- Open Access
Clear cell carcinoid tumor of the distal common bile duct
© Todoroki et al; licensee BioMed Central Ltd. 2007
- Received: 16 November 2006
- Accepted: 17 January 2007
- Published: 17 January 2007
Carcinoid tumors rarely arise in the extrahepatic bile duct and can be difficult to distinguish from carcinoma. There are no reports of clear cell carcinoid (CCC) tumors in the distal bile duct (DBD) to the best of our knowledge. Herein, we report a CCC tumor in the DBD and review the literature concerning extrahepatic bile duct carcinoid tumors.
A 73-old man presented with fever and occult obstructive jaundice. Ultrasonography, computed tomography (CT) and magnetic resonance cholangiopancreaticography (MRCP) demonstrated a nodular tumor projection in the DBD without regional lymph node swelling. Under suspicion of carcinoma, we resected the head of the pancreas along with 2nd portion duodenectomy and a lymph node dissection. The surgical specimen showed a golden yellow polypoid tumor in the DBD (0.8 × 0.6 × 0.5 cm in size). The lesion was composed of clear polygonal cells arranged in nests and a trabecular pattern. The tumor invaded through the wall into the fibromuscular layer. Immunohistochemical stains showed that neoplastic cells were positive for neuron-specific enolase (NSE), chromogranin A, synaptophysin, and pancreatic polypeptide and negative for inhibin, keratin, CD56, serotonin, gastrin and somatostatin. The postoperative course was uneventful and he is living well without relapse 12 months after surgery.
Given the preoperative difficulty in differentiating carcinoid from carcinoma, the pancreaticoduodenectomy is an appropriate treatment choice for carcinoid tumors located within the intra-pancreatic bile duct.
- Bile Duct
- Common Bile Duct
- Carcinoid Tumor
- Extrahepatic Bile Duct
Extrahepatic bile duct carcinoid tumors are extraordinarily rare lesions and account for only 0.32% of all carcinoids of the gastrointestinal tract . Since 1961 when Pilz described the first carcinoid tumor arising from the common bile duct, only 51 cases have been described, excluding the ampulla of Vater, cystic duct, gallbladder and intrahepatic bile ducts. In particular, the morphologically distinct primary clear cell carcinoid tumor of the extrahepatic bile duct is even rarer; there is no previous report to the best of our knowledge.
We report herein a clear cell carcinoid tumor of arising from the distal (intra-pancreatic portion) common bile duct as the first report of a clear cell carcinoid tumor of the extrahepatic bile duct. Because of the rarity of carcinoid tumors in the bile duct as well as the rarity of clear cell carcinoid tumors, it is difficult to adequately assess their malignant potential, their responsiveness to particular treatments and their overall prognosis. Improved understanding can only be obtained by analyzing the collected data from reported cases; accordingly, we reviewed the literature concerning carcinoid tumors originating from the extrahepatic bile ducts.
During laparotomy, a polypoid lesion was palpated in the common bile duct at the head of the pancreas. However, whether tumor was invading the pancreas or not was unclear and regional nodes were soft and slightly swollen. Given the suspicion of distal bile duct carcinoma without node metastasis (less than stage II); the patient underwent a modified pancreaticoduodenectomy. Taking into account possible complications, we tried to preserve not only the pylorus, but also the first and third portions of the duodenum and performed a regional lymphadenectomy.
Recently, the World Health Organization (WHO) developed a new classification system that gives a better description of the characteristics and biological behavior of the carcinoid tumors. These tumors can be malignant and the histopathological differentiation of carcinoid tumors ranges from well differentiated (traditionally known as carcinoid tumors) to poorly differentiated malignancies with neuroendocrine features, typified by small cell carcinoma. Carcinoid tumors derived from neuroendocrine cell compartments and their frequency of occurrence correlate with the site-density of neuroendocrine cells. Most (over 60%) of carcinoid tumors arise from the gastrointestinal system, followed by the bronchopulmonary system (25%). Carcinoid tumors of the extrahepatic bile duct, excluding Vater, intrahepatic bile duct, gallbladder and cystic duct, are extremely rare. The incidence in all gastrointestinal carcinoid tumors is 0.32%, according to the recent analysis of 13,715 carcinoid tumors . On the other hand, more than 80% of the extrahepatic bile duct tumors are adenocarcinomas [2, 3]. Carcinoid tumors are slow-growing malignancies, as was first emphasized by the use of the term "carcinoid" in 1907, referring to the benign nature of the tumor . Pilz reported the first case of a carcinoid tumor of the common bile duct in 1961 ; thereafter, 51 cases of extrahepatic bile duct carcinoid tumors, excluding composite tumors with carcinoma, have been reported in the literature (See Additional file 1). Reports by Davies  and Godwin  were excluded because of the lack of detail. Exploring the original site of the tumor in detail, only 11 cases were found to have arisen from the intra-pancreatic (distal) portion (DBD), 14 cases arose in the middle portion (MBD) and the remaining 26 cases arose in the proximal bile ducts (PBD), including the right, left and common hepatic ducts (see additional file 1).
Only two clear cell carcinoid (CCC) tumors of the gallbladder have been described as originating from the biliary tracts; however, there have been no case reports of CCCs arising from the extrahepatic bile ducts. One case has been interpreted to be a CCC tumor of the gallbladder and appeared to be a distinctive manifestation of von Hippel-Lindau (VHL) disease with diffuse expression of inhibin in the tumor . Those authors hypothesized that inhibin may be a product of CCC tumors associated with VHL disease and a useful marker in distinguishing these from metastatic renal cell carcinomas. On the other hand, in another case the patient's tumor was not associated with VHL disease and the CCC tumor had negative expression of inhibin . In our case, the CCC tumor was also negative for inhibin without any correlation to VHL disease. Although further investigations of inhibin expression in CCC tumors of the biliary tract with and without VHL disease are required, Sinkre's hypothesis is an interesting in suggesting a biomarker to detect concomitant VHL disease.
Carcinoid tumors are composed of multipotential cells with the ability to secrete numerous hormonal substances and vasoactive peptides. These substances cause the clinical features that constitute carcinoid syndrome; however, within the extrahepatic bile duct, only one carcinoid tumor has been associated with the syndrome . The most popular symptom for extrahepatic bile duct carcinoids was obstructive jaundice, accounting for 75 percent of the reported cases. From the viewpoint of treatment, the prime concern is the location of the tumor and the malignant potential of invasion and metastasis rather than the presence of the carcinoid syndrome. When the distal (intra-pancreatic) bile duct is affected, surgery should consist of a head of pancreas resection with a whole duodenectomy (pancreaticoduodenectomy) or a resection of the second portion of the duodenum, as well as pyloric preservation to achieve adequate radicality. In our case, a pancreatic head resection with a 2nd portion duodenectomy was successfully performed with an en bloc resection of the tumor and surrounding structures including regional lymph nodes. In the event of middle to proximal bile duct involvement, an en bloc excision of the bile ducts from the main hepatic ducts down to the upper margin of the pancreas and adjoining lymph nodes (with construction of a Roux-en-Y hepaticojejunostomy or hepaticoduodenostomy) will be appropriate to preserve the patient's prospects for a cure.
Accurate pre-and intra-operative histological diagnosis may be problematic because the discrimination between carcinoid tumors and carcinoma is difficult at times, particularly with frozen section specimens. In some cases, frozen section diagnosis is inconclusive and resection must be undertaken with an indeterminate diagnosis. In our case, cytological examination failed to demonstrate carcinoid cells. However, imaging diagnostic findings obtained from CT, MRCP and ERCP and abdominal angiography were actually regarded as sufficient evidence to precede radical surgery since those images demonstrated a protruding nodular tumor in the distal bile duct and no evidence of metastasis in the regional nodes, distant metastasis and vascular involvement.
Carcinoid tumors are slow-growing malignancies; however, prognosis after treatment depends on the evidence of degree of malignancy. Mitotic counts and the degree of anaplasia cannot reliably determine malignancy; rather, it is microscopic local invasion or gross distant spreads that differentiate the benign from the malignant forms of this disease. Metastases to distant organs (chiefly the liver), regional lymph nodes and direct invasion into the perineural lymph space, microscopic vessels and adjacent structures were found in 21 of 49 reported cases (including our case and excluding three cases which lacked adequate information). Out of those 21 patients with extended tumors, only two deaths)[11, 12] were directly attributable to progression of the carcinoid tumors after radical surgery, although one patient died from its tumor one day after celiotomy for carcinoidomatosis . On the other hand, one patient with a liver metastasis and 15 patients with loco-regional extension are living well 18 months later , and from 6 months to 20 years  after radical resection surgery, respectively (see Additional file 1). The details of earlier reported case are illustrated in additional file 1[16–52]. However, because of the rarity of carcinoid tumors of the bile ducts, it is difficult to accurately and adequately assess the natural history of this disease, the malignant potential of the tumors, their responsiveness to particular treatments, and the overall prognosis after different types of therapy. This can only be achieved with continued reporting of cases in detail.
Definite diagnosis is difficult preoperatively but may be improved with the assessment of neuroendocrine markers in suspected cases. Disease-free survival is prolonged following complete and safe resection of the tumor. Because carcinoid tumors are slow growing and less aggressive than adenocarcinoma, even if these patients have metastases, they should be treated aggressively. Continued reporting of single cases and long-term follow-up should be encouraged with reporting of the results of treatment.
Written consent was obtained from the patient for publication of this case report
- Modlin IM, Lye KD, Kidd M: A 5-decade analysis of 13,715 carcinoid tumors. Cancer. 2003, 97: 934-959. 10.1002/cncr.11105.View ArticlePubMedGoogle Scholar
- Todoroki T, Kawamoto T, Koike N, Fukao K, Shoda J, Takahashi H: Treatment strategy for patients with middle and lower third bile duct cancer. Br J Surg. 2001, 88: 364-370. 10.1046/j.1365-2168.2001.01685.x.View ArticlePubMedGoogle Scholar
- Todoroki T, Kawamoto T, Koike N, Takahashi H, Yoshida S, Kashiwagi H: Radical resection of hilar bile duct carcinoma and predictors of survival. Br J Surg. 2000, 87: 306-313. 10.1046/j.1365-2168.2000.01343.x.View ArticlePubMedGoogle Scholar
- Oberndorfer S: Karzenoide Tumoren des Dünndarms. Frankf Zschr Path. 1907, 1: 426-430.Google Scholar
- Pilz E: [On carcinoid of the bile duct]. Zentralbl Chir. 1961, 86: 1588-1590.PubMedGoogle Scholar
- Davies AJ: Carcinoid tumors (Argentaffinomata). Ann Roy Coll Surg Engl. 1959, 25: 277-297.Google Scholar
- Godwin JD: Carcinoid tumors. An analysis of 2,837 cases. Cancer. 1975, 36: 560-569. 10.1002/1097-0142(197508)36:2<560::AID-CNCR2820360235>3.0.CO;2-4.View ArticlePubMedGoogle Scholar
- Sinkre PA, Murakata L, Rabin L, Hoang MP, Albores-Saavedra J: Clear cell carcinoid tumor of the gallbladder: another distinctive manifestation of von Hippel-Lindau disease. Am J Surg Pathol. 2001, 25: 1334-1339. 10.1097/00000478-200110000-00017.View ArticlePubMedGoogle Scholar
- Konishi E, Nakashima Y, Smyrk TC, Masuda S: Clear cell carcinoid tumor of the gallbladder. A case without von Hippel-Lindau disease. Arch Pathol Lab Med. 2003, 127: 745-747.PubMedGoogle Scholar
- Mandujano-Vera G, Angeles-Angeles A, de la Cruz-Hernandez J, Sansores-Perez M, Larriva-Sad J: Gastrinoma of the common bile duct: immunohistochemical and ultrastructural study of a case. J Clin Gastroenterol. 1995, 20: 321-324. 10.1097/00004836-199506000-00014.View ArticlePubMedGoogle Scholar
- Abe Y, Itoh H, Yoshida M, Suzuki S, Kushibuchi T, KIriyama S: Carcinoid Tumor of the Common Bile Duct, Report of a Case. Stomach Intestine. 1983, 18: 543-548.Google Scholar
- Caglikulekci M, Dirlik M, Aydin O, Ozer C, Colak T, Dag A, Canbaz H, Aydin S: Carcinoid tumor of the common bile duct: report of a case and a review of the literature. Acta Chir Belg. 2006, 106: 112-115.PubMedGoogle Scholar
- Barron-Rodriguez LP, Manivel JC, Mendez-Sanchez N, Jessurun J: Carcinoid tumor of the common bile duct: evidence for its origin in metaplastic endocrine cells. Am J Gastroenterol. 1991, 86: 1073-1076.PubMedGoogle Scholar
- Kopelman D, Schein M, Kerner H, Bahuss H, Hashmonai M: Carcinoid tumor of the common bile duct. HPB Surg. 1996, 10: 41-43.PubMed CentralView ArticlePubMedGoogle Scholar
- El Rassi ZS, Mohsine RM, Berger F, Thierry P, Partensky CC: Endocrine tumors of the extrahepatic bile ducts. Pathological and clinical aspects, surgical management and outcome. Hepatogastroenterology. 2004, 51: 1295-1300.PubMedGoogle Scholar
- Little JM, Gibson AA, Kay AW: Primary common bile-duct carcinoid. Br J Surg. 1968, 55: 147-149.View ArticlePubMedGoogle Scholar
- Bergdahl L: Carcinoid tumors of the biliary tract. Aust N Z J Surg. 1976, 46: 136-138.View ArticlePubMedGoogle Scholar
- Gerlock AJ, Muhletaler CA: Primary common bile duct carcinoid. Gastrointest Radiol. 1979, 4: 263-264. 10.1007/BF01887536.View ArticlePubMedGoogle Scholar
- Nakamuara T, Sawada T, Karaki K, Kawao A: A case of MEA associated with bie duct carcinoid. Gann no Rinnshou. 1981, 27: 1299-1301.Google Scholar
- Vitaux J, Salmon RJ, Languille O, Buffet C, Martin E, Chaput JC: Carcinoid tumor of the common bile duct. Am J Gastroenterol. 1981, 76: 360-362.PubMedGoogle Scholar
- Alexander IA, Thomson KR, Kune GA: Primary common bile duct carcinoid demonstration by computerized tomography, ultrasonography and angiography. Australas Radiol. 1986, 30: 34-37.View ArticlePubMedGoogle Scholar
- Jutte DL, Bell RH, Penn I, Powers J, Kolinjivadi J: Carcinoid tumor of the biliary system. Case report and literature review. Dig Dis Sci. 1987, 32: 763-769. 10.1007/BF01296145.View ArticlePubMedGoogle Scholar
- Bickerstaff DR, Ross WB: Carcinoid of the biliary tree: a case report and review of the literature. J R Coll Surg Edinb. 1987, 32: 48-51.PubMedGoogle Scholar
- Gastinger I, Schutze U, Beetz G, Lippert H: [Obstructive jaundice caused by a carcinoid tumor of the hepatocholedochal duct]. Zentralbl Chir. 1987, 112: 1170-1175.PubMedGoogle Scholar
- Reinhardt D, Thiele H, Weber JC, Hofmann WJ: [Carcinoid of the ductus choledochus. A rare cause of obstructive jaundice]. Chirurg. 1988, 59: 683-687.PubMedGoogle Scholar
- Fujita N, Mochizuki F, Lee S, Satoh K, Kobayashi G, Yano A, Shimoda T: Carcinoid tumor of the bile duct: case report. Gastrointest Radiol. 1989, 14: 151-154. 10.1007/BF01889181.View ArticlePubMedGoogle Scholar
- Bumin C, Ormeci N, Dolapci M, Gungor S: Carcinoid tumor of the biliary duct. Int Surg. 1990, 75: 262-264.PubMedGoogle Scholar
- Brown WM, Henderson JM, Kennedy JC: Carcinoid tumor of the bile duct. A case report and literature review. Am Surg. 1990, 56: 343-346.PubMedGoogle Scholar
- Fellows IW, Leach IH, Smith PG, Toghill PJ, Doran J: Carcinoid tumor of the common bile duct – a novel complication of von Hippel-Lindau syndrome. Gut. 1990, 31: 728-729.PubMed CentralView ArticlePubMedGoogle Scholar
- Besznyak I, Tasnadi G, Hirsch T, Koves I, Schaff Z, Lapis K: [Hepato-lobectomy for carcinoid tumor of the hepatic duct]. Orv Hetil. 1991, 132: 591-594.PubMedGoogle Scholar
- Angeles-Angeles A, Quintanilla-Martinez L, Larriva-Sahd J: Primary carcinoid of the common bile duct. Immunohistochemical characterization of a case and review of the literature. Am J Clin Pathol. 1991, 96: 341-344.PubMedGoogle Scholar
- Newman K, Vates T, Duffy L, Anderson K: Pancreatoduodenectomy with preservation of the stomach and pylorus: a safe and effective alternative in children. J Pediatr Surg. 1992, 27: 1334-1335. 10.1016/0022-3468(92)90290-N.View ArticlePubMedGoogle Scholar
- Dixon JM, Chapman RW, Berry AR: Carcinoid tumor of the ampulla of Vater presenting as acute pancreatitis. Gut. 1987, 28: 1296-1297.PubMed CentralView ArticlePubMedGoogle Scholar
- Rugge M, Sonego F, Militello C, Guido M, Ninfo V: Primary carcinoid tumor of the cystic and common bile ducts. Am J Surg Pathol. 1992, 16: 802-807. 10.1097/00000478-199208000-00010.View ArticlePubMedGoogle Scholar
- Sankary HN, Foster P, Frye E, Williams JW: Carcinoid tumors of the extrahepatic bile duct: an unusual cause of bile duct obstruction. Liver Transpl Surg. 1995, 1: 122-123. 10.1002/lt.500010210.View ArticlePubMedGoogle Scholar
- Belli G, Rotondano G, D'Agostino A, Marano I: Primary extrahepatic bile duct carcinoids. HPB Surg. 1996, 9: 101-105.PubMed CentralView ArticlePubMedGoogle Scholar
- Hao L, Friedman AL, Navarro VJ, West B, Robert ME: Carcinoid tumor of the common bile duct producing gastrin and serotonin. J Clin Gastroenterol. 1996, 23: 63-65. 10.1097/00004836-199607000-00018.View ArticlePubMedGoogle Scholar
- Nahas SC, Lourencao JL, Gazoni E, Mott Cde B, Borba MR, Pinto Filho JO, Lopes LH, Varella D, Nahas CS, Pinotti HW: [Carcinoid tumors of the common bile duct: report of a case]. Rev Hosp Clin Fac Med Sao Paulo. 1998, 53: 26-28.PubMedGoogle Scholar
- Bembenek A, Lotterer E, Machens A, Cario H, Krause U, Holzhausen HJ, Fleig WE, Dralle H: Neuroendocrine tumor of the common hepatic duct: a rare cause of extrahepatic jaundice in adolescence. Surgery. 1998, 123: 712-715. 10.1067/msy.1998.86363.View ArticlePubMedGoogle Scholar
- Perakath B, Chandran BS, Srivastava VM, Nair A, Sitaram V: Carcinoid tumor of common hepatic duct. Indian J Gastroenterol. 1999, 18: 127-PubMedGoogle Scholar
- Ross AC, Hurley JB, Hay WB, Rusnak CH, Petrunia DM: Carcinoids of the common bile duct: a case report and literature review. Can J Surg. 1999, 42: 59-63.PubMed CentralPubMedGoogle Scholar
- Chamberlain RS, Blumgart LH: Carcinoid tumors of the extrahepatic bile duct. A rare cause of malignant biliary obstruction. Cancer. 1999, 86: 1959-1965. 10.1002/(SICI)1097-0142(19991115)86:10<1959::AID-CNCR12>3.0.CO;2-H.View ArticlePubMedGoogle Scholar
- Maitra A, Krueger JE, Tascilar M, Offerhaus GJ, Angeles-Angeles A, Klimstra DS, Hruban RH, Albores-Saavedra J: Carcinoid tumors of the extrahepatic bile ducts: a study of seven cases. Am J Surg Pathol. 2000, 24: 1501-1510. 10.1097/00000478-200011000-00005.View ArticlePubMedGoogle Scholar
- Chan C, Medina-Franco H, Bell W, Lazenby A, Vickers S: Carcinoid tumor of the hepatic duct presenting as a Klatskin tumor in an adolescent and review of world literature. Hepatogastroenterology. 2000, 47: 519-521.PubMedGoogle Scholar
- Juturi JV, Maghfoor I, Doll DC, Evans ML: A case of biliary carcinoid presenting with pancreatitis and obstructive jaundice. Am J Gastroenterol. 2000, 95: 2973-2974. 10.1111/j.1572-0241.2000.00819.x.View ArticlePubMedGoogle Scholar
- Volpe CM, Pryor JP, Caty M, Doerr RJ: An adolescent with bile duct carcinoid tumor. Med Pediatr Oncol. 2003, 40: 137-138. 10.1002/mpo.10125.View ArticlePubMedGoogle Scholar
- Podnos YD, Jimenez JC, Zainabadi K, Ji P, Cooke J, Busuttil RW, Imagawa DK: Carcinoid tumors of the common bile duct: report of two cases. Surg Today. 2003, 33: 553-555.PubMedGoogle Scholar
- Pawlik TM, Shah S, Eckhauser FE: Carcinoid tumor of the biliary tract: treating a rare cause of bile duct obstruction. Am Surg. 2003, 69: 98-101.PubMedGoogle Scholar
- Menezes AAC, Diver AJ, McCance D, Diamond T: Carcinoid tumor of the extrahepatic bile duct – report of a case and literature review. The Ulster medical journal. 2004, 73: 59-62.PubMed CentralPubMedGoogle Scholar
- Ligato S, Furmaga W, Cartun RW, Hull D, Tsongalis GJ: Primary carcinoid tumor of the common hepatic duct: A rare case with immunohistochemical and molecular findings. Oncol Rep. 2005, 13: 543-546.PubMedGoogle Scholar
- Nesi G, Lombardi A, Batignani G, Ficari F, Rubio CA, Tonelli F: Well-differentiated endocrine tumor of the distal common bile duct: a case study and literature review. Virchows Arch. 2006, 449: 104-111. 10.1007/s00428-006-0207-4.View ArticlePubMedGoogle Scholar
- Kim D-H, Song M-H, Kim D-H: Malignant carcinoid tumor of the common bile duct: report of a case. Surg Today. 2006, 36: 485-489. 10.1007/s00595-005-3174-5.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.