Hepatocellular carcinoma (HCC) is the most common primary liver malignancy with a high mortality rate. The gold standard for making the diagnosis is liver biopsy. However, this technique can sometimes be risky and contraindicated. Endoscopic retrograde cholangiopancreatography is a largely used therapeutic procedure in hepatobiliary malignancies in case of jaundice. The latter offers also an easy access to bile samples suitable for cytological examination. In addition to previously reported cases of HCC diagnosed by bile duct brushings, we are reporting the first case of endobiliary HCC diagnosed by bile aspiration. We emphasize this rare and non-invasive cytological technique presenting advantages such as cell block preparation and immunohistochemistry.

Hepatocellular carcinoma (HCC) is listed in recent data as the fifth most common cause of cancer with 750,000 new cases of HCC per year and the second cancer- related death worldwide. It is defined by the World Health Organization as primary malignancy of the liver composed of epithelial cells showing hepatocellular differentiation. The main risk factors include viral hepatitis B and C, alcoholic and non-alcoholic steatohepatitis among others. Liver biopsy remains the gold standard for diagnosing liver diseases and more specifically HCC. In biliary specimens, cholangiocarcinoma is the usual type of carcinoma diagnosed. Few cases of HCC were reported in bile duct brushing (BDB) series, however, none was described in bile duct aspiration cohorts. To our knowledge we report the first case of HCC diagnosed in extra-hepatic bile cytology confirmed by liver biopsy.

A 54 years old male patient was admitted to the emergency department for weakness, jaundice, pruritis and 2 weeks history of abdominal pain. In his past medical history, he had liver cirrhosis, oxygen dependent chronic obstructive pulmonary disease, chronic renal failure and ischemic cardiomyopathy. On physical examination, he was icteric and had abdominal tenderness. Liver blood tests showed cholestasis and cytolysis with elevated conjugated bilirubine, gamma-glutamyl transferase and transaminase associated with high alpha- fetoprotein level. Abdominal ultrasound showed a multi nodular liver parenchyma with bilateral intra hepatic bile duct dilation. Due to acute renal failure, abdominal computed tomography scan (CT scan) was done without contrast injection. Results were no conclusive concerning a suspicious intra hepatic lesion (7.9 × 6.4 cm) along with signs of chronic liver injury. The patient underwent an endoscopic retrograde cholangiopancreatography (ERCP) that showed left and right hepatic duct stenosis. Thick purulent material was evacuated from narrowing site and bile was collected before and after BDB and sent for cytological examination.