Carcinoma of the bile ducts. A case report.

Abstract

Roentgenographic recognition of carcinoma of the biliary ducts preoperatively is seldom possible. In the case to be reported here, a diagnosis of scirrhous neoplastic involvement of the entire common duct, as well as of the right and left hepatic ducts, was made following a percutaneous cholangiographic study. This diagnosis was substantiated at surgery, and a detailed roentgenographicpathologic correlation was possible as a result of autopsy study. The extent of involvement of the duct system, especially extension of the tumor into the porta hepatis, with involvement of the right and left hepatic ducts, permitted us to foresee failure of any contemplated surgical procedure for alleviation of the patient's jaundice. It is possible that, under different circumstances, one might be able to predict the type of operation necessary to carry out successfully a shunt procedure of the obstructed biliary duct system. Case History C. T., a 66-year-old white woman, was admitted March 28, 1957, with a persistent painless jaundice which had been present for three weeks, swelling of the right arm, and multiple purpuric areas over the body, of three days duration. She had noted light stools and dark urine during the preceding three weeks. There was a history of severe rheumatoid arthritis over the last eighteen years. On physical examination, the patient was found to be well developed, moderately obese, and markedly jaundiced, with multiple purpuric areas over the entire body. The liver appeared to be enlarged five fingerbreadths below the costal margin and was suggestively nodular to palpation. There was deformity of both knees, wrists, and the fingers, due to arthritic changes. Laboratory studies revealed findings consistent with obstructive jaundice, and a liver biopsy, April 10, 1957, was interpreted as indicating a low-grade chronic biliary hepatitis with jaundice. Percutaneous cholangiography performed April 12, 1957, with the needle entering the right hepatic duct, delineated the entire duct system, including the common duct, and opaque material entered the duodenum. There was diffuse irregular narrowing of the common duct, extending into the hepatic bifurcation, with involvement of short segments of the right and left hepatic ducts. The remainder of the biliary duct system was markedly dilated. It was felt that the findings were due to an infiltrating neoplasm of the common duct, with involvement of the right and left hepatic ducts. Exploratory surgery, April 12, 1957, revealed a firm, hard gallbladder. A mass of firm rubbery nodes in the region of the porta hepatis was present, with infiltration of the entire common bile duct. It was not possible to cannulate the common duct and no bypass procedure of any type could be carried out. A lymph node removed for biopsy revealed adenocarcinoma.