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Hall C, McLaren M, Mosse C. A pancreatic mass and extreme elevation of CA 19-9: a benign masquerade of cholangiocarcinoma. J Surg Case Rep 2022; 2022:rjac018. [PMID: 35186252 PMCID: PMC8849326 DOI: 10.1093/jscr/rjac018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 01/09/2022] [Indexed: 11/23/2022] Open
Abstract
Carbohydrate antigen 19–9 (CA 19–9) is a specific tumour marker for pancreato-biliary malignancy. Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated condition in which IgG4 deposits infiltrate various organs, including the biliary tract manifesting IgG4 sclerosing cholangitis and pseudotumours. An 83-year-old woman presented with severe obstructive jaundice, weight loss and an extreme elevation of CA 19–9 level of 3295 kU/L. Magnetic resonance cholangiopancreatography (MRCP) revealed a pancreatic mass amputating the biliary tree. Liver function tests revealed a cholestatic pattern and severe hyperbilirubinaemia (289umol/L). IgG4 level was found to be high at 7.97 g/L. After treatment with high-dose corticosteroids, repeat MRCP 2 months later revealed disappearance of the pancreatic mass. There was also normalization of the bilirubin and a dramatic decrease of CA 19–9. This case reports the highest published benign elevation of Ca19.9 level in the setting of IgG4 disease. Differentiation between cholangiocarcinoma and IgG4-RD is important, as the treatment is vastly different.
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Affiliation(s)
- Catherine Hall
- Division of Surgery, The Canberra Hospital, Garran, Australia
| | - Mairi McLaren
- Division of Surgery, The Canberra Hospital, Garran, Australia
| | - Charles Mosse
- Division of Surgery, The Canberra Hospital, Garran, Australia
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De'Ath HD, Nagendram S, Smith E, Ramadan M, Veeramootoo D, Singh S. A high-volume ERCP service led by surgeons is associated with good outcomes and meets national key performance indicators: results from a British district general hospital. Surg Endosc 2022; 36:6016-6023. [PMID: 35020059 DOI: 10.1007/s00464-021-08978-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 12/31/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a common, but technically challenging procedure used in the management of hepatopancreaticobiliary (HPB) disease. It is traditionally performed by medical gastroenterologists. In 2014, the British Society of Gastroenterology (BSG) proposed key performance indicators to evaluate and set standards of ERCP practice. This study aimed to compare our ERCP outcomes against these targets, in a centre where ERCP is exclusively performed by surgeons. METHODS A retrospective analysis of all ERCPs undertaken over a 38 months in a District General Hospital in the United Kingdom (UK), by three Upper Gastrointestinal Surgeons. Study outcomes were based upon, and compared against, BSG key performance indicators, including number of ERCPs per annum, proportion of successful cannulations of bile duct and stone clearance, ERCP-specific complications and mortality. RESULTS The unit's caseload over this period was 1324, equating to approximately 418 per annum (BSG minimum 200 per unit). Management of bile duct stones was the commonest indication for ERCP. Overall, 95% (1253/1324) of bile ducts were cannulated and 92% (645/698) for those undergoing their first ERCP. Bile duct clearance was achieved in 80% of patients (BSG recommend > 75%) and the successful stenting of extra-hepatic strictures in 94% (BSG recommend > 80%). The overall complication rate was 4.3% (BSG standard < 6%). Procedure-specific mortality was 0.3% (4/1324) where death was either caused by pancreatitis or sepsis. CONCLUSION A high-volume ERCP service led and performed exclusively by surgeons meets all BSG performance indicators, with good procedural and patient outcomes. Formal training pathways should be developed to encourage more surgical centres to provide an ERCP service and deal with what are common surgical pathologies.
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Affiliation(s)
- Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK.
| | - Sathyan Nagendram
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Eleanor Smith
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Mohamed Ramadan
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Darmarajah Veeramootoo
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
| | - Sukhpal Singh
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, Surrey, GU16 7UJ, England, UK
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Han JY, Ahn KS, Kim TS, Kim YH, Cho KB, Shin DW, Baek WK, Suh SI, Jang BC, Kang KJ. Liquid Biopsy from Bile-Circulating Tumor DNA in Patients with Biliary Tract Cancer. Cancers (Basel) 2021; 13:cancers13184581. [PMID: 34572808 PMCID: PMC8466375 DOI: 10.3390/cancers13184581] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/31/2021] [Accepted: 09/09/2021] [Indexed: 01/10/2023] Open
Abstract
Simple Summary Utilization of cell free DNA for diagnosing and monitoring patients with biliary tract cancers is emerging and promising. The strength of the present study is in its description of a novel approach using bile rather than blood or tissue samples, which is particularly relevant in biliary tract cancers. This paper largely serves as a proof of concept that ctDNA from bile is potentially feasible. Abstract Although liquid biopsy of blood is useful for cancer diagnosis and prediction of prognosis, diagnostic and prognostic value of ctDNA in bile fluid for BTCs are not clear yet. To determine whether liquid biopsy for circulating tumor DNA (ctDNA) can replace tissue biopsy when assessing somatic mutations in biliary tract cancers (BTCs). Bile samples were obtained from 42 patients with BTC. Matched formalin-fixed paraffin-embedded (FFPE) samples were obtained from 20 of these patients and matched plasma samples from 16 of them. Droplet digital PCR (ddPCR) was used for detection KRAS somatic mutation. KRAS mutations were identified in the bile ctDNA of 20 of 42 (48%) patients. Patients with mutant KRAS showed significantly worse survival than those with wild-type KRAS (2-year survival rates: 0% vs. 55.5%, respectively; p = 0.018). There was 80.0% mutational concordance between the paired bile ctDNA and FFPE samples, and 42.9% between the plasma and FFPE samples. On transcriptomic sequencing of one set of paired bile and FFPE samples, expression level of KRAS-associated signaling oncogenes in the bile and tissue samples showed a strong positive correlation (r = 0.991, p < 0.001). Liquid biopsy of bile reliably detect mutational variants within the bile ctDNA of BTC patients. These results suggest that bile is an effective biopsy fluid for ctDNA analysis.
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Affiliation(s)
- Jin-Yi Han
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (J.-Y.H.); (T.-S.K.); (Y.H.K.); (K.J.K.)
| | - Keun Soo Ahn
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (J.-Y.H.); (T.-S.K.); (Y.H.K.); (K.J.K.)
- Correspondence: ; Tel.: +82-(53)-258-7878
| | - Tae-Seok Kim
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (J.-Y.H.); (T.-S.K.); (Y.H.K.); (K.J.K.)
| | - Yong Hoon Kim
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (J.-Y.H.); (T.-S.K.); (Y.H.K.); (K.J.K.)
| | - Kwang Bum Cho
- Department of Internal Medicine, Division of Gastroenterology, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (K.B.C.); (D.W.S.)
| | - Dong Woo Shin
- Department of Internal Medicine, Division of Gastroenterology, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (K.B.C.); (D.W.S.)
| | - Won-Ki Baek
- Department of Microbiology, Keimyung University School of Medicine, Daegu 1095, Korea; (W.-K.B.); (S.-I.S.)
| | - Seong-Il Suh
- Department of Microbiology, Keimyung University School of Medicine, Daegu 1095, Korea; (W.-K.B.); (S.-I.S.)
| | - Byeong-Churl Jang
- Department of Molecular Medicine, Keimyung University School of Medicine, Daegu 1095, Korea;
| | - Koo Jeong Kang
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Keimyung University Dongsan Hospital, Daegu 1035, Korea; (J.-Y.H.); (T.-S.K.); (Y.H.K.); (K.J.K.)
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Unravelling the Diagnostic Dilemma: A MicroRNA Panel of Circulating MiR-16 and MiR-877 as A Diagnostic Classifier for Distal Bile Duct Tumors. Cancers (Basel) 2019; 11:cancers11081181. [PMID: 31443224 PMCID: PMC6721566 DOI: 10.3390/cancers11081181] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 12/12/2022] Open
Abstract
Accurate diagnosis of pancreatic head lesions remains challenging as no minimally invasive biomarkers are available to discriminate distal cholangiocarcinoma (CCA) from pancreatic ductal adenocarcinoma (PDAC). The aim of this study is to identify specific circulating microRNAs (miRNAs) to diagnose distal CCA. In the discovery phase, PCR profiling of 752 miRNAs was performed on fourteen patients with distal CCA and age- and sex-matched healthy controls. Candidate miRNAs were selected for evaluation and validation by RT-qPCR in an independent cohort of distal CCA (N = 24), healthy controls (N = 32), benign diseases (N = 20), and PDAC (N = 24). The optimal diagnostic combination of miRNAs was determined by multivariate logistic regression analysis and evaluated by ROC curves with AUC values. The discovery phase revealed 19 significantly dysregulated miRNAs, of which six were validated in the evaluation phase. The validation phase confirmed downregulated miR-16 in patients with distal CCA compared to benign disease or PDAC (P = 0.048 and P = 0.012), while miR-877 was significantly upregulated (P = 0.003 and P = 0.006). This two-miRNA panel was validated as a CCA-specific profile, discriminating distal CCA from benign disease (AUC = 0.90) and from PDAC (AUC = 0.88). In conclusion, the present study identified a two-miRNA panel of downregulated miR-16 and upregulated miR-877 with promising capability to diagnose patients with distal CCA.
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Rungsakulkij N, Sornmayura P, Tannaphai P. Isolated IgG4-related sclerosing cholangitis misdiagnosed as malignancy in an area with endemic cholangiocarcinoma: a case report. BMC Surg 2017; 17:17. [PMID: 28202062 PMCID: PMC5311850 DOI: 10.1186/s12893-017-0214-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 02/10/2017] [Indexed: 12/15/2022] Open
Abstract
Background The most common cause of perihilar obstruction is cholangiocarcinoma, especially in Thailand. Benign perihilar stricture represents less than 20% of cases. IgG4-related disease and IgG4-related sclerosing cholangitis, however, have been receiving increased recognition. Isolated IgG4-related sclerosing cholangitis is less common. The preoperative diagnosis of IgG4-related sclerosing cholangitis without pancreatic involvement is very difficult because the clinical presentation and preoperative evaluation are extremely difficult to distinguish from perihilar cholangiocarcinoma. Case presentation We report the case of a 56-year-old man who presented with obstructive jaundice with preoperative imaging showing proximal common bile duct obstruction. He underwent right lobe liver hepatectomy with extrahepatic bile duct resection and regional lymph node dissection due to high suspicion of malignancy. The pathological report showed severe acute and chronic inflammation of the bile duct with morphology and immunohistochemistry suggestive of IgG4-related sclerosing cholangitis. Conclusions IgG4-related sclerosing cholangitis with perihilar obstruction should be considered even in areas where cholangiocarcinoma is endemic.
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Affiliation(s)
- Narongsak Rungsakulkij
- Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.
| | - Pattana Sornmayura
- Department of Pathology, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Penampai Tannaphai
- Department of Radiology, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
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Vergara Suárez F, López Andújar R, Montalvá Orón E, Ramírez Ribelles C, Pérez Rojas J. Hepatolitiasis simulando un colangiocarcinoma hiliar. Cir Esp 2013; 91:535-7. [DOI: 10.1016/j.ciresp.2013.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 03/08/2013] [Indexed: 11/17/2022]
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Cai X, Liu K, Liang Y, Yu H, Lv F, Liang X. Isolated biliary cryptococcosis manifesting as obstructive jaundice in an immunocompetent adult. Int J Med Sci 2012; 9:200-6. [PMID: 22408568 PMCID: PMC3298010 DOI: 10.7150/ijms.3810] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 02/16/2012] [Indexed: 11/05/2022] Open
Abstract
Cryptococcosis is a symptomatic fungal infection caused by Cryptococcus, which frequently occurs in patients who are immunologically compromised or chronically ill. Localized involvement of the hepatobiliary system in an immunocompetent adult is extremely rare. We report a unique case of isolated biliary cryptococcosis manifesting as obstructive jaundice and mimicking hilar cholangiocarcinoma in an immunocompetent woman. By integrating surgical and antifungal drug therapy, the disease was effectively controlled. Despite an increasing incidence of biliary malignancies, hepatobiliary surgeons and gastroenterologists must maintain a high index of suspicion for other rare possibilities of non-specific biliary inflammation.
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Affiliation(s)
- Xiujun Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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