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JAMA Surgery Clinical Challenge
February 2016

Porta Hepatis Mass

Author Affiliations
  • 1Division of Surgical Oncology, Department of Surgery, Moores UCSD Cancer Center, University of California, San Diego, La Jolla
  • 2Division of Infectious Diseases, Department of Medicine, University of California, San Diego, La Jolla
JAMA Surg. 2016;151(2):187-188. doi:10.1001/jamasurg.2015.2425

A 64-year-old man from the Philippines presented with 5 months of progressive fatigue, worsening jaundice, and a 13-kg weight loss. He denied fever, chills, and abdominal pain. Laboratory test results were significant for a total bilirubin level of 14.4 mg/dL (to convert to micromoles per liter, multiply by 17.104), mildly elevated transaminases, and a white blood cell count of 13 300/mL (to convert to ×109/L, multiply by 0.001) with a normal differential. Computed tomography (CT) of the abdomen and pelvis (Figure, A) demonstrated a heterogeneously enhancing hepatic hilar mass with extensive intrahepatic biliary ductal dilatation. The hilar mass measured 4.4 × 4.3 × 3.5 cm; the gallbladder was calcified. A CT scan of the chest demonstrated a 7-mm left upper lobe partially calcified nodule and cardiophrenic and gastroesophageal lymphadenopathy. Endoscopic retrograde cholangiopancreatography demonstrated focal biliary strictures involving the right and left hepatic ducts. Cytological examination of bile duct brushings showed reactive ductal epithelial cells but no malignancy. Endoscopic ultrasonography with fine-needle aspirates revealed inflammatory cells with granulomatous changes. Serum carcinoembryonic antigen and cancer antigen 19-9 levels were 1.9 ng/mL (to convert to micrograms per liter, multiply by 1) and 293 U/mL, respectively. QuantiFERON (interferon-γ release assay; Qiagen), serum cryptococcal antigen, and serum Histoplasma capsulatum antigen results were all negative. Aerobic, anaerobic, mycobacterial, and fungal cultures from the CT-guided liver biopsy were negative. Laparoscopic biopsy (Figure, B) of several hepatic lesions demonstrated necrotizing granulomatous inflammation with giant cells and central necrosis. Grocott methenamine silver and acid-fast bacilli staining were negative for fungal or mycobacterial organisms, respectively.

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