PMC4158657_01
Linear-array echoendoscopic image of the hyperechoic, frondy lesion in the distal bile duct causing obstruction.
nihms623440f1.jpg
PMC4158657_01_nihms623440f1.jpg
F1
A 60-year-old black man with jaundice, pruritus, and weight loss was referred for endoscopic ultrasound (EUS) evaluation, which showed dilation of the common bile duct to 16 mm proximally resulting from obstruction by a hyperechoic, frondy, mobile mass (Fig. 1) within the intrapancreatic portion of the common bile duct (Video 1).
Pathology. a Intraprocedural fine-needle aspiration cytology revealed a highly cellular sample composed of malignant epithelial cells, some with intracytoplasmic vacuoles containing mucin. A diagnosis of adenocarcinoma was rendered (Diff-Quik stain, x400). b Histologic sections of the papillary lesion demonstrated a fibrovascular core supporting papillae lined by highly atypical epithelial cells, without stromal invasion (hematoxylin and eosin stain, x40). c Biliary epithelium adjacent to the papillary lesion also demonstrated partial replacement with malignant epithelial cells, without stromal invasion. Arrow indicates normal epithelium (hematoxylin and eosin stain, x200). d Higher-power image of the malignant epithelium in c, depicting marked nuclear pleomorphism and enlargement with mitotic activity. Arrow indicates adjacent normal epithelium (hematoxylin and eosin stain, x400).
nihms623440f2.jpg
PMC4158657_01_nihms623440f2.jpg
F2
Cytologic examination after fine-needle aspiration using a 25G needle revealed highly atypical epithelial cells consistent with adenocarcinoma (Fig. 2a). Histologically, the lesion was supported by a fibrovascular core with numerous papillae (Fig. 2b) lined by cytologically malignant glandular epithelial cells; malignant cells also involved the mucosa adjacent to the papillary lesion (Fig. 2 c, d).
Spyglass cholangioscopic image of the lesion. Note also the irregular surrounding bile duct mucosa.
nihms623440f3.jpg
PMC4158657_01_nihms623440f3.jpg
F3
The patient subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP) and spyglass cholangioscopy (Fig. 3), which confirmed the polypoidal mass lesion with papillary projections, without visible mucus but showed irregular surrounding bile duct mucosa (Video 1).