This case report describes a rare case of an inflammatory hepatic hilar mass that mimicked cholangiocarcinoma in a 66-year-old man. Imaging and biopsy were initially suggestive of cholangiocarcinoma but surgical exploration revealed the mass to be caused by diffuse fibrotic and inflammatory reactions. A definitive diagnosis of benign inflammatory mass, rather than cholangiocarcinoma, was made based on histopathological examination showing only chronic inflammation. The patient recovered well with conservative management, highlighting the challenges of distinguishing between benign and malignant hilar masses preoperatively.

1. Case of a Rare Inflammatory Hepatic Hilar Mass Mimicking Cholangiocarcinoma
Stephanie Egge MSIII, Debdeep Banerjee MSIII, Subhasis Misra M.D., H. Nail Aydin M.D.
Department of Surgery
Texas Tech University Health Sciences Center, Amarillo
References:
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Discussion
•66-y/o healthy Hispanic male with 3-week
•pruritic jaundice
•nausea/vomiting, steatorrhea
•18-lb weight loss over the prior 1 month
•α-fetoprotein tumor marker (AFP) of 2.1 mM (normal: 0.5-2.5)
•Past Medical History: (1) Alcohol use disorder with 2 year sobriety (2) Cholecystectomy 2 years prior
•Family History: Non-contributory
•Social History: 30 year history of 12-18 12 oz. beers. Denies tobacco or illicit drug use or history.
Table 1. Liver Function Tests on Admission
Imaging Studies
•CT abdomen: Heterogeneous hilar mass with intrahepatic biliary dilatation (Figure 1).
•MRCP confirmed dilatation of intrahepatic ducts involving the confluence (see Figure 2).
•ERCP with brush cytology with 10-Fr stent placement at the common hepatic duct bifurcation.
•Filling studies suggested defect at common hepatic duct, extending to proper hepatic branches
Pathology
Brush histopathology: benign epithelium with evidence of chronic inflammation
CT & US-biopsy: findings consistent with chronic inflammation
Due to minimal extend of biopsies and the clinical picture (i.e. presence of a mass in the hepatic hilum),
surgical exploration was pursued.
Surgical exploration:
Diagnostic laparoscopy showed no evidence of peritoneal carcinomatosis. Open exploration
demonstrated multiple lymphadenopathies of the hepatoduodenal ligament. Frozen sections showed
findings consistent with chronic inflammation and histiocytosis.
Portal dissection revealed diffuse fibrotic and desmoplastic reactions, involving extrahepatic biliary
ductal system and porta hepatis. Fibrosis and chronic inflammation persisted within the intrahepatic
parenchyma, without local mass. Intraoperative-US and full-thickness biopsy were performed at the
area of concern, revealing findings of chronic inflammation.
Based on histopathological evaluation and in the absence of malignancy., the case was terminated.
Patient recovered unremarkably and has improved ever since with outpatient follow-up with
gastroenterology and surgery.
Case Report
Hepatic hilar masses can be of several different etiologies, most commonly malignant. We present a rare
inflammatory hepatic hilar lesion that mimics cholangiocarcinoma. Preoperative distinctions between benign,
inflammatory hyperplasias and cholangiocarcinoma pose a challenge. Benign lesions mimicking
cholangiocarcinoma most commonly auto-immunogenic or infectious etiologies, such as primary sclerosing
cholangitis and recurrent pyogenic cholangitis. Benign and malignant hilar masses usually present with
nonspecific symptoms of painless jaundice, weight loss, fatigue, and malaise. Radiologic techniques are
often inadequate to detect major differences in morphology, and image-guided biopsy lacks adequate
sensitivity to rule-out cholangiocarcinoma in the setting of benign disease. Biopsy-negative lesions are often
presumed as cholangiocarcinoma and treated with extensive resections, and definitive exclusion of
cholangiocarcinoma usually results from post-resection histopathological analysis. Here, we report a case of
a rare inflammatory hepatic hilar mass, mimicking cholangiocarcinoma.
Introduction
Benign inflammatory lesions represent a rare etiology of obstructive hilar masses; however, diagnostic
exclusion requires adequate preoperative and intraoperative work-up. Appropriate histopathological
analysis includes frozen sectioning of hepatic lesion and exploration and biopsy of portal lymph nodes. If
malignancy is evident, resection is indicated. However, in cases of benign histopathology, other potential
etiologies such as infections (particularly viral), autoimmune, and allergic reactions should be explored. In
such cases, non-operative management and further work up may be more appropriate, thereby avoiding
potential morbidity and complications associated with hepatobiliary resection.
Conclusion
Value a
Alkaline phosphatase (ALP) [U/L] 856 ⇑ 44-147
Aspartate aminotransferase (AST) [U/L] 104 ⇑ 10-40
Alanine transaminase (ALT) [U/L] 66 ⇑ 7-56
Total bilirubin [mg/dL] 5.2/ ⇑ 0.3-1.9
Albumin [g/dL] 2.3 ⇓ 3.5-5.5
Value Normal Range
Alkaline phosphatase (ALP) [U/L] 302 ⇑ 44-147
Aspartate aminotransferase (AST) [U/L] 33.0 10-40
Alanine transaminase (ALT) [U/L] 32.0 7-56
Total bilirubin [mg/dL] 0.8 0.3-1.9
Albumin [g/dL] 3.4 3.5-5.5
Figure 1. CT-abdomen revealed a hilar liver mass and intrahepatic biliary
dilation, suggestive of Klatskin tumor. Arrows denoting dilation. Arrow
head denoting heterogeneous enhancement.
Figure 2. MRCP showed
intrahepatic ductal dilatation
as far as the confluence of
the intrahepatic ducts. MRI
weighting is T2 in depicted
images.
Recent patient data is provided in Table 2, supporting physiologic improvement. Recent EGD also
revealed no new lymphadenopathies, inflammation, or mass that would be suspected with cancer.
A
B