Primary extrahepatic bile duct neuroendocrine tumor with obstructive jaundice masquerading as a Klatskin tumor

Challenges in treatment of a patient suffering from neuroendocrine tumor G1 of the hilar bile duct: a case report

Background

Neuroendocrine tumors (NETs) arise from neuroendocrine cells and are extremely rare in the biliary tract. Currently, there are no guidelines for the diagnosis and treatment of biliary NETs. We presented a case with NETs G1 of the hilar bile duct and the challenges for her treatment.

Case presentation

A 24-year-old woman was presented to our department with painless jaundice and pruritus, and the preoperative diagnosis was Bismuth type II hilar cholangiocarcinoma. She underwent Roux-en-Y hepaticojejunostomy with excision of the extrahepatic biliary tree and radical lymphadenectomy. Unexpectedly, postoperative pathological and immunohistochemical examination indicated a perihilar bile duct NETs G1 with the microscopic invasion of the resected right hepatic duct. Then the patient received 3 cycles of adjuvant chemotherapy (Gemcitabine and tegafur-gimeracil-oteracil potassium capsule). At present, this patient has been following up for 24 months without recurrence or disease progression.

Conclusion

We know little of biliary NETs because of its rarity. There are currently no guidelines for the diagnosis and treatment of biliary NETs. We reported a case of perihilar bile duct NETs G1 with R1 resection, as far as we know this is the first report. More information about biliary NETs should be registered.

Neuroendocrine tumor of the common bile duct: A case report of extremely rare cause for obstructive jaundice

•

Common Bile Duct is extremely rare site for primary Neuroendocrine tumors.

•

WHO classification categorized neuroendocrine neoplasms of digestive tract into three subtypes: well differentiated neuroendocrine tumor, poorly differentiated neuroendocrine carcinoma and mixed adenoneuroendocrine carcinoma.

•

The etiology of developing NET in the bile duct tissues is unknown but it is related to chronic inflammation with subsequent metaplasia.

•

Surgical resection is the mainstay of the treatment.

•

Postoperative chemotherapy using cisplatin and etoposide showed promising results.

Introduction

Neuroendocrine tumors (NET) of common bile duct are rare. There have been less than 100 cases reported worldwide.

Presentation of case

A 37-year-old female patient was referred to our center after six months of abdominal pain with no definite diagnosis. At initial presentation, she complained of increased abdominal pain, nausea, vomiting, oral intolerance to food and icteric sclera. Physical examination and laboratory tests were indicative of pancreatitis. At day four, she took retrograde cholangiopancreatography (ERCP) and a mid CBD stenosis or impacted stone was found. In order to locally investigate the lesion, Endoscopic Ultrasound (EUS) examination was performed which reported 16 × 12 mm isoechoic tumoral lesion at the middle of the CBD. In this regard we decided to perform ERCP-guided brushing biopsy of the lesion. The pathology report was highly suggestive for malignancy. She underwent resection of the mid portion of the CBD with Roux-en-Y hepaticojejunostomy, cholecystectomy and portahepatis lymph node dissection. The pathology report indicated that the CBD lesion was well-differentiated neuroendocrine tumor grade II.

Discussion

The exact etiology of developing NET in the bile duct tissues is not clear however cholelithiasis and congenital malformation of the biliary tract has been proposed to cause chronic inflammation with subsequent metaplasia which ultimately transforms into NET.

Conclusion

As there are very few cases of NETs of the CBD, no definite surgical or medical treatment is proposed. Currently, combination of radical surgical resection and lymph node dissection followed by chemotherapy is the treatment of choice.

Mixed adenoendocrine carcinoma in the extrahepatic biliary tract: A case report and literature review

Neuroendocrine neoplasm (NEN) comprises a group of tumors that exhibit neuroendocrine phenotypes. NEN is subclassified into neuroendocrine tumor (NET), neuroendocrine carcinoma (NEC) and mixed adenoendocrine carcinoma (MANEC), based on histopathological parameters. NEN in the extrahepatic biliary tract (EHBT) is uncommon. Little is known about its clinicopathological features and prognostic indicators. The present study presented a case of MANEC in the distal common bile duct (CBD) and reviewed previous cases of NENs in the EHBT to characterize the clinical settings of this disease entity and to identify influencing factors of survival outcomes. A 64-year-old Chinese woman presented with abdominal pain and jaundice. Imaging studies demonstrated malignant stenosis in the distal CBD. Bile duct brush cytology revealed small clusters of atypical cells. Following an initial diagnosis of distal cholangiocarcinoma (CCA), the patient underwent pancreaticoduodenectomy. Histological analysis combined with immunohistochemical investigation of the resected specimen revealed a collision tumor that was composed of poorly differentiated adenocarcinoma and NEC. Each histological component accounted for >30% of the tumor. The definitive diagnosis was a MANEC in the distal CBD. Multiple intrahepatic and pulmonary metastases were observed postoperatively over 8 months. The patient succumbed to the disease 12 months after surgery. In conclusion, NEN occurs infrequently in the EHBT, with NET being the predominant type. NEN in the EHBT is extremely challenging to diagnose preoperatively due to its tendency to mimic CCA. Patients with NEN in the EHBT exhibited extremely distinct oncology outcomes according to pathological types. Additionally, old age (>60 years) and the presence of tumor recurrence were associated with decreased survival of patients with NEN.

Preoperative diagnosis of well-differentiated neuroendocrine tumor in common hepatic duct by brush cytology: A case report

The biological behavior of neuroendocrine tumors (NETs) is heterogeneous and differs from that of cholangiocarcinoma, which is the most common malignant tumor of the biliary tree. However, the preoperative diagnosis of NET in the biliary tree is extremely difficult and to our knowledge, diagnosis by brush cytology has not previously been reported. Herein, we first reported a case of biliary NET preoperatively diagnosed by brush cytology in a 33-year-old female patient. Imaging study revealed a 2.6-cm mass in the common hepatic duct. The brush cytology was characterized by loosely cohesive plasmacytoid tumor cells and scattered clusters of thin vascular septa. The tumor cells showed abundant cytoplasm and severe nuclear size variation but mitosis was not observed. Immunohistochemical staining of the cell block (CB) showed strong positivity for both synaptophysin and chromogranin A and a Ki-67 labeling index of 3.5%. The surgically resected bile duct mass was pathologically confirmed as NET, G2 with lymphovascular and perineural invasion of the tumor cells. The patient showed no evidence of tumor recurrence 10 months after operation without adjuvant chemotherapy. Suspicion of this rare tumor and immunohistochemical staining of the CB are important for the preoperative diagnosis of NET in the biliary tree.

Neuroendocrine tumor of the common bile duct: a case report and review of the literature

We report a rare case of neuroendocrine tumor (NET) in the common bile duct (CBD). The patient is a 56-year-old female who presented to our department with symptoms of fever but without jaundice. A preoperative examination showed a tumor in the CBD. The tumor volume was almost 5.5 × 4.5 × 4 cm³, which is the biggest NET in the CBD reported on PubMed. The imaging results (computed tomography [CT] and magnetic resonance imaging [MRI]) were not consistent with CBD adenocarcinoma. The tumor appeared to oppress the growth of the CBD rather than originate in the bile duct wall; combined with the low blood bilirubin index and lack of jaundice symptoms, the preoperative diagnosis was not clear. We performed a radical resection of the cholangiocarcinoma. The patient recovered well before going home. The pathology was NET (Grade 2). The patient showed no recurrence to date, without intravenous chemotherapy (8 months).