Resident Maimonides Medical Center Brooklyn, New York
Daria Yunina, MD, Richard M. Fazio, MD, Ismail Zahir, MD, Maryanne Ruggiero Delliturri, MD, Ira E. Mayer, MD, FACG, Dmitriy O. Khodorskiy, MD; Maimonides Medical Center, Brooklyn, NY
Introduction: Lung cancer is the second most common malignancy accounting for 27% of cancer related deaths. Typical sites of metastasis include bone, brain, pleura, liver and the adrenals. Cancers rarely spread to the common bile duct (CBD) but when they do, the primary is usually gastric, hepatocellular, colon or breast in origin. The incidence of lung cancer affecting the CBD is less than 1%, with majority being small cell subtype.
Methods: A 38-year-old Chinese man with chronic hepatitis B on Entecavir and stage IV non-small cell lung adenocarcinoma on immunotherapy presented with painless jaundice. Blood work was significant for elevations in aspartate aminotransferase (AST): 989 IU/L, alanine aminotransferase (ALT): 1,718 IU/L, alkaline phosphatase: 849 IU/L, total bilirubin: 8.5 gm/dL and direct bilirubin: 5.3 gm/dL. Liver biopsy was compatible with immunotherapy related drug-induced liver injury (DILI), and intravenous steroids and N-acetyl cysteine were initiated. As liver function tests (LFTs) worsened, magnetic resonance imaging (MRI) was ordered and revealed an atrophic lateral segment of left hepatic lobe, bilateral intrahepatic ductal (IHD) dilation, and circumferential thickening of common hepatic and cystic ducts. Endoscopic ultrasonography (EUS) was then performed, revealing diffusely thickened CBD wall and bilateral IHD dilation, followed by endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, CBD brushings and insertion of plastic stents into anterior and posterior right IHDs. As no improvement in LFTs was observed, MRI was ordered and revealed resolution of right IHD dilation but increase in left IHD dilation, prompting repeat ERCP with placement of third plastic stent into left IHD. Hospital course was complicated by respiratory failure requiring intubation with mechanical ventilation and ultimately patent’s demise. CBD brushings revealed adenocarcinoma of pulmonary origin, staining positive for TTF-1 and Napsin A. Discussion: Staining with hematoxlin-eosin alone is not enough to differentiate between cholangiocarcinoma (CCA) and adenocarcinoma of other origin because over 90% of CCA are adenocarcinomas. Immunohistochemical staining can make the distinction. Cytokerin, Napsin A, CK7 and TTF-1 stain positively for pulmonary malignancies. Although non-gastrointestinal malignancy spread to the CBD is rare it should be on the differential when patients with known malignancy present with jaundice and abnormal hepatobiliary imaging.
New circumferential thickening of the common bile duct and new intrahepatic biliary duct dilation
EUS showing dilated intrahepatic bile ducts (on the left) and cholangiogram (on the right)
Top left: Smear 40x image showing markedly atypical cells Top right: Cell block 40x showing malignant cells in the center and benign bile duct epithelium in the upper right portion of the image Bottom left: Cell block 40x image with TTF-1 stain (nuclear stain marker for lung adenocarcinoma) Bottom right: Cell block 40x image with Napsin A stain (granular cytoplasmic stain marker for lung adenocarcinoma)
Disclosures: Daria Yunina indicated no relevant financial relationships. Richard Fazio indicated no relevant financial relationships. Ismail Zahir indicated no relevant financial relationships. Maryanne Ruggiero Delliturri indicated no relevant financial relationships. Ira Mayer indicated no relevant financial relationships. Dmitriy Khodorskiy indicated no relevant financial relationships.