P3156 - Direct Visualization of Hepatocellular Carcinoma with Complete Bile Duct Invasion Using Peroral Cholangioscopy

Fadi Dahoud, BS¹, Elizza E. Villarruel, BS², Hellen Jumo, BSc¹, Lavender Micalo, BS¹, Laura Mcenerney, MD³, Danny Issa, MD^1
1David Geffen School of Medicine at UCLA, Los Angeles, CA; ²David Geffen School of Medicine at UCLA, La Puente, CA; ³David Geffen School of Medicine at UCLA, Santa Clarita, CA

Introduction: Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, constituting up to 90% of cases. While most tumors originate from hepatocytes, a subset of HCCs originating from the biliary epithelial cells has been reported and is exceedingly rare. Here, we present a very rare case of HCC causing complete invasion into the intra-hepatic bile ducts and review the diagnostic method.

Case Description/Methods: A 66 year-old man with long-standing untreated chronic hepatitis C, type 2 diabetes and recently diagnosed cirrhosis presented with acute RUQ abdominal pain associated with poor oral intake. He described a weight loss of 10 lbs. over 3 months. He underwent a CT scan that revealed liver cirrhosis, a mass in liver segment 8, and portal vein thrombosis. His labs were unremarkable except for elevated hepatitis C RNA level at 1,990,000 IU/mL. Subsequently, a multiphase CT did not demonstrate characteristic findings for HCC. An MRCP revealed an intrahepatic biliary stricture caused by the mass with upstream dilatation. ERCP with the single-operator cholangioscopy revealed a tumor invasion into the right main intrahepatic duct with a complete cut-off of the duct. Direct visualization was concerning for malignancy (Image 1A, B). Cholangioscopy biopsies underwent morphology and immunohistochemical examinations and showed HCC staining for Pancytokeratin, Glypican-3, and cytoskeletal (CK)19 originating from the bile ducts, suggesting a biliary type of HCC (Image 1C, D). The mass was outside Milan criteria, and the patient was started on atezolizumab/bevacizumab therapy. His liver functions worsened rapidly, and he expired 2 months after his presentation.

Discussion: Aggressive HCC tumors can invade into the bile ducts and pose a diagnostic challenge. Imaging modalities may not be accurate in the distinction of bile duct from conventional HCC, and tumor markers such as alpha-fetoprotein, portal vein tumor thrombus, or peripheral blood neutrophil-to-lymphocyte ratio may not be elevated as in our patient. The definitive diagnosis often relies on biopsy followed by histopathological exam and staining. Cholangioscopy during ERCP allows for a high-quality examination and adequate tissue acquisition with the new improved forceps. Caution is advised as this tumor bleeds even with gentle biopsy (Image 1B). The combination of atezolizumab (PD-L1 inhibitor) and bevacizumab has shown to be relatively effective. Overall, the prognosis remains poor, and early detection of this disease is essential.



Disclosures:


Fadi Dahoud, BS¹, Elizza E. Villarruel, BS², Hellen Jumo, BSc¹, Lavender Micalo, BS¹, Laura Mcenerney, MD³, Danny Issa, MD¹. P3156 - Direct Visualization of Hepatocellular Carcinoma with Complete Bile Duct Invasion Using Peroral Cholangioscopy, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.