D0584 - Unanchoring Bias: A Case of Multifocal Hepatocellular Carcinoma and a "Pancreatic" Lesion

Prateek S. Harne, MBBS, MD, Ans Albustamy, MD, Arturo Suplee Rivera, MD, Murthy Badiga, MD, FACG, Asif Zamir, MD, FACG
University of Texas Rio Grande Valley at Doctors Hospital at Renaissance, Edinburg, TX

Introduction: Hepatocellular carcinoma (HCC) is the 4^th leading cause of cancer-related mortality worldwide. About 20-40% of patients with HCC present in advanced stage at the time of diagnosis. Jaundice occurs in 1-12% of cases with HCC (icteric-type or cholestatic type HCC) attributed to tumor infiltration of liver parenchyma, liver failure, advanced cirrhosis and less commonly, obstruction by direct invasion of biliary tree and extrinsic compression by lymph node metastasis. We present a case of HCC that presented with painless jaundice with liver mass, satellite lesions and lymph node metastasis near the pancreatic head mimicking a primary pancreatic malignancy.

Case Description/Methods: A 50-year-old female patient with history of cholecystectomy presented with painless jaundice for ten days with generalized body weakness. Vital signs were stable. Physical examination revealed conjunctival icterus, jaundiced skin, soft, non-tender abdomen. Labs revealed white count 7100, AST 232, ALT 124, ALP 346, total bilirubin 42.4, direct bilirubin 26, AFP 339, CA 19-9 117. CT abdomen with contrast revealed scattered multiple hypodense lesions in liver; largest measuring 5.9 x 4.8cm, cirrhotic morphology and splenomegaly (Image A). Intra and extrahepatic biliary duct dilation was noted with CBD diameter of 16mm. At the level of pancreatic head, a 2cm soft tissue mass attenuating the CBD (Image B) was noted. These images were concerning for primary pancreatic malignancy with metastasis to liver. An ERCP was attempted but CBD could not be cannulated due to extrinsic compression by the mass and patient underwent radiology-guided internal-external percutaneous transhepatic cholangiogram and biliary drainage with CT-guided biopsy of the largest liver lesion which revealed moderately differentiated hepatocellular carcinoma. Patient was evaluated by Oncology and Surgery, but due to the tumor burden and performance status, opted for comfort measures.

Discussion: Metastasis of HCC to pancreatic tissue is rare and sporadically reported. Peripancreatic lymphadenopathy should be considered in patients with hepatic and ‘pancreatic’ masses as in our case, where the mass near the pancreas was a peripancreatic lymph node compressing the CBD, causing obstruction. Such unusual cases can be easily misdiagnosed as primary pancreatic cancer with liver metastasis instead. If doubt persists, biopsy should be used for definitive diagnosis, as misdiagnosis can preclude potentially curative resection.



Disclosures:


Prateek S. Harne, MBBS, MD, Ans Albustamy, MD, Arturo Suplee Rivera, MD, Murthy Badiga, MD, FACG, Asif Zamir, MD, FACG. D0584 - Unanchoring Bias: A Case of Multifocal Hepatocellular Carcinoma and a "Pancreatic" Lesion, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.