Metastatic Transitional Cell Carcinoma Masquerading as Cholangiocarcinoma

Abstract

Introduction: An 85-year old female presented with a 3-week history of RUQ pain radiating to the back. She reports intermittent nausea, nonbilious/nonbloody vomitus, anorexia, weight loss, and was found to have abnormal liver function tests. Her past medical history was significant for a stage II urothelial tumor of the left ureter treated with a left nephrectomy 1 year prior. On exam she was noted to have icterus, mild jaundice, and tenderness to palpation of the RUQ. No masses palpated and no organomegaly was noted. Laboratory findings showed elevated total bilirubin, alkaline phosphatase, AST, and ALT. Sonogram suggested acute cholecystitis and biliary ductal dilatation, and HIDA scan confirmed cystic duct obstruction. An MRI/MRCP was performed that suggested a malignant obstructive process in the RUQ, consistent with a cholangiocarcinoma. The patient underwent ERCP, which revealed a long smooth common bile duct stricture and brush cytology was obtained. A plastic stent was placed across the stricture with biliary drainage. EUS suggested gallbladder carcinoma without evidence of vascular invasion. She then underwent laparascopic investigation with intent to resect the tumor but was found to have encasement of the hepatic artery. An open cholecystectomy was performed and biopsy results were consistent with transitional cell origin (IHC was diffusely positive for GATA-3, p63 and focally positive for uroplakin-2). This was an unexpected finding of metastatic disease from her previous left renal pelvis tumor. More than 90% of ureter and renal pelvis tumors are of urothelial origin. Histologically these represent transitional cell carcinoma (TCC) of the bladder. In the United States and Western Europe, approximately 90% of bladder cancers are TCC. Much less commonly, urothelial cancers can arise in the renal pelvis, ureter, or urethra. TCC rarely spreads to distant sites and this occurs in less than 5% of cases. The most common sites of TCC metastasis are lymph nodes, bone, lung, liver, and peritoneum. Metastasis causing biliary obstruction is extremely rare; there has been only 1 report which described bile duct wall metastasis due to TCC mimicking primary hilar cholangiocarcinoma and 1 case in which TCC metastasized to the gallbladder. Furthermore, to our knowledge, there has not been a case in which TCC not only caused biliary obstruction but also cystic duct obstruction. This is the first case in which a TCC caused common bile duct and cystic duct obstruction. This is an extremely uncommon scenario in the literature. Therefore, physicians should consider, in the appropriate setting, metastatic TCC causing biliary obstruction. The patient in this case was successfully palliated with a cholecystectomy and CBD SEMS placement. She was planned to begin outpatient chemotherapy.