Occult Breast Cancer Metastasis Presenting as Acute Liver Failure

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. Intraoperatively her liver was noted to be cirrhotic and an intraoperative biopsy was done. Upon discharge after surgery her total bilirubin remained elevated. 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. Clinically she continued to have increased abdominal pain and distension, jaundice, and scleral icterus. Intraoperative biopsy pathology showed fragments of benign liver cyst with granulomatous inflammation. During her hospital course she continued to display worsening liver function with elevated AST/ALT, total bilirubin, alkaline phosphatase, and INR. Post-surgical complications including bile leak, viral, autoimmune, and granulomatous causes of acute liver failure were excluded. Further evaluation with transjugular hepatic biopsy was done due to limited diagnostic value of previous biopsy, and revealed cirrhosis. Immunohistochemical staining was positive for GATA-3 immunostain and CK-7 stain, revealing adenocarcinoma most consistent with primary breast carcinoma. 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\u27 duration. As much as 20-40% of ALF is due to unclear causes. Hepatic metastases have been identified in up to 40% of adults with malignant tumors. In the case of breast cancer metastases,the liver is considered to among the common sites of metastasis, along with lungs and bone. However, most metastases present in the form of a discrete mass, and patients do not usually present with liver disease. Isolated liver metastases from breast cancer is rare and only seen in 5-12% of breast cancer patients. 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). Resection of liver metastasis is indicated of helical CT or MRI demonstrates well-circumscribed mass that can be excised without further damaging liver function. Diffuse liver metastasis is very rare and difficult to diagnose as they are not identifiable on routine radiologic diagnostic studies. There are multiple case reports of occult metastatic breast cancer in the liver presenting with acute liver failure, in patients with a history of known and treated breast cancer. The majority of these cases are only identified as metastasis from breast cancer primary upon autopsy, as the prognosis for such a presentation of metastatic breast cancer is appalling. In few reported cases, early diagnosis and treatment resulted in some improvement beyond the 18-24 months expected prognosis in metastatic breast cancer. CONCLUSION: Our patient presents a challenging case in which liver function and performance status was poor prior to diagnosis of metastasis. Helical CT also demonstrated a unique presentation of cirrhotic liver with vastly diffuse metastatic lesions, with no circumscribed mass seen. The findings of this case emphasize the unique presentations of metastatic breast cancer in patients who are in remission, necessitating a broader differential diagnosis at time of presentation.https://scholarlycommons.henryford.com/merf2019caserpt/1123/thumbnail.jp

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic

BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic\u27s CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population\u27s CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P \u3c 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P \u3c 0.001). Our clinic\u27s CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS

Specific Heat Discontinuity, deltaC, at Tc in BaFe2(As0.7P0.3)2 - Consistent with Unconventional Superconductivity

We report the specific heat discontinuity, deltaC/Tc, at Tc = 28.2 K of a collage of single crystals of BaFe2(As0.7P0.3)2 and compare the measured value of 38.5 mJ/molK**2 with other iron pnictide and iron chalcogenide (FePn/Ch) superconductors. This value agrees well with the trend established by Bud'ko, Ni and Canfield who found that deltaC/Tc ~ a*Tc**2 for 14 examples of doped Ba1-xKxFe2As2 and BaFe2-xTMxAs2, where the transition metal TM=Co and Ni. We extend their analysis to include all the FePn/Ch superconductors for which deltaC/Tc is currently known and find deltaC/Tc ~ a*Tc**1.9 and a=0.083 mJ/molK**4. A comparison with the elemental superconductors with Tc>1 K and with A-15 superconductors shows that, contrary to the FePn/Ch superconductors, electron-phonon-coupled conventional superconductors exhibit a significantly different dependence of deltaC on Tc, namely deltaC/Tc ~ Tc**0.9. However deltaC/gamma*Tc appears to be comparable in all three classes (FePn/Ch, elemental and A-15) of superconductors with, e. g., deltaC/gamma*Tc=2.4 for BaFe2(As0.7P0.3)2. A discussion of the possible implications of these phenomenological comparisons for the unconventional superconductivity believed to exist in the FePn/Ch is given.Comment: some disagreement in reference and footnote numbering with the published versio

A comparison of echocardiography to invasive measurement in the evaluation of pulmonary arterial hypertension in a rat model

Pulmonary arterial hypertension (PAH) is a life-threatening condition characterized by progressive elevation in pulmonary artery pressure (PAP) and total pulmonary vascular resistance (TPVR). Recent advances in imaging techniques have allowed the development of new echocardiographic parameters to evaluate disease progression. However, there are no reports comparing the diagnostic performance of these non-invasive parameters to each other and to invasive measurements. Therefore, we investigated the diagnostic yield of echocardiographically derived TPVR and Doppler parameters of PAP in screening and measuring the severity of PAH in a rat model. Serial echocardiographic and invasive measurements were performed at baseline, 21 and 35 days after monocrotaline-induction of PAH. The most challenging echocardiographic derived TPVR measurement had good correlation with the invasive measurement (r = 0.92, P < 0.001) but also more simple and novel parameters of TPVR were found to be useful although the non-invasive TPVR measurement was feasible in only 29% of the studies due to lack of sufficient tricuspid valve regurgitation. However, echocardiographic measures of PAP, pulmonary artery flow acceleration time (PAAT) and deceleration (PAD), were measurable in all animals, and correlated with invasive PAP (r = −0.74 and r = 0.75, P < 0.001 for both). Right ventricular thickness and area correlated with invasive PAP (r = 0.59 and r = 0.64, P < 0.001 for both). Observer variability of the invasive and non-invasive parameters was low except in tissue-Doppler derived isovolumetric relaxation time. These non-invasive parameters may be used to replace invasive measurements in detecting successful disease induction and to complement invasive data in the evaluation of PAH severity in a rat model

Selective Serotonin Reuptake Inhibitor Use Is Associated with Right Ventricular Structure and Function: The MESA-Right Ventricle Study

PURPOSE:Serotonin and the serotonin transporter have been implicated in the development of pulmonary hypertension (PH). Selective serotonin reuptake inhibitors (SSRIs) may have a role in PH treatment, but the effects of SSRI use on right ventricular (RV) structure and function are unknown. We hypothesized that SSRI use would be associated with RV morphology in a large cohort without cardiovascular disease (N = 4114). METHODS:SSRI use was determined by medication inventory during the Multi-Ethnic Study of Atherosclerosis baseline examination. RV measures were assessed via cardiac magnetic resonance imaging. The cross-sectional relationship between SSRI use and each RV measure was assessed using multivariable linear regression; analyses for RV mass and end-diastolic volume (RVEDV) were stratified by sex. RESULTS:After adjustment for multiple covariates including depression and left ventricular measures, SSRI use was associated with larger RV stroke volume (RVSV) (2.75 mL, 95% confidence interval [CI] 0.48-5.02 mL, p = 0.02). Among men only, SSRI use was associated with greater RV mass (1.08 g, 95% CI 0.19-1.97 g, p = 0.02) and larger RVEDV (7.71 mL, 95% 3.02-12.40 mL, p = 0.001). SSRI use may have been associated with larger RVEDV among women and larger RV end-systolic volume in both sexes. CONCLUSIONS:SSRI use was associated with higher RVSV in cardiovascular disease-free individuals and, among men, greater RV mass and larger RVEDV. The effects of SSRI use in patients with (or at risk for) RV dysfunction and the role of sex in modifying this relationship warrant further study