Intrabilary obstruction by colorectal metastases

Intrabilary obstruction by colorectal metastases Intrabiliary colorectal metastases are rare. We present a case of an 84-year-old man who developed obstructive jaundice sec- ondary to intrabiliary growth of colorectal metastases. The patient presented with three weeks of jaundice and significant weight loss in the preceding months. The patient’s background included metastatic colorectal carcinoma, with a previous right hemicolectomy and left hepatectomy for liver metastases. A MRCP showed an obstruction of the biliary tract transi- tioning at the ampulla. Histology confirmed a malignant adenocarcinoma. When compared to the patient’s previous resected colorectal liver metastases, morphology and immunohistochemistry was consistent with colorectal metastases. This case highlights the importance of differentiating a new intraductal papillary neoplasm from a colorectal metastasis. Correctly identifying these lesions requires the use of MRCP and ERCP, as well as immunohistochemistry. This is a priority for clinicians to ensure appropriate therapy. showed alikelymalignant stricture. A sphincterotomy was per- INTRODUCTION formed, the common bile duct was dilated, and a biopsy and bile Intrabiliary colorectal metastases are rare, representing 4.5% duct brushings were taken. As the patient was a poor surgical of all colorectal hepatobiliary metastases [1]. Only half of candidate, a metallic stent was inserted. Histology of the bile duct these metastases will have evidence of a biliary dilation or biopsy showed intestinal differentiation and was morphologically obstruction [1]. Differentiating a new intraductal papillary similar when compared to the patient’s previous resected colorec- neoplasm from a colorectal metastasis is difficult, relying on tal liver metastases. Bile duct brushings showed malignant cells immunohistochemistry. consistent with adenocarcinoma. Immunohistochemistry was cytokeratin-7(CK-7) negativeand CK-20positive, favouringan CASE REPORT intrabiliary colorectal metastasis over a new primary bile duct carcinoma. Post-metallic stent insertion, the patient had a reso- An 84-year-old man presented to the Emergency Department lution of his elevated bilirubin and was referred to Medical with a 3-week history of jaundice. He reported recent dark urine Oncology for palliative chemotherapy. and weight loss of 8 kg over the preceding 3 months. The patient had a previous history of metastatic colorectal carcinoma, with a right hemicolectomy four years ago and a left hepatectomy DISCUSSION one year ago for liver metastases. Bloods revealed a bilirubin of 224 U/L and raised liver enzymes consistent with an obstructive Approximately 93% of all intrabiliary metastases have been picture. He was admitted to the hospital and underwent a mag- shown to be of colorectal origin, with lung and kidney account- netic resonance cholangiopancreatography (MRCP). MRCP ing for the majority of the remainder [1, 2]. In all, 50% of intra- (Fig. 1) showed obstruction of the biliary tract transitioning at biliary colorectal metastases are found in major bile ducts [2, 3]. the ampulla. An endoscopic retrograde cholangiopancreatogra- Intrabiliary colorectal metastases are generally identified within phy (ERCP) demonstrated no choledocholithiasis; however, 28 months of resection of the primary tumour [4]. Received: November 21, 2017. Accepted: January 3, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx259/4812593 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 L. Traeger and G. Kiroff when performing resection for liver metastasis leads to unex- pected recurrences [1]. If surgical resection is not considered appropriate, as with our case, the use of metal stent is prefer- able. Metal stenting with ERCP has been shown to reduce rate of occlusion, lower stent failure rates and less frequent epi- sodes of cholangitis compared to plastic stenting [7]. In summary, intrabiliary colorectal metastases are a rare finding. Patients presenting with jaundice and a past history of colorectal cancer should be approached with a high level of suspicion for intrabiliary metastases. MRCP and ERCP are con- sidered integral in identifying intrabiliary lesions. Clinicians should be aware that correctly identifying intrabiliary lesions is important, as incorrect therapy can be harmful to patients. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES Figure 1: MRCP showing an obstruction of the biliary tract (identified with red arrow) transitioning at the ampulla. 1. Conci S, De Bellis M, Ruzzenente A, Capelli P, D’Onofrio M, Iacono C, et al. Totally intrabiliary colorectal liver metastasis In our case, jaundice was the prominent feature leading to mimicking intraductal growth-type cholangiocarcinoma. diagnosis. Jaundice and increasing carcinoembryonic antigen Updates Surg 2016;68:211–2. (CEA) are the most frequent clinical signs raising the suspicion of 2. Dong Y, Patel H, Patel C. Hepatic metastasis of colorectal car- intrabiliary colorectal metastases, however, these signs do not cinoma mimicking primary cholangiocarcinoma: A case allow differentiation from alternative diagnosis [5]. Computerized report and review of the literature. Case Rep Pathol 2016;2016: tomography (CT), which is commonly used for monitoring of 4704781. colorectal cancer, does not reliably make a diagnosis of intra- 3. Gordo SL, Rubio ER, Torra JT, Garriga LL, Renau AR. biliary colorectal metastases [6]. CT changes can be subtle and Intrabiliary growth of colorectal liver metastases. Cir Esp dilation of ducts may be the only identifiable abnormality [6]. 2016;94:115–6. MRCP is preferred imaging modality if intrabiliary metastasis 4. Estrella JS, Othman ML, Taggart MW, Hamilton SR, Curley is suspected. SA, Rashid A, et al. Intrabiliary growth of liver metastases: Differentiating an intraductal papillary neoplasm from colo- clinicopathologic features, prevalence, and outcome. Am J rectal metastases relies heavily on immunohistochemistry. Surg Pathol 2013;37:1571–9. Primary biliary and pancreatic adenocarcinomas are CK-7 posi- 5. Coppola S, Zucchini N, Romano F, Bovo G, Gilardoni E, tive in 71–100% of cases and CK-20 positive in 22–46% of cases Nespoli L, et al. Colorectal liver metastasis with intrabiliary [7]. Colorectal metastases are CK20 positive in 91–100% of cases growth: case report and review of the literature. Int J Surg and are uncommonly CK-7 positive [7]. Thus in our case the Pathol 2014;22:272–9. intrabiliary lesion is most consistent with a colorectal metas- 6. Peungjesada S, Aloia TA, Kaur H, Marcal L, Choi H, Vauthey tases. Differentiating between intraductal papillary neoplasm JN, et al. Intrabiliary growth of colorectal liver metastasis: and colorectal metastases shouldbeapriority forclinicians spectrum of imaging findings and implications for surgical to ensure appropriate therapy [8]. Incorrectly identifying management. AJR Am J Roentgenol 2013;201:W582–9. intrabiliary colorectal metastases as an intraductal papillary 7. Strauss AT, Clayton SB, Markow M, Mamel J. Colon cancer neoplasm can lead to more radical resection as opposed to a metastatic to the biliary tree. ACG Case Rep J 2016;3:214–6. limited resection [5]. 8. Yamao T, Hayashi H, Higashi T, Takeyama H, Kaida T, Nitta Ideal treatment of patients with colorectal metastasis and H, et al. Colon cancer metastasis mimicking intraductal pap- macroscopic intrabiliary growth requires an anatomical hepa- illary neoplasm of the extra-hepatic bile duct. Int J Surg Case tobiliary resection [5]. Failure to identify intrabiliary invasion Rep 2015;10:91–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx259/4812593 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Intrabilary obstruction by colorectal metastases

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Abstract

Intrabiliary colorectal metastases are rare. We present a case of an 84-year-old man who developed obstructive jaundice sec- ondary to intrabiliary growth of colorectal metastases. The patient presented with three weeks of jaundice and significant weight loss in the preceding months. The patient’s background included metastatic colorectal carcinoma, with a previous right hemicolectomy and left hepatectomy for liver metastases. A MRCP showed an obstruction of the biliary tract transi- tioning at the ampulla. Histology confirmed a malignant adenocarcinoma. When compared to the patient’s previous resected colorectal liver metastases, morphology and immunohistochemistry was consistent with colorectal metastases. This case highlights the importance of differentiating a new intraductal papillary neoplasm from a colorectal metastasis. Correctly identifying these lesions requires the use of MRCP and ERCP, as well as immunohistochemistry. This is a priority for clinicians to ensure appropriate therapy. showed alikelymalignant stricture. A sphincterotomy was per- INTRODUCTION formed, the common bile duct was dilated, and a biopsy and bile Intrabiliary colorectal metastases are rare, representing 4.5% duct brushings were taken. As the patient was a poor surgical of all colorectal hepatobiliary metastases [1]. Only half of candidate, a metallic stent was inserted. Histology of the bile duct these metastases will have evidence of a biliary dilation or biopsy showed intestinal differentiation and was morphologically obstruction [1]. Differentiating a new intraductal papillary similar when compared to the patient’s previous resected colorec- neoplasm from a colorectal metastasis is difficult, relying on tal liver metastases. Bile duct brushings showed malignant cells immunohistochemistry. consistent with adenocarcinoma. Immunohistochemistry was cytokeratin-7(CK-7) negativeand CK-20positive, favouringan CASE REPORT intrabiliary colorectal metastasis over a new primary bile duct carcinoma. Post-metallic stent insertion, the patient had a reso- An 84-year-old man presented to the Emergency Department lution of his elevated bilirubin and was referred to Medical with a 3-week history of jaundice. He reported recent dark urine Oncology for palliative chemotherapy. and weight loss of 8 kg over the preceding 3 months. The patient had a previous history of metastatic colorectal carcinoma, with a right hemicolectomy four years ago and a left hepatectomy DISCUSSION one year ago for liver metastases. Bloods revealed a bilirubin of 224 U/L and raised liver enzymes consistent with an obstructive Approximately 93% of all intrabiliary metastases have been picture. He was admitted to the hospital and underwent a mag- shown to be of colorectal origin, with lung and kidney account- netic resonance cholangiopancreatography (MRCP). MRCP ing for the majority of the remainder [1, 2]. In all, 50% of intra- (Fig. 1) showed obstruction of the biliary tract transitioning at biliary colorectal metastases are found in major bile ducts [2, 3]. the ampulla. An endoscopic retrograde cholangiopancreatogra- Intrabiliary colorectal metastases are generally identified within phy (ERCP) demonstrated no choledocholithiasis; however, 28 months of resection of the primary tumour [4]. Received: November 21, 2017. Accepted: January 3, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx259/4812593 by Ed 'DeepDyve' Gillespie user on 16 March 2018 2 L. Traeger and G. Kiroff when performing resection for liver metastasis leads to unex- pected recurrences [1]. If surgical resection is not considered appropriate, as with our case, the use of metal stent is prefer- able. Metal stenting with ERCP has been shown to reduce rate of occlusion, lower stent failure rates and less frequent epi- sodes of cholangitis compared to plastic stenting [7]. In summary, intrabiliary colorectal metastases are a rare finding. Patients presenting with jaundice and a past history of colorectal cancer should be approached with a high level of suspicion for intrabiliary metastases. MRCP and ERCP are con- sidered integral in identifying intrabiliary lesions. Clinicians should be aware that correctly identifying intrabiliary lesions is important, as incorrect therapy can be harmful to patients. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES Figure 1: MRCP showing an obstruction of the biliary tract (identified with red arrow) transitioning at the ampulla. 1. Conci S, De Bellis M, Ruzzenente A, Capelli P, D’Onofrio M, Iacono C, et al. Totally intrabiliary colorectal liver metastasis In our case, jaundice was the prominent feature leading to mimicking intraductal growth-type cholangiocarcinoma. diagnosis. Jaundice and increasing carcinoembryonic antigen Updates Surg 2016;68:211–2. (CEA) are the most frequent clinical signs raising the suspicion of 2. Dong Y, Patel H, Patel C. Hepatic metastasis of colorectal car- intrabiliary colorectal metastases, however, these signs do not cinoma mimicking primary cholangiocarcinoma: A case allow differentiation from alternative diagnosis [5]. Computerized report and review of the literature. Case Rep Pathol 2016;2016: tomography (CT), which is commonly used for monitoring of 4704781. colorectal cancer, does not reliably make a diagnosis of intra- 3. Gordo SL, Rubio ER, Torra JT, Garriga LL, Renau AR. biliary colorectal metastases [6]. CT changes can be subtle and Intrabiliary growth of colorectal liver metastases. Cir Esp dilation of ducts may be the only identifiable abnormality [6]. 2016;94:115–6. MRCP is preferred imaging modality if intrabiliary metastasis 4. Estrella JS, Othman ML, Taggart MW, Hamilton SR, Curley is suspected. SA, Rashid A, et al. Intrabiliary growth of liver metastases: Differentiating an intraductal papillary neoplasm from colo- clinicopathologic features, prevalence, and outcome. Am J rectal metastases relies heavily on immunohistochemistry. Surg Pathol 2013;37:1571–9. Primary biliary and pancreatic adenocarcinomas are CK-7 posi- 5. Coppola S, Zucchini N, Romano F, Bovo G, Gilardoni E, tive in 71–100% of cases and CK-20 positive in 22–46% of cases Nespoli L, et al. Colorectal liver metastasis with intrabiliary [7]. Colorectal metastases are CK20 positive in 91–100% of cases growth: case report and review of the literature. Int J Surg and are uncommonly CK-7 positive [7]. Thus in our case the Pathol 2014;22:272–9. intrabiliary lesion is most consistent with a colorectal metas- 6. Peungjesada S, Aloia TA, Kaur H, Marcal L, Choi H, Vauthey tases. Differentiating between intraductal papillary neoplasm JN, et al. Intrabiliary growth of colorectal liver metastasis: and colorectal metastases shouldbeapriority forclinicians spectrum of imaging findings and implications for surgical to ensure appropriate therapy [8]. Incorrectly identifying management. AJR Am J Roentgenol 2013;201:W582–9. intrabiliary colorectal metastases as an intraductal papillary 7. Strauss AT, Clayton SB, Markow M, Mamel J. Colon cancer neoplasm can lead to more radical resection as opposed to a metastatic to the biliary tree. ACG Case Rep J 2016;3:214–6. limited resection [5]. 8. Yamao T, Hayashi H, Higashi T, Takeyama H, Kaida T, Nitta Ideal treatment of patients with colorectal metastasis and H, et al. Colon cancer metastasis mimicking intraductal pap- macroscopic intrabiliary growth requires an anatomical hepa- illary neoplasm of the extra-hepatic bile duct. Int J Surg Case tobiliary resection [5]. Failure to identify intrabiliary invasion Rep 2015;10:91–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/1/rjx259/4812593 by Ed 'DeepDyve' Gillespie user on 16 March 2018

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Jan 1, 2018

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