A Case of Cholangiocarcinoma Diagnosed by Skin Biopsy

Abstract

A 72-year-old man presented to an outside hospital with abdominal pain, jaundice, and a 30 lb weight loss. CT showed choledocholithiasis and suspected cholecystitis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) which revealed stones in the common bile duct (CBD). Sphincterotomy and stone extraction with stent placement was performed. A laparoscopic cholecystectomy was done, revealing a hydropic gallbladder (GB) that was pierced open, suctioned and subsequently removed in an endobag. A JP drain was left in the GB bed and pulled through a port site. The patient's jaundice did not improve and he was transferred to another facility where endoscopic ultrasound demonstrated a hilar mass with an associated CBD stricture. An ERCP with brush and biopsy of the CBD stricture was also done, and cytology returned showing only atypia. Both procedures were repeated two weeks later and results were again negative. In the interim, the patient underwent skin biopsy of an enlarging subcutaneous nodule located at a previous surgical port site and the results returned as metastatic adenocarcinoma. A GI pathologist re-examined the GB specimen obtained during the laparoscopic cholecystectomy and noted that there was evidence of cholangiocarcinoma (CCA) within the GB wall. CCA carries a dismal prognosis when detected in an advanced stage and early diagnosis is a challenge. The prevalence of incidental GB carcinoma is between 1% and 2% of all cholecystectomies performed with some studies reporting an incidence as high as 7.4%. Removal of unsuspected GB carcinoma laparoscopically can lead to seeding of tumor cells into the abdominal wall. Incidence of port site recurrence after laparoscopic cholecystectomy for unsuspected GB cancer can be as high as 14%. Intraoperative GB perforation can raise this rate of recurrence to 40%. Recurrences usually occur 6 to 16 months after the operation as was seen in this case. There are several proposed mechanisms of port site recurrence, the most popular of which include: direct wound contamination from laparoscopic instruments; the bile itself containing exfoliated tumor cells which can spread with bile spillage; and also, whether insufflation of the peritoneum can enhance wound metastases. In this case, JP drain placement along with GB perforation may also have been a route of seeding. Physicians should be aware of the risk of tumor seeding when CCA is a possibility in order to avoid the acceleration of metastatic disease.