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Small Cell, Big Liver
October 2013, Vol 144, No. 4_MeetingAbstracts Lung Cancer | October 2013
Small Cell, Big Liver Jessica Moja, MD; Howard Jaffe, MD; Melvin Lopata, MD University of Illinois at Chicago, Chicago, IL Chest. 2013;144(4_MeetingAbstracts):608A. doi:10.1378/chest.1703110
Abstract SESSION TITLE:Cancer Case Report Posters II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION:Small cell lung cancer (SCLC) frequently presents with metastatic disease at the time of diagnosis, but fulminant liver failure is a rare initial presentation. CASE PRESENTATION: A 65 year old initially presented with complaints of fatigue and lower extremity edema. His physical exam showed jaundice, asterexis, hepatomegaly, splenomegaly, and symmetric lower extremity pitting edema. Abnormal liver function tests included: bilirubin 6.03 mg/dL, alkaline phosphatase
439 IU/L, AST 244 IU/L, and
ALT 403 IU/L, all of which were normal two months prior. Imaging showed hepatomegaly with multiple solid lesions infiltrating the liver. CT did not show any masses within the GI tract, but a 1.4 cm spiculated pulmonary nodule was discovered. A 65 pa ck year smoking history made lung cancer with liver metastasis high on the differential. Liver biopsy was performed, and immunohistochemical
staining indicated
SCLC. The patient was discharged with the plan to start chemotherapy as an outpatient. One week later, the patient was admitted to the hospital for failure to thrive and altered mental status. His liver function testing had deteriorated significantly, with bilirubin increasing to 13.2 mg/dL and worsening transaminitis, coagulopathy, and thrombocytope nia. He was admitted to the intensive care unit and treated for septic shock. Three days after admission, the patient and his family wished to shift the focus of care to comfort measures, and the patient shortly succumbed to his illness.
DISCUSSION: Fulmin ant liver failure is rare and involves acute onset of encephalopathy,
coagulopathy, and rapidly deteriorating liver function in individuals
without pre -existing liver disease. The majority of cases are due to viral hepatitis, drug toxicities, autoimmune disease, or hypoperfusion1. Fulminant liver failure resulting from diffuse parenchymal infiltration by a metastatic tumor is rare, but when it occurs prognosis is extremely poor. SCLC frequently presents with metastatic disease at the time of diagnosis, but few cases of hepatic failure due to metastasis have been reported. Karia et al. described 21 previously reported cases of fulminant liver failure from SCLC2. The diagnosis was made at autopsy in the majority of cases. Three of the 21 patients described wer e given chemotherapy despite severe encephalopathy.
The
patients that received chemotherapy had an impressive improvement in survival and encephalopathy.
Due to the rapidity of clinical deterioration, chemotherapy was not
administered in our patient. CONCLUSIONS: This case is significant because fulminant liver failure due to metastatic SCLC while rare, if diagnosed early, has shown good responses chemotherapy with improvement in liver failure, encephalopathy,
to
and survival. A high
index of suspicion and tissue sampling are required to make the diagnosis. Reference #1: Ostapowicz et al. Ann Intern Med 2002;137:947 -954. Reference #2: Kaira et al. World J Gastrol 2006; 12:2466 -2468. DISCLOSURE: The following authors have nothing to disclose: Jessica Moja, Howard Jaffe, Melvin Lopata No Product/Research
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Small Cell, Big Liver Jessica Moja, MD; Howard Jaffe, MD; Melvin Lopata, MD University of Illinois at Chicago, Chicago, IL Chest. 2013;144(4_MeetingAbstracts):608A. doi:10.1378/chest.1703110
Abstract SESSION TITLE:Cancer Case Report Posters II SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION:Small cell lung cancer (SCLC) frequently presents with metastatic disease at the time of diagnosis, but fulminant liver failure is a rare initial presentation. CASE PRESENTATION: A 65 year old initially presented with complaints of fatigue and lower extremity edema. His physical exam showed jaundice, asterexis, hepatomegaly, splenomegaly, and symmetric lower extremity pitting edema. Abnormal liver function tests included: bilirubin 6.03 mg/dL, alkaline phosphatase
439 IU/L, AST 244 IU/L, and
ALT 403 IU/L, all of which were normal two months prior. Imaging showed hepatomegaly with multiple solid lesions infiltrating the liver. CT did not show any masses within the GI tract, but a 1.4 cm spiculated pulmonary nodule was discovered. A 65 pa ck year smoking history made lung cancer with liver metastasis high on the differential. Liver biopsy was performed, and immunohistochemical
staining indicated
SCLC. The patient was discharged with the plan to start chemotherapy as an outpatient. One week later, the patient was admitted to the hospital for failure to thrive and altered mental status. His liver function testing had deteriorated significantly, with bilirubin increasing to 13.2 mg/dL and worsening transaminitis, coagulopathy, and thrombocytope nia. He was admitted to the intensive care unit and treated for septic shock. Three days after admission, the patient and his family wished to shift the focus of care to comfort measures, and the patient shortly succumbed to his illness.
DISCUSSION: Fulmin ant liver failure is rare and involves acute onset of encephalopathy,
coagulopathy, and rapidly deteriorating liver function in individuals
without pre -existing liver disease. The majority of cases are due to viral hepatitis, drug toxicities, autoimmune disease, or hypoperfusion1. Fulminant liver failure resulting from diffuse parenchymal infiltration by a metastatic tumor is rare, but when it occurs prognosis is extremely poor. SCLC frequently presents with metastatic disease at the time of diagnosis, but few cases of hepatic failure due to metastasis have been reported. Karia et al. described 21 previously reported cases of fulminant liver failure from SCLC2. The diagnosis was made at autopsy in the majority of cases. Three of the 21 patients described wer e given chemotherapy despite severe encephalopathy.
The
patients that received chemotherapy had an impressive improvement in survival and encephalopathy.
Due to the rapidity of clinical deterioration, chemotherapy was not
administered in our patient. CONCLUSIONS: This case is significant because fulminant liver failure due to metastatic SCLC while rare, if diagnosed early, has shown good responses chemotherapy with improvement in liver failure, encephalopathy,
to
and survival. A high
index of suspicion and tissue sampling are required to make the diagnosis. Reference #1: Ostapowicz et al. Ann Intern Med 2002;137:947 -954. Reference #2: Kaira et al. World J Gastrol 2006; 12:2466 -2468. DISCLOSURE: The following authors have nothing to disclose: Jessica Moja, Howard Jaffe, Melvin Lopata No Product/Research
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