to date on cancer screening. An abdominal ultrasound revealed cirrhotic morphology of the liver, ascites, and marked hepatic echogenicity. Paracentesis fluid was negative for SBP with a SAAG of 2.5 and fluid protein <1.0. An abdominal MRI needed for listing revealed an enlarged liver that was replaced by innumerable ring-enhancing lesions concerning for metastasis (Image 1). A non-targeted liver biopsy revealed metastatic carcinoma consistent with breast primary with no underlying cirrhosis (Images 2 and 3). Transplant workup was terminated and the patient was referred to Oncology and Palliative Care for further management. DISCUSSION: Diffuse metastatic breast cancer causing ALF is rare. Like most patients with ALF, our patient had a rapid decline with symptoms specific to hepatic failure only. Confirming prior liver disease is of paramount importance prior to listing which is why a non-targeted biopsy was obtained in our patient prior to receiving the MRI results. This diagnosis of breast cancer presenting as ALF was surprising given the acuity, lack of prior history or symptoms, and signs of cirrhosis. Rare presentations such as this argue towards liver biopsy prior to listing fulminant liver failure patients of unknown etiology, which is currently not required.Figure 1.: MRI.Figure 2.: H&E: liver with metastatic tumor cells.Figure 3.: GATA-3 immunohistochemical stain (IHC): nuclear positivity of tumor cells (specific to breast primary).