Expanding Role of Radiofrequency Ablation in the Treatment of Intraductal Papillary Neoplasms of the Bile Duct (IPNB)

Abstract

Introduction: Intraductal papillary neoplasms of the bile duct (IPNB) are relatively rare neoplasms with high malignancy potential. Total surgical resection has been the main curative treatment, but is many times limited by the location and extent of the lesion. Endoscopic retrograde cholangiopancreatography (ERCP) guided radiofrequency ablation (RFA) is a newly immerging therapy primarily used in palliation of pancreaticobiliary malignancies. We present a case using ERCP-guided RFA as an adjuvant curative treatment after incomplete surgical resection of cholangiocarcinoma arising from an IPNB. Case: 59 year old male with no significant past medical history presented forpainless jaundice. Initial bloodwork was consistent with obstructive jaundice, and MRI of abdomen demonstrated marked intrahepatic ductal dilation to the portal confluence. ERCP with Spyglass was performed. Cholangiography showed a single diffuse stenosis 20 mm in length in common hepatic duct, correlating with a frond-like/villous mass in the upper third of the bile duct seen with direct visualization and biopsied. Pathology returned as IPNB with high grade dysplasia (HGD). He underwent an exploratory laparotomy with bile duct resection, but negative margins could not be achieved. Surgical pathology demonstrated cholangiocarcinoma arising from an IPNB, without lymphovascular invasion. HGD was still present at the margin of the intra-pancreatic common bile duct (CBD) remnant. Repeat ERCP was performed one month later. ERCP-guided RFA was successfully performed on the intra-pancreatic CBD remnant, and repeat cholangioscopy demonstrating circumferential whitish mucosa indicative of ablated mucosa. The patient recovered well with initiation of chemotherapy and radiation planned in the future.Figure: IPNB seen on cholangiogram as 2cm stricture.Discussion: IPNB is a term encompassing a large spectrum of neoplasms affecting the biliary system, first categorized by WHO in 2010. Multiple histological subtypes exist, but in general carry a high risk of malignancy. Approximately 75% of IPNBs have features of invasive carcinoma, and pathology within a single IPNB lesion is usually heterogeneous warranting treatment. Ideally total surgical resection should be performed, but as this case demonstrates, may not always be possible. The role of ERCP-guided RFA for the treatment of pancreaticobiliary neoplasms is evolving. Here we demonstrate its utility as an adjuvant therapy in the curative treatment of an IPNB.Figure: Cholangioscopy of hepatic duct mass.Figure: Cholangioscopy after RFA.