Difficulties in the management of Klatskin Tumor: a case report and review of literature

Abstract

Background: Tumours of the biliary tract are rare, and difficult to recognize in early stages. Due to its late presentation and the location of the tumour, a definite diagnosis is not always possible pre operatively. Therefore, some guidelines maintained that diagnosing these tumours may be made intraoperatively or post operatively , when tissue samples are available. We report a patient with jaundice and subsequently diagnosed as Klatskin tumour.Case Description : A 54 years old women came to our surgical clinic with the chief complaint of jaundice for 2 months. MRCP showed mass on the confluent of bile duct, infiltrating both right and left hepatic duct, with no evidence of metastasis or infiltration of portal vein. CEA and CA 19-9 were within normal limits. We found the tumor is clinically did not extend to the bile duct serosa, performed choledocotomy and biopsy of the tumor, requesting frozen section pathology evaluation. The result showed no malignancy. However due to the tumor showed clinical signs of malignancy and caused bile obstruction ,we decided to performed oncological resection of all involved bile ducts and dissection of lymphnodes, and bilateral hepaticojejunostomy bypass Roux en Y. The postoperative pathological evaluation showed an adenocarcinoma.Conclusion : Difficulties in diagnosing common bile duct malignancy lies in nonspecific clinical symptoms (abdominal discomfort, jaundice, weight loss) and obtaining pathological specimens. The later is due to difficult access to the tumor, while risking injury to adjacent organs. Tumor markers (Ca 19-9 and CEA) are not very sensitive or specific for bile duct malignancy (ranging from 60 to 80%). Positive results of endoscopic cytology or biopsy range form 30-80%, and are not widely available in our settings. In our cases, when the general patient condition is good, laparotomy, intraoperative biopsy and subsequent resection if possible and neccessary is a possible approach in the management of possible bile duct malignancy. For clinical and radiological highly suspicious Klatskin tumor, exploratory laparotomy, intraoperative biopsy and intraoperative decision based on the findings may be justified. Surgeon must be prepared to perform all necessary procedure before attempting to do laparotomy.