Carcinoma of the Major Bile Ducts

Carcinoma of the major bile ducts is uncommon but not rare. Well over 250 cases have been reported in the last ten years (7, 18, 23, 25, 27, 31, 32). The disease, however, received little radiological attention until interest in accurate diagnosis of bile duct disease was stimulated by the recent popularity of the percutaneous technic of direct cholangiography (6, 8, 12–14, 30). While these reports included examples of bile duct carcinoma, they dealt largely with the technics, usefulness, and hazards of the examination. I am not aware of previous studies on the specific problem of the radiological diagnosis of bile duct carcinoma. This report summarizes the clinical, pathologic, and radiologic experience with carcinoma of the major bile ducts at one medical center over the past three decades. Of 37 proved cases, over 20 were seen in the last ten years. In this hospital (Grace-New Haven Community Hospital, New Haven, Conn.) the current ratio of pancreatic to bile duct carcinoma is about 8∶1. The anatomical sites of origin of these tumors (Fig. 1) determine significant differences in clinical (Table I) and pathological manifestations. One patient, for example, presented clinically with cervical lymph node metastases from an unknown primary site, and only at autopsy was a small papillary carcinoma of the left hepatic duct found. The patients with cystic duct tumors all had acute right upper quadrant pain and were treated by cholecystectomy. Small scirrhous carcinomas of the cystic duct were recognized only on examination of the pathological specimens. The common duct tumors and those involving the cystic-common duct junction had similar manifestations. The gallbladder was invariably distended in the former, but occasionally found collapsed in the latter. The following case, an example of a tumor in this category, is somewhat unusual in that the evolution of the lesion was observed on serial examinations. Case I: A 55-year-old woman was hospitalized in September 1903 with postnecrotic cirrhosis, portal hypertension, and esophageal varices. An end-to-side portocaval shunt was done, the portal vein being transected just proximal to its bifurcation. An incidental finding was a solitary gallstone which was removed by cholecystostomy. Following the shunt operation, the markedly deranged liver function tests improved somewhat except for a paradoxical rise in alkaline phosphatase. Postoperative cholangiography revealed a slight indentation of indeterminate nature at the junction of the cystic and common ducts (Fig. 2, A). This was slightly increased on repeat study five weeks later (Fig. 2, B). The cholecystostomy tube was removed at this time. The patient returned three months later with complaints of right upper quadrant pain, increasing jaundice, and a palpable gallbladder. Emergency cholecystostomy was performed.