1. Faculty Case Presentation
Stephen Bracewell, R2 10/11/17

2. Patient Presentation
61 year old male presents to the ED with epigastric abdominal pain for the past 48 hours ago after eating fried fish.
Had identical presentation about 1 month ago and no cause for pain was elucidated.
PMH: Hep C treated with ribavirin, varices
PSH: Liver Bx, EGD with banding
PEx: scleral icterus, jaundiced, guarding in RUQ
Labs show mild elevation in AST/ALT. T-bili has doubled from baseline (7.5 from 2.0.)

3. US 1 month earlier 1 month prior for epigastric pain
Cirrhotic morphology
No cholecystitis or biliary obstruction at that time

4. CT Obtained in ED PVP Art phase
CT shows intrahepatic ductal dilatation in the left biliary system (arrows.)
MRCP/ERCP recommended to further characterize left biliary dilation.

5. MRCP Axial HASTE Breath Hold Sequence
White arrows demonstrate dilated left biliary system without identifiable luminal obstructing lesion

6. MRCP PACE DWI PACE ADC Map
Focus of restricted diffusion noted at the CBD hilum (arrow.)

7. MRCP Axial VIBE Delayed Imaging (Post Contrast)
Cirrhotic morphology, Sequelae of Portal HTN
Focus of Enhancement (arrow) at CBD hilum, thought to be prominent vessel

8. Putting it All Together
Cirrhosis, suboptimal treatment of Hep C
MR with no definite mass but left biliary dilatation, left lobe atrophy
Patient with symptomatic biliary colic, laboratory values consistent with obstructive jaundice
Definitive characterization obtained with ERC

9. ERCP
There was narrowing in the left intrahepatic duct at the bifurcation with proximal dilatation of the left intrahepatic duct, with associated rounded filling defect (red arrow,) but the catheter passed easily passed easily proximally.
There were dilated intrahepatic ducts of the left biliary system (green arrow.) The material that was removed looked like neoplastic tissue. Samples were sucked into a tissue trap for pathology.
LABELED AS "BILE DUCT TISSUE", BIOPSY: 
COMPATIBLE WITH HEPATOCELLULAR CARCINOMA, MODERATELY DIFFERENTIATED GB

10. ERCP
MRCP GB

11. Follow Up
Plan to proceed with liver transplant evaluation. There does appear to be a measurable mass on the images reviewed at tumor board.
Now
1yr ago
AFP-TUMOR MARKER (<10)
23.2 
3.9

12. Intraductal HCC
For many intraductal, non mass forming tumors, the mean time from initial misdiagnosis to the correct diagnosis was 2.1 years[1]
HCC-CCA tumor- (also named biphenotypic type tumors). They comprise a minority of primary hepatic malignancies, accounting for 0.4–14.5%. [ 2]
“A relatively reliable feature of small CCA not seen in most HCC, is a targetoid appearance on DWI, consisting of a hyperintense rim and hypointense center.” [3]
Malignant biliary thickening is typically longer than 5 mm and more irregular. Ductal dilatation usually has a segmental or lobar distribution.[3]
Icteric type HCC-predisposing factors for cirrhosis such as positive serologic results for hepatitis B or C and high serum levels of AFP may help to suggest the diagnosis of HCC [4]

13. References Acknowledgements Dr. Andrew Hardie Dr. Kevin Gibbs
1. Adam SZ, Parthasarathy S, Miller FH. Intrahepatic cholangiocarcinomas mimicking other lesions. Abdom Imaging 2015; 40:
2. Oliveira IS, Kilcoyne A, Everett JM, Mino-Kenudson M, Harisinghani MG, Ganesan K. Cholangiocarcinoma: classification, diagnosis, staging, imaging features, and management. Abdom Radiol (NY) 2017.
3. Mar WA, Shon AM, Lu Y, et al. Imaging spectrum of cholangiocarcinoma: role in diagnosis, staging, and posttreatment evaluation. Abdom Radiol (NY) 2016; 41:
4. Kim AY, Jeong WK. Intraductal malignant tumors in the liver mimicking cholangiocarcinoma: Imaging features for differential diagnosis. Clin Mol Hepatol 2016; 22:192-7.