Treatment Of Intraductal Papillary Neoplasm Research Articles

Percutaneous transhepatic cholangioscopy-assisted biliary polypectomy for local palliative treatment of intraductal papillary neoplasm of the bile duct.

Intraductal papillary neoplasm of the bile duct (IPNB) is a premalignant biliary-type epithelial neoplasm with intraductal papillary or villous growth. Currently reported local palliative therapeutic modalities, including endoscopic nasobiliary drainage, stenting and biliary curettage, endoscopic biliary polypectomy, percutaneous biliary drainage, laser ablation, argon plasma coagulation, photodynamic therapy, and radiofrequency ablation to relieve mechanical obstruction are limited with weaknesses and disadvantages. We have applied percutaneous transhepatic cholangioscopy (PTCS)-assisted biliary polypectomy (PTCS-BP) technique for the management of IPNB including mucin-hypersecreting cast-like and polypoid type tumors since 2010. To assess the technical feasibility, efficacy, and safety of PTCS-BP for local palliative treatment of IPNB. Patients with mucin-hypersecreting cast-like or polypoid type IPNB and receiving PTCS-BP between September 2010 and December 2019 were included. PTCS-BP was performed by using a half-moon type snare with a soft stainless-steel wire, and the tumor was snared and resected with electrocautery. The primary outcome was its feasibility, indicated by technical success. The secondary outcomes were efficacy, including therapeutic success, curative resection, and clinical success, and safety. Five patients (four with mucin-hypersecreting cast-like type and one with polypoid type IPNB) were included. Low- and high-grade intraepithelial neoplasia (HGIN) and recurrent IPNB with invasive carcinoma were observed in one, two, and two patients, respectively. Repeated cholangitis and/or obstructive jaundice were presented in all four patients with mucin-hypersecreting cast-like type IPNB. All five patients achieved technical success of PTCS-BP. Four patients (three with mucin-hypersecreting cast-like type and one with polypoid type IPNB) obtained therapeutic success; one with mucin-hypersecreting cast-like type tumors in the intrahepatic small bile duct and HGIN had residual tumors. All four patients with mucin-hypersecreting IPNB achieved clinical success. The patient with polypoid type IPNB achieved curative resection. There were no PTCS-BP-related serious adverse events. PTCS-BP appears to be feasible, efficacious, and safe for local palliative treatment of both mucin-hypersecreting cast-like and polypoid type IPNB.

Argon plasma coagulation treatment of intraductal papillary neoplasm of biliary tract: an alternative approach.

Argon plasma coagulation treatment of intraductal papillary neoplasm of biliary tract: an alternative approach.

Clinical features, diagnosis and treatment of intraductal papillary neoplasm of the bile duct

Objective: To study the clinicopathologic features of intraductal papillary neoplasm of the bile duct(IPNB) and to analyze the diagnostic and therapeutic patterns. Methods: The data of 46 patients with IPNB undergoing surgery in Department of Hepatobiliary and Pancreatic Surgery, the Second Affiliated Hospital of Zhejiang University School of Medicine from January 2013 to November 2017 were retrospectively analyzed.There were 23 males and 23 females with age of (64±8)years.Patients were followed up by clinics and telephone inquiry.Categorical data were compared with χ(2) test or Fisher's exact test. Results: Abdominal pain(in 31 patients), fever (in 15 patients) and jaundice (in 11 patients) were the most common symptoms.Twenty-five patients were accompanied with cholangiolithiasis and 25 were accompanied with liver atrophy.Preoperative laboratory examination was mainly manifested as the abnormal liver function caused by biliary obstruction.Typical imaging findings included bile duct dilation (in 45 patients) and mass within bile duct (in 22 patients). All the patients were diagnosed as IPNB histopathologically.Among them, high-grade intraepithelial neoplasia and related adenocarcinoma were more common in mucus-hypersecretion IPNB ((13/15 vs. 51.6%(16/31))(χ(2)=5.331, P=0.021). Hepatectomy was performed in 25 patients, hepatectomy combined with biliary resection and reconstruction in 12 cases, biliary resection and reconstruction in 3 cases, pancreatoduodenectomy in 3 cases, hepatopancreaticoduodenectomy in 1 case, liver transplantation in 1 case and radiofrequency ablation in 1 case.Forty-one patients were followed up with a median of 30 (12, 41) months.Seven patients suffered recurrence and 6 died. Conclusion: IPNB is a rare disease with limited knowledge currently.Images are the main diagnositc means and surgery is the first choice.

Diagnosis and treatment of intraductal papillary neoplasm of the bile duct

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare tumor arising from epithelia of bile duct, with a better prognosis compared with common cholangiocarcinoma. IPNB can occur anywhere along the biliary tree, and cause the dilation of the bile duct and acute cholangitis. Recent large case series of this peculiar disease in the far eastern countries showed greater incidences of hepatolithiasis and clonorchiasis compared with Western series. According to the immunochemistry features, IPNB can be classified into four subtypes, pancreaticobiliary, intestinal, gastric and oncocytic types. The pancreaticobiliary type is the most common and is usually associated with invasive lesions. Patients without distant metastasis can undergo surgical resection, surgical procedures include pancreaticoduodenectomy, hemihepatectomy, segmental liver resection and liver transplantation, and regional lymphectomy is necessary. Key words: Bile tract neoplams; Papillary neoplasms; Diagnosis; Therapy

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

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.

Roth Net Assisted Stone Removal via Direct Cholangioscopy

Purpose: Around 90% of extrahepatic bile duct stones are treated with endoscopic sphincterotomy followed by stone extraction, while others require additional intracorporeal lithotripsy for complete stone removal. Direct cholangioscopy (DC) with a mother-baby endoscopic system assists in visualizing and removing difficult to extract common bile duct (CBD) stones, but is limited by inferior optics, narrow maneuverability, and restrictive therapeutic applications from its small working channel. Furthermore, the procedure has poor visibility in dilated ducts, is time consuming, and usually requires the presence of two skilled endoscopists. SpyGlass® cholangioscopy (Boston Scientific) eliminates the need for a second endoscopist but much of the other limitations with the mother-baby endoscopic system remains. A 77 y/o male with a Billroth II for peptic ulcer disease underwent emergent endoscopic retrograde cholangiopancreatography (ERCP) with a limited papillotomy and stent placement for cholangitis. One month later he was re-admitted for elective cholecystectomy and ERCP with CBD stent and stone removal. ERCP with a pediatric colonoscope was initially used to traverse the afferent limb and the previous sphincterotomy was extended via needle knife and dilated up to 18 mm with a 15/16.5/18MM CRETM balloon dilator (Boston Scientific). Multiple balloon sweeps were performed with removal of two stones but a possible third retained stone was seen. The colonoscope was removed and an adult Olympus G-160 gastroscope was successfully passed via afferent limb into the ampulla and CBD where a CBD stone was identified. A Roth net was used to successfully retrieve the stone from the CBD, with DC up to the hilum showing no other additional stones. DC offers direct visualization of the biliary tree for diagnostic and therapeutic interventions, such as treatment of intraductal papillary neoplasm of bile duct, APC of recurrent hepatoma and intraductal growth, and EHL for difficult biliary stones. DC has typically been described using small-caliber endoscopes, with tandem endoscopy in intact gastrointestinal anatomy. Here we present a patient s/p Billroth II who underwent single-step DC with an adult gastroscope, with a novel form of CBD stone retrieval via a Roth net.Figure: [206]Disclosure: Dr. Kim - Consultant: Boston Scientific, Speaker: Gilead.