Presentation
RUQ pain and vomiting.
Patient Data
Large necrotic mass lesion centered on the gallbladder measuring 11.1 x 9.2 cm in maximal trans-axial dimension. Adjacent hepatic flexure of the colon demonstrates mural thickening and mucosal hyperenhancement and is associated with adjacent inflammatory fat stranding likely secondary to local invasion. There is no extramural gas to suggest perforation. 5.3 x 3.1 x 3.6 cm collection at the porta hepatis is extrinsically compressing the duodenum, resulting in dilatation of the stomach bubble and a duodenal obstruction. Multiple prominent and enlarged intra-abdominal lymph nodes likely represent nodal metastatic disease.
Case Discussion
This is case of a lady with known progressive metastatic cholangiocarcinoma, having failed first-line chemotherapy. She presented to our emergency department with RUQ pain, fevers and vomiting. CT showed gastric outlet obstruction secondary to a 5x3cm collection at the porta hepatis compressing the duodenum, with a further 11x9cm collection at the gallbladder fossa.
The patient underwent endoscopic ultrasound (EUS) with fine needle aspiration (FNA) and biopsy. Extrinsic compression of D1/D2 secondary to a heterogenous hilar mass was noted on endoscopy. There was no associated high-grade obstruction as the echoendoscope was able to traverse through to D2 and there was minimal fluid contents in the stomach. This was fine-needle biopsied and the fluid was aspirated with an attempt to decrease the size of the mass (diagnostic and partially therapeutic).
Fine-needle biopsy histopathology report:
MACROSCOPIC (BIOPSY)
- Multiple (>10) fragments of tan tissue ranging in size from 1 up to 12mm in maximum extent
MICROSCOPIC (BIOPSY)
- Sections show fine cores composed of dense fibrous connective tissue infiltrated by moderately differentiated adenocarcinoma
- Morphological features are non-specific but would be consistent with metastatic cholangiocarcinoma
Fine-needle aspiration cytology report:
MACROSCOPIC (ASPIRATE)
- Received 20mL of cloudy yellow fluid
MICROSCOPIC (ASPIRATE)
- Specimen contains numerous neutrophils and a small amount of blood with some bi- and multinuclear histiocytes
- This is consistent with an acute inflammatory reaction
- No malignant cells are seen
The patient is now under the care of medical oncologists to trial second- and third-line chemotherapy.
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