Breast cancer pseudocirrhosis with lobar invovlement

Case Discussion

Challenging and unusual case of infiltrative breast cancer metastases with pseudocirrhotic appearance of the left hepatic lobe. 

Breast cancer was confirmed by biopsying both the left hepatic lobe and the segment 7 lesions. 

This is a challenging case and the most important aspect is to make appropriate recommendations to guide definitive next steps. 

Regarding the left hepatic lobe, you can confidently conclude there is an infiltrative tumor based on the liver windows, which shows nodular enhancing soft tissue. The suspicion for tumor is even higher based on the segment 7 lesion. The differential diagnosis will include multifocal HCC, cholangiocarcinoma, or breast cancer pseudocirrhosis. 

HCC would be possible but less likely to narrow the left portal vein (rather than more common tumor thrombus) and unlikely to enhance so uniformly during the portal venous phase of contrast. Normal AFP levels would be reassuring. 

Cholangiocarcinoma would also be possible based on the capsular retraction of segment 4b, but that would not account for the degree of enhancing tumor involving the remainder of the left hepatic lobe, as delayed enhancement is more characteristic. Also there is no biliary ductal dilation. 

Finally, breast cancer pseudocirrhosis is an important consideration and although I have not seen it described in isolated lobar appearance like this, the infiltrative nature of the tumor before chemotherapy has been described and has overlapping features with cirrhosis (at least on first glance). 

Thus, the question that guides your recommendation would be how confident you are that the left hepatic lobe tumor is related to the segment 7 metastasis. To resolve the potential question of two separate diagnoses, it is reasonable to biopsy both targets, as was done in this case.