POSITIVE SCLERAL ICTERUS FREE
Prior studies have shown that isolated liver involvement prognosis improves if patients have hormone positive cancer, normal liver function, good performance status, and have had a long Disease Free Interval (DFI). Isolated liver metastases from breast cancer is rare and only seen in 5-12% of breast cancer patients. However, most metastases present in the form of a discrete mass, and patients do not usually present with liver disease. In the case of breast cancer metastases,the liver is considered to among the common sites of metastasis, along with lungs and bone. Hepatic metastases have been identified in up to 40% of adults with malignant tumors. As much as 20-40% of ALF is due to unclear causes. DISCUSSION: Acute Liver Failure (ALF) is defined as sudden liver dysfunction manifesting as coagulopathy and any degree of encephalopathy in a patient without preexisting cirrhosis with illness lasting less than 26 weeks' duration. Immunohistochemical staining was positive for GATA-3 immunostain and CK-7 stain, revealing adenocarcinoma most consistent with primary breast carcinoma. Further evaluation with transjugular hepatic biopsy was done due to limited diagnostic value of previous biopsy, and revealed cirrhosis. Post-surgical complications including bile leak, viral, autoimmune, and granulomatous causes of acute liver failure were excluded. During her hospital course she continued to display worsening liver function with elevated AST/ALT, total bilirubin, alkaline phosphatase, and INR. Intraoperative biopsy pathology showed fragments of benign liver cyst with granulomatous inflammation. Clinically she continued to have increased abdominal pain and distension, jaundice, and scleral icterus. On presentation she showed signs of acute liver failure and coagulopathy with a bilirubin of 10.5, INR was elevated to 2.8, and AST/ALT downtrending. Upon discharge after surgery her total bilirubin remained elevated. Intraoperatively her liver was noted to be cirrhotic and an intraoperative biopsy was done. CASE: A 45 year-old-female with history of clinically stage IA ER/PR/Her-2 Negative moderately differentiated ductal carcinoma of right breast presented with abdominal pain, abdominal distension, jaundice, and scleral icterus three weeks after laparoscopic cholecystectomy due to acute cholecystitis.
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