Common bile duct stone and lung cancer

Case contributed by Dr Craig Hacking

Presentation

Painless jaundice. Cholestatic LFTs. No mass or hepatomegaly palpable. Alcoholic.

Patient Data

Age: 85-90 years
Gender: Male

There are numerous variable sized ill-defined low density lesions within the liver in keeping with metastatic disease. The portal vein is clear. Moderate intrahepatic bile duct dilatation and marked extra hepatic bile duct dilatation is secondary to a well-defined 13 mm round slightly hyperdense (to bile) filling defect obstructing the distal CBD. It has a central tiny focus of calcification and I cannot see any connection to the bile duct wall. There are numerous small calcified dependent gallstones within the distended gallbladder, none of which however are the size of the CBD filling defect. There is also a possible enhancing mural nodule arising from the gallbladder neck although this could represent a lymph node.

No definite colon primary malignancy is identified however there is there are 2 areas of mildly suspicious wall irregularity, within the hepatic flexure and the sigmoid colon. Simple cyst in the left kidney. No adrenal mass. Small volume of pelvic free fluid noted.

Lung bases are clear and emphysematous. No bony metastasis evident. Compression fractures of L3. L4 and L5 are likely long-standing.

Conclusion

Diffuse metastatic disease of the liver without an obvious primary identified. The bile ducts are obstructed at the level of the distal CBD by a likely 13 mm predominantly non-calcified calculus. It would be uncommon for this to represent a pedunculated bile duct tumour.

Potential sites for malignancy include a possible gallbladder enhancing nodule (gallbladder carcinoma) and minor colonic irregularity of the hepatic flexure and sigmoid colon (colorectal primary). Other common primaries such as lung and melanoma require exclusion. CXR is advised in the first instance.

Large right lower lobe superior segment mass with ill-defined opacity inferior to it represents primary lung tumour until proven otherwise. The left lung is clear. No pleural effusion. Cardiomediastinal contour is unremarkable. No suspicious osseous lesion.

Further evaluation with CT chest recommended.

Large lobulated mass in the apical segment of the right lower lobe, abutting the oblique fissure. There is extensive nodularity adjacent to the mass. Inferior to the mass tubular opacities appear continuous with the bronchus and may represent impacted mucus rather than additional tumour.

Patch of groundglass opacity in the right upper lobe. Background centrilobular emphysema throughout both lungs. Trachea and main bronchi are normal.

Right hilar node enlargement with calcific focus and prominent round pre-tracheal node.

The oesophagus is dilated and fluid filled, representing an aspiration risk.

Multiple liver lesions and duct dilatation are again noted as described previously. No destructive skeletal lesion although there is a sclerotic focus in the lateral right third rib.

Conclusion

Large right lower lobe mass in keeping with a primary lung cancer with liver metastases. Prominent right hilar and pretracheal lymph nodes are suspicious of further metastases.

Fluoroscopy

The large distal CBD stone was removed at ERCP.

Case Discussion

Ex-smoker 30 pack years. Bx showed NSCLC.

PlayAdd to Share

Case information

rID: 38381
Case created: 16th Jul 2015
Last edited: 15th Aug 2017
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.