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LETTER
Year : 2013  |  Volume : 59  |  Issue : 2  |  Page : 164-166

Fulminant hepatic failure secondary to diffuse melanoma infiltration in a patient with a breast cancer history


1 Departments of Anatomic Pathology and Scentifical and Technological Bioresources Nucleus (BIOREN), Universidad de La Frontera, Temuco, Chile
2 Medical Specialties, School of Medicine, Universidad de La Frontera, Temuco, Chile

Date of Web Publication21-Jun-2013

Correspondence Address:
F Schafer
Medical Specialties, School of Medicine, Universidad de La Frontera, Temuco
Chile
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0022-3859.113822

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How to cite this article:
Bellolio E, Schafer F, Becker R, Villaseca M A. Fulminant hepatic failure secondary to diffuse melanoma infiltration in a patient with a breast cancer history. J Postgrad Med 2013;59:164-6

How to cite this URL:
Bellolio E, Schafer F, Becker R, Villaseca M A. Fulminant hepatic failure secondary to diffuse melanoma infiltration in a patient with a breast cancer history. J Postgrad Med [serial online] 2013 [cited 2019 Nov 14];59:164-6. Available from: http://www.jpgmonline.com/text.asp?2013/59/2/164/113822


Dear Editor,

Malignant hepatic infiltration is a very rare cause of fulminant hepatic failure (FHF). Liver metastases are diagnosed in up to one-third of patients with advanced melanoma and are associated with a worse prognosis. To our knowledge, this is the first report that shows a FHF by diffuse melanoma infiltration in a patient with a breast cancer history. Interestingly, epidemiologic and genetic studies have suggested an association between breast cancer and melanoma. [1],[2]

A 44-year-old hispanic woman was admitted with a 2-week history of abdominal pain, jaundice, acolia, and coluria. She had a medical history of breast cancer 5 years earlier, which had been treated by total mastectomy plus axillary lymph node dissection, bilateral oophorectomy, and radiochemotherapy. Since then, she had been taking tamoxifen. At admission, the liver was palpable 10 cm below the right costal margin. Abdominal computed tomography showed marked hepatomegaly without focal lesions and an extensive infiltrative process [Figure 1]a. Due to the cancer history, hepatic metastasis of breast cancer was suspected, and a liver biopsy was indicated. Unfortunately, the patient's clinical course began to worsen rapidly and she died from FHF. Autopsy revealed that the liver, spleen and perihepatic lymph nodes were black-colored [Figure 1]b and c. Due to the fact that the metastatic malignant melanoma was considered, we investigated the whole body, including mucosal surfaces (e.g., gastrointestinal, genitourinary, and nasopharyngeal tract) and skin. Nevertheless, no primary site was found. Histologically, malignant melanoma cells had infiltrated diffusely into the liver, spleen and perihepatic lymph nodes [Figure 2]a and b and stained positively for HMB-45 and S-100 proteins and negatively for estrogen and progesterone receptors [Figure 2]c-f.
Figure 1: (a) Abdominal computed tomography showed marked hepatomegaly without focal lesions and an extensive infiltrative process. (b) Autopsy revealed that the liver was black-colored and its weight was 6800 g.(c) A section of formalin-fixed liver showed diffuse dark-brown lesions

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Figure 2: (a) Liver biopsy showed an altered architectural pattern with intrasinusoidal infiltration by spindle cell melanoma (H and E staining, original magnification ×40). (b) Spindled melanoma cells with melanin pigment (H and E staining, original magnification ×400). (c‑f) Malignant melanoma cells stained positively for HMB‑45 and S‑100 proteins and negatively for estrogen and progesterone receptors, respectively

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Diffuse hepatic melanoma infiltration is less common than other malignancies such as hematological malignancies and adenocarcinomas. [3],[4] Taking into account that no nodular lesions are found by imaging studies, a noninvasive diagnosis is usually difficult and requires a high degree of suspicion. These cases have a high mortality rate and are often diagnosed postmortem, and death is a direct result of FHF.

Sometimes, melanoma occurs as apparent metastasis to lymph nodes or viscera with an unknown primary origin. This clinical presentation can be found in 3.7% of melanoma cases. Cutaneous malignant melanoma can have a partial or complete regression. Therefore, the possibility of a regressed skin lesion cannot be ruled out in our patient.

A bidirectional association between breast cancer and melanoma has been reported. [1],[2] This raises the possibility of a common genetic predisposition for both tumors. CDKN2A mutation positive melanoma families have a 3.8-fold increase in frequency of breast cancer. [5] Furthermore, BCR2A mutation carriers have an increased risk of melanoma with a relative risk ranging from 2.58 to 99.4. [6],[7] Interestingly, young female breast cancer patients and treatment with radiation have an increased risk for subsequent cutaneous melanoma. In our case, the patient had these two conditions.

In conclusion, awareness should be raised amongst clinicians of the potential association between these two malignancies and the need for careful screening of patients with melanoma or breast cancer history emphasized. This medical practice may detect early stages of the disease, so appropriate interventions can be done with a potentially curative treatment.

 
 :: References Top

1.Ho WL, Comber H, Hill AD, Murphy GM. Malignant melanoma and breast carcinoma: A bidirectional correlation. Ir J Med Sci 2011;180:901-3.  Back to cited text no. 1
    
2.Goggins W, Gao W, Tsao H. Association between female breast cancer and cutaneous melanoma. Int J Cancer 2004;111:792-4.  Back to cited text no. 2
    
3.Kaplan GG, Medlicott S, Culleton B, Laupland KB. Acute hepatic failure and multi-system organ failure secondary to replacement of the liver with metastatic melanoma. BMC Cancer 2005;5:67.  Back to cited text no. 3
    
4.Te HS, Schiano TD, Kahaleh M, Lissoos TW, Baker AL, Hart J, et al. Fulminant hepatic failure secondary to malignant melanoma: Case report and review of the literature. Am J Gastroenterol 1999;94:262-6.  Back to cited text no. 4
    
5.Borg A, Sandberg T, Nilsson K, Johannsson O, Klinker M, Måsbäck A, et al. High frequency of multiple melanomas and breast and pancreas carcinomas in CDKN2A mutation-positive melanoma families. J Natl Cancer Inst 2000;92:1260-6.  Back to cited text no. 5
    
6.Moran A, O'Hara C, Khan S, Shack L, Woodward E, Maher ER, et al. Risk of cancer other than breast or ovarian in individuals with BRCA1 and BRCA2 mutations. Fam Cancer 2012;11:235-42.  Back to cited text no. 6
    
7.Buecher B, Gauthier-Villars M, Desjardins L, Lumbroso-Le Rouic L, Levy C, De Pauw A, et al. Contribution of CDKN2A/P16 (INK4A), P14 (ARF), CDK4 and BRCA1/2 germline mutations in individuals with suspected genetic predisposition to uveal melanoma. Fam Cancer 2010;9:663-7.  Back to cited text no. 7
    


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