2176 An Old Friend in a New Neighborhood: The Presentation and Management of Intraductal Hepatocellular Carcinoma

Abstract

INTRODUCTION: Hepatocellular carcinoma (HCC) remains one of the most commonly addressed issues by gastroenterologists and tops the differential list for many liver lesions. However, this common disease can find rare ways to surprise even the very experienced, as occurred in the case of our 32 year old patient admitted for ascending cholangitis, later deemed secondary to intraductal invasion of hepatocellular carcinoma with a right lobe mass. Prognosis is generally better if a parenchymal mass is present. Isolated intraductal HCC is considered a third separate entity from HCC and cholangiocarcinoma with the suspicion that it arises either from intermediate cell line with features of both or as a concurrent "double-primary" malignancy. Both entities are uncommon processes with varied approaches to management of biliary obstruction. With exception of those transplanted, the management is palliative and generally focused on debulking and sometimes biliary stenting. We approached our case differently, opting for intraductal RFA as a palliative measure alongside chemoembolization of the primary mass. CASE DESCRIPTION/METHODS: A 32-year-old male with non-cirrhotic chronic hepatitis B presented with epigastric pain, vomiting, and serologic features of ascending cholangitis. Total bilirubin was 16.8 mg/dL, alpha fetoprotein 114 ng/mL, cancer antigen 19-9 1.0 U/mL. Imaging raised concern for HCC versus cholangiocarcinoma and he underwent percutaneous biopsy confirming moderately differentiated HCC. Magnetic resonance imaging raised concern for bile duct luminal irregularities. Endoscopic retrograde cholangiography that followed showed multifocal stenoses of a dilated biliary system and cholangioscopy was used to biopsy a polypoid mass near the biliary bifurcation. Pathology showed HCC. Endobiliary radiofrequency ablation was then employed endoscopically to ablate the intraductal lesions. Subsequent bilirubin 22 days later was 1.8 mg/dL. He suffered no complications related to intraductal RFA and experienced notable clinical improvement. DISCUSSION: While few cases are known and even fewer published, most intraductal HCC is diagnosed by percutaneous biopsy, exam of explant, or post-mortem. To our knowledge, this is the first described case demonstrating reliable diagnosis of intraductal HCC by single operator cholangioscopic biopsy and subsequent treatment with endobiliary RFA, highlighting the exciting potential of new technology used to treat an atypically presenting commonly encountered condition.