Intraductal papillary carcinoma of common bile duct diagnosed by endoscopic ultrasound-guided fine-needle aspiration.

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 16mm proximally resulting from obstruction by a hyperechoic, frondy, mobile mass (●" Fig.1) within the intrapancreatic portion of the common bile duct (●" Video1). The pancreatic parenchymawas unremarkable and the pancreatic duct was of normal caliber. Cytologic examination after fine-needle aspiration using a 25G needle revealed highly atypical epithelial cells consistent with adenocarcinoma (●" Fig.2a). 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 (●" Video1). A 10-Fr, 9-cm-long plastic stent was inserted for bile duct drainage and the patient subsequently underwent Whipple pancreaticoduodenectomy with negative lymph nodes. The surgical pathology specimen demonstrated a dilated commonbile Fig.2 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,×400). 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, ×40). 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, ×200). d Higherpower 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, ×400). Fig.1 Linear-array echoendoscopic image of the hyperechoic, frondy lesion in the distal bile duct causing obstruction.