Cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct.

A case of cholangiocellular carcinoma in the caudate lobe with intraluminal growth in the extrahepatic bile duct is reported. The main tumor in the caudate lobe was detected by computed tomography and angiography, and two intraluminal tumors at the hepatic hilus and at the root of the right posterior segmental duct were well demonstrated by cholangiography and percutaneous transhepatic cholangioscopy. Independent total caudate lobectomy with bile duct resection was performed. Cholangiocellular carcinoma of the liver with intraluminal growth in the extrahepatic bile duct is very rare and has not been reported in the literature. Independent caudate lobe resection requires a rather complicated technique. However, this method has the advantage of reducing to a minimum the hepatic volume to be resected, and is useful for poor-risk patients or for cases with localized carcinoma at the hepatic hilus.     

CD24 expression predicts distant metastasis in extrahepatic bile duct cancer

AIM: To evaluate the prognostic significance of CD24 expression in patients undergoing adjuvant chemoradiotherapy for extrahepatic bile duct (EHBD) cancer. METHODS: Eighty-four patients with EHBD cancer who underwent curative resection followed by adjuvant chemoradiotherapy were enrolled in this study. Postoperative radiotherapy was delivered to the tumor bed and regional lymph nodes up to a median of 40 Gy (range: 40-56 Gy). All patients also received fluoropyrimidine chemotherapy for radiosensitization during radiotherapy. CD24 expression was assessed with immunohistochemical staining on tissue microarray. Clinicopathologic factors as well as CD24 expression were evaluated in multivariate analysis for clinical outcomes including loco-regional recurrence, distant metastasisfree and overall survival. RESULTS: CD24 was expressed in 36 patients (42.9%). CD24 expression was associated with distant metastasis, but not with loco-regional recurrence nor with overall survival. The 5-year distant metastasis-free survival rates were 55.1% and 29.0% in patients with negative and positive expression, respectively (P=0.0100). On multivariate analysis incorporating N stage, histologic differentiation and CD24 expression, N stage was the only significant factor predicting distant metastasis-free survival (P=0.0089), while CD24 expression had borderline significance (P=0.0733). In subgroup analysis, CD24 expression was significantly associated with 5-year distant metastasis-free survival in node-positive patients (38.4% with negative expression vs 0% with positive expression, P=0.0110), but not in nodenegative patients (62.0% with negative expression vs 64.0% with positive expression,P=0.8599). CONCLUSION: CD24 expression was a significant predictor of distant metastasis for patients undergoing curative resection followed by adjuvant chemoradiotherapy especially for node-positive EHBD cancer.     

An extrahepatic bile duct metastasis from a gallbladder cancer mimicking Mirizzi's syndrome

We report a case of an extrahepatic bile duct metastasis from a gallbladder cancer that mimicked Mirizzi's syndrome on cholangiography. A 67-yr-old woman was admitted to our hospital with a diagnosis of acute calculous cholecystitis. As obstructive jaundice developed after the admission, percutaneous transhepatic biliary drainage was performed to ameliorate the jaundice and to evaluate the biliary system. Tube cholangiography revealed bile duct obstruction at the hepatic hilus, and extrinsic compression of the lateral aspect of the common hepatic duct, with nonvisualization of the gallbladder. No impacted cystic duct stone was visualized on CT or ultrasonography. Laparotomy revealed a gallbladder tumor as well as an extrahepatic bile duct tumor. We diagnosed that the latter was a metastasis from the gallbladder cancer, based on the histopathological features. This case is unique in that the extrahepatic bile duct metastasis obstructed both the common hepatic duct and the cystic duct, giving the appearance of Mirizzi's syndrome on cholangiography. Metastatic bile duct tumors that mimic Mirizzi's syndrome have not been previously reported. The presence of this condition should be suspected in patients with the cholangiographic features of Mirizzi's syndrome, when the CT or ultrasonographic findings fail to demonstrate an impacted cystic duct stone.     

A case of early extrahepatic bile duct cancer showing diffuse growth]

A 74-year-old woman visited our hospital for a health checkup, and liver dysfunction and cholangiectasis were detected. Further examinations revealed a protruding lesion spreading diffusely from the upper to the lower extra-hepatic bile duct. On a diagnosis of extra-hepatic bile duct cancer, the patient underwent pancreato-duodenectomy with preservation of the pyloric ring. Small papillary denticulate lesions, forming papillary adenocarcinoma, was scattered over a flat granular lesion of atypical hyperplasia. This morphological pattern is rare, and suggests that the cancer cells may have derived from atypical hyperplastic epithelium.     

Carcinosarcoma of the extrahepatic bile duct

A rare case of a carcinosarcoma of the extrahepatic bile duct demonstrating interesting features is described. A 75-year-old woman with a history of choledocholithotomy presented with acute obstructive suppurative cholangitis. Ultrasonography and computed tomography showed a thickened choledochal wall, with calcification. Percutaneous transhepatic and endoscopic retrograde cholangiography revealed a round filling defect accompanied by an irregular obstruction in the common bile duct. Carcinosarcoma was diagnosed from a protruding lesion in the common bile duct obtained by intraoperative frozen sectioning, and pylorus-preserving pancreatoduodenectomy was performed. Histological examination by light microscopy showed a transition between the carcinomatous and sarcomatous components and positive immunoreactivity for epithelial markers in the sarcomatous component. The patient died of a local recurrence 2 years after the surgery. Polypoid growth and ossification in the tumor could be representative features of carcinosarcoma of the extrahepatic bile duct.     

Fascin expression is correlated with tumor progression of extrahepatic bile duct cancer

BACKGROUND/AIMS: Fascin, an actin-crosslinking protein, participates in cell motility. Fascin over-expression induces a high potential for invasion and metastasis in various malignancies. The aim of this study was to determine the relationship of fascin expression to clinicopathological findings in patients with extrahepatic bile duct cancer. Furthermore, we investigated the correlation between fascin expression and intracellular adhesion molecular (E-cadherin and beta-catenin). METHODOLOGY: We evaluated the expression of fascin, E-cadherin and beta-catenin by immunohistochemistry in surgical specimens from 26 patients with extrahepatic bile duct cancer. RESULTS: Normal epithelial cells of the bile duct was not immunoreactive for fascin, and cancer cells often show immunoreactivity, which was found more frequently at the invasive tumor fronts than at other tumor areas. The present study demonstrated a statistically significant correlation between fascin expression and gender, tumor status, vascular invasion, and disease stage. We detected that increased immunoreactivity for fascin had tendencies to disrupt membranous immunoreactivity for E-cadherin and beta-catenin. CONCLUSIONS: We conclude that fascin expression is correlated with tumor progression. The expression of fascin is frequently detected at the invasive tumor fronts, indicating that invading tumor cells express fascin abundantly. In tumor cells with an over-expression of fascin, E-cadherin and betacatenin expressions often disrupt membranous immunoreactivity.     

自制简易胆道支架修复兔胆道缺损的动物实验研究

目的探讨支架法修复胆道缺损的可行性和安全性。方法采用医用静脉采血针制造简易胆道支架。将30只兔随机分为A组和B组,每组15只。在A组动物,切除胆总管0.5 cm;B组切除1.0 cm。应用自制简易胆道支架与缺损的胆总管断端进行捆绑,恢复其连续性。于术后1、3、6月各处死5只家兔,观察两组动物术后的生存情况、术前术后肝功能变化,肝脏、新生胆管组织和新生胆管组织病理学改变。结果两组均顺利完成手术,无术后黄疸发生。术后A组1只兔因胆漏死亡;B组1只因应激性溃疡死亡。A组动物术前ALT为(56.36±6.35)IU/L,术后1、3、6月分别为[(59.63±5.02)IU/L、(54.63±8.26)IU/L、(59.85±7.43)IU/L,P0.05];AST为(54.13±7.63)IU/L,术后1、3、6月分别为[(57.42±8.31)IU/L、(55.42±5.21)IU/L、(53.62±5.61)IU/L,P0.05];ALP为(207.35±63.47)IU/L,术后1、3、6月分别为[(218.42±73.23)IU/L、(195.31±46.73)IU/L、(189.31±37.64)IU/L,P0.05];TBIL为(0.15±0.08)μmol/L,术后1、3、6月分别为[(0.17±0.04)μmol/L、(0.14±0.05)μmol/L、(0.16±0.07)μmol/L,P0.05]。B组动物术前ALT为(60.26±3.65)IU/L,术后1、3、6月分别为[(69.21±5.13)IU/L、(63.79±8.35)IU/L、(59.97±6.47)IU/L,P0.05];AST为(51.33±6.43)IU/L,术后1、3、6月分别为[(55.43±7.26)IU/L、(61.62±5.73)I U/L、(52.32±5.31)IU/L,P0.05];ALP为(217.25±53.72)IU/L,术后1、3、6月分别为[(228.62±71.32)IU/L、(200.35±46.83)IU/L、(209.83±36.41)IU/L,P0.05];TBIL为(0.14±0.05)μmol/L,术后1、3、6月分别为[(0.16±0.04)μmol/L、(0.12±0.02)μmol/L、(0.13±0.06)μmol/L,P0.05];术后两组动物肝组织病理学与术前比较无显著变化;术后1月,两组支架已覆盖充血水肿的新生胆管组织;术后3月两组新生的胆管组织已无水肿存在;术后6月两组新生胆管组织在外观上与正常胆管组织无差异。结论本实验表明在血供丰富、缺损1.0 cm以内的胆总管具有很强的再生和形成新生胆管的能力。支架法修复1.0 cm以内的胆道缺损安全可行。     

Resection of liver metastasis from extrahepatic bile duct carcinoma previously treated by pancreatoduodenectomy

No English report of a 5-year survivor with liver metastasis from periampullary carcinoma has been published to date. Here, we report a 52-year-old woman with liver metastasis previously treated with pylorus-preserving pancreatoduodenectomy for extrahepatic bile duct carcinoma, who underwent hepatectomy and has survived for more than 5 years without recurrence after the procedure. This outcome suggests that hepatic resection is effective for selected patients with liver metastasis from extrahepatic bile duct carcinoma previously treated by pancreatoduodenectomy. When a patient has a solitary metastasis of the liver with no other evidence of recurrence, surgical resection of the liver metastasis should be considered a valid option.     

Intraductal ultrasonography for the diagnosis of proximal invasion in extrahepatic bile duct cancer

Intraductal ultrasonograpy (IDUS) was performed on 22 patients with extrahepatic bile duct cancer, using the percutaneous transhepatic approach. Intraductal ultrasonograpy images of the proximal invasion of the bile duct cancer were defined. In addition, three patients were examined through the peroral approach, to try to diagnose whether or not the cancer invaded to the bifurcation of the hepatic duct. Intraductal ultrasonograpy images obtained through the percutaneous approach could be classified into three patterns, types 1, 2 and 3, according to the features of the interior surface of the bile duct and the thickness of the bile duct wall. Type 1 images, which did not show protrusions into the bile duct lumen and had a bile duct wall of even thickness, were not likely to show bile duct cancer. Type 2 images showed protrusions of the tumour into the bile duct lumen and the surfaces of the protrusions were irregular. Type 3 images showed single or multiple low echoic papillary masses in the bile duct. Using the peroral technique, we considered all three cases to be type 1 and could diagnose that cancer had not invaded to the bifurcation of the hepatic ducts. From the results of this study, we suggest that proximal invasion of extrahepatic bile duct cancer can be diagnosed using IDUS.     

Mucin ball-producing extrahepatic bile duct carcinoma

The characteristic features of surgically curable mucin-producing extrahepatic bile duct carcinoma (MPEBC) have not previously been elucidated. Three (6.5%) of 46 patients who underwent surgery in our department for bile duct carcinoma between 1986 and 1997 had MPEBC. Clinicopathological features, diagnostic procedures and operative methods for patients with MPEBC were investigated. Tumors in the bile duct were identified by cholangioscopy combined with cholangiography after removal of mucin balls. Tumors were located close to the hepatic confluence in these patients. Two patients underwent hepatic lobectomy together with caudate lobectomy while the other underwent resection of the hepatic confluence. Absence of residual tumors was confirmed histologically in these patients. All three patients remain alive without evidence of recurrence, 22-54 months after surgery. MPEBC is a curable disease. Accurate localization in the biliary tree is essential and can only be obtained after, i) removal of mucin balls, and ii) extensive diagnostic work-up including cholangiography, cholangioscopy and intraoperative pathological examination.     

Endocrine cells in extrahepatic bile duct carcinoma

Summary A total of 44 extrahepatic bile duct carcinomas comprising 13 well-differentiated adenocarcinomas, 25 moderately differentiated adenocarcinomas, and 6 poorly differentiated adenocarcinomas were examined histologically and immunohistochemically for somatostatin, gastrin, and glicentin. Argyrophil cells, argentaffin cells, and somatostatin- and gastrin-immunoreactive cells within the tumor were detected in 46.2%, 15.4%, 23.1%, and 15.4% of well-differentiated adenocarcinomas, and in 16.0%, 8.0%, 12.0%, and 4.0% of moderately differentiated adenocarcinomas, respectively. No tumor tissues of poorly differentiated adenocarcinomas contained endocrine cells. A statistically significant difference in the frequency of argyrophil cells was observed between well and poorly differentiated adenocarcinoma. The incidence of argyrophil cells and somatostatin-immunoreactive cells in nonneoplastic mucosa adjacent to well-differentiated adenocarcinoma was higher than in that adjacent to poorly differentiated adenocarcinoma. Glicentin-immunoreactive cells could not be demonstrated either in tumor tissue or in nonneoplastic mucosa of the extrahepatic bile duct. With reference to the histogenesis of extrahepatic bile duct carcinoma, it was assumed from these results that the development of well-differentiated adenocarcinoma might be closely related to the occurrence of endocrine cells and that poorly differentiated adenocarcinoma might develop from ordinary mucosa.     

Studies on surgical operations and prognosis of extrahepatic bile duct cancer

AIM: To perform a clinical evaluation of the surgical procedures of extrahepatic bile duct cancer and their influence on prognosis. METHODS: A total of 55 patients with pathologically and clinically verified extrahepatic bile duct cancer treated in our department between January 1984 and December 1993 were analyzed retrospectively. Clinical courses, with respect to the surgical procedures, investigated by follow-up and the survival period was assessed. RESULTS: Among the 55 patients, 24 received surgery that involved the upper third of extrahepatic biliary tract, 12 involving the middle third, and 19 involving the lower third. The diagnosis of bile duct cancer was confirmed histopathologically in 42 of the patients, with a clear predominance of adenocarcinoma (97.6%). Eleven (26.2%) of the patients received curative resection, 30 received palliative procedures (i.e. biliary-enteric bypass (n = 14) and external drainage (n = 16)), 6 received permanent percutaneous transhepatic cholangio-drainage (PTCD) alone, and 8 received exploratory laparotomy only or conservative treatment. Forty-eight patients (87.3%) were followed-up. The overall mean survival period was 10.8 ± 9.7 mo (¯x ± s); patients with curative resection had the longest survival period (21.4 ± 16.7 mo, P < 0.01) and highest survival rate (P < 0.05). A significant survival difference was observed for patients with biliary-enteric anastomosis as compared with those who had external drainage, etc. (P < 0.05), but there was no significant difference in survival period between patients who had preoperative PTCD (n = 23) and those who did not (n = 26) (P < 0.05). CONCLUSION: Curative resection is the treatment of choice for suitable patients with extrahepatic bile duct cancer; biliary-enteric anastomosis is preferable for those with unresectable tumor in order to improve prognosis and quality of life.     

Risk factor for extrahepatic bile duct cancer in patients with anomalous pancreaticobiliary ductal union

BACKGROUND/AIMS: Anomalous connection between the choledochus and pancreatic duct is considered to be a factor in the development of biliary tract diseases such as choledochal cyst, pancreatitis, cholangitis, gallbladder cancer, and bile duct cancer. Our purpose was analysis of combined disease, especially biliary neoplasm and evaluated microscopic changes of extrahepatic bile ducts. METHODOLOGY: To study the clinical characteristics of anomalous pancreaticobiliary ductal union (APBDU), we reviewed 14 APBDU cases from June 1994 to June 1998. We studied the associated disease, surgical treatment, and the histological findings of the extrahepatic bile ducts. RESULTS: Gallbladder cancer was identified in 5 out of 14 patients with APBDU. The incidences of metaplasia of gallbladder and bile duct with APBDU were higher than that of control gallbladder epithelium. The proliferating cell nuclear antigen-labeling index of the gallbladder in patients with APBDU was significantly higher than that in the control group. CONCLUSIONS: The patients with APBDU showed high incidence of gallbladder carcinoma and metaplasia in epithelium of gallbladder and bile duct. As this metaplasia in the gallbladder and bile duct is thought of as a precancerous condition, it is important to remove the place that causes bile stasis and to stop backflow of pancreatic juice into the bile duct in managing patients with this anomaly. In other words, prophylactic cholecystectomy and reconstruction of the biliary tract are both necessary.     

A case of cystic duct metastasis from rectal cancer

A 67-year-old man underwent laparoscopic low anterior resection and open medial segmentectomy of the liver for rectal cancer and liver metastasis. During the operation, a cystic duct mass, 1cm in diameter, was found. Therefore cholecystectomy with partial resection of the common bile duct was also performed. The rectal tumor and liver tumor were diagnosed pathologically as moderately differentiated adenocarcinoma. The cystic duct mass was mainly located in the lamina propria and its histological aspects were similar to the rectal cancer. Immunohistochemical staining revealed that rectal, hepatic, and cystic duct lesions were all negative for CK7 but were all positive for CK20. These findings confirmed the diagnosis of rectal cancer with metastases to the liver and the cystic duct. Metastatic cystic duct tumor is extremely rare and has never been reported in the Japanese literature.     

Lymphatic spread differs according to tumor location in extrahepatic bile duct cancer

BACKGROUND/AIMS: Identification of nodal involvement according to primary tumor location in extrahepatic bile duct carcinoma may guide surgical therapy. METHODOLOGY: Pathologic data of 81 patients who underwent curative operation for bile duct carcinoma were studied to clarify the differences in lymphatic spread from distal bile duct carcinoma, middle bile duct carcinoma, and proximal bile duct carcinoma. RESULTS: Lymph node metastases were present in 25 of 41 patients (61%) with distal bile duct carcinoma, 9 of 19 (47%) with middle bile duct carcinoma, and 11 of 21 (52%) with proximal bile duct carcinoma. The number of positive nodes per node-positive patient was greater in patients with middle bile duct carcinoma than in those with distal- or proximal bile duct carcinoma (mean 5.33 vs. 3.56 or 2.64, p < 0.05). Lymph nodes in the hepatoduodenal ligament were most frequently involved regardless of the primary tumor location. The frequency of distal- and middle bile duct carcinoma patients with metastasis to the superior mesenteric or para-aortic nodes was significantly higher than that of proximal bile duct carcinoma patients (p < 0.05 and p < 0.05). CONCLUSIONS: Patterns of lymphatic spread were different according to primary tumor location in bile duct carcinoma. Metastatic nodes were spread widely, from the hepatoduodenal ligament or posterior pancreaticoduodenal region to the nodes around the superior mesenteric artery and abdominal aorta, in distal- and middle bile duct carcinoma.     

Prognostic value of 18F-fluorodeoxyglucose positron emission tomography in patients with extrahepatic bile duct cancer

Background

¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) is used in the differential diagnosis and staging of extrahepatic bile duct cancer (EBDC), but its prognostic value has not been fully elucidated. In this study, we investigated the prognostic value of FDG-PET in EBDC patients.

Methods

The study included 73 consecutive patients with EBDC, of whom 48 underwent surgical resection for EBDC. The effects of clinicopathological factors including the standardized uptake value (SUV) of the primary lesion and lymph node metastasis detected by FDG-PET (PET-N) on overall survival were evaluated.

Results

In all 73 patients, multivariate analysis showed that surgical resection (risk ratio 2.5, 95% confidence interval [CI] 1.17?C5.35, P?=?0.018) and the SUV (2.0, 1.07?C3.91, P?=?0.030) were independent predictors of survival. In the 48 patients who underwent surgical resection, multivariate analysis revealed that perineural invasion (risk ratio 3.2, 95% CI 1.28?C7.93, P?=?0.012), pathologic lymph node metastasis (3.4, 1.27?C9.17, P?=?0.015), and PET-N (4.0, 1.10?C15.25, P?=?0.036) were independent predictors of overall survival. In the 25 patients without surgical resection, the SUV showed a significant relationship with overall survival (P?=?0.014).

Conclusion

Our data suggest that the SUV of the primary lesion is a useful prognostic factor in patients with EBDC, and the prognosis for patients with PET-N remains very poor despite surgical resection.