Roundtable Roundup: February | Biliary Tract Cancer

CASE SUMMARY

• A 72-year-old man presented to a local hospital with a 4-month history of jaundice, dark urine, itchy skin, and unintentional weight loss of 8 lb.
• He was referred to a gastrointestinal specialist 2 months ago by his primary care physician but had no resolution of symptoms.
• Physical examination showed an obese, tired-appearing man.
• His medical history was unremarkable aside from a 20 pack-year history of smoking and relatively heavy alcohol consumption at approximately 15 drinks per week.
• His laboratory results showed the following: Total bilirubin: 22.9 mg/dL
  • Direct bilirubin: 19.2 mg/dL
  • Alkaline phosphatase: 89 U/L
  • Alanine aminotransferase: 89 U/L
  • Aspartate aminotransferase: 99 U/L
  • γ-glutamyl transpeptidase: 222 U/L
  • Cancer antigen 19-9: 293 U/mL
  • Carcinoembryonic antigen: 10 ng/mL
  • α-fetoprotein: 20 ng/mL
• Hepatitis B screening and autoimmune profile were negative.

CASE UPDATE

• The patient underwent endoscopic retrograde cholangiopancreatography with brush cytology.
• Bile duct strictures were visualized during the procedure.
• Pathologic diagnosis:
  • Atypical tumor cells with enlarged nuclei and prominent nucleoli
  • Abundant stromal component with a desmoplastic reaction
  • Moderately differentiated infiltrative glands arising from a biliary intraepithelial neoplasia at the site of the choledocus, consistent with extrahepatic cholangiocarcinoma
• Three weeks after surgery:
  • Total bilirubin: 1.2 mg/dL
  • Direct bilirubin: 0.2 mg/dL
• A CT scan demonstrated multiple liver lesions plus extrahepatic perihilar regional lymph nodes and lesions in the left lung and left femur.