ELECTRONIC IMAGE OF THE MONTH
A Rare Tumor of the Common Hepatic Duct Causing Biliary
Obstruction
Anthony W. H. Chan,* Yue–Sun Cheung,‡ and Kit–Fai Lee‡
*Department of Anatomical and Cellular Pathology, and ‡Department of Surgery, Prince of Wales Hospital,
The Chinese University of Hong Kong, Hong Kong
57-year-old woman with a history of diabetes
A mellitus, hypertension, hyperlipidemia, and uter-
ine fibroid presented with epigastric pain, fever, and
tea-colored urine. Blood tests showed leukocytosis
(white cell count, 13.3  109/L) and deranged liver func-
tion (albumin level, 42 g/L; total bilirubin level,
108 mmol/L; alkaline phosphatase level, 413 U/L; and
alanine aminotransferase level, 863 U/L). Serum amylase
level was normal, and viral hepatitis serology was negative.
Ultrasonography of the abdomen showed a dilated prox-
imal common bile duct and intrahepatic ducts. Endoscopic
retrograde cholangiopancreatogram showed a tumor at the
common hepatic duct extending to the junction of the left
and right intrahepatic ducts causing proximal dilatation
(Figure A). A biopsy specimen obtained by endoscopic
retrograde cholangiopancreatography showed ulcer base
tissue only. Computed tomography showed a 1  0.9 cm
hypodense nodule in the common hepatic duct with hetero-
geneous contrast enhancement in the delayed phase
(Figure B). She subsequently underwent a left hepatectomy
with resections of caudate lobe, extrahepatic bile duct, and
porta lymphatics.
Gross examination showed a 2-cm pedunculated
polypoid multilocular cystic tumor in the common hepatic
duct with extension into the left hepatic duct (Figure C).
Thin mucinous material was found within the tumor.
Histologic sections of the tumor showed a multilocular
cystic tumor lined by a single layer of bland cuboidal
to columnar, variably mucin-producing, epithelial
cells, which were supported by dense ovarian-type
Clinical Gastroenterology and Hepatology 2014;12:e29–e30
ELECTRONIC IMAGE OF THE MONTH, continued
mesenchymal stroma (Figures D and E). Those stromal
cells were immunoreactive to progestrogen receptor
(Figure F). Cytologic or architectural atypia was lacking.
Hepatic parenchymal invasion, lymphovascular perme-
ation, and perineural invasion were absent. The histologic
features were typical of mucinous cystadenoma.
Hepatic mucinous cystadenoma is an uncommon
cyst-forming epithelial neoplasm accounting for less
than 5% of all intrahepatic cystic lesions. It currently is
known as a noninvasive mucinous cystic neoplasm, which
is adopted in the latest World Health Organization
classification paralleling its pancreatic counterpart.1 It is
seen almost exclusively in females, with a mean age of
45 years. It is a benign hepatic neoplasm and carries
an excellent prognosis after complete excision. It typi-
cally does not communicate with large bile ducts in
contrast to intraductal papillary neoplasm of bile duct,
which formerly was known as biliary papilloma or pap-
illomatosis. Mucinous cystadenoma with an intraductal
protrusion is rare, with fewer than 10 cases reported
in the literature.2,3 It should be differentiated from
other hepatic tumors with intraductal growth including
e30
intraductal papillary neoplasms of bile duct and chol-
angiocarcinomas. The definitive diagnosis requires his-
tologic confirmation of the presence of benign mucinous
epithelial lining and the characteristic ovarian-type
mesenchymal stroma.
References
1. Tsui WMS, Adsay NV, Crawford JM, et al. Mucinous cystic
neoplasms of the liver. In: Bosman FT, Carneiro F, Hruban RH,
et al, eds. WHO classification of tumours of the digestive sys-
tem. Lyon: International Agency for Research on Cancer,
2010:236–238.
2. Gonzalez M, Majno P, Terraz S, et al. Biliary cystadenoma
revealed by obstructive jaundice. Dig Liver Dis 2009;41:
e11–e13.
3. Vyas S, Markar S, Ezzat T, et al. Hepato-biliary cystadenoma
with intraductal extension: unusual cause of obstructive jaun-
dice. J Gastrointest Cancer 2012;43:32–37.
Conflicts of interest
The authors disclose no conflicts.
© 2014 by the AGA Institute
1542–3565/$36.00
http://dx.doi.org/10.1016/j.cgh.2013.08.047