HPB Surgery, 1995, Vol. 8, pp. 245-248
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Papillary Adenocarcinoma
of the Common Bile Duct
O. ARIO(3UL*, B. H. GVEN,A. EMRE, K. ACARLI, A. ALPER and A. OKTEN
Department of Hepatobiliary Surgery and Hepatology of Istanbul Medical Faculty,
tapa,Istanbul, Turkey
(Received FebruarylO, 1994)
Five patients with papillary adenocarcinoma of the common bile duct (CBD) are described.
These are rare tumors and make up 5% of all malignant tumors of the biliary tract. The
symptoms and signs at the time ofinitial diagnosis resemble benign obstructive lesions ofthe bile
ducts. The tumor is soft, less invasive to adjacent tissues and tends to grow into the lumen. The
early onset of the symptoms results in early intervention, with a better prognosis. Two of our
patients are doing well after two and four years, where as three others were readmitted with
recurrent disease.
KEY WORDS: Common bile duct papillary adenocarcinoma
INTRODUCTION
Papillary adenocarcinoma of the CBD is regarded as
an uncommon tumor with a more favourable progno-
sis and better survival compared with other carcino-
mas ofthe extrahepatic bile ducts1-4. These tumors are
raised, soft, frond-like lesions. They are covered with
epithelium and grow into the lumen of the bile duct
producing incomplete obstruction, with signs and
symptoms resembling bile duct stones or strictures2-4.
It seems that, detection ofearly intraluminal growth
is followed by early surgical resection with a relatively
better survival rate. In this report five cases are pres-
ented and current methods of diagnosis and treatment
ofpapillary adenocarcinoma ofthe CBD are reviewed.
CASE REPORTS
Case 1: A 45 year old male was referred with a six-
month history ofjaundice, pruritus, weight loss, chills
and fever, accompanied by right upper quadrant pain.
He had been operated on twice elsewhere without
any apparent diagnosis. Percutaneous transhepatic
* Address for correspondence to: Dr. O. Anogul, Zincirlikuyu
cad.Da apt. 72/6, 80600 Etiler, Istanbul, Turkey.
cholangiography (PTC) showed a tumor mass in the
proximal CBD.
Peroperative findings were a papillamatous, fround-
like, soft tumoral mass pouring out of the transected
CBD, and a cholestatic liver. The tumor was identified
as a papillary adenocarcinoma on frozen section.
A hepatico-duodenostomy was performed following
resection of the CBD. The patient was discharged on
the 21st postoperative day. He was readmitted 2.5
years later with obstructive jaundice, was re-explored
and found to have a tumor infiltrating the hilum of the
liver. A bilio-digestive anastomosis was established
using the segment III duct. The patient died three
months after the operation (Table 1).
Case 2:A sixty-one year-old male complained of
weight loss, jaundice, pruritus, high fever, fatigue and
right upper quadrant pain lasting nine months. Physi-
cal examination showed jaundice with mild hepa-
tomegaly. Ultrasonography (US) demonstrated
dilated intrahepatic ducts with a tumor mass in the
proximal part of the CBD. A papillary tumor was
found at the level of the cystic duct junction per-
operatively. Tumor was identified as papillary adeno-
carcinoma of the CBD. A Roux en-Y hepatico-
jejunostomy was performed following CBD resection.
The patient was discharged on the 26th post-operative
day, only to be readmitted two months later, he was
245
246 O. ARIOGUL et al.
+
+
+
reexplored and found to have carcinomatosis perito-
nei.
Case 3:A sixty-four year old male had complained of
jaundice, pruritus, fever, fatigue, weight loss and post-
prandial abdominal pain for six months. PTC showed
a filling defect in the CBD. At operation, the CBD was
found to be 30 mm in diameter with a soft amorphous
polypoid tumoral mass filling the lumen,just below the
cystic duct junction. Frozen section showed papillary
adenocarcinoma. A Hepatico-duodenostomy was per-
formed following CBD resection and cholecystectomy;
an enlarged suprapancreatic lymph node was also
removed. Histo-pathologic examination showed papil-
lary adenocarcinoma with lymph node metastasis. The
patient has been well for four years postoperatively.
Case 4:A forty-year old female complained ofjaun-
dice, pruritus and fever for four months. PTC showed
dilated right intrahepatic ducts, the left intrahepatic
ducts were not seen, there was partial obstruction of
the CBD beginning at the cystic duct junction and
extending upward to the left hepatic duct. At operation
the CBD was found to be 25 mm in diameter, contain-
ing a papillary tumor, which was identified as a papil-
lary adeno-carcinoma by frozen section. Hepatic ducts,
along with the CBD were removed. Reconstruction
was done by a Roux en-Y hepatico-jejunostomy. The
patient was discharged on the 23rd postoperative day
and now has liver metastasis three years after the
operation.
Case 5:A sixty-five year old female presented with
jaundice, fever, abdominal pain and pruritus for five
months. She had undergone a cholecystectomy five
years ago. On physical examination there was marked
jaundice and a tender right upper quadrant mass.
A filling defect was detected in the CBD by PTC.
Operative findings were, a soft palpable mass within
the CBD and marked cholestasis in the liver. Frozen
section showed papillary adenocarcinoma. Ahepatico-
duodenostomy was performed following resection of
the CBD. The patient has been well for two years
postoperatively.
DISCUSSION
Tumors of the CBD are rare neoplasms. Papillary
adenocarcinomas constitute 5% of all malignant
tumors of the biliary tract. These tumors are easily
resected, with a better prognosis when compared with
the non-papillary types1'a-6
Biliary tract tumors are seen mostly during the sixth
decade7
and in older patients papillary tumors of the
PAPILLARY ADENOCARCINOMA 247
bile ducts should be considered, as a cause ofjaundice.
Papillary adenocarcinomas often lead to early signs
and symptoms of obstructive jaundice resembling be-
nign biliary tract disorders. The tumor is soft and
fragile in nature, it allows bile to pass intermittently;
consequently serum bilirubin levels are lower in com-
parison to the non-papillary types1-3. All of our pa-
tients were admitted with cholangitis. The mean
bilirubin level in our five cases was 114 tmol/L, while it
is calculated to be 23ltmol/L in nonpapillary tumors.
Even with present day imaging techniques, there are
still cases that undergo repeated operations, until the
tumor is found. Our first case is such an example1'3'7.
The most commonly used diagnostic techniques in
biliary tract disease are US and PTC. Papillary tumor
can be seen as a silhouette growing into the lumen,
adjacent to the wall8. Recently, ERCP and bile duct
drainage fluid cytology has been introduced into clini-
cal use, and has proved to be quite effective9.
Early diagnosis has considerable importance in the
treatment of papillary tumors of the CBD. The wall of
the bile duct is often normal in the early stage and in
such cases the tumor can simply be overlooked during
exploration.
As for treatment, conservative resection of the CBD
with either primary reanastomosis or enteric drainage
is recommended1'7'8'1. We were able to resect the soft
tumor mass along with the common bile duct in all of
our cases. We have not seen any invasion of the tumor
beyond the lumen of the CBD. Intraluminal growth of
the tumor and lack ofmural invasion has enabled us to
perform these resections. The overall resectability rate
of all bile duct tumors does not exceed 28 to 32% in
recent studies6'11'12. In those cases where the tumor is
located in the distal CBD, the need for a duodeno-
pancreatectomy along with the common bile duct will
be unavoidable, a situation that we have not yet con-
fronted. One of our patients died six months after
surgical intervention with carcinomatosis peritonei.
One of our patients survived three years, another two
were alive two to four years postoperatively.
Papillary type tumors show a better survival rate
when compared to nonpapillary types, in all
series2-5'7. Okuda8
reported successful resection in all
of the four cases of papillary tumors, where as resecta-
bility rate fell to 10% in the other tumor types.
Histologically papillary carcinomas of the bile duct
are composed of characteristic cells which vary from
round to polyhedral configuration and are arranged in
a papillary like pattern (Fig. 1)3'9'13. The differential
diagnosis between moderate to poorly differentiated
papillary duct carcinomas and other bile duct carcino-
mas however, is said to be impossible9. Whether those
who survive for long periods without recurrence, may
Figure 1 The cells are arranged in a papillary pattern showing tumoral infiltration with a typical nuclei under the epithelial surface of the
tissue (Magnification X 125).
248 O. ARIOGUL et al.
actually be cases of benign papillomas with minor foci
of early adenocarcinoma is a matter of discussion.
There are reports of papillary type tumors showing
malignant degeneration12.
In conclusion, papillary tumors of the common bile
duct should be born in mind in the differential diag-
nosis ofbenign lesions of the biliary tract. The resecta-
bility of these tumors when recognised at an early
stage, points to the importance of this differential
diagnosis.
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