Successful Endoscopic Resection of Stage T1 Intraductal Biliary Adenocarcinoma

Abstract

SymbolIntroduction: Intraductal biliary cancers are typically managed surgically. We present a case of an intraductal biliary adenocarcinoma that was successfully managed endoscopicallySymbolMethods: A 78-year-old female with a past medical history of COPD on home O2 and obesity, presented with acute right upper quadrant (RUQ) pain. Labs were notable for ALT=43U/L, alkaline phosphatase=130U/L, and total bilirubin=0.2mg/dl. RUQ ultrasound was limited given patient’s body habitus. CT abdomen revealed a normal pancreas without evidence of biliary ductal abnormalities. Given persistent biliary pain, an endoscopic ultrasound was performed and revealed a dilated CBD (14.1 mm) with stones and an isoechoic-filling defect in the distal CBD. The pancreatic duct (PD) was normal. At ERCP, the ampulla was prominent. The CBD stones were removed and while performing balloon sweep, a 3 cm polypoid friable lesion everted out of the distal CBD and was biopsied. Pathology revealed a villous adenoma. Given her high surgical risk, endoscopic resection was elected. At repeat ERCP, the intraductal polyp was everted using a balloon sweep and the lesion was resected en bloc using hot snare cautery. A focal duodenal wall perforation was noted and the defect was closed completely with endoclips. PD and CBD stents were quickly placed. Patient recovered uneventfully. Pathology revealed adenocarcinoma arising within the villous adenoma with submucosal invasion (stage T1). There was no malignancy identified at the resection margin. Given the patient’s early tumor stage and co-morbidities, the multi-disciplinary tumor board recommended close endoscopic surveillance. Two months later, surveillance ERCP with biopsy revealed no further malignancy. Results: Intraductal biliary tumors are relatively rare. Symptoms of intraductal biliary tumors can include obstructive jaundice, biliary colic, abdominal pain, and weight loss. The tumors are often found incidentally as seen in our patient. Treatment modalities include surgery (pancreaticoduodenectomy) and endoscopic resection. The gold standard of treatment remains surgery, but in patients that are high risk, endoscopic management offers a safe and effective alternative. Conclusion: Endoscopic management of early stage intraductal biliary neoplasia with close endoscopic surveillance is an acceptable alternative to surgery in high-risk patients.