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• W2074069431 abstract "See related articles, Lok AS et al, on page 493 in Gastroenterology and, Miura H, on page xxiv in this issue of CGH. See related articles, Lok AS et al, on page 493 in Gastroenterology and, Miura H, on page xxiv in this issue of CGH. The patient was a 69-year-old man who had been diagnosed as having chronic hepatitis C 7 years earlier. In 2009, multiple hepatocellular carcinomas (HCCs) were discovered in the liver and he was admitted to our hospital. The HCCs were detected in segments I and V, and measured 30 mm and 28 mm in diameter, respectively. Dynamic computed tomography (CT) scan showed that the peripheral bile ducts were dilated in segment I, but there was no apparent portal venous tumor thrombus or intra–bile duct thrombus (Figure A;arrowheads, dilated bile ducts; arrows, HCC). We chose transcatheter arterial chemoembolization (TACE) and occluded the feeding arteries (right anterior branch and left hepatic artery) with a mixture of lipiodol (iodized oil) (Lipiodol Ultrafluide; Laboratoire Guerbet, Aulnay-Sous-Bois, France), epirubicin, and gelatin sponge particles. On plain CT images immediately after TACE, the lipiodol had accumulated in all tumors including the tumor in segment I. The patient had a low-grade fever for about 6 days, and the increased C-reactive protein level after TACE (maximum, 7.15 mg/dL at day 4) decreased to 4.75 mg/dL 9 days after TACE. On day 10 after TACE, the patient unexpectedly developed a high-grade fever (39°C) and severe right hypochondrial pain. Dynamic CT scan showed dilation of the common bile duct containing a high-density deposit, similar to a stone, at the bottom (Figure B). The C-reactive protein level had increased again to 9.78 mg/dL, alkaline phosphatase and total bilirubin levels were 389 IU/L and 0.63 mg/dL, respectively; therefore, cholangitis as a result of biliary obstruction by the mass was suspected. We then performed an endoscopic sphincterotomy and removed the lesion. Although the mass had looked like a stone on CT, the extracted mass was a gray, soft, and fragile solid tissue fragment, not a stone. Immediately after the procedure the patient's symptoms resolved. Microscopic examination of the lesion showed necrotic tissue preserving the structure of moderately differentiated HCC (Figure C; H&E, 100×). A possible explanation of the findings in this case is that HCC had invaded the bile duct and was embolized by lipiodol-containing material, became disrupted, and then dislodged into the bile duct, causing bile duct obstruction that subsequently induced cholangitis. Although an obvious intraductal tumor was not detected before TACE, the peripheral bile duct had been dilated in segment I, suggesting that the stone-like mass had originated from HCC in that segment. An intraductal tumor is a rare finding in HCC. The incidence previously was reported to be less than 10% and associated with varying degrees of jaundice at admission or during the course of the disease.1Kojiro M. Kawabata K. Kawano Y. et al.Hepatocellular carcinoma presenting as intrabile duct tumor growth: a clinicopathologic study of 24 cases.Cancer. 1982; 49: 2144-2147Crossref PubMed Scopus (210) Google Scholar However, there are a few reports of common bile duct obstruction by sloughing of disrupted HCC after TACE. In those reports, obstruction occurred between 2 and 50 days after TACE,2Choi K.H. Cho Y.K. An J.K. et al.Acute obstructive cholangitis after transarterial chemoembolization: the effect of percutaneous transhepatic removal of tumor fragment.Korean J Radiol. 2009; 10: 197-201Crossref PubMed Scopus (3) Google Scholar, 3Spahr L. Frossard J.L. Felley C. et al.Biliary migration of hepatocellular carcinoma fragment after transcatheter arterial chemoembolization therapy.Eur J Gastroenterol Hepatol. 2000; 12: 243-244Crossref PubMed Scopus (9) Google Scholar whereas in our case, obstruction occurred 10 days after TACE. Physicians should recognize the risk of common bile duct obstruction caused by disrupted HCC fragments when patients suddenly complain of abdominal pain and have a high-grade fever after TACE. Synchronous Hepatocellular Carcinoma and Metastatic Squamous Cell Carcinoma With Life-Threatening HypercalcemiaClinical Gastroenterology and HepatologyVol. 8Issue 2PreviewA 72-year-old Japanese man presented with appetite loss, general malaise, and transient disorientation. On physical examination, he was generally in a cachectic condition. On laboratory study, the serum level of calcium was found to be elevated up to 13.3 mg/dL with hypophosphatemia accompanied by abnormal liver function tests with positive hepatitis C virus serology. The serum level of intact parathyroid hormone was 19.2 pg/mL (normal value, 12–72) and 1,25 (OH)2 vitamin D was 52.2 pg/mL (normal value, 20–60); however, the level of parathyroid hormone-related protein was elevated to 14.7 pmol/L (normal value, 0–1.1) and increased up to 56.7 pmol/L thereafter, which suggested inappropriate hypersecretion of parathyroid hormone-related protein. Full-Text PDF" @default.
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• W2074069431 date "2010-02-01" @default.
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• W2074069431 title "Hepatocellular Carcinoma Mimicking Bile Duct Stone" @default.
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