Abstract
Introduction Hepatocellular carcinoma (HCC) is the second most common cause of cancer death and one of the most prevalent worldwide; survival rates range between 6 and 20 months. Obstructive jaundice as the main clinical feature is uncommon in HCC. HCC with bile duct invasion is much rarer than HCC with vascular invasion and is not well characterized. Here we present a case where a patient's HCC was diagnosed by ERCP with digital cholangioscopy (DC) as the cancer manifested as an obstructing lesion in the intrahepatic duct but not in the liver. Case A 40-year-old African man presented with intermittent right upper quadrant pain and hyperbilirubinemia. Initial MRCP showed a possible distal common bile duct stone with mild intrahepatic dilatation. An ERCP was performed but no stone was seen. Laparoscopic cholecystectomy with intraoperative cholangiography showed a filling defect in the left intrahepatic duct. The patient lost to follow up until three months later again presenting with RUQ pain with fever. A second MRCP demonstrated a low level enhancing material in the left intrahepatic duct, concerning for malignancy. A second ERCP was performed with DC. An obstructing mass was visualized in the left intrahepatic duct. Biopsy of the lesion revealed a poorly differentiated HCC. The patient received a curative left hepatectomy. It was noted that the patient had background liver cirrhosis from the surgical specimen which was not described by all previous imaging studies. No clear etiology for cirrhosis could be identified. Discussion HCC with extrahepatic spread is present at the time of diagnosis in only 5%-15% of cases, and mostly with primary tumors > 5 cm. Known sites of metastases include lung, lymph nodes, bone, adrenal glands, and brain. Obstructive jaundice associated with HCC occurs only in 0.5%-13% of cases, with the leading cause being bile duct tumor thrombus. Other rare causes include a growing distal tumor or a migrated fragment of a necrotic tumor. The sensitivities for ultrasound, CT, and MRI for HCC are fairly high. In this case, we observed a rare presentation of HCC as an intrahepatic ductal mass, not a classical hepatic mass with cirrhosis, causing biliary obstruction. Furthermore, we believe this was the first reported case where HCC was diagnosed during an ERCP using DC. As the lesion was detected early, the patient received curative surgical resection with favorable outcome.