S3032 Hiding in Plain Sight: An Atypical Presentation of Metastatic Breast Cancer as Acute Decompensated Cirrhosis

Abstract

Introduction: Liver is a common site of breast cancer metastases, which are typically identified as hypervascular lesions on imaging. We present a rare case of breast cancer leading to diffuse, intra-sinusoidal, radiographically occult metastases in a patient presenting with new hepatic decompensation. Case Description/Methods: A 65-year-old woman with a remote history of grade IIIa invasive ductal carcinoma of the right breast status post lumpectomy, chemotherapy, and local radiation therapy was referred to liver clinic for 1 month of abdominal pain and newly elevated AST 144 U/L, ALT 143 U/L, total bilirubin 5.2 mg/dL, conjugated bilirubin 3.7 mg/dL, and alkaline phosphatase 652 U/L. She denied use of alcohol, substances, new medications, or supplements. Physical exam did not demonstrate stigmata of chronic liver disease. Work up for infectious, autoimmune, and common infiltrative etiologies of liver disease were negative; several tumor markers were elevated (Table 1). A routine surveillance PET-CT and subsequent MRCP demonstrated diffuse heterogeneous liver attenuation with cirrhotic morphology, splenomegaly, trace ascites, and intrabdominal lymphadenopathy. No discrete masses were seen on either study. The following week the patient was admitted for rapidly progressive failure to thrive, worsening ascites, jaundice, and oliguria. Inpatient labs demonstrated worsening hyperbilirubinemia (total bilirubin 14.8 mg/dL, conjugated bilirubin 12.2 mg/dL), hyponatremia, and AKI. Admission MELD-Na score was 31 and CLIF-C ACLF score was 46. Paracentesis demonstrated SAAG 1.6 with ascites protein 1.8 g/dL confirming Child Pugh Class B Cirrhosis. Transjugular liver biopsy measured hepatic venous pressure gradient 12mmHg and pathology demonstrated metastatic breast carcinoma of the sinusoidal and vascular spaces with background steatosis and non-bridging fibrosis. Despite aggressive treatment with fulvestrant and abemaciclib, she had worsening multiorgan failure. Given her overall poor prognosis, the patient elected to transition to hospice. Discussion: Metastatic breast cancer uncommonly presents with diffuse, intra-sinusoidal metastases that are radiographically occult. This case highlights the importance of maintaining a high index of suspicion for metastatic disease in patients with a history of malignancy presenting with new hepatic decompensation even in absence of typical radiographic findings. In such cases, liver biopsy may be required for a definitive diagnosis. (Table) Table 1. - Work up for etiologies of chronic liver disease Autoimmune markers ANA Positive (1:320, speckled) Anti-mitochondrial Ab < 1:20 dsDNA < =200 Smooth muscle Ab < 20 RNP Ab < 20 SSA Ab 68 (Elevated) SSB Ab < 20 Rheumatoid Factor < 10 Thyroid Peroxidase Ab 135 (Elevated) Beta-2-Glycoprotein IgA/IgG/IgM < 10 Cardiolipin IgA/IgG/IgM < 20 C-ANCAMyeloperoxidase AbP-ANCAProteinase-3 Ab < 1:20< 1:20< 1:20< 1:20 Infectious studies Hep A Ab Nonreactive Hep C Ab Nonreactive Hep B surface Ab < 10 Hep B surface Ag Nonreactive Hep B core Ab Nonreactive MTB-Quantiferon-Gold Negative Other causes of Liver Disease Alpha-1-antitrypsin Negative SPEP/UPEP No monoclonal bands observed Ceruloplasmin Elevated Copper Elevated Ferritin Elevated Tumor Markers AFP 4.2 ng/mL, decreased to < 1.82 ng/mL CEA 84 ng/mL, increased to peak 3042 ng/mL (Elevated) CA 125 930 U/mL CA 19-9 1166 U/mL CA 27.29 7450.1 U/mL (Elevated)