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• W4387247913 abstract "SESSION TITLE: Palliative Care and End of Life Issues Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Hepatobiliary carcinoma; including Hepatocellular carcinoma, Gallbladder cancer and Intrahepatic or Extrahepatic Cholangiocarcinoma are common malignancies. The incidence of those malignancies combined in the United States reached 46461 cases for the year 2019, with 32097 deaths reported. The majority of patients present with abdominal pain, weight loss, ascites or obstructive jaundice. Tumor markers have limited sensitivity and specificity in the diagnosis of hepatobiliary malignancies. The Carbohydrate antigen (Ca 19-9) is mostly elevated in pancreatic cancer, hepatobiliary malignancies or conditions like acute cholangitis, cholestasis or liver abscesses. Extremely elevated levels are mostly reported in cholestasis and liver abscesses, which will further decrease the sensitivity and the specificity of Ca 19-9 for pancreaticobiliary cancers. We report a challenging case of hepatobiliary adenocarcinoma with extremely elevated Carbohydrate antigen (Ca 19-9) diagnosed after multiple scans and invasive procedures. CASE PRESENTATION: A 62 year-old African American female who presented with a two-month history of right upper quadrant abdominal pain, weakness and decreased appetite. She had undergone an ERCP with biliary stenting for obstructive jaundice at a different facility two months prior to admission. brush cytology was negative then. Patient was tachycardic and febrile on admission. Laboratory data was pertinent for elevated WBC: 11.9/μl, ALT: 137 IU/l, AST: 256 IU/l, ALP: 530 IU/l, direct bilirubin: 2.2 mg/dl, total bilirubin: 2.8 mg/dl, procalcitonin 124.57 ng/ml. Hepatitis panel was negative, CEA 97.3 ng/ml, AFP 1.7, CA 19-9: 188815 U/ml. CT scan abdomen on admission showed multiple hypoattenuating liver lesions, with largest diameter 16*3 cm and perihepatic collections (Figure 1). Patient underwent CT scan guided perihepatic drainage and cultures were obtained. This was followed by ERCP with cholangioscopy and repeat brush cytology and biopsies twice. All results came back negative for malignancy, but positive for multiple fungal and bacterial microorganisms. Due to the persistent symptoms and patient's clinical deterioration, with uptrending Ca 19-9 to 23857 U/mL; Patient underwent diagnostic laparoscopy, adhesiolysis and excision of peritoneal nodule biopsy which showed adenocarcinoma, with IHC results suggestive of pancreatic,biliary or gastrointestinal primary. Patient decided not to undergo treatment and she passed away a few days later. DISCUSSION: Our case was challenging to diagnose due to multiple reasons. The patent underwent multiple invasive interventions but the biopsy continued to be negative. The strong clue that helped us diagnose was the persistent up trending of elevated CA 19-9 despite treatment of presumed liver abscess. Unfortunately, even though we made a diagnosis of adenocarcinoma, the tumor had metastasized and did not leave us with enough time for interventions. Palliative care and goal of care discussion with the possibility of cancer diagnoses should be discussed early to avoid unnecessary intervention. CONCLUSIONS: In conclusion, diagnosis of hepatobiliary carcinoma can be challenging. Elevated tumor markers in the setting of an infectious process such as cholangitis or liver abscesses may warrant repeating tumor marker levels after the resolution of the acute insult. More invasive procedures such as gross tissue biopsies may be necessary for an accurate diagnosis. REFERENCE #1: Giannaris, Markos & Dourakis, Spyros & Alexopoulou, Alexandra & Archimandritis, Athanasios. (2006). Markedly elevated CA 19-9 in the pus and the serum of a patient with pyogenic liver abscess [7]. Journal of clinical gastroenterology. 40. 657. 10.1097/00004836-200608000-00026. REFERENCE #2: Yoshino Y, Seo K, Koga I, Matsunaga N, Kitazawa T, Takamori Y, Ota Y. Liver Abscess With a Markedly High Level of Carbohydrate Antigen 19-9. Gastroenterology Res. 2012 Oct;5(5):205-207. doi: 10.4021/gr475w. Epub 2012 Sep 20. PMID: 27785207; PMCID: PMC5051103. REFERENCE #3: Sohaib, Muhammad MD; Hegazi, Mohamed MD; Calderon, Dawn DO. MRSA Liver Abscess Associated With Very High CA 19-9 Levels: 421. American Journal of Gastroenterology 109():p S126, October 2014. DISCLOSURES: No relevant relationships by Ahmad Al-Alwan No relevant relationships by Alaa Alkhatib No relevant relationships by Montaser alrjoob No relevant relationships by Husam Bader No relevant relationships by Awais Khalid No relevant relationships by Charmee Vyas" @default.
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• W4387247913 date "2023-10-01" @default.
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• W4387247913 title "HEPATOBILIARY ADENOCARCINOMA PRESENTING AS MULTIPLE PYOGENIC LIVER ABSCESSES WITH ELEVATED CA 19-9: A DIAGNOSTIC CHALLENGE" @default.
• W4387247913 doi "https://doi.org/10.1016/j.chest.2023.07.3353" @default.
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