Systematic Review and Meta-analysis of Current Experience in Treating IPNB: Clinical and Pathological Correlates. Ann Surg. 2016;263:656-663. [PMID: 26501712 DOI: 10.1097/sla.0000000000001426]

Clinicopathological findings and imaging features of intraductal papillary neoplasm of the bile duct: comparison between contrast-enhanced ultrasound and contrast-enhanced computed tomography

PURPOSE

Intraductal papillary neoplasms of the bile duct (IPNBs) are a group of rare lesions with uncertain clinical findings and imaging features. We aim to investigate the clinicopathological features and imaging findings of IPNBs on contrast-enhanced ultrasound (CEUS) and contrast-enhanced computed tomography (CECT).

METHODS

From February 2005 to March 2018, 30 patients with pathologically confirmed IPNBs were retrospectively identified in our hospital. Demographic, clinical, and pathological data, CEUS and CECT features and surgical strategies were analyzed.

RESULTS

The most common clinical manifestations were abdominal pain (53.3%), jaundice (23.3%), and acute cholangitis (10.0%). Among all lesions, 5/30 (16.7%) lesions presented as dilated bile ducts only, while 13/30 (43.3%) lesions presented as dilated bile ducts with intraductal papillary masses, and 12/30 (40.0%) presented as solid masses with dilated bile ducts. For the 20 patients who underwent both CEUS and CECT, 18 lesions were hyperenhanced on CEUS, and 17 lesions were hyperenhanced on CECT in the arterial phase. In total, 16 and 18 lesions showed washout in the portal and late phases on CEUS, while the corresponding number of lesions that showed washout in the portal and late phases on CECT were 11 and 13. Twelve lesions (40.0%) showed atypical hyperplasia, while 16/30 (53.3%) lesions underwent malignant transformations.

CONCLUSIONS

There are 3 major forms of IPNBs on grayscale ultrasound, including diffusely dilated bile ducts without visible mass; focal dilated bile duct with intraductal papillary masses; and solid mass surrounded by dilated bile ducts. The enhancement patterns of IPNBs on CEUS and on CECT were consistent. IPNB has a high malignant potential, and patients should be treated with surgical resection after the diagnosis is established.

Impact of Tumor Location on Postoperative Outcome of Intraductal Papillary Neoplasm of the Bile Duct

BACKGROUND

The concept of intraductal papillary neoplasm of the bile duct (IPNB) has been proposed to be the biliary equivalent of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. While the classification of IPMNs is based on their location of duct involvement, such classification has not been fully evaluated for IPNBs. The aim of this study is to investigate the value of IPNB classification based on its location.

METHODS

A total of 306 consecutive patients who underwent surgical resection with a diagnosis of bile duct tumor were enrolled. Among these patients, 21 were diagnosed as having IPNB. The IPNBs were classified into two groups as follows: extrahepatic IPNB, which located in the distal or perihilar bile duct, and intrahepatic IPNB, which located more peripherally than the hilar bile duct. The clinicopathological features of the two groups were then compared.

RESULTS

Extrahepatic IPNB tended to show more invasive characteristics than intrahepatic IPNB (presence of invasive component: 40.0 vs. 9.1%, p = 0.084). Moreover, patients with extrahepatic IPNB showed significantly poorer relapse-free survival (RFS) than those with intrahepatic IPNB [5-year RFS rate (%): 81.8 vs. 16.2, p = 0.014].

CONCLUSION

Patients with intrahepatic IPNB show more favorable pathological characteristics and postoperative survival outcomes than those with extrahepatic IPNB.

Outcome Determining Factors of Intraductal Papillary Neoplasm of the Biliary Tract (IPNB)-a Single Center Survey and Analysis of Current Literature

PURPOSE

Intraductal papillary neoplasms of the biliary tract (IPNB) are rare tumors originating from the bile duct epithelium. Metastatic disease of IPNB is extremely rare and only reported in a small number of cases worldwide. Due to this limitation in number, the treatment of IPNB mainly relies on retrospective case series.

PATIENTS AND METHODS

We reported three cases of IPNB, one benign, one carcinoma with lymph node metastasis, and one case with histologically proven metachronous pulmonary metastasis. We correlated our findings with the existing data found in the literature. All patients underwent hemihepatectomy and complete tumor resection was achieved.

RESULTS

Diagnosis of IPNB can be challenging due to varying presentation. The treatment of choice is surgical oncological resection in an early tumor stage. Long-term outcome highly depends on the underlying grade of dysplasia, multiplicity, and tumor-free margins. Aggressive tumor invasion is reported in up to 72% of cases in IPNB. Furthermore, the recurrence rate of IPNB is high with up to 22%. Further factors associated with an impaired survival are incomplete resection, lymph node involvement, and MUC1 expression.

CONCLUSION

High potential for dysplasia and proof of invasive carcinoma upon diagnosis are hallmarks of IPNB. Metastatic disease in IPNB is reported only in small numbers. IPNB is an aggressive tumor entity with impaired long-term outcomes. A drawback for interpretation of current data is the fact that they rely on case series and reports and are not validated through more powerful randomized multicentric trials.

Intraductal papillary neoplasm of the bile duct: Assessment of invasive carcinoma and long-term outcomes using MRI

BACKGROUND & AIMS

Imaging characteristics for discriminating the malignant potential of intraductal papillary neoplasm of the bile duct (IPNB) still remain unclear. This study aimed to define the magnetic resonance (MR) imaging findings that help to differentiate IPNB with an associated invasive carcinoma from IPNB with intraepithelial neoplasia and to investigate their significance with respect to long-term outcomes in patients with surgically resected IPNB.

METHODS

This retrospective study included 120 patients with surgically resected IPNB who underwent preoperative MR imaging with MR cholangiography before surgery from January 2008 and December 2017 in two tertiary referral centers. Clinical and MR imaging features of IPNB with intraepithelial neoplasia (n = 34) and IPNB with an associated invasive carcinoma (n = 86) were compared. Regarding significant features for discriminating IPNB with or without an associated invasive carcinoma, recurrence-free survival (RFS) rates were evaluated.

RESULTS

Significant MR imaging findings for differentiating IPNB with an associated invasive carcinoma from IPNB with intraepithelial neoplasia were intraductal visible mass, tumor size ≥2.5 cm, multiplicity of the tumor, bile duct wall thickening, and adjacent organ invasion (all p ≤0.002). The 1-, 3-, and 5-year RFS rates for surgically resected IPNB were 93.8%, 79.1%, and 70.0%, respectively. RFS rates were significantly lower in patients with each significant MR imaging finding of IPNB with an associated invasive carcinoma than in those without significant MR imaging findings (all p ≤0.039).

CONCLUSIONS

MR imaging with MR cholangiography may be helpful in differentiating IPNB with an associated invasive carcinoma from IPNB with intraepithelial neoplasia. Significant MR imaging findings of IPNB with an associated invasive carcinoma have a negative impact on RFS.

LAY SUMMARY

Significant magnetic resonance imaging findings that differentiated between an intraductal papillary neoplasm of the bile duct (IPNB) with an associated invasive carcinoma and an IPNB with intraepithelial neoplasia were intraductal visible mass, tumor size ≥2.5 cm, multiplicity of the tumor, bile duct wall thickening, and adjacent organ invasion. Significant magnetic resonance imaging findings of invasive IPNB have a negative impact on recurrence-free survival.

Uncommon Intraluminal Tumors of the Gallbladder and Biliary Tract: Spectrum of Imaging Appearances

Intraluminal pathologic conditions of the bile ducts and gallbladder are common, most frequently consisting of calculi and adenocarcinoma. In recent years, intraductal papillary neoplasm of the bile ducts (IPN-B), which is analogous to intraductal papillary mucinous neoplasm of the pancreas, has been recognized as a distinct pathologic entity and a precursor lesion to adenocarcinoma of the bile ducts. Intraductal tubulopapillary neoplasm (ITPN) of the bile duct was subsequently described as a distinct pathologic entity. With increased awareness and advances in imaging techniques, these lesions are diagnosed with increased frequency at preoperative imaging. A similar neoplasm in the gallbladder is referred to as intracholecystic papillary neoplasm. These lesions are often diagnosed at a preinvasive stage and have a better prognosis than invasive cholangiocarcinoma when treated with curative resection, underscoring the importance of an accurate imaging diagnosis. The most common causes of polypoid lesions of the gallbladder are cholesterol polyps and adenomyomatosis. These lesions need to be differentiated from the less common but clinically important adenocarcinoma of the gallbladder. Imaging is crucial to identify polyps that are at high risk for malignancy so that the appropriate management choice between imaging follow-up and cholecystectomy can be made by the treating physicians. Other less common gallbladder tumors, such as gallbladder adenomas, lymphoma, and metastases to the gallbladder, can manifest as intraluminal tumors; and awareness of these lesions is also important. In this article, the recent literature is reviewed; and the imaging appearances, histopathologic findings, and management of uncommon intraluminal tumors of the bile ducts and gallbladder and their mimics are discussed. ^©RSNA, 2019.

Liver and Pancreas: Do Similar Embryonic Development and Tissue Organization Lead to Similar Mechanisms of Tumorigenesis?

The liver and pancreas are closely associated organs that share a common embryological origin. They display amphicrine properties and have similar exocrine organization with parenchymal cells, namely, hepatocytes and acinar cells, secreting bile and pancreatic juice into the duodenum via a converging network of bile ducts and pancreatic ducts. Here we compare and highlight the similarities of molecular mechanisms leading to liver and pancreatic cancer development. We suggest that unraveling tumor development in an organ may provide insight into our understanding of carcinogenesis in the other organ.

[Upper abdominal pain and febrile episodes in a 44-year-old Filipino woman]

A 44-year-old Filipino woman presented with abdominal pain and fever. Clinical examination and blood tests revealed no pathological results; however, (cross-sectional) imaging showed saccular cystic bile duct dilatation in the right liver with solid intraductal masses. Due to the clinical presentation the patient was admitted for surgical intervention with the diagnosis of Caroli disease. During the surgical procedure histopathology showed an intraductal papillary neoplasm of the bile duct (IPNB). The planned segmentetomy was extended to hemihepatectomy. IPNB is a rare entity of premalignant lesions of the bile duct system first recognized by the World Health Organization in 2010.

Intraductal papillary neoplasm of the bile duct: a case report

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 is regarded as a biliary counterpart of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. IPNBs are mainly found in patients from Far Eastern areas, where hepatolithiasis and clonorchiasis are endemic. The Western experience, however, remains limited. In this article, we report a 56-year-old man, referred to our hospital because of deranged liver function tests. Further imaging modalities showed a cystic lesion of 9 cm diameter, arising from the left hepatic duct. Inlying was a heterogeneous, lobulated mass. The patient underwent a left hemihepatectomy and adjuvant chemotherapy. Despite recent advanced technologies, diagnosis of IPNB is still challenging, especially in western countries due to its rarity. Early identification and resection of lesions, even in asymptomatic or minimally symptomatic patients, are however important prognostic factors.

Long-term observation and treatment of a widespread intraductal papillary neoplasm of the bile duct extending from the intrapancreatic bile duct to the bilateral intrahepatic bile duct: A case report

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There have been few studies of the long-term outcomes of surgically resected intraductal papillary neoplasm of the bile duct (IPNB).

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Mucus might be produced even after the R0 resection of IPNB, and frequent cholangitis or jaundice might be occurred.

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The biliary tract of the remnant liver after curative resection should be managed carefully for a long time after surgical resection.

Introduction

Few studies have reported the long-term outcomes of surgical resected intraductal papillary neoplasm of the bile duct (IPNB). Here, we describe the long-term observation and treatment of a case of widespread IPNB.

Presentation of case

A 57-year-old male was referred to our hospital due to jaundice and dilation of the intrahepatic bile duct. Computed tomography showed dilation and irregularities of the right intrahepatic and extrahepatic bile ducts together with a 3 cm nodule in the common hepatic duct. Peroral cholangioscopy revealed mucinous discharge from the ampulla of Vater, which resulted in a diagnosis of IPNB. A biopsy of the nodule and the bile duct revealed papillary adenoma in all of them. Right hepatectomy, caudate lobectomy, extrahepatic bile duct resection, and left hepaticojejunostomy were performed. The nodule was histologically diagnosed as papillary carcinoma in situ, and R0 resection was performed. However, mucus production from the papillary adenoma in the B3 and B4 was observed. We carefully managed the patient's biliary tract by inserting a biliary drainage tube into the segment 2, and he has survived for more than 7 years since the initial treatment.

Discussion

Mucus might be produced after the surgical resection of IPNB even if s surgical margin was benign. Five-year survival rate of benign IPNB was reported from 85% to 100%. That might be caused by difference of the postoperative management of the biliary tract.

Conclusions

Careful management of the biliary tract should be performed after surgical resection of IPNB.

Successful endoscopic treatment of an intraductal papillary neoplasm of the bile duct

We present a case of a 76-year-old man with right upper quadrant abdominal pain and weight loss, who was found to have an intraductal papillary neoplasm of the bile duct (IPNB) of the pancreaticobiliary subtype, deemed curatively resectable. The patient declined surgery and opted for endoscopic therapy. He underwent two sessions of endoscopic retrograde cholangiopancreatography (ERCP)-guided radiofrequency ablation (RFA). Ten months later, no evidence of recurrence was identified on repeat ERCP. To our knowledge, this is the first reported case of successful use of RFA as a primary treatment modality for resectable IPNB.

Intraductal papillary neoplasm originating from an anomalous bile duct

An 82-year-old woman who had been suffering from repeated obstructive jaundice for 7 years was referred to our hospital. Although endoscopic aspiration of the mucin in the common bile duct had been temporally effective, origin of the mucin production had not been detectable. The patient thus had been forced to be on long-term follow-up without curative resection. Endoscopic retrograde cholangioscopy on admission revealed massive mucin in the common bile duct. In addition, an anomalous bile duct located proximal to the gallbladder was identified. Since the lumen of the anomalous duct was irregular and the rest of biliary tree was completely free of suspicious lesions, the anomalous duct was judged to be the primary site. Surgical resection of the segment 4 and 5 of the liver combined with the extrahepatic biliary tract was performed. Pathological diagnosis was compatible to intraductal papillary neoplasm with high-grade intraepithelial dysplasia of the anomalous bile duct. The patient has been free from the disease for 6.5 years after resection. This is the first case of intraductal papillary neoplasm derived from an anomalous bile duct, which was resected after long-term conservative treatment. The present case suggested the slow growing character of natural history of the neoplasm.

Long-term outcome of surgical resection for intraductal papillary neoplasm of the bile duct

BACKGROUND AND AIMS

Intraductal papillary neoplasm of the bile duct (IPNB) is a specific type of bile duct tumor. Studies about the surgical outcomes for IPNB are few; therefore, we investigated the survival of patients who underwent curative surgical resection of IPNB.

METHODS

We retrospectively reviewed the medical and pathological records of 148 IPNB patients who underwent curative-intent hepatic resection between January 2005 and December 2011, to examine the prognosis of IPNB. All demographic and operative parameters were analyzed the effect on survival of patients.

RESULTS

The median survival of IPNB patients was 1326 days with a respective 1, 3, and 5 year overall survival of 83.6% (95%CI: 76.5-88.7), 64.4% (95%CI: 56.0-71.6), and 47% (95%CI: 38.4-55.7). The level of invasiveness of IPNB predicted survival very well. For malignant IPNB, univariate analysis showed that serum CA19-9 level, lymph node metastasis, and completeness of resection were significant prognostic factors. Lymph node metastasis and completeness of resection were found in multivariate analysis to be significantly related to survival of the patients.

CONCLUSIONS

The level of invasiveness and lymph node status were found to be associated with patient survival, as was adequacy of surgery. We recommend R0 resection be attempted for patients with IPNB.