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Clinical evidence for overcoming capecitabine resistance in a woman with breast cancer terminating in radiologically occult micronodular pseudo-cirrhosis with portal hypertension: a case report.

Fournier C, Tisman G, Kleinman R, Park Y, Macdonald WD - J Med Case Rep (2010)

Bottom Line: The new discovery of radiologically occult intrasinusodal hepatic metastases with secondary micronodular cirrhosis was found to be the cause of her sudden onset portal hypertension.This is the first report of a reversal of clinical resistance to capecitabine (Xeloda) by changing from the schedule of 14/7 day to a biweekly 7/7 day schedule.This suggests that a biweekly schedule may be best for some patients.

View Article: PubMed Central - HTML - PubMed

Affiliation: Glenn Tisman, M,D, Medical Corporation, Bailey Street, Whittier, California, 90601, USA. christa324@gmail.com.

ABSTRACT

Introduction: We report a case of stage IV breast cancer terminating in an unusual picture of radiologically occult micronodular pseudo-cirrhosis. Contrast-enhanced computed tomography showed no evidence of metastatic breast cancer within the liver. Unlike the few previously reported cases of intrasinusoidal spread of breast cancer, our patient was palliated with a transjugular intrahepatic portosystemic shunt along with salvage chemohormonal therapy. In addition, our patient demonstrated proof of the principle of the dependence of capecitabine (Xeloda) efficacy on dose scheduling as predicted by laboratory studies based on Gompertzian tumor growth and the Norton-Simon hypothesis.

Case presentation: We report the case of a 52-year-old Caucasian woman who developed radiological signs of portal hypertension without radiological evidence of hepatic metastasis five years after being diagnosed with metastatic breast cancer. She was receiving chemotherapy for stage IV breast cancer initially thought to be metastatic only to the bones. During salvage therapy with high-dose estradiol (Estradiol valerate), vinorelbine (Navelbine) and bevacizumab (Avastin), she suddenly developed signs of portal hypertension confirmed on computed tomography and by portal and systemic venous pressure measurements. Drug toxicity due to bevacizumab (Avastin) was initially and incorrectly entertained as a cause. The patient underwent palliative transjugular intrahepatic portosystemic shunt and transhepatic venous liver biopsy, which revealed the presence of rapidly progressive and uncontrolled metastatic breast cancer. The new discovery of radiologically occult intrasinusodal hepatic metastases with secondary micronodular cirrhosis was found to be the cause of her sudden onset portal hypertension. The patient's resistance to capecitabine (Xeloda) was reversed by changing the schedule of medication to biweekly 7/7 (7 days ingesting drug alternating with 7 days off drug) from the 14/7 (14 days ingesting drug alternating with a 7 day rest period) day schedule approved by the US Food and Drug Administration.

Conclusion: This case report demonstrates an unusual presentation of radiographically occult hepatic metastasis from breast cancer palliated with transjugular intrahepatic portosystemic shunt. All patients with advanced breast cancer developing unexpected portal hypertension should be considered candidates for liver biopsy despite normal computed tomography of the liver imaging results. This is the first report of a reversal of clinical resistance to capecitabine (Xeloda) by changing from the schedule of 14/7 day to a biweekly 7/7 day schedule. This suggests that a biweekly schedule may be best for some patients.

No MeSH data available.


Related in: MedlinePlus

630× magnification of photomicrograph showing the results of immunohistochemical staining for the estrogen receptor. Note the metastatic, estrogen receptor positive breast carcinoma cells infiltrating the liver sinusoids (arrow).
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Figure 7: 630× magnification of photomicrograph showing the results of immunohistochemical staining for the estrogen receptor. Note the metastatic, estrogen receptor positive breast carcinoma cells infiltrating the liver sinusoids (arrow).

Mentions: Meanwhile, histopathology revealed the true nature and cause for our patient's symptoms and portal hypertension. Biopsy revealed the unusual pattern of micronodular cirrhosis induced by a diffuse intrasinusoidal infiltration of moderately-differentiated breast cancer cells. The cells biopsied were HER-2/neu negative, with estrogen receptor (ER) at 7% and progesterone receptor (PR) at 3%. The original tumor prior to any therapy was marked with an ER of 69%, PR of 27%, and negative HER-2/neu negative. Metastatic breast carcinoma cells with distinct ductal histoarchitecture were diffusely infiltrating our patient's liver sinusoids (Figures 4, 5, 6, 7), which was similar to the cases presented by Allison et al. [1]. Our patient's ascitic fluid contained morphologically similar tumor cells. She continued a rapid downhill course with her total bilirubin increasing to 17 mg/dl. A last effort using the administration of infusional cisplatinum (Cisplatin) 25 mg/m2/d for 5 days was associated with a slight decrease in all her tumor markers, although this lasted only for days. The patient and her family subsequently requested hospice care. A graph showing our patient's tumor markers since she was diagnosed with breast cancer, along with the dates she began different treatments, is shown in Figure 1.


Clinical evidence for overcoming capecitabine resistance in a woman with breast cancer terminating in radiologically occult micronodular pseudo-cirrhosis with portal hypertension: a case report.

Fournier C, Tisman G, Kleinman R, Park Y, Macdonald WD - J Med Case Rep (2010)

630× magnification of photomicrograph showing the results of immunohistochemical staining for the estrogen receptor. Note the metastatic, estrogen receptor positive breast carcinoma cells infiltrating the liver sinusoids (arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2865501&req=5

Figure 7: 630× magnification of photomicrograph showing the results of immunohistochemical staining for the estrogen receptor. Note the metastatic, estrogen receptor positive breast carcinoma cells infiltrating the liver sinusoids (arrow).
Mentions: Meanwhile, histopathology revealed the true nature and cause for our patient's symptoms and portal hypertension. Biopsy revealed the unusual pattern of micronodular cirrhosis induced by a diffuse intrasinusoidal infiltration of moderately-differentiated breast cancer cells. The cells biopsied were HER-2/neu negative, with estrogen receptor (ER) at 7% and progesterone receptor (PR) at 3%. The original tumor prior to any therapy was marked with an ER of 69%, PR of 27%, and negative HER-2/neu negative. Metastatic breast carcinoma cells with distinct ductal histoarchitecture were diffusely infiltrating our patient's liver sinusoids (Figures 4, 5, 6, 7), which was similar to the cases presented by Allison et al. [1]. Our patient's ascitic fluid contained morphologically similar tumor cells. She continued a rapid downhill course with her total bilirubin increasing to 17 mg/dl. A last effort using the administration of infusional cisplatinum (Cisplatin) 25 mg/m2/d for 5 days was associated with a slight decrease in all her tumor markers, although this lasted only for days. The patient and her family subsequently requested hospice care. A graph showing our patient's tumor markers since she was diagnosed with breast cancer, along with the dates she began different treatments, is shown in Figure 1.

Bottom Line: The new discovery of radiologically occult intrasinusodal hepatic metastases with secondary micronodular cirrhosis was found to be the cause of her sudden onset portal hypertension.This is the first report of a reversal of clinical resistance to capecitabine (Xeloda) by changing from the schedule of 14/7 day to a biweekly 7/7 day schedule.This suggests that a biweekly schedule may be best for some patients.

View Article: PubMed Central - HTML - PubMed

Affiliation: Glenn Tisman, M,D, Medical Corporation, Bailey Street, Whittier, California, 90601, USA. christa324@gmail.com.

ABSTRACT

Introduction: We report a case of stage IV breast cancer terminating in an unusual picture of radiologically occult micronodular pseudo-cirrhosis. Contrast-enhanced computed tomography showed no evidence of metastatic breast cancer within the liver. Unlike the few previously reported cases of intrasinusoidal spread of breast cancer, our patient was palliated with a transjugular intrahepatic portosystemic shunt along with salvage chemohormonal therapy. In addition, our patient demonstrated proof of the principle of the dependence of capecitabine (Xeloda) efficacy on dose scheduling as predicted by laboratory studies based on Gompertzian tumor growth and the Norton-Simon hypothesis.

Case presentation: We report the case of a 52-year-old Caucasian woman who developed radiological signs of portal hypertension without radiological evidence of hepatic metastasis five years after being diagnosed with metastatic breast cancer. She was receiving chemotherapy for stage IV breast cancer initially thought to be metastatic only to the bones. During salvage therapy with high-dose estradiol (Estradiol valerate), vinorelbine (Navelbine) and bevacizumab (Avastin), she suddenly developed signs of portal hypertension confirmed on computed tomography and by portal and systemic venous pressure measurements. Drug toxicity due to bevacizumab (Avastin) was initially and incorrectly entertained as a cause. The patient underwent palliative transjugular intrahepatic portosystemic shunt and transhepatic venous liver biopsy, which revealed the presence of rapidly progressive and uncontrolled metastatic breast cancer. The new discovery of radiologically occult intrasinusodal hepatic metastases with secondary micronodular cirrhosis was found to be the cause of her sudden onset portal hypertension. The patient's resistance to capecitabine (Xeloda) was reversed by changing the schedule of medication to biweekly 7/7 (7 days ingesting drug alternating with 7 days off drug) from the 14/7 (14 days ingesting drug alternating with a 7 day rest period) day schedule approved by the US Food and Drug Administration.

Conclusion: This case report demonstrates an unusual presentation of radiographically occult hepatic metastasis from breast cancer palliated with transjugular intrahepatic portosystemic shunt. All patients with advanced breast cancer developing unexpected portal hypertension should be considered candidates for liver biopsy despite normal computed tomography of the liver imaging results. This is the first report of a reversal of clinical resistance to capecitabine (Xeloda) by changing from the schedule of 14/7 day to a biweekly 7/7 day schedule. This suggests that a biweekly schedule may be best for some patients.

No MeSH data available.


Related in: MedlinePlus