1404 Sclerotic Bone Metastasis From Cholangiocarcinoma: A Case Report

Abstract

INTRODUCTION: Cholangiocarcinoma (CCA) account for 3% of gastrointestinal malignancies. Commonly it metastasizes to liver, peritoneum and lymph nodes. Rarely it metastasizes to bone with lytic lesions. We are presenting a case of metastatic CCA with sclerotic bone metastasis. CASE DESCRIPTION/METHODS: 59-year-old female with no medical history presented with diffuse abdominal pain for 2 weeks. She denied other complaints, illicit drug use, personal or family of history of malignancy. She was a 40-pack year smoker and social drinker. Vitals and physical exam were unremarkable except minimally diffuse tender abdomen. Labs revealed elevated AST, ALT, ALP and Bilirubin which were 524, 640, 2300 and 1.7 respectively. CT abdomen with IV contrast showed intrahepatic biliary ductal dilatation and prominence of the common hepatic duct with abrupt tapering of the duct proximal to a small, high density mass versus short segment ductal wall thickening, normal Pancreatic duct and widespread sclerotic bone lesions. MRCP showed 3 cm long nonspecific stricture involving the mid CBD regional to the insertion of the cystic duct. No associated mass or abnormal enhancement with moderate intrahepatic biliary duct dilatation in both liver lobes. CA 19-9, CEA, and AFP were elevated to 492, 700, and 7 respectively. Bone scan showed extensive diffuse increased activity over multiple focal areas within the calvarium, sternum, bilateral ribs, scapulae, entire spine, pelvis, diffusely involving most femurs. ERCP with spyglass was done along with brush biopsy and metal stent placement. Biopsy samples were not adequate for tissue diagnosis. Iliac crest biopsy was sent for pathology, immunohistochemistry (IHC), flow cytometry and chromosome analysis which showed metastatic adenocarcinoma, by IHC (pankeratin+ CK7+, CK20+, MOC31+, CK19+, CA19-9+) most compatible with pancreatobilliary primary. Flow cytometry did not show any evidence of myeloproliferative disorder and chromosome analysis could not be done due to nondividing cells. Pt underwent palliative chemotherapy for metastatic CCA with gemcitabine and cisplatin. DISCUSSION: Metastatic CCA to the bone is rare. In the few case reports describing this finding, bony lesions are usually lytic in nature. Sclerotic bone metastasis from CCA has never been reported in literature. Prognosis is extremely poor due to the minimal response to conventional chemotherapy or radiotherapy, symptom control, particularly pain, is the mainstay of treatment for improving the quality of life of the patients.