Successful liver transplantation for diffuse biliary papillomatosis

Biliary papillomatosis

Biliary papillomatosis (BP) is a rare disorder of the biliary tract characterized by the presence of multiple papillary adenomas spread along the biliary tree. Although benign, it carries a significant risk of malignant transformation. Due to low sensitivity and specificity of conventional radiologic modalities, the diagnosis as well as estimation of disease extent is difficult. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreaticography (ERCP) are superior although direct peroral cholangioscopy (POC) is currently the most accurate diagnostic method. Mainly because it provides more detailed information and makes targeted histological diagnosis possible. The treatment of biliary papillomatosis consists of surgical resection, liver transplantation (LT) or a combination of both. Unfortunately, the recurrence rate after radical surgery without LT remains high due to the diffuse distribution of the disease.

Surgical treatment of malignant biliary papillomatosis invading adjacent organs: A case report

BACKGROUND

Biliary papillomatosis (BP) is a rare disease characterized by multiple papillary adenomas in the intrahepatic and extrahepatic biliary tree and has a high risk of malignant transformation. Early diagnosis and treatment for BP are challenges, as it spreads along the biliary tract. A radical resection with an adequate resection margin is advocated in patients with malignant BP.

CASE SUMMARY

We report a case of BP with malignant transformation in a 52-year-old female patient who presented with emaciation, severe malnutrition, and a T-tube for biliary drainage that was placed for almost 2 years at the time she visited us. The enhanced magnetic resonance imaging of the upper abdomen revealed a neoplasm with a diameter of 15 cm located in the gallbladder area surrounding the common bile duct where a drainage tube was placed. It was the first case with malignant BP involving multiple organs and the abdominal wall and receiving a radical resection. Plastic surgeons helped close the incision by transferring the rectus muscle and external oblique muscle flap. A diagnosis of papillary carcinoma with diffuse malignant papillomatosis of the biliary duct was given. The postoperative course was uneventful and she was asymptomatic and in good physical condition at 35 mo postoperatively with appropriate chemotherapy.

CONCLUSION

Aggressive surgical treatment with appropriate chemotherapy is advocated for patients with malignant BP even if multiple organ invasion is present.

Successful surgical treatment of extrahepatic biliary papillomatosis diagnosed with endoscopic retrograde cholangiopancreatography: a case report

Introduction

Biliary papillomatosis is a condition characterized by multiple papillary tumors of variable distribution and extent within the biliary tract. Papillary carcinoma can develop in these lesions. It is a rare biliary pathological entity and its clinical features and outcome are not well known.

Case presentation

We experienced a case of biliary papillomatosis in a 51-year-old North African man who presented with obstructive jaundice. Laboratory tests showed elevated bilirubin, alkaline phosphatase and gamma-glutamyl transpeptidase levels. Imaging (ultrasound and magnetic resonance imaging) was suggestive of Klatskin tumor associated to common bile duct stones. After endoscopic retrograde cholangiopancreatography, a balloon sweep retrieved friable tissue from his bile ducts. Histology demonstrated papillary adenomatous proliferation showing high-grade dysplasia and he was referred for surgical management.

Conclusions

Although biliary papillomatosis is rare, it is a premalignant condition that should be well known and considered in all diagnoses of obstructive jaundice. We report a new case of biliary papillomatosis and highlight the contribution of endoscopic retrograde cholangiopancreatography in the diagnosis of this condition.

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.

A clinical analysis of 11 cases of bile duct adenoma

AIM: To investigate the clinicopathologic features, diagnosis and treatment of bile duct adenoma.

METHODS: The clinical data for 11 patients with pathologically confirmed bile duct adenoma at our hospital were retrospectively analyzed.

RESULTS: This group of patients included 9 females and 2 males. Their age ranged from 25 to 75 years, with an average of 62.2 years. Abdominal pain, jaundice and fever were main clinical manifestations. Diagnosis must rely on histopathological examination. Radical resection of the tumor is the most important treatment owing to the high incidence of malignant transformation. Eight patients had papillary adenoma, and 3 had tubule-papillary adenoma. Six cases were associated with cancer, and four cases had varying degrees of dysplasia. One patient underwent biopsy, and 10 patients underwent radical tumor resection. All patients showed no obvious signs of recurrence throughout the follow-up period.

CONCLUSION: Bile duct adenoma has a high incidence of malignant transformation. It is difficult to diagnose before surgery and is easily misdiagnosed. Diagnosis must rely on histopathological examination. Surgical resection is an effective way to treat the disease with a good prognosis.

Comprehensive review of the diagnosis and treatment of biliary tract cancer 2012. Part I: diagnosis-clinical staging and pathology

Biliary tract cancers (gallbladder cancer, intra- and extra-hepatic cholangiocarcinoma, and selected periampullary cancers) accounted for 12,760 new cases of cancer in the USA in 2010. These tumors have a dismal prognosis with most patients presenting with advanced disease. Early, accurate diagnosis is essential, both for potential cure where possible and for optimal palliative therapy in all others. This review examines the currently available and emerging technologies for diagnosis and treatment of this group of diseases.

Biliary papillomatosis in three Caucasian patients in a Western centre

INTRODUCTION

Biliary papillomatosis (BP) is a rare condition with a strong potential for malignant transformation and cases from Western centres are sparse.(1) We discuss the presentation, investigation and management of this condition in three Caucasian patients and present a review of the existing literature on BP.

PATIENTS AND METHODS

The case notes of three Caucasian patients with BP who presented to our tertiary referral centre were reviewed. Their case histories, investigations and managements are presented. A search of MEDLINE, PubMed and Cochrane databases was performed to review relevant literature around BP.

DISCUSSION

BP is a rare condition characterised by multiple papillary adenomas involving the biliary tree which lead to recurrent attacks of cholangitis. It is a low-grade neoplasm with high malignant potential and should be regarded as a pre-malignant lesion.

Liver transplantation for multiple angiomyolipomas complicating tuberous sclerosis complex

Tuberous sclerosis complex is a genetic multisystem disorder characterised by widespread hamartomas in several organs, including the brain, heart, skin, eyes, kidney, lung, and liver. Hepatic multiple, bilateral angiomyolipomas are a rare and usually asymptomatic complication in patients with tuberous sclerosis. We report here the case of a patient who needed liver transplantation because of debilitating manifestations and mechanical complications of massive liver involvement by multiple angiomyolipomas (severe malnutrition, anorexia and abdominal pain). Seventeen tumors, from 2 to 16 cm in diameter, were identified at examination of the liver explant. No feature suggestive of malignant behaviour was identified at histological examination. In conclusion, this unusual indication of liver transplantation underlines the interest of this therapeutic approach for benign tumors for which the multiplicity of the lesions and their huge volume prevent any attempt at surgical resection.

Surgical strategy of biliary papillomatosis in Western countries

Surgical resection, considered the optimal treatment of biliary papillomatosis, often remains incomplete due to high risk of recurrence in view of positive margins or recurrence on the remnant bile duct because of its multifocality. Resection of the whole biliary tree by liver transplantation and duodenopancreatectomy can be regarded as the only curative treatment. However, this approach has resulted in unfavorable results in patients with advanced tumor invasion and/or positive lymph nodes. For the majority of biliary tumors, preoperative assessment is often insufficient. Therefore, we advocate initial partial resection as a first step to eliminate both advanced tumor invasion and/or positive lymph nodes on definitive analysis of the specimen. We propose the strategy of initial resection for selecting the patients who would actually benefit from liver transplantation.

Advances in research on biliary papillomatosis

Biliary papillomatosis is a rare disease that occurs more commonly in elderly males. The usual presentation of this disease is obstructive jaundice or recurrent cholangitis. Characterized by multiple papillary adenomas involving extensive areas of the biliary tree, biliary papillomatosis has a high recurrence rate and a significant risk of malignant transformation. Here, we will review the pathogenesis, clinical features, diagnosis and therapy of biliary papillmatosis.

Successful photodynamic therapy for biliary papillomatosis: A case report

Papillomatosis of the bile duct is a rare disease with a high risk of malignant transformation. Therapeutical options include partial hepatectomy and liver transplantation. A previously healthy 65-years old male developed jaundice and right upper abdominal quadrant pain in 1996. A villous adenoma of the distal bile duct was diagnosed. A Whipple procedure was performed. In 2002 the patient turned symptomatic again. Another adenoma was found in the right hepatic duct resulting in a right hepatectomy. Two years later the patient again developed cholestasis. After drainage of the left hepatic duct with a percutaneous transhepatic cholangial drainage (PTCD) catheter, a recurrent biliary adenomatosis was diagnosed by cholangioscopy. As there was no surgical option left, the patient received photodynamic therapy (PDT) for the recurrent biliary papillomatosis. Three mo after he received further photodynamic therapies, the bile duct epithelium appeared normal and the patient had no signs of adenomatosis, both macroscopically and histologically. The follow-up cholangioscopy in late 2005 revealed only a small papilloma without the need for intervention. In early 2006, the patient died of multi organ failure without signs of extrahepatic cholestasis or cholangitis at the age of 75, 10 years after the diagnosis of biliary papillomatosis was established. The patient exceeded the average life expectancy of patients with biliary papillomatosis by far. Thus, PDT might be a sufficient therapeutic option for recurrent papillomatosis patients with no significant side effects.

Papillomatosis of intra- and extrahepatic biliary tree: Successful treatment with liver transplantation

Approximately 60 cases of biliary papillomatosis have been reported in the world literature, while only 6 cases have been reported to be treated with liver transplantation. This rare disease, which is characterized by relapsing episodes of obstructive jaundice and cholangitis that lead to secondary cirrhosis and death from sepsis or liver failure, it is also considered premalignant because of its frequent malignant transformation (25-50%). We present a case of a 43-year-old white man with papillomatosis of intra- and extrahepatic biliary tree who sought care for repeated episodes of obstructive jaundice and cholangitis. The diagnosis was suspected after endoscopic retrograde cholangiopancreatography and confirmed by liver and common bile duct biopsies. The patient underwent orthotopic liver transplantation with Roux-en-Y hepatico-jejunostomy to treat end-stage liver cirrhosis. Fifteen months' follow-up revealed a patient with normal graft function and with no clinically or laboratory findings of disease recurrence or cancer development.

Malignant potential of intrahepatic biliary papillomatosis: a case report and review of the literature

Background

Biliary papillomatosis (BP) is a rare disease entity with a strong malignant potential. It is characterized by multiple papillary adenomas involving both the intrahepatic and extrahepatic biliary tree. BP was considered in the past to be a disease with low malignant potential. However, a current review of the English literature revealed a high rate of malignant occurrence of approximately 41% and histological analysis along with the expression pattern of mucin core proteins (MUC) and mucin carbohydrate antigens suggests that BP is a borderline or low grade malignant neoplasm with a high malignant potential.

Case presentation

A 68 year-old male patient was referred to our hospital due to the presence of sudden right upper quadrant abdominal pain, nausea and dark urine. Imaging workup demonstrated dilatation of the left hepatic duct without the presence of a space-occupying lesion. A left hepatectomy and cholecystectomy were carried out and histological analysis revealed a moderately to poorly differentiated carcinoma of the left hepatic duct in the background of biliary papillomatosis. Postoperative course was uneventful. Unfortunately, two years after initial diagnosis the patient rapidly deteriorated and died from multiple pulmonary secondary deposits.

Conclusion

BP should not be considered to be a benign disease. The clinical behavior, the high recurrence rate and the even higher malignant transformation occurrence, as well as the presence of carcinogenetic indicators (K-ras mutation, overexpression of p53, MUC and Tn antigens) strongly support that BP is a low-grade neoplasm with high malignant potential.