A 68-Year-Old Woman With Weight Loss and Abdominal Pain

Nafisa Kuwajerwala, MD; Angad Pordal, MD


October 19, 2018

Surgical options for invasive ductal carcinoma are tailored to each patient and range from total mastectomy to breast-conserving therapy with sentinel lymph node biopsy and possible axillary lymph node dissection.[2] In some instances, postoperative radiation therapy and systemic chemotherapy with or without hormonal therapy—as determined by their receptor status—are administered as adjuvant therapy.

Those who prefer breast conservation undergo preoperative radiologic localization (needle or radiologic seed), as the lesions are often not grossly palpable. The area of concern is surgically excised with negative margins. Although wide margins were originally thought to be associated with better outcomes, margins that are negative on ink for invasive cancer are now presumed to be oncologically adequate. Postoperatively, patients undergo radiation to the tumor bed in addition to systemic chemotherapy if the sentinel nodes are positive for disease or if they are found to have triple negative receptor expression. Those patients whose cancers have hormonal receptor positivity undergo hormonal therapy, with or without trastuzumab, based on their HER2/neu status.[2] Unfortunately, approximately 20% of patients with breast cancer develop metastasis, with hepatic involvement in half of these cases.[3]

Patients with hepatic metastasis present with nonspecific abdominal symptoms including nausea, vomiting, and abdominal pain. Weight loss is common, as well as decreased appetite. Liver function test results may be mildly elevated. Bilirubinemia and jaundice can occur based on the involvement of the biliary tree.[3]

CT scanning is the modality of choice in evaluating for hepatic metastasis because of the effects of the liver's dual blood supply on the enhancement of metastasis in comparison to the normal parenchyma; however, MRI allows for the effective localization and evaluation of vascular invasion of the lesions.[4]

Once the lesions are confirmed through imaging, tissue diagnosis is necessary. Ultrasonography-guided biopsy is the most practical and cost-effective modality for liver biopsy and was the modality used in this case. A biopsy of this patient's liver mass confirmed the presence of ER/PR-negative, HER2-positive invasive ductal carcinoma. Compared with her original breast biopsy findings of ER-positive, PR-negative, HER2-negative invasive ductal carcinoma, these findings make it unclear whether her current metastatic disease is due to an undiagnosed primary tumor or, as is the case in most instances, to the heterogeneity of the tumor.


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