title: Characterization of the syndrome of acute liver failure caused by metastases from breast carcinoma.
abstract: OBJECTIVE
  To characterize syndrome of acute liver failure (ALF) from metastatic breast cancer to promote premortem diagnosis. Up to now, only 25 % of the reported 32 cases of this syndrome were diagnosed premortem.
  
  
  METHODS
  Cases identified by computerized literature review and review of files maintained by senior investigator.
  
  
  RESULTS
  Among 32 cases, average age at presentation was 47.9 ± 9.9 years. Common signs include jaundice, hepatomegaly, shifting dullness, and bilateral leg edema. Mean serum level of AST was 296.4 ± 204.0 U/L, ALT, 183.2 ± 198.9 U/L; alkaline phosphatase, 641.5 ± 610.1; and total bilirubin, 8.6 ± 8.3 mg/dL. Twenty-seven patients (84 %) have known prior breast cancer (mean diagnosis = 4.1 + 4.8 years earlier). Abdominal ultrasound findings (N = 10) include hepatomegaly in three cases, heterogeneous/multifocal hepatic lesions in three, ascites in three, and other in two. Abdominal CT findings (N = 16) include heterogeneous/multifocal hepatic lesions in six cases, ascites in five, hepatomegaly in three, cirrhosis in three, fatty liver in two, other in two. Hepatic metastases may not be suspected when abdominal CT shows no hepatic lesions. The diagnosis is made postmortem in 24 cases and antemortem in eight, with a statistically significant trend of increasing premortem diagnosis since 2000 (0 % before 2000 vs. 50 % after 2000; p = .001, 95 %--ORCI ≥ 2.86, Fisher's exact test). A new case of ALF from breast cancer is reported with notable features: abdominal CT revealed no discrete hepatic lesions despite widespread hepatic metastases demonstrated by liver biopsy; hepatic metastases occurred 21 years after original breast primary; and original diagnosis of lobular breast cancer in primary lesion was corrected to mixed ductal and lobular carcinoma, based on immunohistochemistry, performed 21 years afterward.
  
  
  CONCLUSIONS
  This review characterizes the clinical presentation and natural history of this syndrome to promote liver biopsy for premortem diagnosis and appropriate therapy.
authors.affiliation: Division of Gastroenterology and Hepatology, MOB 602, Department of Medicine, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI, 48073, USA.
authors.forename: Estela
authors.initials: E
authors.lastname: Mogrovejo
authors.forename: Palaniappan
authors.initials: P
authors.lastname: Manickam
authors.forename: Mitual
authors.initials: M
authors.lastname: Amin
authors.forename: Mitchell S
authors.initials: MS
authors.lastname: Cappell
mesh_terms: D001943:Breast Neoplasms / Q000473:pathology*; D018270:Carcinoma, Ductal, Breast / Q000473:pathology*; D018275:Carcinoma, Lobular / Q000556:secondary*; D000075202:Contraindications; D005260:Female; D006801:Humans; D017114:Liver Failure, Acute / Q000209:etiology* / Q000601:surgery; D008113:Liver Neoplasms / Q000175:diagnosis / Q000473:pathology / Q000556:secondary*; D016031:Liver Transplantation; D008875:Middle Aged; D013577:Syndrome; D014057:Tomography, X-Ray Computed