Ankle metastasis as a sign of intrahepatic cholangiocellular carcinoma

A 51-year-old man presented with a 1-month history of right ankle pain and swelling that gradually increased (Panel A). There was no history of associated abdominal symptoms. X-ray examination showed an osteolytic lesion of the calcaneus and talus measuring 6.6 cm × 6 cm × 4 cm (Panel B). An abdominal CT scan revealed macronodular liver cirrhosis with a hypovascular lesion measuring 8.3 cm × 7.3 cm involving the 5th and 6th liver segment suspicious of a primary liver malignancy. A positron emission tomography (PET) scan showed pathologic flourodeoxyglucose (FDG) uptake in the right liver lobe, right talus, talocalcaneal joint and calcaneus (Panel C). A right hepatectomy and simultaneous foot amputation was indicated. Intraoperatively, a liver cirrhosis and a stage 4 liver tumor was found which was infiltrating vascular structures in the hepatoduodenal ligament and therefore was inoperable (Panel D). A liver biopsy was performed and the planned amputation of the foot was not carried out. Pathohistologic analysis confirmed an intrahepatic cholangiocarcinoma.