An Abortive Hepatocellular Carcinoma Presenting as Obstructive Jaundice

Abstract

This is the case of an 80 year old Hispanic man that came to the emergency room due to right upper quadrant discomfort and yellowing of the skin for the past weeks. He also reported dark colored urine, clay color stools and a 30 pound weight loss. He was taking apixaban for chronic atrial fibrillation and had a prior cholecystectomy due to gallstones. He was jaundiced, the liver edge was palpable, and had right upper quadrant tenderness. Laboratory tests revealed hemoglobin of 11.1 mg/dL, thrombocytosis of 389 x 103, prolonged PT at 18.4 sec, bilirubin in 25 mg/dL, alkaline phosphatase of 1,079 u/L and elevated hepatic enzymes consistent with a cholestatic pattern. An abdominal CT with intravenous contrast demonstrated intrahepatic biliary ductal dilation with prominent distention of the common hepatic duct. A soft tissue density measuring 1.8 cm x 1.3 cm, was observed within the proximal common bile duct, which appeared to be the cause of the obstruction (Figure 1). An ERCP revealed a large filling defect in distal common bile duct. After sphincterotomy, a balloon sweep helped remove a fibrinogenous longitudinal mass with blood clots resolving the obstruction (Figure 2). Histologic examination of aborted cast and the immunoperoxidase studies, which showed strong reaction for hepatocyte specific antigen and were negative to CDX-2, CEA, CK-20, were compatible with hepatocellular carcinoma (HCC). Work up for pre-existing liver disease was negative for viral hepatitis and autoimmune markers. Subsequent hepatic contrast MRI demonstrated a large infiltrative mass replacing the liver and extending into the inferior vena cava and proximal right atrium (Figure 3). HCC is one of the most common cancers in the world. Obstructive jaundice due to HCC is rare. It has been described in approximately 0.5-9% of all cases. This presentation is known as icteric type hepatocellular carcinoma (IHCC). There are several mechanisms for which obstruction can occur in IHCC; tumor compression, hemobilia, migration of the tumor debris or by tumor growth into the bile ducts. IHCC is associated with a poor prognosis, although depends on stage of disease, and the location and extension of tumor thrombi. In view of this rare presentation experts referred to IHCC as a special type of HCC. We report an uncommon case, diagnosed by ERCP, of an abortive HCC presenting as obstructive jaundice. In our case, the use of anticoagulation may have contributed to this unusual presentation.Figure: Axial view, with prominent distention of the common hepatic duct of 1.8 cm x 1.3 cm, with portions of central intra-hepatic duct soft tissue density most compatible with cholangiocarcinoma. There is an area of prominent irregular mass like bulging of the hepatic contour noted hepatic dome measuring approximately 5.2 x 6.9 x 4.4 cm and concerning for peripheral neoplastic mass.Figure: White Fibrinogenous material extracted after balloon sweep and send for analysis.Figure: Axial MRI view showing arge infiltrating hepatic mass extending into the inferior vena cava and proximal right atrium.