AB171. Biliary duct tumour thrombosis with hepatocellular carcinoma—a case report

Abstract: Jaundice in hepatocellular carcinoma (HCC) is an unusual presentation and may be multifactorial. A rare cause of obstructive jaundice in HCC is biliary metastasis, known as bile duct tumour thrombosis (BDTT). BDTT can be challenging to diagnose but has characteristic histopathological features. There is considerable uncertainty regarding optimal surgical management of BDTT and its contribution to HCC-related morbidity and mortality. We present the case of an eighty-year-old gentleman diagnosed with BDTT. We discuss jaundice in HCC, the diagnosis and management of BDTT and finally provide some learning points for future. The patient initially presented with obstructive jaundice and was diagnosed with both gallstones and fasciola hepatica. After jaundice persisted, an Endoscopic retrograde cholangiopancreatography (ERCP) was undertaken and four separate histopathologists identified hepatocellular tissue in the bile duct samples. No fasciola was proven. A repeat computed tomography (CT) revealed a segment intravenous (IV) HCC and the patient was formally diagnosed with BDTT. He was not considered suitable for a surgical intervention but to his medical comorbidities and age and was managed conservatively before being discharged home. BDTT is rare and can be difficult to diagnose. There was considerable diagnostic uncertainty in our patient until the histology had been reported. BDTT is often associated with vascular invasion, and suspected mechanism of spread likely involves direct tumour extension and haemobilia, leading to poorer outcomes. While surgery is recommended, the role of a thrombectomy is contested, with most surgeons advocating bile duct excision. Obstructive jaundice in the presence a liver lesion should alert clinicians to the possibility of BDTT. Where possible a liver resection and bile duct excision should be attempted as this seems to offer the best outcome. Lastly, further clarity is needed on whether BDTT has an adverse effect on HCC survival and recurrence, and whether or not a bile duct excision is preferable to a thrombectomy.

Keywords: Bile duct tumour thrombosis (BDTT); hepatocellular carcinoma (HCC); obstructive jaundice; biliary thrombi; biliary metastases; thrombectomy; bile duct excision; prognosis; educational