Ann Hepatobiliary Pancreat Surg.  2018 May;22(2):150-155. 10.14701/ahbps.2018.22.2.150.

A huge intraductal papillary neoplasm of the bile duct treated by right trisectionectomy after right portal vein embolization

• Aliyev V
• Yasuchika
• Hammad A
• Tajima T
• Fukumitsu
• Hata K
• Okajima H
• Uemoto S

• KMID: 2412430
• DOI: http://doi.org/10.14701/ahbps.2018.22.2.150

Abstract

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare variant of bile duct tumors characterized by papillary growth within the bile duct lumen and recognized precursor of invasive carcinoma. IPNB was detected incidentally in a 60-year-old woman during check up. Radiologic images revealed a huge cystic mass with papillary projection and markedly dilated bile ducts. Biopsies revealed high-grade IPNB. Cholangioscopy detected a connection between the right posterior bile duct and cyst lumen with epithelial dysplasia of the bile duct. Right posterior sectional duct opened in the left hepatic duct. Consequently, right trisectionectomy and extrahepatic bile duct resection were conducted. Histological studies revealed intraductal papillary neoplasm with high-grade intraepithelial neoplasia (carcinoma in situ). IPNB patients without distant metastases are candidates for surgery and complete resection should be conducted to achieve long-term survival.

Keyword

Intraductal papillary neoplasm of the bile duct; Portal vein embolization; Right trisectionectomy

MeSH Terms

Bile Ducts*
Bile Ducts, Extrahepatic
Bile*
Biopsy
Female
Hepatic Duct, Common
Humans
Middle Aged
Neoplasm Metastasis
Portal Vein*

Figure

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  Fig. 1 Preoperatoive imaging findings. (A) Abdominal ultrasonography (US) revealed multiple hyper-echoic solid lesions (arrows). (B) Enhanced computed tomography (CT) revealed a huge (10×7 cm) cystic tumor with surrounding high-density components (arrows) involving the right hemiliver and the left medial section.

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  Fig. 2 Non-enhanced magnetic resonance imaging (A) revealed huge solid mass in the right hemiliver and the left medial segment of the liver. Bile ducts were markly dilated. Suspicious communication between right posterior bile duct (arrow) and the cystic lesion. Magnetic resonance cholangiography (B) revealed a marked aneurysmal dilatation of the bile duct.

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  Fig. 3 Endoscopic retrograde cholangiogram revealed communication between the proximal right hepatic duct and cyst.

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  Fig. 4 Peroral cholangioscopy findings. Papilla Vater canulation (A). No abnormal finding on hepatic hilum (B). Tumor invading the right posterior bile duct (C). Biliary papillomatosis inside of the cyst (D).

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  Fig. 5 Positron emission tomography-computed tomography scan revealed tumorous lesions with abnormal uptake and marginal dominance of FDG accumulation in the right lobe. Intrahepatic and extrahepatic metastasis were not detected.

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  Fig. 6 Three-dimensional computed tomography image before percutaneous transhepatic portal vein embolization.

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  Fig. 7 Right portal vein embolization.

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  Fig. 8 Sagittal computed tomography before (A) and after (B) percutaneous transhepatic portal vein embolization.

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  Fig. 9 Microscopic finding showing prominent papillary proliferation with fibrovascular cores.

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  Fig. 10 Gross appearance of the resected section. (A) Well defined cystic mass with multiple polypoid mural nodules (black arrows). Communication between the right posterior bile duct and the cyst cavity (yellow arrow). (B) Segment II and III bile ducts stump (B2 and B3, yellow arrows).

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