Hepatocellular carcinoma embolus to the common hepatic duct with no detectable primary hepatic tumor

Obstruction of the common bile duct (CBD) by direct extension of tumor is occasionally found in patients with hepatic neoplasms. Tumor embolus to the CBD is very rare, however, when no primary hepatic tumor is found. The patient described herein was a 74-year-old man who presented with a new onset of jaundice, nausea, anorexia, and epigastric pain. There was a history of dark urine and clay-colored stools, but no fever. Endoscopic retrograde cholangiopancreatography (ERCP) showed partial obstruction of the common hepatic duct and dilated intrahepatic bile ducts. A computed tomography (CT) scan of the upper abdomen showed no masses. Results of a mesenteric and selective hepatic arteriogram were normal. On abdominal exploration, no tumor was noted. There were no palpable stones in the gallbladder, but a firm mass was felt in the common hepatic duct. Exploration of the CBD produced light-colored debris organized into a cast of the common hepatic duct. Frozen section analysis was negative for tumor cells, but review of the permanent sections confirmed the presence of hepatocellular carcinoma. When non-calculous material is found to be obstructing the CBD, even in the absence of an obvious primary hepatic tumor, tumor embolus or metastasis from a distant site must be considered and the material sent for pathological evaluation.