An unusual malignant main bile duct stricture: a biliary metastasis of endometrial adenocarcinoma.

Biliary strictures are frequently encountered in interventional endoscopy. Their etiological diagnosis may be complicated [1]. Endoscopic ultrasound (EUS) guided biopsies, brush cytology, and wire-guided biopsies allow a diagnosis in most cases. Single-operator cholangioscopy (SOC) has radically changed the diagnostic approach, allowing visualization of the lesion, endoscopic characterization, and targeted biopsies [2].

We report the case of a 71-year-old woman with a history of endometrial adenocarcinoma, with muscular and bone recurrence 4 years after treatment. She developed a sudden jaundice without any other clinical signs. A magnetic resonance cholangiopancreatography found a circumferential parietal thickening of the main bile duct with dilatation of the intrahepatic bile ducts ([Fig. 1]). We decided to perform an EUS, which showed extensive cholangitis in the middle part of the bile duct with circumferential thickening of the bile duct mucosa. A 22 G needle biopsy was performed. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed ([Fig. 2]) with SOC, which showed that the strictured area was indeed a fibrous stenosis with anarchic vascularization ([Video 1]).

Fig. 1 Biliary magnetic resonance cholangiopancreatography imaging (MRCP) showing the main bile duct stricture with dilatation of the intrahepatic bile ducts. a MRCP sequence showing the biliary stricture (red arrow) and biliary dilatation. b Three-dimensional reconstruction of the biliary system showing the biliary stenosis (red arrow).

Fig. 2 Retrograde cholangiography showing the different stages of the endoscopic retrograde cholangiopancreatography procedure. a Retrograde cholangiography showing the stricture of the main bile duct (black arrow). b Retrograde cholangiography with single-operator cholangioscopy (black arrow). c Retrograde cholangiography with wire-guided forceps (black arrow). d Placement of three plastic biliary stents.

Video 1 Endoscopic retrograde cholangiopancreatography and single-operator cholangioscopy for the diagnosis of indeterminate biliary stenosis and drainage with three plastic stents.

Biopsies were taken with forceps. Brush cytology and wire-guided biopsies were also performed. The procedure was completed with the placement of three plastic stents (one 15 cm and 8.5 Fr stent in the left bile duct; one 12 cm and 8.5 Fr stent and one 12 cm and 7 Fr stent in the right intrahepatic bile ducts). Histological examination found carcinomatous cells (mutated p53, PAX8 +), which were presumed to be metastasis of gynecological origin ([Fig. 3]).

Fig. 3 Biopsies of the main bile duct under single-operator cholangioscopy. a Normal biliary epithelium (black arrow) and neoplastic cells (red arrows) with hematoxylin-eosin stain (magnification × 200). b Neoplastic cells of gynecological origin with immunohistochemistry stain (PAX 8).

The use of SOC allows a finer analysis of indeterminate biliary stenosis. The presence of aberrant vascularization seems to be correlated with the neoplastic nature of the lesion [3]. SOC therefore allows macroscopic analysis of the lesion and targeted biopsies, probably making biliary sampling less random [4] [5].

Endoscopy_UCTN_Code_TTT_1AR_2AB

Competing interests

The authors declare that they have no conflict of interest.

Acknowledgement

This work was supported by French state funds managed within the “Plan Investissements d’Avenir” and by the ANR (reference ANR-10-IAHU-02).

• References

• 1 Bowlus CL, Olson KA, Gershwin ME. Evaluation of indeterminate biliary strictures. Nat Rev Gastroenterol Hepatol 2016; 13: 28-37
• 2 Gerges C, Beyna T, Tang RSY. et al. Digital single-operator peroral cholangioscopy-guided biopsy sampling versus ERCP-guided brushing for indeterminate biliary strictures: a prospective, randomized, multicenter trial (with video). Gastrointest Endosc 2020; 91: 1105-1113
• 3 Robles-Medranda C, Oleas R, Sánchez-Carriel M. et al. Vascularity can distinguish neoplastic from non-neoplastic bile duct lesions during digital single-operator cholangioscopy. Gastrointest Endosc 2021; 93: 935-941
• 4 Angsuwatcharakon P, Kulpatcharapong S, Moon JH. et al. Consensus guidelines on the role of cholangioscopy to diagnose indeterminate biliary stricture. HPB (Oxford) 2021; 24: 17-19
• 5 Almadi MA, Itoi T, Moon JH. et al. Using single-operator cholangioscopy for endoscopic evaluation of indeterminate biliary strictures: results from a large multinational registry. Endoscopy 2020; 52: 574-582

Publication History

Article published online:
04 August 2022