Clinical and pathological features of primary carcinoma of the cystic duct

Clinical implication of the geometric location (fundal end versus cystic ductal end) of gallbladder cancer

BACKGROUND

Management of early-stage gallbladder cancer is becoming more important as the rate of early detection is increasing. Although there have been many studies about the clinical implication of the invasion depth or peritoneal/hepatic location of gallbladder cancers, there is no study on the clinical implication of the geometric location of cancer along the longitudinal length of the gallbladder.

METHODS

The location of gallbladder cancer was defined as the geometric center of the primary site of a tumour, which lies on the longitudinal diameter of the surgical specimens. We compared the oncologic outcomes following surgery between gallbladder cancers located on the fundal end and those located on the cystic ductal end. We also analysed patients with stage 1 gallbladder cancer who recurred after surgery.

RESULTS

A total of 575 patients with gallbladder cancer were included in this study. Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence-free survival (P = 0.016) and overall survival (P = 0.023) compared to those with gallbladder cancer on the fundal end. Among 90 patients with stage 1 gallbladder cancer, three patients had a recurrence, all of whom had cystic ductal end gallbladder cancer and showed cystic duct invasion or concomitant xanthogranulomatous cholecystitis in permanent pathology.

CONCLUSIONS

Gallbladder cancers on the cystic ductal end had worse postoperative oncologic outcomes compared with those on the fundal end.

Case and Management Considerations of Low-Grade Cystic Duct Stump Dysplasia after Laparoscopic Cholecystectomy

Cholecystectomies have become one of the more commonly practiced procedures. As a result, there has been a rise in neoplastic changes in excised specimens. Due to this, surgeons must be prepared to manage possible malignancy after resecting what was previously thought to be a benign gallbladder. While management for high-grade dysplasia has been more clearly laid out in literature, data on management of low-grade dysplasia are limited. Here, we report a novel case of a 46-year-old woman with an incidental low-grade dysplasia of the cystic duct stump after a laparoscopic cholecystectomy for biliary colic. The decision was made to excise the remaining stump without further surveillance postoperatively given benign pathology findings. More documented cases and their management and ultimately longitudinal cohort studies will help facilitate the creation of guidelines for managing this particular pathology.

Challenges in diagnosing and managing cystic duct carcinoma: A case report from Syria

INTRODUCTION AND IMPORTANCE

Primary cystic duct carcinoma, an uncommon and aggressive biliary cancer variant, poses a significant challenge in clinical practice. This study examines recent clinical cases, focusing on diagnostics, interventions, and implications in managing this disease, with a prevalence ranging from 0.03 % to 0.05 %, contributing to 2.6-12.6 % of extrahepatic biliary neoplasms.

CASE PRESENTATION

A 57-year-old male, a smoker with hypertension and hyperuricemia, presented symptoms of severe upper right abdominal pain, jaundice, and altered stool color. Diagnosis revealed ulcerated papillary adenocarcinoma invading all gallbladder layers (2.5 cm). Surgical resection and Roux-en-Y anastomosis were performed. Histopathological examination showed invasive tumor proliferation, preserved lymph node architecture, and severe hepatic microsteatosis. Lymph nodes were tumor-free, and a benign hepatic biopsy (0.5 cm) displayed chronic portitis. The final diagnosis confirmed cystic duct carcinoma, emphasizing the complex diagnostic and therapeutic aspects in biliary cases.

CLINICAL DISCUSSION

The clinical discussion unveils the complexities associated with primary cystic duct carcinomas. Emphasizing the necessity of a multidisciplinary approach, this case highlights the importance of efficient management strategies-from initial diagnosis to surgical intervention-in dealing with this challenging malignancy.

CONCLUSION

In conclusion, this case underscores the intricate nature of primary cystic duct carcinomas. It accentuates the essential role of a multidisciplinary approach, urging the need for continuous research endeavors to further comprehend and enhance the treatment methodologies for this rare and complex malignancy.

High predictive ability of apparent diffusion coefficient value for wall-invasion pattern of advanced gallbladder carcinoma

PURPOSE

The wall-invasion pattern classification of advanced gallbladder carcinoma (GBC) has been reported. However, its association with clinical findings remains unclear. We aimed to clarify relationships between clinicopathological characteristics, prognosis, and apparent diffusion coefficient (ADC) values of advanced GBC based on the wall-invasion pattern.

METHODS

We reviewed the data of 37 patients who had undergone advanced GBC cholecystectomy at our institution between 2009 and 2021. Clinicopathological findings, prognosis, and ADC values were retrospectively analyzed.

RESULTS

Based on the wall-invasion pattern, patients were classified into infiltrative growth (IG) type (n = 22) and destructive growth (DG) type (n = 15). In the DG-type, the incidence of venous invasion (P = 0.027), neural invasion (P = 0.008), and lymph node metastasis (P = 0.047) was significantly higher than in the IG-type, and recurrent-free survival (RFS) was significantly shorter (P = 0.015); the median RFS was 11.4 months (95% confidence interval, 6.3-16.5 months) in the DG-type and not reached in the IG-type. The ADC value in the DG-type was significantly lower than in the IG-type (median, 1.19 × 10^-3 mm²/s vs. 1.86 × 10^-3 mm²/s, P < 0.001). The area under the receiver operating characteristic curve for the ADC values to differentiate wall-invasion patterns was 0.95 (95% confidence interval, 0.87-1.00). The optimal cutoff ADC value was 1.45 × 10^-3 mm²/s (sensitivity, 92.9%; specificity, 90.9%).

CONCLUSIONS

The wall-invasion pattern of advanced GBC is associated with its aggressiveness and prognosis, and can be predicted by ADC values with high accuracy.

A Preoperative Diagnosis of Advanced Cystic Duct Carcinoma Using SpyGlass DS Cholangioscopy: A Report of Two Cases

Primary cystic duct carcinoma is a rare tumor. The curative treatment of cystic duct carcinoma is complete surgical resection, for which the evaluation of local extension is important. We herein report two cases of cystic duct carcinoma in which a preoperative examination was performed using per-oral cholangioscopy (POCS). Both patients underwent POCS due to suspicion of cystic duct carcinoma based on imaging findings. A visual analysis and biopsy were performed to evaluate local extension, which led to surgery. These cases suggest that POCS is useful for the preoperative assessment of local extension in advanced cystic duct carcinoma.

Cystic Duct Carcinoma: A New Classification System and the Clinicopathological Features of 62 Patients

Background

Cystic duct carcinoma (CDC) is a rare biliary malignancy with a low incidence and poor prognosis. However, the clinical landscape of the disease has not been clarified and no widely applicable classification system has been developed.

Methods

Sixty-two patients with CDC were included in this retrospective study, and a new classification system was established using imaging data. Blood indices, radiological characteristics, pathological features, surgical procedures, and overall survival data were collected. The efficacy of the new classification in predicting resectability was evaluated using receiver operating characteristic (ROC) curves, and K-means clustering and t-distributed stochastic neighbor embedding were applied to verify the conclusion.

Results

The pT stage of patients with type II CDC was significantly worse than that of type I. Patients with type II CDC were more likely to experience distant metastasis and invasion of the nervous system, vascular system, and liver. The resectability of patients with type II CDC was significantly worse than that of patients with type I CDC. Patients with type II CDC had worse prognoses. ROC curve analysis and K-means clustering revealed that the new classification could better categorize patients with CDC than currently available systems.

Conclusion

Patients with type II CDC have significantly worse clinicopathological outcomes. The new classification system has better accuracy in grouping patients with CDC.

Early Detection of High-grade Biliary Intraepithelial Neoplasia (BilIN-3) in the Cystic Duct Visualized by SpyGlass DS Cholangioscopy

An 84-year-old man was admitted with epigastralgia. Computed tomography showed contrast-enhanced wall thickness in the cystic duct. An endoscopic examination revealed short irregular stricture in the cystic duct, and per-oral cholangioscopy revealed a reddish papillary tumor at the stricture site. Surgical resection revealed high-grade biliary intraepithelial neoplasia (BilIN) at the stricture site of the cystic duct. To our knowledge, this is the first case of a solitary high-grade BilIN epithelium in the cystic duct detected by per-oral cholangioscopy.

A case of obstructive jaundice due to early carcinoma of the cystic duct protruding into the common bile duct

INTRODUCTION

Cystic duct carcinoma is a rare disease, and only 33 cases reported worldwide have completely fulfilled the criteria first established by Farrar in 1951. Here we describe an extremely rare case of early cystic duct carcinoma that fulfilled the Farrar criteria, the papillary tumour protruding into the common bile duct, leading to obstructive jaundice.

CASE PRESENTATION

A 76-year-old man visited a clinic with icteric conjunctivae, and was referred to our hospital for investigation of suspected obstructive jaundice. He was initially diagnosed as having a distal bile duct carcinoma on the basis of ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiography (MRC), and underwent pancreatoduodenectomy with regional lymphadenectomy. Macroscopic examination showed that the stalk of the papillary tumour originated from the cystic duct, and that the protruding lesion was 50 mm in size. Histopathological examination revealed the tumour to be a papillary adenocarcinoma confined within the fibromuscular layer, with no evidence of lymph node metastasis. Therefore, the final diagnosis was early cystic duct carcinoma.

CONCLUSION

To our knowledge, this is the first case report of obstructive jaundice due to early carcinoma of the cystic duct protruding into the bile duct, with characteristics fulfilling the Farrar criteria.

Clinicopathological features and prognosis of advanced biliary carcinoma centered in the cystic duct

BACKGROUND

Whether to classify "advanced (subserosal layer or greater invasion)" biliary carcinoma centered in the cystic duct (BCCD) as gallbladder carcinoma (GBC) or perihilar cholangiocarcinoma (PHCC) remains unclear.

METHODS

The clinicopathological features and overall survival (OS) of patients with advanced BCCD were examined through a comparison with those of patients with advanced PHCC and with GBC.

RESULTS

290 patients were classified as 199 PHCC, 44 GBC, and 47 BCCD. Patients with BCCD (median, 23 months) had significantly worse OS than those with PHCC (44 months, p = 0.030). OS of patients with BCCD, all of whom were classified as pT3 or pT4 by the American Joint Committee on Cancer (AJCC) classification of GBC, was similar to 27 patients with pT3 or pT4 GBC (23 months, p = 0.840). When the patients with BCCD were classified by the AJCC classification of PHCC, 36 were classified as pT2. OS among the patients with BCCD classified as pT2 by the PHCC classification (29 months) was significantly worse than that among patients classified as pT2 PHCC (48 months, p = 0.040).

CONCLUSION

These findings suggest that advanced BCCD is appropriately classified as a subtype of GBC because it can grow through the serosa.

Primary carcinoma of the cystic duct: a case report and review of classifications

Background

The incidence of extrahepatic bile duct malignancies is about 2–3.6% of all gastrointestinal malignancies. Primary carcinoma of cystic duct is a rare condition comprising a fraction of all extrahepatic bile duct malignancies with less than 70 cases reported worldwide. Majority of these cases were reported from East Asia. There is paucity in such case being reported from Indian subcontinent. We present a case of primary carcinoma of the cystic duct encountered during laparoscopic cholecystectomy.

Case presentation

A 65-year-old lady presented to us with symptomatic gall stone disease. Investigations revealed a distended gall bladder with multiple stones. Patient was taken up for laparoscopic cholecystectomy, during surgery a stony hard structure was found at cystic duct-common bile duct junction which was not amenable for clear dissection. Procedure was converted to open, and the patient underwent cholecystectomy with resection of common bile duct with Roux-en-Y hepaticojejunostomy and regional lymphadenectomy. Histopathological findings revealed it to be moderately differentiated adenocarcinoma of the cystic duct.

Conclusion

Primary carcinoma of cystic duct is a rare condition where early diagnosis can be difficult and if accidentally detected may add to surgeon’s dilemma. Proper surgery with en-bloc resection of gallbladder, cystic duct, common bile duct, and regional lymphadenectomy is the mainstay of treatment. The prognosis of carcinoma of cystic duct is better than extrahepatic bile duct malignancies. The old classification system has outlived its time and is more rigid in definition which is not practical in advanced cases; the new classification systems of this century offer better insight into understanding the tumor characteristics and prognosis.

Combined extrahepatic bile duct resection for locally advanced gallbladder carcinoma: does it work?

BACKGROUND

Prophylactic combined extrahepatic bile duct resection remains controversial for locally advanced gallbladder carcinoma without extrahepatic bile duct invasion. The aim of this study is to resolve this issue and establish an appropriate surgery for locally advanced gallbladder carcinoma.

METHODS

A total of 52 patients underwent surgical resection combined with extrahepatic bile duct resection for locally advanced gallbladder carcinoma without extrahepatic bile duct invasion, and their medical records were retrospectively reviewed for microvessel invasion (MVI), including lymphatic, venous, and/or perineural invasions, around the extrahepatic bile duct.

RESULTS

Of the 52 patients, 8 (15 %) had MVI around the extrahepatic bile duct. All of the 8 patients had Stage IV disease. According to a survival analysis of the 50 patients who tolerated surgery, MVIs around the extrahepatic bile duct and distant metastasis were identified as independent prognostic factors. Survival for patients with MVI around the extrahepatic bile duct was dismal, with a lack of 2-year survivors.

CONCLUSIONS

MVI around the extrahepatic bile duct is a sign of extremely locally advanced gallbladder carcinoma; therefore, prophylactic combined bile duct resection has no survival impact for patients without extrahepatic bile duct invasion.

Cystic duct carcinoma mimicking a middle bile duct tumour

Cystic duct carcinoma was defined by Farrar as a tumour restricted to the cystic duct, making it a rare disease. The authors describe a case of a cystic duct carcinoma that fulfils Farrar's strict diagnostic criteria and that became clinically relevant by compressing the common hepatic duct, thus causing cholestasis. A cholecystectomy was performed with en bloc resection of the cystic and extrahepatic bile duct with a regional lymphadenectomy.

Repeated negative biopsies in isolated high-grade cystic duct dysplasia with progression to adenocarcinoma

Cystic and bile duct dysplasia is a rare histological finding, especially when found in the absence of an underlying malignancy. We report a patient who presented with jaundice and weight loss. Clinical and cytological evidence suggested a diagnosis of cholangiocarcinoma and the patient underwent a pancreatico-duodenectomy. Histopathological examination suggested a diagnosis of two foci of biliary dysplasia: cystic duct and lower common bile duct. Fifteen months later, the patient re-presented with signs of obstructive jaundice and biliary sepsis. Although CT scan revealed images highly indicative of metastatic disease, repeated biopsies failed to confirm this. Eventually a liver biopsy did reveal moderately differentiated adenocarcinoma, however oncological interventional was no longer appropriate and the patient was managed palliatively. This case report focuses on the current understanding of progression of biliary dysplasia.

Preoperative diagnosis of an asymptomatic cancer restricted to the cystic duct

INTRODUCTION

Even now, cystic duct cancer (CDC) as defined by Farrar is rare and has a better prognosis than gallbladder cancer, although CDC as defined by Ozden et al., the definition of which could apply to early and advanced cases of CDC, is not rare and has a poorer prognosis than the CDC defined by Farrar.

PRESENTATION OF CASE

A 78-year-old woman with no complaints was found to have a tumor restricted to the cystic duct. Three cytology examinations of the patient's bile could not establish that the tumor was an adenocarcinoma. However, adenocarcinoma was suspected due to the hypervascularity shown on contrast-enhanced computed tomography. Cholecystectomy and extrahepatic bile duct resection with D2 lymph node dissection was performed. The pathological study revealed it to be CDC. Her postoperative course has been uneventful and without recurrence for 21 months.

DISCUSSION

At their first medical examination, many CDC patients are found to have such advanced spread of the cancer to adjacent organs that an extended operation might be necessary. As in our case, better patient outcome results when no lymph node or remote metastasis is present.

CONCLUSION

Diagnosing CDC as early as possible contributes to curative resections and favorable patient outcomes and also allows surgeons to recommend a mini-invasive procedure to their patients rather than extended resection including that of adjacent organs.

Early cystic duct carcinoma of new classification

INTRODUCTION

Classically defined cystic duct carcinoma is extremely rare owing to its strict diagnostic criteria, which are not suitable in actual clinical settings. Recently, several new classifications of cystic duct carcinoma were reported, which defined it as a tumor with its center located in the cystic duct. On the other hand, the incidence of cystic duct carcinoma, based on the new classifications, is not rare, but all reported cases are advanced.

PRESENTATION OF CASE

A 77-year-old man with dilatation of the common bile duct, a stricture at the level of the cystic duct junction, and a filling defect of contrast medium into cystic duct in endoscopic retrograde cholangiopancreatography was diagnosed with cystic duct carcinoma. Radical cholecystectomy with bile duct resection was performed. In the resected specimen, we found that a 2 cm tumor whose center was located in the cystic duct and vertically limited to the mucosal layer. Horizontally, the tumor was superficially spread in the gallbladder, which were also limited to the mucosal layer.

DISCUSSION

Here we report a first case of early cystic duct carcinoma diagnosed according to a new classification that had spread superficially into the gallbladder. When treating an early cystic duct carcinoma, it is important to note that even localized carcinoma can potentially invade into adjacent organs or metastasize to regional lymph nodes due to the location of cystic duct.

CONCLUSION

It is suggested that perform radical resection such as cholecystectomy with gallbladder fossa resection, extrahepatic bile duct resection and regional lymphadenectomy is the treatment of choice.

Preoperative diagnosis of early cystic duct cancer using endoscopic ultrasonography and endocholangioscopy: report of a case

Primary cystic duct carcinoma is a rare condition, for which preoperative diagnosis is difficult. We herein report a case of early primary carcinoma of the cystic duct, which was diagnosed preoperatively using endoscopic ultrasonography and endocholangioscopy. A 76-year-old man was admitted to our hospital with epigastric pain and liver dysfunction. Endoscopic ultrasonography revealed a cystic duct tumor, in diameter of 2.2 cm, which extended to the common bile duct. Endocholangioscopy revealed a well movable papillary tumor at the origin of the cystic duct. The patient underwent cholecystectomy and excision of the extrahepatic bile duct and lymph node. Histological findings confirmed the diagnosis of early papillary adenocarcinoma of the cystic duct.