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Medical Resident Research Case Reports

13 PRIMARY BREAST CANCER PRESENTING AS OBSTRUCTIVE JAUNDICE

Kimaya Council, MD, PGY3; Sylvester Tamakloe, MD, PGY1; Akshay Duddu, MD Corresponding author: kimaya.council@lpnt.net

Sovah Health - Danville, Danville, Virginia

Given the elevated CEA and CA-19-9 levels and recent positive Cologuard, a colonic primary was initially suspected. Patient was unable to tolerate bowel prep due to persistent nausea and vomiting, and a decision was made to perform outpatient colonoscopy. Of note, patient's last screening mammogram in August 2024 revealed a slightly irregular nodule within the outer mid to lower left breast. A follow-up ultrasound and diagnostic mammogram revealed findings most consistent with a cyst, and resuming annual routine screening was recommended. Liver biopsy findings returned consistent with primary ER/PR negative HER2 positive breast cancer with metastatic disease. Additional imaging revealed multiple irregular pulmonary nodules bilaterally, a mass-like consolidation within the left upper lobe, and a solitary right occipital lobe lesion. Nuclear bone scan also showed suspicious lesions involving left-sided ribs and possible lesions of the lumbar spinous processes, confirming a widespread metastatic disease. Oncology recommended a plan to discharge the patient with a PICC line to begin chemotherapy and radiation therapy as outpatient.

Context: Metastatic breast cancer diagnosed in a 59-year-old female presenting with obstructive jaundice and with no significant family history and recent negative breast cancer screenings. Report of Case: Patient is a 59-year-old female with a medical history significant for essential hypertension, insulin-dependent diabetes mellitus, and hyperlipidemia who initially presented to the emergency department with a chief complaint of intractable nausea and vomiting. On examination, she was ill-appearing, jaundiced, and dyspneic, with diffuse abdominal tenderness. Laboratory values on admission were significant for transaminitis and hyperbilirubinemia. CT abdomen and pelvis without contrast upon admission revealed findings concerning multifocal pneumonia, cholecystitis, and multiple areas of heterogeneous hypo enhancement throughout the right and left liver lobes, suggestive of metastatic disease. General surgery was consulted, did not recommend operative management, and suggested a liver biopsy to further evaluate the liver lesions.

Comments: Methods: Terms searched via PubMed: metastatic breast cancer, jaundice, bile duct obstruction, HER2+ Common sites for breast cancer to metastasize include the lungs, liver, bone, lymph nodes, and brain. Through review of literature, there have been multiple case reports detailing unusual presentations of primary breast cancer as they relate to GI symptoms. Obstructive jaundice secondary to breast cancer, caused by hepatic metastases involving the bile ducts, is a rare initial presentation, particularly in patients with recent negative breast cancer screening, representing an interval cancer that developed between standard screening intervals. Diagnosis: Primary breast cancer with metastatic disease to the liver, lung, and brain, presenting as obstructive jaundice.

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144 Edward Via College of Osteopathic Medicine (VCOM)