Biliary papillomatosis

Pathologic Features of Primary and Metastatic Hepatic Malignancies

In the mammalian liver, 60 % of the cellular components are hepatocytes while the remainder (35 %) includes biliary epithelium, Kupffer cells, endothelial cells, fat storing cells and connective tissue cells. Although neoplasms of hepatocytes are the most common, a significant number of both benign and malignant primary liver neoplasms arising from other cell types can develop, such as tumors of bile duct epithelium (Table 1). In addition, the liver is one of the most susceptible sites for metastatic tumors arising from other organs of the body. Not too long ago, liver tumors were left untreated because the liver was considered a complex and mysterious organ inaccessible to surgery. Advances in imaging procedures and surgical techniques over the past 40 years have revolutionized the approaches to the treatment of benign and malignant liver tumors. Subsegmentectomy, segmentectomy, lobectomy, and transplantation are routinely performed for the treatment of primary and metastatic liver tumors with minimal morbidity and mortality. Since accurate diagnosis remains the key to clinical and surgical management, the emphasis of this chapter is on classification, morphological features and differential diagnosis of malignant neoplasms of the liver.

Rare event of biliary papillomatosis arising in a choledochal cyst

A 31-year-old man presented with features of recurrent cholangitis for 7 months. Examination revealed icterus and a palpable 10×8 cm lump in the right hypochondrium extending into the epigastrium. Total and direct bilirubin was raised (8.4, 6.7 mg/dL). Alkaline phosphatase (468 U/L) was raised but other liver enzymes were normal. Ultrasound of the abdomen showed dilated intrahepatic biliary radicals (IHBRs) and common hepatic duct (CHD) with a significant intrahepatic portion. Contrast-enhanced CT scan of the abdomen showed similar findings. MR cholangiopancreatography demonstrated diffusely dilated IHBRs and choledochal cyst involving the CHD. The common bile duct was mildly dilated without any filling defect. Tumour markers (carcinoembryonic antigen and cancer antigen 19-9) were normal. The patient underwent complete excision of the extrahepatic biliary system including choledochal cyst and Roux-en-Y hepaticojejunostomy. Opening up the bile duct showed very thick gelatinous material and multiple pedunculated papillary type structures arising from the wall of the choledochal cyst.

Diagnosis and treatment of mucobilia: A review and analysis of 80 cases

AIM: To discuss the epidemiology, diagnosis, and treatment of mucobilia in China to provide a reference for clinicians.

METHODS: All statistical data were obtained from the available literature. Non-overlapping cases were all selected, while cases with the longest time span or with the largest number were selected when overlapping cases existed. A total of 12 papers were included, and 4 of them reported more than 5 cases. The largest number of cases in a single paper is 22.

RESULTS: A total of 12 qualified papers reporting 80 cases of mucobilia were included. Preoperative diagnosis of mucobilia is difficult. The rate of misdiagnosis reached 48%, and mucobilia has no significant specificity compared with some diseases presenting with benign and malignant obstructive jaundice. The annual mortality rate was 16.44%. Preoperative diagnosis mainly depends on clinical presentation and ultrasound, CT, ERCP, PTC and other auxiliary examinations. If intraoperative bile duct exploration reveals a large amount of jelly-like mucus in the cavity, a diagnosis of mucobilia can be established.

CONCLUSION: Mucobilia is a rare biliary disease having many causes such as inflammation of the bile duct and carcinoma of the bile duct. The location, extent and nature of the primary disease can be confirmed by choledochofiberscopy and biopsy. Preferred treatment is a complete resection of primary lesions to ensure both good and smooth drainage of the bile duct.

Characteristics of common solid liver lesions and recommendations for diagnostic workup

Due to the widespread clinical use of imaging modalities such as ultrasonography, computed tomography and magnetic resonance imaging (MRI), previously unsuspected liver masses are increasingly being found in asymptomatic patients. This review discusses the various characteristics of the most common solid liver lesions and recommends a practical approach for diagnostic workup. Likely diagnoses include hepatocellular carcinoma (the most likely; a solid liver lesion in a cirrhotic liver) and hemangioma (generally presenting as a mass in a non-cirrhotic liver). Focal nodular hyperplasia and hepatic adenoma should be ruled out in young women. In 70% of cases, MRI with gadolinium differentiates between these lesions. Fine needle core biopsy or aspiration, or both, might be required in doubtful cases. If uncertainty persists as to the nature of the lesion, surgical resection is recommended. If the patient is known to have a primary malignancy and the lesion was found at tumor staging or follow up, histology is required only when the nature of the liver lesion is doubtful.

Successful photodynamic therapy for biliary papillomatosis: A case report

Papillomatosis of the bile duct is a rare disease with a high risk of malignant transformation. Therapeutical options include partial hepatectomy and liver transplantation. A previously healthy 65-years old male developed jaundice and right upper abdominal quadrant pain in 1996. A villous adenoma of the distal bile duct was diagnosed. A Whipple procedure was performed. In 2002 the patient turned symptomatic again. Another adenoma was found in the right hepatic duct resulting in a right hepatectomy. Two years later the patient again developed cholestasis. After drainage of the left hepatic duct with a percutaneous transhepatic cholangial drainage (PTCD) catheter, a recurrent biliary adenomatosis was diagnosed by cholangioscopy. As there was no surgical option left, the patient received photodynamic therapy (PDT) for the recurrent biliary papillomatosis. Three mo after he received further photodynamic therapies, the bile duct epithelium appeared normal and the patient had no signs of adenomatosis, both macroscopically and histologically. The follow-up cholangioscopy in late 2005 revealed only a small papilloma without the need for intervention. In early 2006, the patient died of multi organ failure without signs of extrahepatic cholestasis or cholangitis at the age of 75, 10 years after the diagnosis of biliary papillomatosis was established. The patient exceeded the average life expectancy of patients with biliary papillomatosis by far. Thus, PDT might be a sufficient therapeutic option for recurrent papillomatosis patients with no significant side effects.

Papillomatosis of intra- and extrahepatic biliary tree: Successful treatment with liver transplantation

Approximately 60 cases of biliary papillomatosis have been reported in the world literature, while only 6 cases have been reported to be treated with liver transplantation. This rare disease, which is characterized by relapsing episodes of obstructive jaundice and cholangitis that lead to secondary cirrhosis and death from sepsis or liver failure, it is also considered premalignant because of its frequent malignant transformation (25-50%). We present a case of a 43-year-old white man with papillomatosis of intra- and extrahepatic biliary tree who sought care for repeated episodes of obstructive jaundice and cholangitis. The diagnosis was suspected after endoscopic retrograde cholangiopancreatography and confirmed by liver and common bile duct biopsies. The patient underwent orthotopic liver transplantation with Roux-en-Y hepatico-jejunostomy to treat end-stage liver cirrhosis. Fifteen months' follow-up revealed a patient with normal graft function and with no clinically or laboratory findings of disease recurrence or cancer development.

Intraductal growth-type mucin-producing peripheral cholangiocarcinoma associated with biliary papillomatosis

A 64-year-old woman with upper abdominal pain, nausea, and vomiting was admitted. The magnetic resonance imaging revealed marked dilation and "crowding" of the segment 4 bile ducts with an area suspicious for a stone or tumor. Ultrasonography-guided percutaneous transhepatic cholangiography revealed multiple filling defects in the segment 4 bile ducts, the left and common hepatic ducts. A left hepatectomy and cholecystectomy was performed. Dilated bile ducts containing mucinous material and a mass in the cystically dilated bile ducts of segment 4 were detected in the gross examination. It showed continuity within the surrounding dilated bile ducts. The dilated bile ducts of the segments 2 and 3 contained mucinous material without any apparent mass formation. Microscopically, the bile ducts were lined by biliary epithelium displaying simple and complex papillary structures with moderate to severe degree of dysplastic changes. The mass was composed of complex papillary structures filling the bile duct with a few foci of invasion. The papillary structures were composed of mucin-producing columnar cells as well as cells with oncocytic appearance. Patchy cytokeratin 7, cytokeratin 19, hepatocyte paraffin 1, MUC2, and CDX2 immunopositivities were observed. Biliary papillomatosis, mucin-producing intrahepatic cholangiocarcinoma, and intraductal papillary-type peripheral cholangiocarcinoma are in the same disease spectrum of papillary biliary neoplasm and termed as intraductal papillary neoplasm of the liver. Mucinous hypersecretion and signs of mucobilia are considered specific and should raise the suspicion of lesions in this spectrum.

Intraductal papillary mucinous tumor of the bile ducts

Papillary tumors of the bile ducts are intraductal tumors with numerous minute frondlike papillary projections. Some intraductal papillary tumors of the bile ducts produce a large amount of mucin that disturbs bile flow and causes severe biliary dilatation. In the presence of a tumor of this subgroup, the entire biliary tree is dilated; segmental or lobar bile ducts are dilated disproportionately, and aneurysmal dilatation may occur. Mucin is depicted at cholangiography as multiple elongated or cordlike filling defects, and the tumor is depicted on cross-sectional images as a castlike, polypoid, or fungating mass in the dilated biliary tree. Based on these characteristic imaging features-dilatation, mucin, and tumor-correct diagnosis of intraductal papillary mucinous tumor of the bile ducts may be made.

Clinicopathologic review of 58 patients with biliary papillomatosis

BACKGROUND

Biliary papillomatosis (BP) is a rare disease that is characterized by multiple numerous papillary adenomas in the biliary tree. The clinical features and outcome, however, are not well known. The authors retrospectively analyzed their clinicopathologic features and long-term follow-up results.

METHODS

Between March 1995 and January 2003, 58 patients were diagnosed with BP by cholangioscopic and histologic findings at a tertiary referral center, Asan Medical Center (University of Ulsan College of Medicine, Seoul, Korea). The authors retrospectively reviewed the medical records to obtain demographic, radiologic, cholangioscopic, and pathologic data.

RESULTS

The common clinical manifestations at the presentation of patients were repeated episodes of abdominal pain, jaundice, and acute cholangitis. Acute cholangitis was more common in patients with mucin-hypersecreting BP (MBP), whereas patients with nonmucin-producing BP (NMBP) were more asymptomatic (P < 0.05). Papillary adenocarcinoma and mucinous carcinoma were detected in 48 patients (83%) with papillary adenomas. Overall survival rates of NMBP and MBP were 89% and 69% at 1 year, 57% and 37% at 3 years, and 52% and 19% at 5 years, respectively. The mean survival period of NMBP and MBP was 52.27 +/- 6.72 months and 30.84 +/- 8.36 months, respectively.

CONCLUSIONS

BP should be regarded as a premalignant disease with high malignant potential. The pathogenesis of progression from benign to malignant disease may follow the adenomacarcinoma sequence. Although clinical presentations were somewhat different for patients with NMBP and MBP, the long-term survival rate was similar.

Papillary neoplasms of the bile duct that mimic biliary stone disease

Papillary tumors of the bile duct are intraductal tumors with innumerable minute, frondlike papillary projections. These tumors may be either fixed to or detached from the bile duct wall. However, because the papillary projections on the surface of papillary tumors are long and slender, the tumors are friable and slough easily. The sloughed tumor fragments may float within the bile ducts, resulting in intermittent partial biliary obstruction and mimicking bile duct stones at clinical examination and at ultrasonography (US), computed tomography (CT), and cholangiography. A tumor manifests radiologically as thickening and irregularity of the bile duct wall or as a fixed or sloughed intraductal mass. A nonshadowing intraductal echogenic cast seen at US, an intraductal noncalcified soft-tissue mass with asymmetric wall thickening seen at CT, and an intraductal mass with a papillary surface and a serrated bile duct margin seen at cholangiography are all appearances that suggest a papillary tumor and may be helpful in differentiating a tumor from a bile duct stone.

Malignant intrahepatic biliary papillomatosis associated with viral C cirrhosis

Biliary papillomatosis is a rare entity characterized by multiple papillary adenomas involving extensive areas of the biliary tract with a great potential for recurrence and malignant transformation. It has been reported in association with Caroli disease and a choledochal cyst. We report herein a case of malignant intrahepatic biliary papillomatosis associated with cirrhosis secondary to hepatitis C. To the best of our knowledge, this is the first report of this association.

Six-year recurrence free survival after intraluminal iridium-192 therapy of human bilobar biliary papillomatosis. A case report

BACKGROUND

Biliary papillomatosis is rare and often fatal. Liver resection or transplantation is recommended but may be impossible due to tumor or patient factors; furthermore, it appears to the authors of this study that no follow-up results after transplantation have been reported in previous studies.

METHODS

Bilobar but limited biliary papillomatosis in a man age 54 years was mapped by cholangiopancreatography, cholecystectomy, and operative cholangioscopy. After cholangioscopic electrocoagulation, iridium-192 wires were temporarily inserted into the affected bile ducts, giving a dose of 60 grays at a 3-mm distance. Another percutaneous cholangioscopic electrocoagulation was performed 3 weeks later.

RESULTS

The patient has been free of tumor and in good health for 80 months, but he has a long term stenting of a nonneoplastic stricture at the confluence of the bile ducts.

CONCLUSIONS

Mechanical tumor reduction and intraluminal brachytherapy could possibly replace transplantation (which up to now has been suggested but not reported) when this life-threatening disease is bilobar, and also possibly replace liver resection for limited tumors in patients who are too frail for surgery.

Six-year recurrence free survival after intraluminal iridium-192 therapy of human bilobar biliary papillomatosis. A case report

BACKGROUND

Biliary papillomatosis is rare and often fatal. Liver resection or transplantation is recommended but may be impossible due to tumor or patient factors; furthermore, it appears to the authors of this study that no follow-up results after transplantation have been reported in previous studies.

METHODS

Bilobar but limited biliary papillomatosis in a man age 54 years was mapped by cholangiopancreatography, cholecystectomy, and operative cholangioscopy. After cholangioscopic electrocoagulation, iridium-192 wires were temporarily inserted into the affected bile ducts, giving a dose of 60 grays at a 3-mm distance. Another percutaneous cholangioscopic electrocoagulation was performed 3 weeks later.

RESULTS

The patient has been free of tumor and in good health for 80 months, but he has a long term stenting of a nonneoplastic stricture at the confluence of the bile ducts.

CONCLUSIONS

Mechanical tumor reduction and intraluminal brachytherapy could possibly replace transplantation (which up to now has been suggested but not reported) when this life-threatening disease is bilobar, and also possibly replace liver resection for limited tumors in patients who are too frail for surgery.

Fine-needle aspiration cytologic diagnosis of intrahepatic biliary papillomatosis (intraductal papillary tumor): report of three cases and comparative study with cholangiocarcinoma

Biliary papillomatosis is a rare tumor of the intrahepatic and extrahepatic biliary tree, and its FNA findings have not been reported. The cytologic features of 3 cases of intrahepatic biliary papillomatosis were studied and compared with 5 cases of cholangiocarcinoma. The distinctive features include: 1) hypercellular smear, 2) very broad and often double-cell layered sheets of ductal columnar epithelium, 3) papillary configuration, 4) preserved honeycomb pattern with even nuclear spacing, and 5) dysplastic but not frankly malignant nuclear features. The constellation of these features is highly characteristic of biliary papillomatosis and helpful in distinguishing it from cholangiocarcinoma and other differential diagnoses. A firm preoperative diagnosis can thus be achieved, allowing better planning in management of this borderline malignant tumor.

Case report: two cases of biliary papillomatosis with unusual associations

Papillomatosis arising from the biliary tree is a well recognized but rare entity. We encountered two patients with this condition. However, one of them had associated hepatocellular carcinoma and cirrhosis and the other had concomitant recurrent pyogenic cholangitis. To our knowledge, these associations have not been reported before. We, therefore, present these clinical problems and highlight the added difficulty in the management of these patients.

Sonographic features of mucinous biliary papillomatosis: case report and review of imaging findings

Because of its indolent course, high recurrence rate, and risk of malignant transformation, mucinous biliary papillomatosis is an important consideration in the differential diagnosis of bile duct obstruction. We report a case of mucinous biliary papillomatosis and review the sonographic and other imaging findings previously reported in the literature. On sonography, these tumors appear as nonshadowing intrabiliary masses that are clearly defined and associated with proximal biliary dilatation. They may be multiple and associated with mucoid sludge. The imaging findings reflect the macroscopic appearance of a doughy papilliferous tumor of a bile duct. Associated findings include cholelithiasis, choledocholithiasis, and gallbladder dysplasia.