Challenges in the Diagnosis of Biliary Malignancies: Klatskin Tumor, A Case Report

Abstract

Klatskin described cholangiocarcinomas arising at the level of the hepatic duct bifurcation in 1965, hence its name (1). They comprise 3% of all the gastrointestinal malignancies from the biliary tract. In the United States the higher prevalence ranks among African Americans and Asian Pacific Islanders (2). Due to the location of these lesions and non-specific symptoms, they are usually caught on very late stages, making treatment and prognosis an issue. At the same time, diagnosis can be challenging as invasive procedures like endoscopic retrograde cholangiopancreatography (ERCP) and tissue biopsy are required for a better characterization of any lesion in the biliary tree. We report the case of a 74 years old male who presented with jaundice, abdominal pain, dark loose stools and weight loss for three months. He was noted to have a total bilirubin of 14mg/dl, alkaline phosphatase 888mg//dl. A computer tomography showed a perforation vs malignancy in the gallbladder surrounded by pericholic abscess. He received a course of antibiotics to prevent cholangitis. A drain was placed relieving the obstruction; the cholangiogram revealed an obstruction at the confluence of the left and right hepatic ducts. The Radiology service considered a MRCP would not be beneficial due to high amount of gas and stones. Surgery determined that a biopsy could not be done due to inaccessibility and also he was a poor surgical candidate for any intervention. Tumoral markers were elevated. We could not establish the diagnosis of cholangiocarcinoma by tissue biopsy although the tumor markers and location of the lesion were highly suggestive for Klatskin tumor. Due to poor prognosis, the patient opted for hospice care. As mentioned before, the diagnosis of cholangiocarcinoma can be challenging due to its location and, like in this case, the possibility of synchronous malignancies (gallbladder). A proper diagnosis can be made through lesion biopsy. Unfortunately, just 26% of patients are surgery candidates either due to poor prognosis, late stage of diagnosis or multiple comorbidities (3). ERCP/MRCP are very useful imaging techniques that allow a fairly direct visualization of the biliary tree, however, due to the amount of gas and stones, this modality is not always optimal. The prognosis of these malignancies is very bad, around 7 months since the time of diagnosis. Poor prognostic factors are: the presence of metastasis, perineural invasion or involvement of the cystic duct.(4)2907_A Figure 1. Severe intrahepatic biliary ductal dilatation. Pericholecystic abscess.2907_B Figure 2. Obstruction at the level of hepatic cysts bifurcation concerning for malignancy.