Using peroral cholangioscopy to diagnose an intraductal papillary neoplasm of the bile duct

Malignancy of intraductal papillary neoplasm of the bile duct

The intraductal papillary neoplasm of the bile duct (IPNB) is an uncommon disease which was first included in the World Health Organization classification of neoplasms in 2010. Although some patients may be asymptomatic, symptoms include most frequently abdominal pain, cholangitis and jaundice. Contrary to the pancreatic intraductal papillary mucinous neoplasm, this entity has higher risk of malignancy and progression to invasive carcinoma. However, the postsurgical prognosis for a patient with IPNB is good, with no need of adjuvant therapy. We present the case of a patient with biliary septic shock that prompted urgent surgical intervention. Diagnosis was histopathologically confirmed with the surgical specimen, which showed malignant transformation. During follow up, the patient developed peritoneal carcinomatosis and progression of the disease despite chemotherapy.

Common bile duct lesions - how cholangioscopy helps rule out intraductal papillary neoplasms of the bile duct: A case report

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare variant of bile duct tumors, characterized by an exophytic growth exhibiting a papillary mass within the bile duct lumen and it can be localized anywhere along the biliary tree, with morphological variations and occasional invasion.

CASE SUMMARY

We present a patient with obstructive jaundice who was diagnosed with IPNB using cholangioscopy during endoscopic retrograde cholangio-pancreatography. Using the SpyGlass DS II technology, we were able to define tumor extension and obtain targeted Spy-byte biopsies. After multidisciplinary evaluation, the patient was scheduled for surgical resection of the tumor, which was radically removed.

CONCLUSION

Cholangioscopy appears to be crucial for the rapid and clear diagnosis of lesions in the bile duct to achieve radical surgical resection.

Intraductal papillary mucinous neoplasm: a new entity among biliary tract neoplasms

Biliary tract intraductal papillary mucinous neoplasms (BT-IPMN) are a rare entity that develop within the bile duct lumen and are recognized as a precursor of invasive carcinoma in up to 40-80 % of cases.

Intraductal Papillary Neoplasm of Bile Duct: Updated Clinicopathological Characteristics and Molecular and Genetic Alterations

Intraductal papillary neoplasm of the bile duct (IPNB), a pre-invasive neoplasm of the bile duct, is being established pathologically as a precursor lesion of invasive cholangiocarcinoma (CCA), and at the time of surgical resection, approximately half of IPNBs show stromal invasion (IPNB associated with invasive carcinoma). IPNB can involve any part of the biliary tree. IPNB shows grossly visible, exophytic growth in a dilated bile duct lumen, with histologically villous/papillary neoplastic epithelia with tubular components covering fine fibrovascular stalks. Interestingly, IPNB can be classified into four subtypes (intestinal, gastric, pancreatobiliary and oncocytic), similar to intraductal papillary mucinous neoplasm of the pancreas (IPMN). IPNBs are classified into low-grade and high-grade based on lining epithelial features. The new subclassification of IPNB into types 1 (low-grade dysplasia and high-grade dysplasia with regular architecture) and 2 (high-grade dysplasia with irregular architecture) proposed by the Japan–Korea pathologist group may be useful in the clinical field. The outcome of post-operative IPNBs is more favorable in type 1 than type 2. Recent genetic studies using next-generation sequencing have demonstrated the existence of several groups of mutations of genes: (i) IPNB showing mutations in KRAS, GNAS and RNF43 belonged to type 1, particularly the intestinal subtype, similar to the mutation patterns of IPMN; (ii) IPNB showing mutations in CTNNB1 and lacking mutations in KRAS, GNAS and RNF43 belonged to the pancreatobiliary subtype but differed from IPMN. IPNB showing mutation of TP53, SMAD4 and PIK3CA might reflect complicated and other features characterizing type 2. The recent recognition of IPNBs may facilitate further clinical and basic studies of CCA with respect to the pre-invasive and early invasive stages.