AGGRESSIVE BREAST CARCINOMA IN A 26 YEARS-OLD LADY: A YOUNG AGE AT DIAGNOSIS

Ali AlAmri, *Hadeel AlOmran, Fatimah AlKhunaizi and Aysha Ahmed. Department of Internal Medicine and Pathology, King Fahad University Hospital, University of Dammam, Kingdom of Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Immuno-histochemical staining showed tumor cells that are strongly positive for estrogen receptors and CK19. However, progesterone receptors and HER2 are negative [ Figure 3 and 4].
Based on these findings, breast carcinoma was suspected, and indeed, breast examination showed left breast mass, measuring 3x3 cm that was fixed to the skin with no nipple discharge, along with cervical lymphadenopathy.
Our patients passed away within less than 4 weeks of her presentation due to disseminated intravascular coagulopathy secondary to hepatic metastasis from breast carcinoma and hepatic failure.
Because of the quick deterioration of the health state of the patient and death, it was not possible to perform a mammography or initiate any kind of interventional or palliative therapy.

Discussion:-
Invasive breast carcinoma is uncommon in women younger than 40 years old. It accounts for less than 1.8% in females with breast cancer younger than 30 years of age. [4] As far as we know, the youngest reported age of woman with breast cancer in the literature was 21. [6] In Saudi Arabia, the median age at diagnosis of breast cancer is 48, a decade younger than the reported median age in the developed countries, where the median age at diagnosis is 61 and 58 years old for white and black women, respectively. [2,3] In general, it's been noticed in the literature that a higher proportion of patients were diagnosed with breast cancer at an age less than 40 in Africa and the Middle East; and the researches to reveal whether environmental factors or genetic differences contribute to this early occurrence, are ongoing. [7] Several, however, uncommon factors contribute to the prognosis and the aggressive nature that might lead to an unfortunate ending in breast cancer patients, including young age at diagnosis as previously discussed, hormone receptor status, elevated tumor marker levels, hepatic metastasis as well as family history of familial syndromes of breast cancer; and our patient had many of these factors.
Breast cancer in young patients tends to be more invasive and aggressive clinically, biologically, and in term of its histological aspects leading to poor prognosis. [5,8] Younger patients often tend to have lower ER positivity and higher HER2 positivity; our patient showed the contrary. [7] Young patients presenting with breast cancer may have abnormal single genes mutation transmitted as autosomal dominant such as BRCA1 and BRCA2, or genes as TP53 and CHEK2whichare transmitted as autosomal recessive genes that may play a fundamental role in developing breast cancer in patients younger than 40 years 2250 ofage. [3,7,9] However, our patient did not mention positive family history of breast cancer, ovarian cancer, prostate cancer or colon cancer that support familial risk of her breast cancer.

Investigations of our patient showed an isolated extensive liver metastasis with infiltrative pattern.
Some studies showed that isolated hepatic breast cancer metastasis ranges from 2% to 26% with a median survival of only a few months. [10] The liver function test of our patient showed bilirubin of 5 mg/dl and albumin level of 2 gm/dl indicating liver failure.Studies have shown that patients with breast cancer andmarked impaired hepatic function secondary to breast carcinoma had poor prognosis and some patients died at the first cycle of chemotherapy. Just like our patient, the range of survival of such patients varies from only two weeks up till 6 weeks. [10] Features indicating very poor prognosis of patients with hepatic metastasis of breast cancer include extensive invasion of the liver, low albumin, less than 2gm/dl and high bilirubin, more than 5 mg/dl. [10] All in all, our patient had deleterious progressive hepatic metastasis and she passed away within less than 4 weeks from her admission. It was not possible to provide any active therapy such as palliative chemotherapy since the patient performance status at admission was 3 (based on ECOG) and presented with marked impaired liver function secondary to hepatic failure from the metastasis.

Conclusion:-
Breast cancer in young females < 40 years of age is relatively uncommon hence, young age at diagnosis is considered as a poor prognostic factor. It often follows an aggressive and invasive course with poor outcomes as what happened with our patient whose symptoms were sudden and progressive with liver failure that lead to her death in less than 4 weeks.