Samuel H. Cheong, DO1, Brandon Witten, MD2, Shivanand Bomman, MD2, Alexis Elliott, MD2, Gebran Abboud, MD2 1Banner - University of Arizona, Tucson, AZ; 2University of Arizona College of Medicine, Tucson, AZ
Introduction: Hepatic hemangioendotheliomas are rare vascular tumors with an estimated incidence rate of 1-2 per million. Extrinsic biliary obstruction of hemangioendotheliomas are even more rarely encountered previously not being described in the literature. In this case report we describe the diagnosis and management of hemangioendothelioma whose mass effect and likely multiple chemotherapy regimens caused biliary obstruction necessitating repeated ERCP.
Case Description/Methods: 70 year old female past medical history significant for estrogen/progesterone receptor positive breast cancer subsequently treated with lumpectomy and letrozole post surgery. CT scan in 2018 showed evidence of hepatic masses in segments 3, 6 and 7, subsequently biopsied confirming the diagnosis of hemangioendothelioma. Initially managed with Y90 embolization to the right hepatic artery and pazopanib. The left hepatic lesion was then treated with cryo-ablation. Treatment was complicated by hepatitis and cholestasis leading to eventual choledocholithiasis and CBD stricture requiring ERCP, sphincterotomy and stent. CBD biopsies were negative for malignancy. During repeat ERCP five months later CBD stricture was noted to have resolved.
Repeat MRI of the abdomen revealed that the left lobe lesion responded radiographically to the cryo-ablation, with associated left lobe hypertrophy but the right lobe lesions had grown despite radio-embolization. Subsequently underwent right hepatectomy with pathology confirming tumor involvement in the parenchymal margin. Since that time hemangioendothelioma remained stable with only small increase in tumor size. Approximately three years after the resection she developed obstructive cholelithiasis ERCP revealed common hepatic duct stricture treated with plastic stent. Subsequently has been undergoing ERCP with balloon dilations and placement of two side-by-side 10 Fr x 9 cm plastic biliary stents every three months.
Discussion: Hemangioendothelioma and the treatment effects of chemotherapy, Y90 embolization/microwave ablation leading to recurrent biliary obstruction displays an unique challenge. This case highlights the need for multi-disciplinary involvement in managing a complex case. ERCP and experienced interventional gastroenterologists play a crucial role in the ruling out malignancy involving the common bile duct and relieving biliary obstructions especially in with altered right hepatectomy anatomy.
Figure: A: Mid CBD stricture likely inflammatory in etiology due to hemangioendothelioma/chemotherapy. 10x7cm stent subsequently placed. B: Common bile duct stricture, 10x9cm stent subsequently placed. C: Intracytoplasmic vacuoles demonstrating red blood cell extravastation and poorly vasoformitive epitheloid cells with intracytoplasmic vacuoles. D: CAMTA1 staining positivity confirming diagnosis of epitheloid hemangioendothelioma.
Disclosures:
Samuel Cheong indicated no relevant financial relationships.
Brandon Witten indicated no relevant financial relationships.
Shivanand Bomman indicated no relevant financial relationships.
Alexis Elliott indicated no relevant financial relationships.
Gebran Abboud indicated no relevant financial relationships.
Samuel H. Cheong, DO1, Brandon Witten, MD2, Shivanand Bomman, MD2, Alexis Elliott, MD2, Gebran Abboud, MD2. P2824 - Biliary Blockade: Liver Hemangioendothelioma Causing Common Bile Duct and Common Hepatic Duct Obstructions, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
