A comparison between intraductal papillary neoplasms of the biliary tract (BT-IPMNs) and intraductal papillary mucinous neoplasms of the pancreas (P-IPMNs) reveals distinct clinical manifestations and outcomes

Clinicopathological features and surgical treatments of intraductal papillary neoplasm of the bile duct: a case report and literature review

Intraductal papillary neoplasm of bile duct (IPNB), as a precancerous lesion of cholangiocarcinoma, is a rare biliary tract tumor. A 66-year-old female patient was found to have a bile duct mass by routine examination. The liver function tests and tumor markers were normal. Imaging findings revealed a 2.6 cm mass in the common hepatic duct, accompanied by dilatation of both intrahepatic and extrahepatic bile ducts. The patient underwent open extrahepatic bile duct resection, cholecystectomy and Roux-en-Y hepaticojejunostomy. We also conducted a literature review to summarize the clinicopathological features and surgical treatments of IPNB.

A Review of Type 1 and Type 2 Intraductal Papillary Neoplasms of the Bile Duct

Intraductal papillary neoplasm of the bile duct (IPNB) is a heterogeneous disease similar to intraductal papillary mucinous neoplasm of the pancreas. These lesions have been recognized as one of the three major precancerous lesions in the biliary tract since 2010. In 2018, Japanese and Korean pathologists reached a consensus, classifying IPNBs into type l and type 2 IPNBs. IPNBs are more prevalent in male patients in East Asia and are closely related to diseases such as cholelithiasis and schistosomiasis. From a molecular genetic perspective, IPNBs exhibit early genetic variations, and different molecular pathways may be involved in the tumorigenesis of type 1 and type 2 IPNBs. The histological subtypes of IPNBs include gastric, intestinal, pancreaticobiliary, or oncocytic subtypes, but type 1 IPNBs typically exhibit more regular and well-organized histological features than type 2 IPNBs and are more commonly found in the intrahepatic bile ducts with abundant mucin. Due to the rarity of these lesions and the absence of specific clinical and laboratory features, imaging is crucial for the preoperative diagnosis of IPNB, with local bile duct dilation and growth along the bile ducts being the main imaging features. Surgical resection remains the optimal treatment for IPNBs, but negative bile duct margins and the removal of lymph nodes in the hepatic hilum significantly improve the postoperative survival rates for patients with IPNBs.

MRI features of intraductal papillary mucinous neoplasm of the bile ducts, "The myth about the cyst": A systematic review

Rationale and objectives

Intraductal papillary mucinous neoplasm of the bile ducts (IPMN-B) is a true pre-cancerous lesion, which shares common features with pancreatic IPMN (IPMN-P). While IPMN-P is a well described entity for which guidelines were formulated and revised, IPMN-B is a poorly described entity.We carried out a systematic review to evaluate the existing literature, emphasizing the role of MRI in IPMN-B depiction.

Materials and methods

PubMed database was used to identify original studies and case series that reported MR Imaging features of IPMN-B. The search keywords were "IPMN OR intraductal papillary mucinous neoplasm OR IPNB OR intraductal papillary neoplasm of the bile duct AND Biliary OR biliary cancer OR hepatic cystic lesions". Risk of bias and applicability were evaluated using the QUADAS-2 tool.

Results

884 Records were Identified through database searching. 12 studies satisfied the inclusion criteria, resulting in MR features of 288 patients. All the studies were retrospective. Classic features of IPMN-B are under-described. Few studies note worrisome features, concerning for an underlying malignancy. 50 % of the studies had a high risk of bias and concerns regarding applicability.

Conclusions

The MRI features of IPMN-B are not well elaborated and need to be further studied. Worrisome features and guidelines regarding reporting the imaging findings should be established and published. Radiologists should be aware of IPMN-B, since malignancy diagnosis in an early stage will yield improved prognosis.

Intraductal papillary neoplasm of the bile duct: review of updated clinicopathological and imaging characteristics

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a relatively rare disease and is known as one of the premalignant lesions in the biliary tract. The concept of IPNB has changed through numerous studies and is still evolving. As a lesser studied clinical entity compared with its pancreatic counterpart, intraductal papillary mucinous neoplasm, IPNB has been described in many similar terms, including biliary papillomatosis, biliary intraductal papillary-mucinous neoplasm, and papillary cholangiocarcinoma. This is based on the diversity of histopathological spectrum of IPNB.

METHODS

This review investigated previous studies including original articles, case studies, and expert opinions. Recently, two types of IPNB (types 1 and 2) have been proposed and validated based on the content first established in the WHO 2010 criteria.

RESULTS

This review provides a comprehensive analysis of existing literature, summarizing the clinical, radiological, morphological, and pathological characteristics of IPNB.

CONCLUSION

Given the ongoing ambiguity and controversies surrounding IPNB, future research, including large population-based studies and molecular investigations, is essential to enhance understanding of this disease.

Intraductal papillary mucinous neoplasm of the biliary tract in the caudate lobe of the liver: a case report and literature review

An intraductal papillary mucinous neoplasm of the biliary tract (BT-IPMN) in the caudate lobe of the liver is a rare tumor originating from the bile duct. Approximately 40% of the intraductal papillary neoplasms of the biliary tract (IPNB) secrete mucus and can grow in the intrahepatic or extrahepatic bile ducts. A 65-year-old woman presented with recurrent episodes of right upper pain. She developed her first episode 8 years ago, which resolved spontaneously. The frequency of symptoms has increased in the last 2 years. She underwent laparoscopic hepatectomy and choledochal exploration and was pathologically diagnosed with a rare BT-IPMN of the caudate lobe after admission. Here, we review studies on IPNB cases and systematically describe the pathological type, diagnosis, and treatment of IPNB to provide a valuable reference for hepatobiliary surgeons in the diagnosis and treatment of this disease.

Comparison of the Malignant Predictors in Intrahepatic and Extrahepatic Intraductal Papillary Neoplasm of the Bile Duct

Background: Intraductal papillary neoplasm of the bile duct (IPNB) is a precancerous lesion of cholangiocarcinoma, for which surgical resection is the most effective treatment. We evaluated the predictors of malignancy in IPNB according to anatomical location and the prognosis without surgery. Methods: A total of 196 IPNB patients who underwent pathologic confirmation by surgical resection or endoscopic retrograde cholangiography or percutaneous transhepatic cholangioscopic biopsy were included. Clinicopathological findings of IPNB with invasive carcinoma or mucosal dysplasia were analyzed according to anatomical location. Results: Of the 116 patients with intrahepatic IPNB (I-IPNB) and 80 patients with extrahepatic IPNB (E-IPNB), 62 (53.4%) and 61 (76.3%) were diagnosed with invasive carcinoma, respectively. Multivariate analysis revealed that mural nodule > 12 mm (p = 0.043) in I-IPNB and enhancement of mural nodule (p = 0.044) in E-IPNB were predictive factors for malignancy. For pathologic discrepancy before and after surgery, IPNB has a 71.2% sensitivity and 82.3% specificity. In the non-surgical IPNB group, composed of nine I-IPNB and seven E-IPNB patients, 43.7% progressed to IPNB with invasive carcinoma within 876 days. Conclusions: E-IPNB has a higher rate of malignancy than I-IPNB. The predictive factor for malignancy is mural nodule > 12 mm in I-IPNB and mural nodule enhancement in E-IPNB.

Cytologic Assessment of Cystic/Intraductal Lesions of the Pancreatobiliary Tract

CONTEXT.—

Because of new and improved imaging techniques, cystic/intraductal pancreatobiliary tract lesions are increasingly being discovered, and brushings or endoscopic ultrasound/computed tomography/magnetic resonance imaging-guided fine-needle aspiration biopsies from these lesions have become an integral part of pathologists' daily practice. Because patient management has become increasingly conservative, accurate preoperative diagnosis is critical. Cytologic distinction of low-risk (pseudocysts, serous cystadenoma, lymphoepithelial cysts, and squamoid cysts of the pancreatic duct) from high-risk pancreatic cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) requires incorporation of clinical, radiologic, and cytologic findings, in conjunction with chemical and molecular analysis of cyst fluid. Cytopathologists must ensure appropriate specimen triage, along with cytologic interpretation, cyst classification, and even grading of some (mucinous) cysts. Epithelial atypia in mucinous cysts (intraductal papillary mucinous neoplasm and mucinous cystic neoplasm) has transitioned from a 3-tiered to a 2-tiered classification system, and intraductal oncocytic papillary neoplasms and intraductal tubulopapillary neoplasms have been separately reclassified because of their distinctive clinicopathologic characteristics. Because these lesions may be sampled on brushing or fine-needle aspiration biopsy, knowledge of their cytomorphology is critical.

OBJECTIVE.—

To use an integrated, multidisciplinary approach for the evaluation of cystic/intraductal pancreatobiliary tract lesions (incorporating clinical, radiologic, and cytologic findings with [chemical/molecular] cyst fluid analysis and ancillary stains) for definitive diagnosis and classification.

DATA SOURCES.—

Review of current literature on the cytopathology of cystic/intraductal pancreatobiliary tract lesions.

CONCLUSIONS.—

Our knowledge/understanding of recent updates in cystic/intraductal pancreatobiliary lesions can ensure that cytopathologists appropriately triage specimens, judiciously use and interpret ancillary studies, and incorporate the studies into reporting.

Intraductal papillary neoplasm of the bile duct - A comprehensive review

BACKGROUND

Intraductal papillary neoplasm of the bile ducts is a rare tumor type. Management decisions are currently based upon a small case series. The authors have large own experience with IPNB.

OBJECTIVE

The review aims at reporting on clinicopathological features of IPNB in order to provide guidance for management.

METHODS

We searched PubMed, Medline, Microsoft Academic and Embase databases to identify studies of relevance. The analysis of own experience was also included.

RESULTS

We analyzed 59 retrospective series and 25 cases from authors' clinical experience. The main sign was jaundice and cholangitis, 33% and 48%, respectively. CT's were performed in 63-76% and MR in 40-56%. Intraductal mass was found in 31-32% and duct dilatation in 27-30%. Endoscopic Retrograde Cholangio-Pancreatography (ERCP) was performed in 48-62%. IPNB with invasive carcinoma was found in 35.7-60% and IPNB with intraepithelial neoplasia in 36-60%. Histopathological confirmation before surgery was rare. The main treatment of IPNB is resection, in our material, both, hepatectomy and hepatectomy plus bile duct resections were performed in 40% of patients. The percentage of postoperative complications was 20%. The 5-year survival rate of all IPNB's patients was 53.6%; in patients with associated invasive carcinoma - 22.2% and without invasive carcinoma - 100% (p ​= ​0.001).

CONCLUSIONS

Early surgery is advisable for radiologically suspected IPNB. The results of treatment depend on histopathology. They are worse at intraductal invasive carcinoma than at neoplasm with neoplasia.

Reappraisal of pathological features of intraductal papillary neoplasm of bile duct with respect to the type 1 and 2 subclassifications

The pathological spectrum of intraductal papillary neoplasm of bile duct (IPNB) remains to be clarified. A total of 186 IPNBs were pathologically examined using the type 1 and 2 subclassifications proposed by Japanese and Korean biliary pathologists incorporating a two-tiered grading system (low-grade and high-grade dysplasia), with reference to four subtypes (intestinal [i], gastric [g], pancreatobiliary [pb], and concocytic [o] subtype). IPNBs were classifiable into type 1 composed of low-grade dysplasia and 'high-grade dysplasia with regular structures' (69 IPNBs), and type 2 of 'high grade dysplasia with irregular structures and complicated lesions' (117 IPNBs). Type 1 was more common in the intrahepatic bile duct (78%), whereas type 2 was frequently located in the extrahepatic bile duct (58%). Mucin hypersecretion was more common in type 1 (61%) than in type 2 (37%). IPNBs were classifiable into the four subtypes: 86 iPNBs, 40 gIPNBs, 31 pbIPNBs, and 29 oIPNBs. The four subtypes were histologically evaluable with reference to the type 1 and 2 subclassifications. iIPNB and pbIPNBs were frequently classified as type 2, whereas types 1 and 2 were observed at similar rates in gIPNB and oIPNB. Stromal invasion was almost absent in type 1, irrespective of subtype, but was found in 66 of 117 type 2 IPNBs (P < .01), and postoperative outcome was favorable in IPNBs without invasion compared with IPNBs with invasion (P < .05). The type 1 and 2 subclassifications with reference to the four subtypes may provide useful information for understanding IPNB.

Intrahepatic Biliary Intraductal Papillary Mucinous Neoplasm With Intermittent Jaundice: Case Report

Intraductal papillary mucinous neoplasms (IPMNs) represent a relatively new clinical entity. IPMNs have malignant potential which exhibit a broad histological spectrum, ranging from adenoma to invasive carcinoma. Although IPMNs are commonly seen within pancreas, they may develop anywhere within the biliary ductal system and produce mucin which may cause intermittent jaundice. This report details the case of 50-year-old woman presenting with intermittent jaundice who was diagnosed as hepatic IPMN.

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.

Intraductal Papillary Neoplasm of the Bile Ducts: Case Reports with Review of the Literature

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare variant of bile duct tumors, which is a counterpart of pancreatic intraductal papillary mucinous neoplasm (IPMN). These tumors need to be differentiated from other common bile duct tumors such as cholangiocarcinoma, as IPNB carries a better prognosis. A combination of enhancing intraluminal papillary filling defect, demonstrating washout and associated upstream and downstream biliary dilation, should raise the suspicion of IPNB.

Clinicopathologic analysis of intraductal papillary neoplasm of bile duct: Korean multicenter cohort study

BACKGROUND

IPNB is very rare disease and most previous studies on IPNB were case series with a small number due to low incidence. The aim of this study is to validate previously known clinicopathologic features of intraductal papillary neoplasm of bile duct (IPNB) based on the first largest multicenter cohort.

METHODS

Among 587 patients previously diagnosed with IPNB and similar diseases from each center in Korea, 387 were included in this study after central pathologic review. We also reviewed all preoperative image data.

RESULTS

Of 387 patients, 176 (45.5%) had invasive carcinoma and 21 (6.0%) lymph node metastasis. The 5-year overall survival was 80.9% for all patients, 88.8% for IPNB with mucosal dysplasia, and 70.5% for IPNB with invasive carcinoma. According to the "Jang & Kim's modified anatomical classification," 265 (68.5%) were intrahepatic, 103 (26.6%) extrahepatic, and 16 (4.1%) diffuse type. Multivariate analysis revealed that tumor invasiveness was a unique predictor for survival analysis. (p = 0.047 [hazard ratio = 2.116, 95% confidence interval 1.010-4.433]).

CONCLUSIONS

This is the first Korean multicenter study on IPNB through central pathologic and radiologic review process. Although IPNB showed good long-term prognosis, relatively aggressive features were also found in invasive carcinoma and extrahepatic/diffuse type.

Gastric subtype of intraductal papillary neoplasm of the bile duct: The pathologic spectrum

BACKGROUND AND AIMS

Intraductal papillary neoplasms of bile duct (IPNBs) remain a challenging entity to manage.

METHODS

The pathologic spectrum of 34 gastric subtype of IPNB (gIPNB) cases was examined in consideration of the type 1 and 2 subclassification proposed by Japan-Korea consensus and compared with gastric subtype of pancreatic intraductal papillary mucinous neoplasm (gIPMN) (44 cases).

RESULTS

Type 1 gIPNBs (17 cases) showed regular papillary foveola with variable tubular pyloric glands. Eight of the type 1 gIPNBs showed low-grade dysplasia. Type 2 cases (n = 17) showed complicated papillary and tubular structures and high-grade dysplastic foveola and pyloric glands. Foveolas were predominant in 15 cases, while pyloric glands were predominant in 10 cases, and considerable areas of foveolas and pyloric glands in the remaining: these three were found similarly in type 1 and 2 gIPNB. gIPMNs showed central foveola with a peripheral pyloric gland. Such a pattern was recognizable in type 1 but vague in type 2. Type 1 was frequently found in the intrahepatic bile ducts and showed abundant mucin, as in gIPMNs, while type 2 also occurred in the extrahepatic bile ducts and were pathologically more malignant.

CONCLUSION

Type 1 lesions shared features of gIPMN, while type 2 lesions differed from gIPMN and were more pathologically malignant.

Characterization of Intraductal Papillary Neoplasm of the Bile Duct with Respect to the Histopathologic Similarities to Pancreatic Intraductal Papillary Mucinous Neoplasm

Intraductal papillary neoplasms of the bile duct (IPNBs) are known to show various pathologic features and biological behaviors. Recently, two categories of IPNBs have been proposed based on their histologic similarities to pancreatic intraductal papillary mucinous neoplasms (IPMNs): type 1 IPNBs, which share many features with IPMNs; and type 2 IPNBs, which are variably different from IPMNs. The four IPNB subtypes were re-evaluated with respect to these two categories. Intestinal IPNBs showing a predominantly villous growth may correspond to type 1, while those showing papillay-tubular or papillay-villous growth correspond to type 2. Regarding gastric IPNB, those with regular foveolar structures with varying numbers of pyloric glands may correspond to type 1, while those with papillary-foveolar structures with gastric immunophenotypes and complicated structures may correspond to type 2. Pancreatobiliary IPNBs that show fine ramifying branching may be categorized as type 1, while others containing many complicated structures may be categorized as type 2. Oncocytic type, which displays solid growth or irregular papillary structures, may correspond to type 2, while papillary configurations with pseudostratified oncocytic lining cells correspond to type 1. Generally, type 1 IPNBs of any subtype develop in the intrahepatic bile ducts, while type 2 IPNBs develop in the extrahepatic bile duct. These findings suggest that IPNBs arising in the intrahepatic ducts are biliary counterparts of IPMNs, while those arising in the extrahepatic ducts display differences from prototypical IPMNs. The recognition of these two categories of IPNBs with reference to IPMNs and their anatomical location along the biliary tree may deepen our understanding of IPNBs.

Recurrence After Resection for Intraductal Papillary Neoplasm of Bile Duct (IPNB) According to Tumor Location

BACKGROUND

No studies have yet analyzed the characteristics of recurrence after resection for intraductal papillary neoplasm of bile duct (IPNB) based on tumor location. We analyzed the patterns, timing, and risk factors for recurrence.

METHODS

From 1994 to 2014, data from 103 patients who were diagnosed with IPNB were retrospectively reviewed. Among these, 44 were extrahepatic IPNB (E-IPNB) and 59 were intrahepatic IPNB (I-IPNB).

RESULTS

CK20, pancreaticobiliary type, tumor invasion beyond ductal wall, tumor invasion to adjacent organs, and invasive disease were more frequently found in E-IPNB than in I-IPNB (22.7 vs. 8.5%; p = 0.043, 38.6 vs. 23.7%; p = 0.050, 20.5 vs. 11.9%; p < 0.001, 4.5 vs. 1.7%; p < 0.001 and 93.2 vs. 55.9%; p < 0.001). E-IPNB has poorer 5-year recurrence-free survival (RFS) compared to I-IPNB (51.7 vs. 91.4%; p < 0.001). There was no significant difference in the rate of initial isolated locoregional recurrence and initial distant recurrence according to tumor location (14.6 in E-IPNB vs. 3.0% in I-IPNB; p = 0.123, 19.5 in E = IPNB vs. 12.0% in I-IPNB; p = 0.136). Recurrence rate according to timing was different between E-IPNB and I-IPNB: within 1 year (33.3% vs. 83.3%; p = 0.061) and 1-3 years (50.0% vs. 0%; p = 0.052). The independent prognostic factors for RFS were tumor location (p = 0.034) and lymph node metastasis (p = 0.013).

CONCLUSIONS

E-IPNB has a worse prognosis than I-IPNB. Different follow-up schedules for surveillance according to tumor location are needed after surgery.

Magnetic Resonance Imaging versus Computed Tomography for Biliary Tract Intraductal Papillary Mucinous Neoplasm (BT-IPMN): A Diagnostic Performance Analysis

BACKGROUND In most cases, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is depicted by pathological features rather than on imaging modalities, but fine-needle aspiration cytology cannot provide complete information on tumor(s). Computed tomography (CT) has the advantage of high spatial resolution and multiplanar capabilities, while magnetic resonance imaging (MRI) has greater contrast resolution than CT. The purpose of this study was to compare the diagnostic performance of CT vs. MRI for the diagnosis of BT-IPMN using surgical pathology as the reference standard. MATERIAL AND METHODS Data from CT, MRI, and surgical pathology of 210 patients with complaints of abdominal discomfort, vomiting, and/or jaundice for at least 6 months were included in the analysis. Intra-observer agreements for diagnosis of neoplasm was evaluated by kappa statistics. RESULTS CT and MRI respectively detected 171 and 33 patients with BT-IPMN, 6 and 176 with biliary intraductal tubulopapillary neoplasms (BT-ITPN), and 28 and 6 with inconclusive results. Surgical pathology reported 179 patients with BT-IPMN and 25 patients with BT-ITPN. CT and MRI both had the same accuracy (97.14%) for BT-IPMN. The sensitivities for diagnosis of BT-IPMN were 87.75%, 83.81%, and 81.43% for the surgical pathology, MRI, and CT, respectively. Intra-observer agreements for diagnosis of neoplasm were substantial (k=0.79), perfect (k=0.81), and perfect (k=0.85) for CT, MRI, and surgical pathology, respectively. CONCLUSIONS MRI appears to be a more accurate and reliable method than CT for depicting BT-IPMN.

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.

Metachronous Intraductal Papillary Neoplasm of the Bile Duct and Intraductal Papillary Mucinous Neoplasm of the Pancreas in a Patient Diagnosed With Mucinous Adenocarcinoma

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare biliary tumor, which shares some radiologic and histologic similarities with pancreatic intraductal papillary mucinous neoplasm (IPMN). IPNB is a recognized precursor lesion of invasive adenocarcinoma. We present a case of metachronous IPNB and IPMN lesions in a patient with mucinous adenocarcinoma of the pancreas who presented with jaundice and abdominal pain. The patient was treated with surgery and adjuvant chemotherapy.

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.

Comparison of the Clinicopathologic Characteristics of Intraductal Papillary Neoplasm of the Bile Duct according to Morphological and Anatomical Classifications

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a recently defined entity and its clinical characteristics and classifications have yet to be established. We aimed to clarify the clinical features of IPNB and determine the optimal morphological classification criteria.

METHODS

From 2003 to 2016, 112 patients with IPNB who underwent surgery were included in the analysis. After pathologic reexamination by a specialized biliary-pancreas pathologist, previously suggested morphological and anatomical classifications were compared using the clinicopathologic characteristics of IPNB.

RESULTS

In terms of histologic subtypes, most patients had the intestinal type (n = 53; 48.6%) or pancreatobiliary type (n = 33; 30.3%). The simple "modified anatomical classification" showed that extrahepatic IPNB comprised more of the intestinal type and tended to be removed by bile duct resection or pancreatoduodenectomy. Intrahepatic IPNB had an equally high proportion of intestinal and pancreatobiliary types and tended to be removed by hepatobiliary resection. Morphologic classifications and histologic subtypes had no effect on survival, whereas a positive resection margin (75.9% vs. 25.7%; P = 0.004) and lymph node metastasis (75.3% vs. 30.0%; P = 0.091) were associated with a poor five-year overall survival rate. In the multivariate analysis, a positive resection margin and perineural invasion were important risk factors for survival.

CONCLUSION

IPNB showed better long-term outcomes after optimal surgical resection. The "modified anatomical classification" is simple and intuitive and can help to select a treatment strategy and establish the proper scope of the operation.

Intraductal papillary neoplasm of the bile duct: a single-center retrospective study

Objective Intraductal papillary neoplasm of the bile duct (IPNB) has been increasingly recognized and reported. However, its clinical features are still controversial because of its low incidence. In the present study, we investigated the characteristics of IPNB. Methods In total, 28 patients with IPNB were treated at our institution from January 2000 to December 2016. Clinical data were collected and a retrospective accurate database was constructed. Demographic characteristics, perioperative management, and prognosis were retrospectively analyzed. Results Abdominal discomfort was the most common symptom. Preoperative imaging revealed biliary tract dilatation in 23 patients. Left lateral or left hepatic lobectomy was the most frequently performed surgical procedure. Histological analysis revealed malignancy in 17 patients. Eighty-eight lymph nodes were swept from the patients with malignant disease, but only three were metastatic. Twenty-one patients were followed up for 3 to 60 months (mean, 29.4 ± 18.2 months). Seven patients died during the follow-up period. Patients with benign tumors had significantly greater disease-free survival. Conclusions IPNB is a rare biliary disease that occurs mainly in patients of advanced age. The most common symptom is abdominal discomfort. Lymphatic metastasis is uncommon. Patients with benign tumors may have a better prognosis than those with malignant tumors.

Intraductal papillary neoplasia of the bile duct with malignancy: a differentiated entity of cholangiocarcinoma with a better prognosis. A review of three new cases

INTRODUCTION

Intraductal papillary neoplasms of the bile duct have been recognized as a differentiated entity to other biliary tumors since 2001. They are characterized by intraductal growth, with or without mucus production, and have malignant potential, although they have a better prognosis than other types of cholangiocarcinoma.

CASE REPORTS

From January 2010 to August 2015, we included three patients with a confirmed diagnosis of bile duct intraductal papillary neoplasia with malignancy that were treated at our center. Two cases were male and one female with a mean age of 67.3 years. All three patients presented malignancy at the time of diagnosis. One patient was asymptomatic and the diagnosis was reported in the hepatectomy specimen after a liver transplant due to autoimmune hepatitis. The other two patients presented with cholestasis and acute cholangitis and the diagnosis was made based on imaging tests (computed tomography [CT] and magnetic resonance imaging [MRI]) and endoscopic retrograde cholangiopancreatography (ERCP) with brushing and a biopsy. The treatment in both cases was surgical with a left hepatectomy, and resection of the left bile duct and segment I. They did not receive adjuvant treatment. None of the cases had recurrence of the disease.

DISCUSSION

Malignant intraductal papillary neoplasias of the biliary tract represent a different entity of cholangiocarcinoma with a better prognosis. Its diagnosis is based on imaging tests and histology by ERCP. The treatment is surgical, achieving a high rate of success with a low relapse rate.

Intraductal Papillary Neoplasm of the Bile Duct: Clinical, Imaging, and Pathologic Features

OBJECTIVE

We outline the concept of intraductal papillary neoplasm of the bile duct (IPNB), discuss the morphologic features of IPNB and the differential diagnoses, and describe the radiologic approaches used in multidisciplinary management.

CONCLUSION

The concept of IPNB has been evolving. Because the imaging features of IPNB can be variable, different mimickers according to IPNB subtype can be considered. A multimodality approach is essential to obtain an optimal diagnosis and establish treatment plans.

[Precancerous and early stage cancer of the bile duct system]

Early stage cancer of the bile duct system is still difficult to diagnose. In cases of suspect lesions a stepwise diagnostic procedure consisting of computed tomography (CT), magnetic resonance imaging (MRI) with MR cholangiography (MRC) and possibly endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology should immediately be carried out. If there is a sufficient suspicion for premalignancy or early stage cancer the indications for surgical intervention should clearly be defined. Only resection can lead to a decrease in the recurrence rate and a better long-term outcome. If the patient is in a functionally nonresectable condition the possibility of liver transplantation should be considered.

Morphological classification of intraductal papillary neoplasm of the bile duct

OBJECTIVES

To investigate the morphological classification of intraductal papillary neoplasm of the bile duct (IPNB), as well as morphological differences between IPNB without mucin secretion (IPNB-NM) and IPNB with mucin secretion (IPMN-B).

METHODS

Eighty-one patients with IPNB were retrospectively analysed. Imaging examinations included computed tomography (CT), magnetic resonance imaging (MRI), gadolinium-ethoxybenzyl-diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced MRI and positron emission tomography-computed tomography (PET-CT). According to the morphology of tumours and extent of bile duct dilations, IPNB was classified into seven types: I, upstream-ductectatic type; II, typical type; III, superficial-spreading type; IV, no-mass-forming type; V, intrahepatic-cystic type; VI, extrahepatic-cystic type; and VII, infiltrating type.

RESULTS

Thirteen IPNB-NM patients comprised type I (11 cases), type II (1 case) and type VII (1 case); 68 IPMN-B patients comprised type I (2 cases), type II (30 cases), type III (6 cases), type IV (11 cases), type V (13 cases), type VI (2 cases) and type VII (4 cases). Bile duct dilations were more severe in IPMN-B than in IPNB-NM. PET-CT and Gd-EOB-DTPA-enhanced MRI clearly demonstrated the extension of infiltrating IPNB.

CONCLUSIONS

IPNB can be classified into seven morphological types. IPNB-NM and IPMN-B have different morphological features.

KEY POINTS

• IPNB can be classified into seven morphological types. • IPNB-NM and IPMN-B have different morphological features. • Enhanced CT and MRI can display different types of IPNB. • Morphological classification of IPNB facilitates management of the disease.

Comparative radiological pathological study of biliary intraductal tubulopapillary neoplasm and biliary intraductal papillary mucinous neoplasm

PURPOSE

Biliary tract intraductal tubulopapillary neoplasms (BT-ITPNs) and intraductal papillary mucinous neoplasms (BT-IPMNs) are rare and poorly described. Herein, we examined the magnetic resonance imaging (MRI) features of BT-ITPNs and BT-IPMNs and correlated them with key gross and microscopic pathological findings.

METHODS

We retrospectively identified five patients with definitive pathological findings of BT-ITPN and available diagnostic MRI findings. Key MRI features were correlated to the gross and microscopic pathology and compared to those of BT-IPMNs (19 patients).

RESULTS

All BT-ITPNs showed ductal dilatation and visible intraductal soft tissue with peribiliary liver parenchyma enhancement. One BT-ITPN patient had synchronous lung metastases, and another showed rapid tumor growth rate. The intraductal soft tissue proportion of BT-ITPNs was significantly more than that of BT-IPMNs (p < 0.05). CA-199 level was elevated in 60% of BT-ITPN cases. The overall combined 1-year and 3-year survival rates in the BT-ITPN group was 100% and 40%, and in the BT-IPMN group was 100% and 58%, respectively. A high intraductal soft tissue proportion, a lack of intraluminal mucin, and immunohistochemical absence of MUC5AC are radiological and pathological characteristics that differentiate BT-ITPN from BT-IPMN.

CONCLUSIONS

Although rare, BT-ITPN should be suspected when solid intraductal soft tissue and peribiliary liver parenchyma enhancement are present, particularly if the bile duct upstream and downstream of the lesion have a normal diameter, without mucin. Owing to the aggressive nature of the tumor, recognition of these features may indicate the need for more aggressive treatment in selected patients.

Uncommon neoplasms of the biliary tract: radiological findings

OBJECTIVE

To report our cancer centre experience in the biliary tumours incidence other than cholangiocellular-carcinoma, emphasizing the radiological features.

METHODS

197 patients with biliary disease undergoing Gd-EOB-DTPA-enhanced MRI were reviewed. Four radiologists evaluated retrospectively size, structure, anatomical site and signal intensity of lesions on MRI. Enhancement-pattern during the arterial-, portal- and late-phase on ultrasound, CT and MR study was assessed as well as the enhancement pattern during the hepatobiliary-phase on MRI.

RESULTS

23 patients were selected. The lesion was intraductal in 5 cases, periductal in 14 and intrahepatic in 4. 16 lesions were solid, 5 uniloculated cystic and 2 complex cystic. In five patients the lesion was simple cyst, with a signal intensity in T₁ weighted (T1W) and T₂ weighted (T2W) similar to the gallbladder. In two patients with complex cystic lesion, the solid component was heterogeneously hypointense in T₁ W, hyperintense in T₂ W with a restricted diffusion. The solid component showed heterogeneous contrast-enhancement on CT, MR and ultrasound. The tumour was intrahepatic in two patients, with signal hypointense in T₁ W and hyperintense in T₂ W. Diffusion was restricted. The lesions showed heterogeneous contrast-enhancement. The periductal lesions were hypointense in T₁ W, hyperintense in T₂ W with restricted diffusion. The lesion showed progressive contrast-enhancement. Peribiliary melanoma was hyperintense in T₁ W, hyperintense in T₂ W with restricted diffusion and progressively contrast-enhanced.

CONCLUSION

Biliary tumours can have a wide spectrum of radiologic appearances and consequently represent a diagnostic challenge for the radiologist. Advances in knowledge: MRI is the technique of choice in diagnosing biliary tumours, including rare (non-CCC) tumours.

Clinicopathological features of intraductal papillary neoplasms of the bile duct: a comparison with intraductal papillary mucinous neoplasm of the pancreas with reference to subtypes

Intraductal papillary epithelial neoplasms of the pancreatobiliary system (intraductal papillary neoplasm of the bile duct (IPNB) and intraductal papillary mucinous neoplasm (IPMN)) seem to share many clinicopathological features; however, IPNB has not been fully characterized. In order to understand the clinicopathological/immunohistochemical features of IPNB better, we compared 52 cases of IPNB with 42 cases of IPMNs with mural nodules. The IPNB cases were divided into two groups according to their histological similarity and according to five key histological findings. All IPNB and IPMN cases mainly affected middle-aged to elderly people, predominantly men. Mucin hypersecretion was less frequent in IPNB compared to IPMN. Group 2 IPNB more frequently had a higher histopathological grade and more extensive stromal invasion than IPMN. Group 1 IPNB and IPMN were further classified into four subtypes (gastric, intestinal, pancreatobiliary, and oncocytic). Although each subtype of IPNB and IPMN showed similar histology, the immunohistochemical results were different. The gastric type of IPNB was less frequently positive for CDX2, and intestinal IPNB was more frequently positive for MUC1 and less frequently positive for MUC2, MUC5AC, and CDX2 compared to each subtype of IPMN, respectively. In conclusion, IPNB and IPMN have some clinicopathological features in common, but mucin hypersecretion was less frequent both in IPNBs than in IPMN. Group 2 IPNB differed from IPMN in several parameters of tumor aggressiveness. Additional clinicopathological and molecular studies should be performed with respect to the subtypes of IPNB and IPMN.

Over 700 Whipples for Pancreaticobiliary Malignancies: Postoperative Morbidity Is an Additional Negative Prognostic Factor for Distal Bile Duct Cancer

BACKGROUND

Distal cholangiocarcinomas and pancreatic cancers both arise from pancreaticobiliary epithelium. Despite their common origin, there is a possible discrepancy in outcome. We analysed the surgical, pathological and survival outcome of resected distal cholangiocarcinoma compared with pancreatic cancer.

METHODS

All cases of resected distal cholangiocarcinoma and pancreatic cancer from 1998 to 2014 were extracted from our database. Outcomes were compared.

RESULTS

There were 54 (7.6%) cases of cholangiocarcinoma and 656 (92.4%) pancreatic cancer. Cholangiocarcinoma showed lower T and N stage, lymphatic and perineural invasion (p < 0.05), worse surgical outcome (p < 0.05) and less access to adjuvant therapy if compared with pancreatic cancer (72.7 vs. 83.1%, p = 0.05). Both showed a similar disease-specific survival (35 vs. 29 months, p = 0.3). Independent predictors of prognosis for pancreatic cancer were resection margin, grading, perineural invasion, T and N status, whereas for cholangiocarcinoma were grading and occurrence of POPF.

CONCLUSION

Considering a large cohort of resected periampullary cancers, cholangiocarcinoma is extremely rare. An earlier diagnosis is associated with better pathological predictors of outcome but increased postoperative morbidity compared to pancreatic cancer, particularly POPF. Consequent decrease in the access to adjuvant therapy for complicated cholangiocarcinoma might explain why survival is as poor as for pancreatic cancer.

A Rare Case of Intraductal Papillary Mucinous Neoplasm of the Biliary Duct in a Patient with Prostate Adenocarcinoma

Intraductal papillary mucinous neoplasms (IPMNs) are mucin-producing papillary neoplasms of the pancreatic or biliary ductal system that exhibit variable cellular atypia and cause ductal dilation. There are few reported cases of IPMN arising from the biliary tree in the literature. It has a higher propensity to undergo malignant transformation compared to IPMN arising from the pancreatic duct. An 80-year-old male underwent cross-sectional tomography (CT) imaging of the abdomen for evaluation of prostate adenocarcinoma, which revealed an incidental 2.3 × 2.7 cm soft tissue mass centered at the porta hepatis with diffuse dilatation of the left intrahepatic biliary ductal system and mild prominence of the right intrahepatic ductal system. Endoscopic ultrasound showed 2 adjacent hilar masses involving the common hepatic duct and the left hepatic duct with protrusion of the tissue into the lumen of the duct and upstream ductal dilatation. Endoscopic retrograde cholangiopancreatography revealed a large filling defect in the common hepatic duct extending into the left hepatic duct. A large amount of clot and soft tissue with a fish-egg appearance was retrieved. The patient underwent left hepatic lobectomy, radical resection of the common hepatic duct with Roux-en-Y hepaticojejunostomy to the right hepatic duct. Histopathological examination of the resected specimen revealed intraductal papillary mucinous neoplasm with diffuse high-grade dysplasia. Follow-up CT scan of the abdomen 2 months after the surgery was negative for any masses.

Latest advances in the pathological understanding of cholangiocarcinomas

Cholangiocarcinomas (CCAs) are anatomically classified into intrahepatic, perihilar, and distal types. The gross pathological classification of intrahepatic CCAs divides them into mass-forming, periductal-infiltrating, and intraductal-growth types; and perihilar/distal CCAs into flat- and nodular-infiltrating and papillary types. Unique preinvasive lesions appear to precede individual gross types of CCA. Biliary intraepithelial neoplasia, a flat lesion, precedes periductal-, flat-, and nodular-infiltrating CCAs, whereas intraductal papillary neoplasm of the bile duct (IPNB) precedes the intraductal-growth and papillary type of CCAs. IPNBs are heterogeneous in their histological and pathological profiles along the biliary tree. Hepatobiliary cystadenomas/adenocarcinomas are reclassified as cystic IPNBs and hepatic mucinous cystic neoplasms. Peribiliary glands may participate in the development of CCAs. These latest findings present a new challenge for understanding the pathology of CCAs.

Comparative clinicopathological study of biliary intraductal papillary neoplasms and papillary cholangiocarcinomas

AIMS

The aim of this study was to achieve a better definition of intraductal papillary neoplasms of the bile duct (IPNBs).

METHODS AND RESULTS

Biliary tumours that showed predominantly intraductal papillary growth were provisionally classified as IPNBs (n = 25) and papillary cholangiocarcinomas (n = 27). IPNB was defined as a neoplasm that is confined to the epithelium or is regularly arranged in a high-papillary architecture along thin fibrovascular stalks, whereas the term 'papillary cholangiocarcinoma' was used for tumours with more complex papillary structures (e.g. irregular papillary branching or mixed with solid-tubular growth). In our consecutive cohort of biliary neoplasms, 5% were classified as IPNBs, and 10% as papillary cholangiocarcinomas. IPNBs differed from papillary cholangiocarcinomas by less advanced invasion, gross mucin overproduction (72% versus 7%), and their prevalent location (84% of IPNBs in intrahepatic/hilar ducts; 70% of papillary cholangiocarcinomas in extrahepatic ducts). Gastric-type and oncocytic-type tumours were only detected in IPNBs. Expression of mucin core proteins and cytokeratin 20 significantly differed between the two groups. KRAS and GNAS were wild-type genotypes in all but one case of KRAS-mutated IPNB. Patients with IPNB had better recurrence-free survival than those with papillary cholangiocarcinoma (P = 0.007). In multivariate analysis, in which several other prognostic factors (e.g. stromal invasion and lymph node metastasis) were applied, the classification of the two papillary tumours was an independent prognostic factor (P = 0.040).

CONCLUSIONS

Given the significant contrast in clinicopathological features between IPNBs and papillary cholangiocarcinomas, it may be more appropriate to use the diagnostic term 'IPNB' for selected tumours that show regular papillary growth, separately from papillary cholangiocarcinomas.

Systematic Review and Meta-analysis of Current Experience in Treating IPNB: Clinical and Pathological Correlates

OBJECTIVE

To systematically review studies reporting clinicopathological features of intraductal papillary neoplasm of the bile duct (IPNB) to provide evidence-based guidance for management.

BACKGROUND

IPNB is a rare tumor type. Management decisions are currently based upon anecdotal evidence and small case series. To data, there has been no systematic review of IPNB literature.

METHODS

MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched and data were extracted from relevant studies. Meta-analysis was used to pool study estimates. Evidence of association was determined by comparing pooled crude odds ratios (OR) derived from abstracted data.

RESULTS

Fifty-seven retrospective case series were included. At least 43% of 476 specimens contained invasive disease. Invasive tumors were found at significantly higher frequency in pancreaticobiliary than intestinal, gastric or oncocytic-type IPNB [pooled OR 2.5, 95% confidence interval (CI) 1.5-4.2, P < 0.001]. A significantly higher proportion of pancreaticobiliary tumors compared with intestinal tumors expressed MUC-1 [86.4% (95% CI 75.1%-94.7%) vs 13.2% (95% CI 4.6%-25.2%), respectively P < 0.001]. IPNB identified in centers from Asia were more likely to be intrahepatic and were less frequently invasive compared with those from Western centers. Pooled estimates of absolute survival after IPNB resection were 96% (95% CI 93%-99%) at 1 year, 79% (95% CI 69%-88%) at 3 years, and 65% (95% CI 46%-76%) at 5 years.

CONCLUSIONS

Early surgery is advisable for radiologically suspected IPNB as it is frequently invasive. The pathobiology of IPNB demonstrates geographic variation. Pancreaticobiliary IPNB expresses MUC1 and is more frequently associated with invasive disease than other IPNB subtypes.

An observational and comparative study on intraductal papillary mucinous neoplasm of the biliary tract and the pancreas from a Chinese cohort

BACKGROUND

Intraductal papillary mucinous neoplasms of the biliary tract (BT-IPMNs) are unique but very rare biliary tumors. The relationship between BT-IPMNs and intraductal papillary mucinous neoplasm of the pancreas (P-IPMNs) was still unclear and controversial.

OBJECTIVE

We aimed to evaluate the clinical, radiological, histopathological, and prognostic characteristics of BT-IPMNs and P-IPMNs to achieve a better understanding of these two rare bilio-pancreatic diseases and their connections.

METHODS

Data of a total of 116 patients who were all surgically treated and histopathologically diagnosed as BT-IPMNs or P-IPMNs from January 2004 to December 2014 in our single institution was all retrospectively collected and analyzed.

RESULTS

This study respectively enrolled 32 patients with BT-IPMNs and 84 ones with P-IPMNs. The differences between BT-IPMNs and P-IPMNs in age, sex ratios, clinical presentation, elevated tumor markers and proportion of malignancy were not statistically significant (P>0.05), while the tumor diameter of BT-IPMNs was notably smaller than P-IPMNs (1.72cm, 4.56cm, respectively; P=0.028). Patients with BT-IPMNs were more likely manifest the symptoms of cholangitis, compared to those with P-IPMNs who showed pancreatitis (75%, 30%, respectively; P=0.039). Bile duct dilatation (100%), tumor of bile duct cavity (50%) or/and cystic dilatation of the bile duct (50%) were the typical manifestations of preoperative imaging examinations of BT-IPMNs, in which tumors were mainly located in intrahepatic or hepatic hilar region (26, 81%). Surgery has been the curable treatment for BT-IPMNs in which left hepatic lobectomy was the most commonly performed procedure (20, 63%). Finally, compared with P-IPMNs, the overall mean survival time of patients with BT-IPMNs was a little shorter (59.1mon, 86.7mon, respectively; P=0.002).

CONCLUSION

BT-IPMNs are a sort of rare and separate biliary tract neoplasm, which might be related with the stones of biliary tract or the infections of parasite. Although arising in different organs and representing different features, BT-IPMNs and P-IPMNs shared considerable clinical and pathological similarities which might represent related or similar development process in the bilio-pancreatic duct systems.

Characterization of intraductal papillary neoplasm of bile duct with respect to histopathologic similarities to pancreatic intraductal papillary mucinous neoplasm

Intraductal papillary neoplasm of bile duct (IPNB) is a papillary tumor covered by well-differentiated neoplastic epithelium with fine fibrovascular cores in the dilated bile ducts. It reportedly shows similarities to intraductal papillary mucinous neoplasm of pancreas (IPMN), to various degrees. Herein, IPNB was pathologically analyzed by classifying 52 cases into 4 groups based on the histopathologic similarities to IPMN: group A (identical to IPMN, 19 cases), group B (similar to but slightly different from IPMN, 18 cases), group C (vaguely similar to IPMN, 5 cases), and group D (different from IPMN, 10 cases). In group A, intrahepatic and perihilar regions were mainly affected, most cases were of low/intermediate or high grade without invasion, and gastric type was the most common phenotype, followed by oncocytic and intestinal types. In groups C and D, perihilar and distal bile ducts were affected, almost all cases were of high grade with invasion, and most of them were of intestinal and pancreatobiliary phenotypes. Most group B cases were of intestinal phenotype, and all were of high grade with or without invasion. In conclusion, these 4 groups of IPNB showed unique pathologic features and behaviors. Group A cases were less aggressive and shared many features with IPMN, whereas group C and D cases were more aggressive and mainly found in perihilar and distal bile ducts. Group B resembling IPMN was intermediate between them. This classification may be useful in clinical practice and holds promise for a novel approach to analyze IPNB tumorigenesis.

Clinical and pathological features of intraductal papillary neoplasm of the biliary tract and gallbladder

BACKGROUND

Intraductal papillary neoplasms of the biliary tract (IPNB) and intracholecystic papillary neoplasms (ICPN) are rare tumours characterized by intraluminal papillary growth that can be associated with invasive carcinoma. Their natural history remains poorly understood. This study examines clinicopathological features and outcomes.

METHODS

Patients who underwent surgery for IPNB/ICPN (2008-2014) were identified. Descriptive statistics and survival data were generated.

RESULTS

Of 23 patients with IPNB/ICPN, 10 were male, and the mean age was 68 years. The most common presentations were abdominal pain (n = 10) and jaundice (n = 9). Tumour locations were: intrahepatic (n = 5), hilar (n = 3), the extrahepatic bile duct (n = 8) and the gallbladder (n = 7). Invasive cancer was found in 20/23 patients. Epithelial subtypes included pancreatobiliary (n = 15), intestinal (n = 7) and gastric (n = 1). The median follow-up was 30 months. The 5-year overall (OS) and disease-free survivals (DFS) were 51% and 57%, respectively. Decreased OS (P = 0.09) and DFS (P = 0.05) were seen in patients with tumours expressing MUC1 on immunohistochemistry (IHC).

CONCLUSION

IPNB/ICPN are rare precursor lesions that can affect the entire biliary epithelium. At pathology, the majority of patients have invasive carcinoma, thus warranting a radical resection. Patients with tumours expressing MUC1 appear to have worse OS and DFSs.

Gd-EOB-DTPA-enhanced magnetic resonance imaging for bile duct intraductal papillary mucinous neoplasms

AIM: To investigate gadolinium-ethoxybenzyl-diethylenetriamine-pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) of intraductal papillary mucinous neoplasms of the bile duct (IPMN-B).

METHODS: The imaging findings of five cases of IPMN-B which were pathologically confirmed at our hospital between March 2012 and May 2013 were retrospectively analyzed. Three of these cases were diagnosed by duodenal endoscopy and biopsy pathology, and two cases were diagnosed by surgical pathology. All five patients underwent enhanced and non-enhanced computed tomography (CT), magnetic resonance cholangiopancreatography, and Gd-EOB-DTPA-enhanced MRI; one case underwent both Gd-EOB-DTPA-enhanced MRI and positron emission tomography-CT. The clinical data and imaging results for these cases were compared and are presented.

RESULTS: Conventional imaging showed diffuse dilatation of bile ducts and multiple intraductal polypoid and papillary neoplasms or serrated changes along the bile ducts. In two cases, Gd-EOB-DTPA-enhanced MRI revealed dilated biliary ducts and intraductal tumors, as well as filling defects caused by mucin in the dilated bile ducts in the hepatobiliary phase. Gd-EOB-DTPA-enhanced MRI in one case clearly showed a low-signal tumor in the hepatobiliary phase, similar to what was seen by positron emission tomography-CT. In two patients, routine inspection was unable to discern whether the lesions were inflammation or tumors. However, Gd-EOB-DTPA-enhanced MRI revealed a pattern of gradual enhancement during the hepatobiliary phase, and the signal intensity of the lesions was lower than the surrounding liver parenchyma, suggesting tissue inflammation in both cases, which were confirmed by surgical pathology.

CONCLUSION: Gd-EOB-DTPA-enhanced MRI reveals the intraductal mucin component of IPMN-B in some cases and the extent of tumor infiltration beyond the bile ducts in invasive cases.

Biliary tract intraductal papillary mucinous neoplasm: Report of 19 cases

AIM: To gain a better understanding of biliary tract intraductal papillary mucinous neoplasm (BT-IPMN).

METHODS: From January 2000 to December 2013, 19 cases of BT-IPMN were retrospectively identified from a total of 343 biliary tract tumors resected in our single institution. Demographic characteristics, clinical data, pathology, surgical strategies, and long-term follow-up were analyzed.

RESULTS: The mean age of the 19 BT-IPMN cases was 53.8 years (range: 25-74 years). The most common symptom was abdominal pain (15/19; 78.9%), followed by jaundice (7/19; 36.8%). Cholangitis was associated with most (16/19; 84.2%) of the BT-IPMN cases. Macroscopically visible mucin was detected in all 19 patients, based on original surgical reports. The most common abnormal preoperative imaging findings for BT-IPMN were bile duct dilation (19/19; 100%) and intraluminal masses (10/19; 52.6%). Thirteen (68.4%) cases involved the intrahepatic bile duct and hilum. We performed left hepatectomy in 11/19 (57.9%), right hepatectomy in 2/19 (10.5%), bile duct resection in 4/19 (21.1%), and pancreatoduodenectomy in 1/19 (5.3%) patients. One (5.3%) patient was biopsied and received a choledochojejunostomy because of multiple tumors involving the right extrahepatic and left intrahepatic bile ducts. Histology showed malignancy in 10/19 (52.6%) patients. The overall median survival was 68 mo. The benign cases showed a non-significant trend towards improved survival compared to malignant cases (68 mo vs 48 mo, P = 0.347). The patient without tumor resection died of liver failure 22 mo after palliative surgery.

CONCLUSION: BT-IPMN is a rare biliary entity. Complete resection of the tumor is associated with good survival, even in patients with malignant disease.

Intraductal papillary mucinous neoplasm of the liver: GI image

Intraductal papillary mucinous neoplasms (IPMNs) are rare, mucin-producing, predominantly noninvasive tumors arising from epithelial cells. Most IPMNs arise from the pancreas. There exists a subset of IPMN of the biliary tract (BT-IPMN). IPMNs regardless of origin produce large amounts of mucin relative to scant amounts of epithelial cells, leading to mass effect disturbances in bile flow. Affected bile ducts exhibit marked dilatation. The majority of IPMN patients present with a non-malignant neoplasm. Because of potential for transformation, surgery is the treatment of choice. Bronchobiliary fistulas can present as congenital defects, following thoracoabodominal trauma, or as rare complications of diseases of the biliary tract such as BT-IPMN. There are no reported cases in the literature of bronchobiliary fistula associated with BT-IPMN, but there is a clear theoretical risk.

Intraductal papillary neoplasm of the bile duct

Intraductal papillary neoplasm of the bile duct (IPNB) is a variant of bile duct carcinoma that is characterized by intraductal growth and better outcomes compared with common cholangiocarcinoma. IPNBs are mainly found in patients from Far Eastern areas, where hepatolithiasis and clonorchiasis are endemic. According to the immunohistochemical profiles of the mucin core proteins, IPNBs are classified into four types: pancreaticobiliary, intestinal, gastric, and oncocytic. Approximately 40%-80% of IPNBs contain a component of invasive carcinoma or tubular or mucinous adenocarcinoma, suggesting that IPNB is a disease with high potential for malignancy. It is difficult to make an accurate preoperative diagnosis because of IPNB’s low incidence and the lack of specificity in its clinical manifestation. The most common abnormal preoperative imaging findings of IPNB are intraductal masses and the involvement of bile duct dilation. Simultaneous proximal and distal bile duct dilation can be detected in some cases, which has diagnostic significance. Cholangiography and cholangioscopy are needed to confirm the pathology and demonstrate the extent of the lesions. However, pathologic diagnosis by biopsy cannot reflect the actual stage in many cases because different foci may be of different stages and because mixed pathologic findings may exist in the same lesion. Surgical resection is the major treatment. Systematic cholangioscopy with staged biopsies and frozen sections is recommended during resection to ensure that no minor tumors are left and that curative resection is achieved. Staging, histologic subtype, curative resection and lymph node metastasis are factors affecting long-term survival.