Pseudocirrhosis of Breast Cancer Metastases to the Liver Treated by Chemotherapy
A 47-year-old woman visited our hospital in January 2003 because of a painful right breast mass with skin dimpling. On initial evaluation, chest CT revealed the presence of a heterogeneous enhancing breast mass measuring 9 cm with skin invasion and multiple conglomerated lymph nodes in the right axillary area. In addition, multiple metastatic pleural masses with malignant pleural effusion and mediastinal lymph node enlargement were also observed. A bone scan showed increased uptake in the sternum and right sixth anterior rib. There was no evidence of liver metastases on the initial CT scan (). Fine-needle aspiration cytology of the breast mass showed atypical malignant cells. Accordingly, she was diagnosed with stage IV right breast cancer with multiple pleural and bone metastases. She subsequently received palliative chemotherapy with docetaxel and epirubicin. Follow-up CT scan performed after four cycles of chemotherapy showed partial regression of the breast mass and multiple metastatic masses in the pleura and axillary area. She then underwent palliative total mastectomy of her right breast because of an ulcerated skin lesion. Pathological examination showed invasive ductal carcinoma with nuclear grade 2 and lymphatic and perineural invasion. Immunohistochemistry studies showed positive staining for the estrogen receptor (ER) protein, progesterone receptor protein, and human epidermal growth factor receptor 2 (HER2) (score 3). She received two additional cycles of chemotherapy with docetaxel and epirubicin. A follow-up CT scan showed stable disease and she then started taking tamoxifen (20 mg daily) in July 2003.\nTwo years later, in November 2005, a surveillance breast ultrasound showed an irregular circumscribed mass measuring 1 cm on theright mastectomy site. The patient underwent a wide local excision and pathology confirmed an invasive ductal carcinoma. Although previous metastatic lesions showed stable disease, a new chest wall lesion had developed; therefore, her treatment was switched from tamoxifen to the non-steroidal aromatase inhibitor anastrozole. At that time, she was postmenopausal, based on her serum follicle-stimulating hormone levels. In January 2007, a bone scan showed new increased uptake in the right second rib, the third anterior rib, and the right acetabulum. She had progressive disease of the bone; therefore, capecitabine (an oral prodrug of 5-fluorouracil; 2,500 mg/m2/day) was started (two weeks on, one week off). After nine cycles of chemotherapy, she had stable disease and was off chemotherapy for approximately four years with no evidence of progression.\nHowever, follow-up CT scan performed in June 2011 showed multiple newly developed peripheral enhancing nodules in the liver (). She received six cycles of chemotherapy until November 2011, and CT scan showed that her metastatic hepatic lesions were stable. Since then, her chemotherapy has been discontinued because of grade 4 neutropenia and osteomyelitis of the mandible. Four months later, follow-up CT scan showed ill-defined heterogeneous enhancing lesions in the entire liver with surface nodularity. The liver had a nodular contour consistent with cirrhosis, as well as moderate ascites (). F18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET-CT) also showed disseminated and innumerable lesions throughout almost the entire liver with increased FDG uptake (maximum standardized uptake value [SUVmax], 7.3), suggesting diffuse liver metastasis (). Palliative chemotherapy with docetaxel and epirubicin was started again. Endoscopy showed grade 3 large esophageal varices with a red color sign. She denied a history of liver disease, alcohol use, and risk factors for viral hepatitis. Serologies for viral or autoimmune etiologies of cirrhosis were negative and the serum level of alpha-fetoprotein was normal. An ultrasound-guided liver biopsy was performed in order to confirm the cause of the cirrhotic changes. Pathological examination showed that the hepatic parenchyma was diffusely infiltrated by poorly differentiated carcinoma cells. Hepatocytes were almost replaced by carcinoma cells and extensive fibrosis between clusters of cancer cells was observed (). Immunohistochemical staining was positive for gross cystic disease fluid protein-15, MOC 31, ER, and HER2 (score 3), but negative for hepatocytes (). Follow-up PET-CT showed progression of liver metastases with increased FDG uptake (SUVmax, 9.0) since the scan performed in June 2011. Therefore, we concluded that the hepatic metastases from breast cancer had progressed and led to cirrhotic changes in the liver.\nSubsequently, her chemotherapy regimen was changed to trastuzumab and docetaxel. However, bleeding of esophageal varices occurred on the sixth day after initiation of chemotherapy, and hepatic failure progressed gradually. Therefore, the patient decided to discontinue chemotherapy.