Maeda Takashi, Ebata Tomoki, Yokoyama Yukihiro, Igami Tsuyoshi, Mizuno Takashi, Yamaguchi Junpei, Onoe Shunsuke, Watanabe Nobuyuki, Nagino Masato
Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
Surg Case Rep. 2019 Nov 9;5(1):177. doi: 10.1186/s40792-019-0745-z.
In situ cholangiocarcinoma is difficult to detect by imaging studies. Thus, cholangiocarcinoma is rarely resected with a preoperative definitive diagnosis, especially nonpapillary flat type in situ carcinoma, which is extremely rare.
A 70-year old man was diagnosed with gallbladder cancer and received open cholecystectomy with lymphadenectomy at a local hospital. Histologically, the tumor was localized in the mucosal layer, and no lymph node metastases were found. Three months later, hilar bile duct stricture due to delayed bile duct ischemia was found. Then, biliary drainage was performed with endoscopic biliary stenting. Three months later, the patient experienced cholangitis with septic shock, and percutaneous transhepatic biliary drainage (PTBD) into the left intrahepatic bile duct was performed. Unexpectedly, the aspiration bile cytology of the PTBD catheter showed malignant cells, and the patient was referred to our clinic for possible surgical treatment. According to additional studies, the hilar bile duct stricture was 3 cm in length. None of the imaging studies detected malignant cells in the bile duct around the hilar stricture. The left portal vein was obstructed due to inadvertent puncture of the PTBD. No findings indicated cholangiocarcinoma. We performed left hepatectomy with caudate lobectomy and extrahepatic bile duct resection. The postoperative course was uneventful. In the final pathology, flat type in situ carcinoma was found at the confluence of the right and left hepatic ducts, which was distant from the biliary stricture.
When a tumor is undetectable but cytology is positive, in situ cholangiocarcinoma may exist; thus, surgery should be carefully considered.
原位胆管癌很难通过影像学检查发现。因此，胆管癌很少在术前明确诊断后进行切除，尤其是非乳头状扁平型原位癌，极为罕见。
一名70岁男性在当地医院被诊断为胆囊癌，并接受了开腹胆囊切除术及淋巴结清扫术。组织学检查显示，肿瘤局限于黏膜层，未发现淋巴结转移。三个月后，发现因胆管缺血延迟导致肝门部胆管狭窄。随后，通过内镜胆管支架置入术进行胆道引流。三个月后，患者发生胆管炎并伴有感染性休克，遂行经皮经肝胆道引流（PTBD）至左肝内胆管。出乎意料的是，PTBD导管吸出的胆汁细胞学检查显示有恶性细胞，患者被转诊至我院考虑可能的手术治疗。根据进一步检查，肝门部胆管狭窄长度为3厘米。所有影像学检查均未在肝门部狭窄周围的胆管中检测到恶性细胞。由于PTBD意外穿刺导致左门静脉阻塞。未发现提示胆管癌的迹象。我们进行了左半肝切除、尾状叶切除及肝外胆管切除。术后过程顺利。最终病理检查发现，左右肝管汇合处存在扁平型原位癌，距胆管狭窄部位较远。
当肿瘤无法检测到但细胞学检查呈阳性时，可能存在原位胆管癌；因此，应谨慎考虑手术治疗。
