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Metastatic Breast Carcinoma Mimicking Macronodular Cirrhosis

2003; Elsevier BV; Volume: 78; Issue: 11 Linguagem: Inglês

10.4065/78.11.1431

1942-5546

G.V. Wallace, Theresa L. Conologue, Timothy J. Murphy,

Radiopharmaceutical Chemistry and Applications

To the Editor: Although breast cancer often metastasizes to the liver, associated hepatic failure with cirrhosis is rare. We report an unusual case of metastatic breast cancer mimicking macronodular cirrhosis with portal hypertension, varices, and fulminant hepatic failure. A 42-year-old woman presented to our facility with new-onset ascites, hepatic failure, and evolving hepatic encephalopathy. Invasive lobular breast carcinoma had been diagnosed 1 year previously, and the patient had received 4 cycles of adjuvant doxorubicin and cyclophosphamide, 4 cycles of paclitaxel, 8 weeks of radiation therapy, and adjuvant hormonal therapy with tamoxifen citrate. She had done well until 3 weeks before the current admission, when she developed general malaise, fatigue, progressive jaundice, and marked abdominal distention. Computed tomography (CT) of the abdomen showed extensive ascites and a small, hypoperfused liver. Although metastatic breast carcinoma was strongly suspected, cytologic examination of the ascitic fluid and CT findings did not support this diagnosis. Ultrasonography of the abdomen revealed a small liver with relative sparing of the left hepatic and caudate lobes, consistent with macronodular cirrhosis. Blood flow within the main portal vein was hepatofugal, suggesting portal hypertension. Multiplanar magnetic resonance imaging showed a small, cirrhotic-appearing liver with esophageal and gastric varices but no evidence of a focal mass. Together, these findings suggested cirrhosis, not metastatic breast cancer. Therefore, we performed a liver biopsy, which showed portal hypertension and varices. The tissue obtained was histologically compatible with metastatic breast carcinoma. Small foci of residual hepatocytes were evident, with nearly complete replacement of the liver by metastatic adenocarcinoma. The patient returned to her home medical facility, where she died of her illness. Metastatic carcinomatous cirrhosis is a rare syndrome. Although the liver is a frequent site of metastasis, hepatic failure with cirrhosis is rare, and the associated portal hypertension and esophageal varices seen in our patient are even more unusual. A 20-year retrospective study of the development of esophageal varices secondary to primary and metastatic liver tumors identified 72 patients with radiological, endoscopic, or postmortem evidence of esophageal varices.1Kurtz RC Sherlock P Winawer SJ Esophageal varices: development secondary to primary and metastatic liver tumors.Arch Intern Med. 1974; 134: 50-51Crossref PubMed Scopus (17) Google Scholar Liver metastasis was believed to be the cause of portal hypertension and esophageal varices in 17 cases, 8 due to metastatic breast cancer. Young et al2Young ST Paulson EK Washington K Gulliver DJ Vredenburgh JJ Baker ME CT of the liver in patients with metastatic breast carcinoma treated by chemotherapy: findings simulating cirrhosis.AJR Am J Roentgenol. 1994; 163: 1385-1388Crossref PubMed Scopus (96) Google Scholar examined CT patterns mimicking cirrhosis in patients with breast cancer metastatic to the liver who underwent chemotherapy. In their prospective study, all 22 patients had pseudocirrhosis, 12 had portal hypertension, and only 2 had esophageal varices. Liver biopsies showed residual tumor with no evidence of cirrhosis. Shirkhoda and Baird3Shirkhoda A Baird S Morphologic changes of the liver following chemotherapy for metastatic breast carcinoma: CT findings.Abdom Imaging. 1994; 19: 39-42Crossref PubMed Scopus (29) Google Scholar reported severe cirrhotic changes on CT in 4 of 32 patients with breast carcinoma metastatic to the liver. The morphologic CT criteria included irregular border, decreased size, and presence of ascites. The 4 patients with cirrhosis had no common pattern of chemotherapy administration. Ogawa et al4Ogawa Y Murata Y Nishioka A Inomata T Yoshida S Tamoxifen-induced fatty liver in patients with breast cancer [letter]?.Lancet. 1998; 351: 725Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar reported that 36.4% of patients given tamoxifen had fatty liver on annual CT examinations. We were unable to determine whether chemotherapy or tamoxifen played a role in the development of cirrhotic changes in our patient. The pathologic findings suggested pseudocirrhosis due to almost complete replacement of hepatocytes with adenocarcinoma. Breast cancer with liver metastasis has a grave prognosis, and early detection may have clinical importance, although therapy is limited. In our patient, the diagnosis of metastasis was needed to redirect her therapy. She was not a candidate for cytotoxic therapy, but she was a candidate for trastuzumab, a monoclonal antibody targeted against the HER-2/neu oncoprotein that was overexpressed in her breast cancer. Unfortunately, the patient died before treatment could be initiated. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.