Metastatic breast cancer presenting as fultninant hepatic failure:...

$: Metastatic breast cancer presenting as fultninant hepatic failure: …downloads.hindawi.com/journals/cjgh/1989/595098.pdf · 2019-08-01 · RESUME: On rapportl' le ens d\in cancer$
CA~E. RECORl )

Metastatic breast cancer presenting as fultninant hepatic failure: A case

report and literature review

MAI ( tll 11.1 '"'· T1u11.m1 I-., f\11), t. \\11 lll)N N. (,111, I, 1'11), l)'\\ Ill It (1!l\NT, 1'1l), (' \Rl)f l'-1 A. Ml Li \!'J, MP

ABSTRACT: A case of meLa,tntiL hreast u1rc111(lmt1 presenung .is fowl fulmm.mr hepauc fatlurc ,., presented. The patient did nut ha,·e prl'\' tousl ) J1 ,1gno~cd hn:a~t cancer anJ presented wi th asc ites, Jilu11llile, ahdnm 111,1I pain, nausea, \\llll lllng and hepatiL l'ncepha lopmhy. She d ied within four \\l'l' b ot tlK· oml'I. :::,c,en "mil.tr cases pil'\' l\lLISI) repo rted arc reviewed. Mernst ,ltH. carunrnna ,hnuld he considered in the d1ffcrenual diagnns" of fulmmant lwpatll failure. Can J Gastrocntcrol 1989;3(4 ): 149- 152

Key Words: Asrnes, Brec111 carcinoma, Fulmincmr he/)wic fail11re, Mewsc,11es

Le cancer metastatique du sein prescntant !es symptomcs d'une insuffisance hepatique fulminantc: Observation et revue de la litteraturc medica te

RESUME: On rapportl' le ens d\in cancer mccaswuquc du sc111 ,c present.int ,nmmc urn: 111suffis,m cc hcpattquc fulm 111antc fatale. Le cancer du ,cm n \l\ ,lit ra~ l'lC d1agnos11quc auparav,mt chc: la paticn1e; die prcsl•nu111 de l'asutc, de l'ictcrc , des Joulcurs ahdom111.ilcs, des n.iusCl'S, de~ vomisscment, ct une ,nccphalopath1c h cpallqlll'. Le dcccs L'S( ,un l'llll lllllll1S Jc quatrl' ,cm,111w, apr~s l'.1ppant ion Jl' cc, ,ympl(llllC~. Sept C.1' semhl.1hlc, Jcji\ rappnrtcs sont examine,. I 'en:ncual1tc J 'un cancer mcw,1.mqul' dcvran 0tre c lllhllk·rce dan, le d1agnosuc.: ,litfcrentic l de l'hcpatitc hcpm ique fu lminantl'.

fJ.:/>t.ow1u1r, of \l.:d,nnt:. \m,1!,'n ,m,1 l',uli11lo~,, l 11,r,·1,11, I lm/111111. /."11ilo>1. ( )111<11w Ctni·.:1/~n11.b1tc ,nd n:/n1111, I Jr ( · I\J l ,/it:111. l '11i1n,11, I l"'/>Ud, /'() H"' 5 > N. /.1111,/011,

nwrio NoA 'i \ 'i R,ct:rn•d fin p11hl1rn111111 ,\fon Ii / 'i. / l)tN \, ,·t:/>r,·d lime<), / l)I,,;<)

T l II 11\1 R 1-. \ l'll1\l1'1l ll\ -.1'11: fl)R

111ct,1,1.1ses nt l,ll'l 1t11>ma, p,H•

11 u1l.11I~ fn,111 th l' lung,u,IPn, 1,,mul'it,

and hrl·,ist. In lll1l' .1utnt"'r sl'IIL'' i:-1-mund,Pn ,md Cr,11g (I) rq,,irtl·d 1h,11

5 2 '\, pf pat ll'nt s h,l\ l' had 'l'llll' hcpillll ,1gn, nr ') mpt11111s rl'ier,1hle to tl,l.

me1,1sta,e,. I lo\\l'\'l'r, tu lminant

hcpalll l,ulure ,ts thl· lllllt,tl dtn1l,tl

prcsl'nt.tl llll1 <>I llll'la,t.1111.. 11\'l'I' dhl'i\Sl'

is r,trl'. S111Lt' 11\ l'I transplantatllm h,1,

hecome the ,KCl'pted llll' lll llf thl'r.111\ IPr sPmc lilu,e, llf ful111111ant hep.till

f.iilurl', it 1, 1mport,m1 10 identify th,,

small !.(roup uf p.1t1enh tll llbtitut<.:

the1.11'Y (if .n,11l.1hle) d11L'lll'd at thl· m.il 1gnanq ,tnd 1<1 l·,dudc l hem ,t,

1 ran,plant L,111d1d,1tl''· t\ Li1Sl' nl pre \ iuu,h und1,1gn,1sl•d hrc,1,1 utrL inuma

prc,en1111g as tulm1nant hl'l',ll lL l,1ilu1l' IS dc,L n hl•1.I.

CASE PRESENTATION t\ -+ 7 -ye.ir-ol.l \\ hill' fem.de ,, .1,

rdl·rrl·d tn l hl' ,llll hur,' h1 "1'1 l i1 I l'l'l ,lllsl'

T!U~IHLI cc al

Figure I ) Uros.1 (l{l{lcarnnce of rnr '111fac't' of ln•er

F igu re 2) M1crmco/>1c a/>/Jeawnce of re{lre1emaut•e scctron of liwr. Note che J1ffme c111nmtr mfilmwm1 mterspciwd 1ruh nc,rm(I/ hc/lluoc~tes, mid c\tcmiw fihrn.m. ( Marnm crichrome sewn X 20L1)

offulminant hepnt ic failure. Four weeb pm1r to aJmi~sinn malaise anJ 111cn.:as-111 g r ight upper q uadrnnt pain Lkn: loped. N,n1,e,1 ,md inte rm11 ten t \'(Hniung abn developed. Two weeb later weight g:-i in (>kg). abdu1111nal dis-

tentinn and peripheral eJemH devcll1ped. There was tw hbwry, 1fl iver dtsense, hcp,H t t is.Jaund 1cc. int r,1VL'nnu, drug u,c, tran,fu,i\ll1, nlu1hnl ,1husc or exposure to tox tn, ur medicat ion,. P,i,t hi,t\ll'Y indudcd tihrocystic disease \If

both brcn,ts with henign hiopstes 111

1984, henign fine neeJk a~ptrntion 111

1987 and negative m.11nmogrnphy m 1987.

On admiss ion tn another hospn.11 the fo llowing lahoratmy result s were nh1.1 1ned: a,pnrt,He amincnransfl'r,N 265 iu/L; ;1laninc aminutr.m,frrnse 18l iu/L; alkaline phnsph,ttasl' 290 iu/1, ga mm,1 glutamyl tra11speptidase 126 iu/L; hi liruhin 56 µmol/L; prnthrrnnhm time 14.6 s; parttal thromhopla,tin tune 66 ,; and tnt ,11 pro1 c in 56 g/L. U I Lrn so nl1grnph y ,d,owed a,Lit l'\, chnlclithia,is and a 3 cm L'L hogt'111L lesion in the righ t Johl' felt tll hl' ,I

hl'mangiom;i. I lcparic venograph) l'X·

eluded ;1<.: ute Budd-Ch iari syndmml, wit h normal hepati c Vl'tn,

demonsl rn teJ. A pcrcutaneuus ltl'l'r hinpsy IV<b attempted hut nn tissue w,1, obtmned.

The patient was transferrl'd to thl' authors' centre. She was drowsy an,I ec1nfused with asterixi, presenr nn .ir

ri val. Viral ,igns wcrl' stahle and ,he w,1,

afehn lc. Nu stigmata of d1ron1c liv1:r disea,e were appa rcnr. A,citcs \l'il\

prcsen1 wtthnut ahdnminal tenderncs, or ahdominill wall venow, collaterals. The liver was pnlpahl y enl.irged ( 18 cm) ll'ith ,1 firm edge. Pit ri ng edema wa, present to the knees. A s1rn1 ll , ti rm, irregular mass wa s pnlpahlc in tht' righ t hreast with lnca li:ed right .ixillmy lymphadernipathy.

Initial lah work revealed: sodium 126 mmol/L; potassium 5.5 mmoln, chloride 100 mrnol/L; cn rhon Jiox1d~ 14 .5 mnwl/ L; urcu 10.2 mmol/1; crcntinine 192 µrnol/L; hiliruhin 166 µmnl/L; albumin 29.6 g/L; total protem 58. 3 g/L; pmthmmhin t imc 14 ,; partial th romhopbstin time 95 s (reduced to 14 and 69.5 s, respectively will, vitamm K); leukocytes 22. I x I 09

/ .; hemoglobin 11 l 01-; platelets 19 3 X 10) /L; and lrngmcntat ion, polychrumntic and nucle,1ted rl'd hluod cdb (6/ 100 white blood cell~) were see n on th e pertphe rn l hlood smear. Asp,1rrn1e nminotrnnsfernse was 46 iu/L; alanine ;1min\1t ranskrn,e 109 iu/L; ,1 Jkn I ine phosphatn,e 186 n1/L; g,1 111m,1 glutnmyl trampeptida,c 412 iu/L; scrum hcpa1 i1 is B surf.ice anttgl'n 1v;1s neg,ll ive; I. 5 L nf grossly hloody ,1,citcs were rcmol'ed with the foll l111

l 'iO C ,\:s!JU1\',Tl\t)Jls:TJR(.)J Vtll 1Ntl4SJ.l'Tl·.~ll1l:Rl\l89

Acute liver failure from breast cancer

TABLE 1 Symptoms and signs on admission of previously published cases of acute liver failure secondary to breast carcinoma

Case (reference) 1 (2) 2 (2) 3 (2) 4 (3) 5 (4) 6 (5) 7 (8) 8.

Age (years) 37 58 55 57 27 44 46 47 Duration 4 5 4 3 3 13 days 8 4 of illness (weeks) Jaundice + + + + + + + + Abdominal pain + + + + + + + ~ausea and + + + + + vomiting Ascites + + + + Encephalopathy + + + + + Post breast Yes Yes Yes No Yes Yes Yes No cancer 811irubln 135 176 50 227 55 35.2 115 166 AST (iu/L) 180 149 74 507 830 339 46 AP (iu/L) 450 1730 1945 1011 315 I IX normal l 6Xnormal 186 PT 14% Normal 10% 38 s 17.3 s 18 9 s 75"/o 111 s Albumin 26 28 28 27 29 Pathology Widespread Ascose l None obtoned Widespread Diffuse W1desp1ead Widespread As

metastases Recovered W1th metas1ases sinusoidal metastases metastases case D1ttuse 1nt1ltrat1on chemo and Liver 1960g 1nf11tral1on with Liver 1800 g , Liver 11135 g 1 of liver with necrosis radiotherapy ln11llrat1on of fibrosis. massive diffuse 5'IUS0ldol Diffuse vascular

vessels sinusoids nccroSIS ,nldlrat,on and lymphatic lymphatics Liver 1500y 1nf1ltrat1on Death from Intense f1bros1s varlceal hemorrhage

Diagnosis Yes Yes Yes No No Yes suspected

· Present case AP Alkaline phosphatase AST Aspartate aminotransferase. PT Profhrombm time

l) 111.~ resu lh: leukocy1l', 6 X Ill /L ( 4tl"11 polym()rrhonu<..lea r leukn1.. \ ll',), re,I

1)

H1l<xl cell, l) I X 10 /L ,111LI dw I..) 1nlng~ 11·;1, negath·1..'.

De,p11e I rearml'nt tnr inkued a,llt1.·, and 11\'er failur1..· 11·1t h 1111 r,11 enou, ,d(1x111n, nlhum1n, fk,h frl1:en pl.i,m:1, 111.1111111 Kand lauu l!l,e, thl' p.n1en1\ cond1r1nn w11r,1..·ne,I. A needle hH1p,) llf 1hr right hren,t m,is, 11•:1, pl•rfiirm1..•d under lnc.11 ,me,t h(:-1,1 \Virh1n 24 h ,h,· 11.1, mm,terred tll dw 1nte11'1H· 1..,irl' unit hecau,e llf hyplltl'llSllll1, nligun ,1 .,nd re,piratory failurL'.

Rcrc,ll ahdnm 111,1 I u It r,N 11111graph, rt'1·ealed thl.'.l'L hogcn,c ngh1 lnhL' lc,ion ,rcn earlil'r, asutl'' and a d,ffu,ely 111-h11111ogene,iu, li\'\•r p:1rL'1,chym,1. The b,op,y nf the right hrea,t wa, rq,oned 11i ,h()\\' adl'noc.irL 111llma. She died ,hlirtly rhereaftcr n f mulr,pk' nrgan 1.1ilure. The l'ntlrl' durntilll1 (if her ill nt•,s 11·a, fl iur \\'ceb.

AUTOP Y The ,llllllp,y rL' \L':tkd infiltr.11 ing

Jud,11 1..arL11111ma lif thL· right hrca,t With l'Xtl'lbl\'e llll't.1,t,he, lll fL'glllll,tl

nlldc,, 1 he left hrl':tsl, I II er. ,pkL·n, hom· m,irr\lw .1111.I 1, mph .1n g11 ll t ,trunom,110,1, llf 1he lung. M11..rll,u>pll meta , 1,1,e, were prl''l'nt 111 hr.tin , e p1l.1rd111111, th) ru1d, adren,il gl.111d , ll\ , II') ,111d ranue,1'.

T he li1Tr \l'l'1glwd I 69Cl g and 11·:1, diffu,d) ydl,l\\ 11 nh l.11'!.!L' .1rea, <ll tan mnttlmg (Figurl' I). Ex1L'l1'11l' 111m<lu 1 111filtra1ion o t p<lna l trnus, lym1,h,1110 and ,111u,01,b 11 .1, prl',en1 ( h f.!ure 2). t\ L1x1111al IIW<lh 1..·ment <lf the l\lhuk 11.h ,een ar11und tl1l· centr:d I cm. 1'1.trkcd de,1rn1pl.ist11.. rt·.iu11m 1,1 the tlllll()lll 11 a, 1'r1..•,e111. A ry1,1cal 1..a1·emu11, hL·t11,t11· g1l lt11,1 wa, 1Lknut1cd in the ngh1 llihc.

DICUS ION Tht· pat11..·nt exh1h1tl'd ;i r,1p1d

dl1\l'nhdl Cllur,L' wnh ,!Lu te l11Tr l.ulure ,ind died tour 11eeb ,11!1..· r rhe <ll1'L'l ,1f the f,r,t ,ymptom,. Wit h<lut rh,· hre,1,1 m.1,, ,ind , uhequcnt u1nfirm,1111111 ,if ,11..knnc1rc111()ma hy needle hllir,). the et1Plog) of he , liver l.1d11rl' ll'lluld hav,· rem a med t111Lkar. SL'\ l'l1 prL'\ Hiu,h puhl,,he,I 1..,1,l'' ,if ,11.. lllL' l11·er f.11lurl' ,ccnnd.ir,· tu hrl',ht l';t rt 111, 1111.1 Wl're

Ct, J G,,.._Tl(l 11 ;,.;Tl I\\ 11 \ ( \I , ( 1 4 ~I !Tl ~tlll R I 9S<J

.11 ,1il,1hk· Im rl'1 IL'\I' .ind ,lit' , 11m111,1r1,t·d 111 T.,hk· I (2-5.~) A, with 1he prL·,1.·nt

p,tt 11..·111, 11ght llf'P1..'r quadrant .1hdu111111.1l 1,a111 (1111.· of ,c1L'll) .md p1und11..L' ( ,1:,. of \l' I l'll) \\'l'fl' (lllll lll\111 pre,e111111g k:1tu11..·,. These d1nic.tl kalt11cs ,Ill' tllll1l111>n ,d,111)! 11·1th ,hllte, 111 .ti I l \ pt·, pf llll'l ,1,t.11 IL I II l'r d N':hl' ( 6)

,rnd I,, n d1,e.1w 1n gL'nl' ral. ThL· ;tl111)lll)( (ll lllll1lllll' l"l'l' l.lt l'llll'nt fl'• qui rl'd tll 1' rndt11..t' ,, m1,1u111' 1, 1 .tn,ihle hut ,n \ll)L" \l'IIL'' <lf p,ttll'llls \\'llh hq1at IL L(llll,l .111 h:td Cl'l',ll l.'.r th,111 50°11 rq,lalL't111.·n1 ( 7)

In h1ur of ,L·n·n piltll'111' the d1.1g· n<1, 1, 1,·.1, unc ka, ,md 1n t w1 1 of tlw,e 11 1\',h Clltillh un,u,pt·ued. In one of dw,L' p,mt·nt, the pn111.1r) hre,1,t c,m cer 11':1'

,1L·ud1 ,md in till' othe r the d1:1gn(l,i:, 11 ,1, 1u ll L' hcp.11111, de,plt L' .1 m,,,teL l<H11\ fourmonth,t·,1rl 1l'r(5). l'atholngy \\',l', ,l\',ll l.thlc Ill SIX ot SL'\ 1..·n pa l 1en1, wh() d1t·1..I. A II ,h(1wed l'Xtl'n,11 e , 1m1'111d.tl , , .1,utl ,1 1 ,md l ~ mphat 1c 111-f ii t r:tr tlln hy tlllllllllf \\'Ith \'itrl, Ihie degrl'e, nf hepat IL neull,1,. Th{lsL' \I'll h markl'd neLn"'' (three pat11..·nh) may h.n·t· ,uftt·rl·d tnm111,tl hypotL·n, 1,111 llr

Ii I

Tl\l\!1111 et al

had lt111l(lur comprumismg hcpauc \';1',

cu lar !,t1(1ply. Six of 20 C1Sl'S 111 the l'C\'ICW nf

diffuse mlrasinu~oidal mctasliHiL disl'f1'l' werl' due to breast Gll1Ler hut the clinical clet,1ih, \\'l'rl' imuffilic•nt, ap.irt from the index case, to be included here a, fulfillmg uitnia for f11lm1n.1nt hepatic fatltirl' ( 5 ). Vari,1hlc degrees oi fihrn,b can accompany t hl' tumours hur 1t can he M> 111tc11Se ,,, tll m11nic cirrho,1, ll'ith pnrial hypcrten,1011 and lead l(l

, ariceal hemnrrhage as I he I crmi nal e\Tnt (H). hdminant hepatic (ailurc' ha, hecn rcpllrtcd \\'1th ,mall Ll'II car-

REFERENCES I. Edmund",n I IA, ( ~ra1g JR. Ncllpl.1,111,

nf the liver. In: Sd111f, ,•d [)i,c',1'l'' ,,t rhe Li\'l'r, 6th c•dn. Philadelphia: L1ppinwu C,. I lJ87: I I l19-5H.

2. Ra:l'nhcrg l'l'A, T.1"1 RC,. Alhu,-Lu11l'r CE. Hcpnt>c h1dtm· du1: 1,1 lin:r llll't,isliN'., 111 hrea,t c,incl'r. Nl'th .I Med I 9ti5;28:29'i 8. Mnrri,on WL. l\·nnmgt,111 ( 'R I 1v,·r 11w1.i,t.1,c·, tr,1111 ;lll ,1,ud1 hrl·.1,1 ,,>r< .. 11\lllll:1 pn.:,l'nting ·" acute lul 111111.mt hq,allc failurl'. Br .I ( '!in Pmc 1984, 1.S:Jt H.

4. \c:hm·rckr R, C,hl·n A Ful1n11\,llll hepar1l h11lure c, 1mpl 1,m1ng 111,·t,1,1 at ll hre,>st ctrLinnnu. Snuth Med .I 1984, 77:84-6.

cinom,1 nt" lung, adenoc,1rc111rnm1 of pancrc,1s and primary m,dignant hemangtocndnthcl inma o( I h·cr (9-12).

Early di,1gnosh ts csscnti,11 to offer aggressive chemotherapy tii re~r, 1m1,·e tumours \\'hich may alter outu)me (2)

and LO exclude these palll'nt, ,b

tramplnn1 1-cl ip1l·nts. Th,, m.iy he d1fiicult ii thl' primary lesion is OLetill and thL' cl111ical p1uure unclcnr. These pat icnts arc often u11,,u11;1hle for perLu tanc(ius Ii, er biopsy (.1sc1tes, co,1gul, 1pat hy) so t r,mwennu, hiopsy ,huuld he con,iderl'd.

Sherl(ick ( I ~) ha, sumnrnri:ed well

5. Smith JC. D1ffLN' 1nrrn,inus.11d.il mc•1av l,ll IL c.mccr llf till' li,·er. Ann Intern ~kd ]961;14:104-1 t

6. F.:11.stl'r LF, 1'1:nskm Ci. l-.,lanik,1.11 mn, ,,f mcrast,HIL lllin\lrs nf the 11\'cr: A stud) of 81 pallcnts suhJecte,I Ill needle· h,up,y. Am J Med 1961; H :BH-48.

7. Era, P, Sherlnck r I kpal IC ((ltl)i\ ,cu>nd,Ir) IP 111,·ta,1at1c l11·L-r d1w,1s,·. ·\nn Intern Med 1971;74-'iKI ~

K. B,,r1,1 f:R, 11,,n JM, Pugh RI' Ml·r.1s t.llk carLilllllllill<1'is p( Lht.: lt\l'r 111111ll(k•

mg c1rrhllsi,. ( '.1,e rep,,n and re'\ ll'\\ t1! rh,· lnn,Hurl'. Cinccr I lJ75; Vi:H5-lJ.

9. 11.,rriwl\ I IR, M1ddktt111 11~1111, Cr.,shy JI I. l\ishcr MN Jr. hilmm,\!11 hep,nic failuri:: An \ltllN!iil prl',cntalllll1 nt ll\l't,1,t,ll IL It \'l'r d 1sl',hl'.

the n1~11roHLh to rhL· p,lliL'nt \\' tlh lul· minant hep,llic failure. Thl' prc,l'l\l authms emphas1~e the need tn Lon,1dcr mcubt,Hic disca,l' 1n rhl' dilll'n:n11.,I diagnosis of fulnunant hepal ic tarlurc. From this re\'ie\\' .in un11s11.dly l,1\\ lcvd ni ,uum I rnn,am111,1,cs ,,·11 h dl'\ .11111n

of ,ii kn Ii nc pho,phat a,l' 111 1 hl· selling 1ll fulminant hq,,ll1L IHtlurL' ,uggl'st1

met,lst;ltlc L,m.:111,,ma a, the l'l1lllt1~1. air huugh akuhol1c 11\'er d1,ea,~ ,m.l Wils(1!1\ ,li~ca,l' llHl\ ,dstl present 11 fulminanr hl'p,llil l.11lme 1,1il1 1r.111,.

,\111111,lsl' lc,·L·b less th,1n I() llllll's nt1r• mal.

( i,is1 r, 1entn11lllg\ I lJK I ;8l\t\20-1. I 0. Kr.1t1" FA, L11d\\ 1g l'\X/, Summ·1 11\V

Mc•t,tstal iL L.trl 1111 >ll1,l J'l'Cll'nllng ,11 tul mina111 hcpat IC l.11lurl'. 1\m I C,,1,ln>c'l1lc'rlll l 97<!;7 2:6S 1-4.

11. Mal Illy TB, C.1,ill'm:111 R, l',1lll, H· .. C,tsc· r,•c, ir,1' nt I h(' ~ 1."'"l hlN'lls Uenl'r,il l lmp11,1I (C.i-c No 12401) N Engl J Ml'd l 94Ci:2 l'i:521 4

12. ~tl'1t1 AM, hl\1,1: K. Tahn: A. Blam h,1rd R, 11-,u S. /\.lulu!t,c;il milliun.1111 hl·m,mg1uc·n,l,>thL·liPm.1 pn·,t·111· mg a, ,KUil' hL'J"ilit 1,. Am I Ua,rrt1l'tHen1I 1977:67: 170 4.

I 'l. Sherlock S. Acut,· (tul1111n.1n1) lwr,111, l.11lurc'. In. l)1"''1Sl',1>l thl' L11·l'1,md Bili.iry System, 7th edn. l\mton:Bliid Wl'li ',ll\'11llfll 1'uhl1l,lll<ll1>, (lJ/15: ( (0-\.

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