|Primary neuroendocrine tumor of the left hepatic duct: a case report with review of the literature.|
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|PMID: 23213596 Owner: NLM Status: PubMed-not-MEDLINE|
|Primary Biliary Tract Neuroendocrine tumors (NET) are extremely rare tumors with only 77 cases been reported in the literature till now. We describe a case of a left hepatic duct NET and review the literature for this rare malignancy. To the best of our knowledge the present case is the first reported case of a left hepatic duct NET in the literature. In spite of availability of advanced diagnostic tools like Computerized Tomography (CT) Scan and Endoscopic Retrograde Cholangio Pancreaticography (ERCP) a definitive diagnosis of these tumors is possible only after an accurate histopathologic diagnosis of operative specimens with immunohistochemistry and electron microscopy. Though surgical excision remains the gold standard treatment for such tumors, patients with unresectable tumors have good survival with newer biologic agents like Octreotride.|
|Ajay H Bhandarwar; Taher A Shaikh; Ashok D Borisa; Jaydeep H Palep; Arun S Patil; Aditya A Manke|
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|Type: Journal Article Date: 2012-11-18|
|Title: Case reports in surgery Volume: 2012 ISSN: 2090-6919 ISO Abbreviation: Case Rep Surg Publication Date: 2012|
|Created Date: 2012-12-05 Completed Date: 2012-12-06 Revised Date: 2013-03-05|
Medline Journal Info:
|Nlm Unique ID: 101580191 Medline TA: Case Rep Surg Country: United States|
|Languages: eng Pagination: 786432 Citation Subset: -|
|Division of GI and HPP Surgery, Department of Surgery, Grant Medical College & Sir JJ Group of Hospitals, Byculla, Mumbai 400008, India.|
|APA/MLA Format Download EndNote Download BibTex|
Journal ID (nlm-ta): Case Rep Surg
Journal ID (iso-abbrev): Case Rep Surg
Journal ID (publisher-id): CRIM.SURGERY
Publisher: Hindawi Publishing Corporation
Copyright © 2012 Ajay H. Bhandarwar et al.
Received Day: 29 Month: 4 Year: 2012
Accepted Day: 29 Month: 8 Year: 2012
Print publication date: Year: 2012
Electronic publication date: Day: 18 Month: 11 Year: 2012
Volume: 2012E-location ID: 786432
PubMed Id: 23213596
|Primary Neuroendocrine Tumor of the Left Hepatic Duct: A Case Report with Review of the Literature|
|Ajay H. BhandarwarI1*|
|Taher A. ShaikhI1|
|Ashok D. BorisaI1|
|Jaydeep H. PalepI1|
|Arun S. PatilI1|
|Aditya A. MankeI1|
|Division of GI and HPP Surgery, Department of Surgery, Grant Medical College & Sir JJ Group of Hospitals, Byculla, Mumbai 400008, India
|Correspondence: *Ajay H. Bhandarwar: firstname.lastname@example.org
[other] Academic Editors: T. Çolak and M. Ganau
NET is derived from the embryonal neural crest cells called Argentaffin or Kulchitsky cells and have a potential for secreting serotonin. This tumor can arise anywhere in the distribution of the Argentaffin cell system. In addition to the most common sites of occurrence, namely, ileum and appendix these tumors have reported to occur in bladder, prostate, rectum, stomach, bronchi, pancreas, and biliary tree.
The Literature documents about 77 cases of neuroendocrine tumor arising from the biliary tree which includes common bile duct, common hepatic duct, cystic duct, and hilar confluence.
We report a case of Primary Biliary NET arising from the left hepatic duct. An extensive search of the literature has yielded no reference regarding a NET arising from the left Hepatic ducts. The present case is the first reported case of a NET arising in the left hepatic duct.
A 69-years-old female presented with colicky pain in the right hypochondrium since 3 years. She had past history of open cholecystectomy done for gall stones 15 years back. On physical examination the patient was anicteric with soft abdomen. An Ultrasonography (USG) of the abdomen showed a hypoechoic lesion of size 3.5 cm × 4 cm in segment 4 of the liver. Computerized Tomography (CT) of the abdomen showed a 4.1 × 3.7 cm heterogeneously enhancing mass lesion in segment IV of liver abutting the left branch of portal vein (Figure 1). A Magnetic Resonance Imaging (MRI) of upper abdomen with Magnetic Resonance CholagioPancreaticography (MRCP) showed a filling defect in the left hepatic duct with lesion in the adjacent part of liver in segment IV, suggestive of a left hepatic duct tumor with infiltration in the liver (Figure 2). Tumor marker serum alfa fetoprotein was mildly raised. Patient was worked up for left hepatectomy. Intraopertaively a lesion arising from the left hepatic duct involving the left branch of portal vein and extending upto the portal confluence was found (Figure 3) rendering the tumor unresectable. A biopsy was taken from the mass and procedure was abandoned in view of inoperability. Histopathology showed typical rosette appearance of a neuroendocrine tumor (Figure 4) and immunohistochemistry positive for CD56, Chromogranin and Synaptophysin (Figure 5). Ultrastructural study of the cell with electron microscopy (Figure 6) showed the presence of multiple neurosecretory granules with muscle tissue.
A whole body Positron Emission Tomography (PET) scan and an Octreotride labeled radionulceotide scan showed somatostatin receptor expressing lesion in the hepatobiliary system (Figure 7).
The patient was started on long-acting Octreotride therapy single dose every month. The patient has received 12 of such doses and is doing well after a 1-year followup without any complications. A follow up MRI (Figure 8) upper abdomen with MRCP at 1 year showed the absence of filling defect in the Left hepatic duct that was seen previously which showed tumor regression.
Primary Biliary-tract NETs are very rare. They account for 0.2–2% of all gastrointestinal NET [1, 2] reason being the paucity of enterochromaffin cells from which NETs arise in this area. Chronic inflammation of the bile duct epithelium is responsible for metaplasia of these enterochromaffin cells and formation of NET.
Davies  in 1959 reported NET of the distal bile duct and pancreatic duct which represented more of a periampullary NET rather than a biliary tract. Pilz  in 1961 was credited to report the first case of a Biliary Tract NET. After an extensive search of the Medline only 77 cases of Biliary Tract NET have been reported so far in the literature since 1961 (Table 1).
Till now no NET in the literature has been reported in the isolated left hepatic duct possibly making our case the first reported case of an isolated left hepatic duct NET.
The most common site of malignancy in the biliary tract was common bile duct (57.14%) followed by the hilar confluence (27.28%), the cystic duct (9.1%), common hepatic duct (5.12%) and finally the left hepatic duct (1.23%).
The mean age of presentation was 47 years (range 6 years to 79 years).
The male to female ratio is 1 : 1.23 showing that the biliary NET has a preponderance for female.
By far the most common symptom in patients of Biliary tract NET is Jaundice (63.4%) followed by Pain (14.1%), jaundice with pain (12.7%) and remaining nonspecific symptoms like weight loss.
The incidence of a Carcinoid syndrome in patients of Biliary Tract NET is very rare. Only 4 cases which include a single case published by Nesi et al.  in 2006 with symptoms of diarrhea due to secretion of serotonin and 3 cases by Price et al.  in 2009 with features of Zollinger Ellison syndrome due to secretion of gastrin from tumor in CBD.
Biliary Tract NET are rare tumors that typically present with jaundice and pain. As compared to its counterpart Cholangiocarcinoma Biliary NET occurs in a younger age group with a female preponderance . Biliary NET usually are nonsecreting tumor. Preoperative diagnosis of these tumors require a high index of suspicion and accurate histopathological diagnosis which must include a immunohistochemistry study and electron microscopy. Biliary tract NET are slow-growing indolent tumor which have a limited propensity for local and metastatic spread. Surgical resection aimed at complete tumor excision with bilio-enteric continuity offers the best cure and high survival rates. Patients who have undergone resection have a long term survival. Even in inoperable patients chemotherapy with newer biologic agents like Octreotride have a favorable outcome on the patient's survival.
The authors declare that they have no conflict of interest.
We would like to thank Padmashree Dr. T. P. Lahane Dean of Grant Medical College Mumbai for the support and encouragement provided to publish this paper. We would also like to thank Dr. Sanjay Navani and Dr. M. B. Tayade Head of department General Surgery Grant Medical College Mumbai.
|1.||Modlin IM,Sandor A. An analysis of 8305 cases of Carcinoid tumorsCancerYear: 19977948138299024720|
|2.||Lauffer JM,Zhang T,Modlin IM. Review article:current status of gastrointestinal carcinoidsAlimentary Pharmacology & TherapeuticsYear: 199913327128710102959|
|3.||Davies AJ. Carcinoid tumors (Argentaffinomata)Annals of the Royal College of Surgeons of EnglandYear: 19592527729719310224|
|4.||Pilz E. On carcinoid of the bile ductZentralblatt Fur ChirurgieYear: 1961861588159013735780|
|5.||Little JM,Gibson AA,Kay AW. Primary common bile-duct carcinoidBritish Journal of SurgeryYear: 19685521471492-s2.0-00142516355635925|
|6.||Bergdahl L. Carcinoid tumours of the biliary tractAustralian and New Zealand Journal of SurgeryYear: 19764621361382-s2.0-00171825831067071|
|7.||Judge DM,Dickman PS,Trapukdi S. Nonfunctioning argyrophilic tumor (APUDoma) of the hepatic duct. Simplified methods of detecting biogenic amines in tissueAmerican Journal of Clinical PathologyYear: 197666140452-s2.0-001707748859542|
|8.||Gerlock AJ,Muhletaler CA. Primary common bile duct carcinoidGastrointestinal RadiologyYear: 1979432632642-s2.0-0018648208488613|
|9.||Vitaux J,Salmon RJ,Langville O,Buffet C,Martin E,Chaput JC. Carcinoid tumor of the common bile ductAmerican Journal of GastroenterologyYear: 19817643603622-s2.0-00198485857325150|
|10.||Nakamuara T,Sawada T,Karaki K,Kawao : A. A case of MEA associated with bie duct carcinoidGann No RinnshouYear: 19812712991301|
|11.||Abe Y,Itoh H,Yoshida M,et al. Carcinoid tumor of the common bile duct, report of a caseStomach and IntestineYear: 19831855435482-s2.0-0020587118|
|12.||Goodman ZD,Albores Saavedra J,Lundblad DM. Somatostatinoma of the cystic ductCancerYear: 19845334985022-s2.0-00213689796318950|
|13.||Jutte DL,Bell PH,Penn IM,Powers J,Kolinjivadi J. Carcinoid tumor of the biliary systemDigestive Diseases and SciencesYear: 1986327637693595390|
|14.||Nicolescu PG,Popescu A. Carcinoid tumor of the cystic ductMorphologie et EmbryologieYear: 19863242752772-s2.0-00228015092949144|
|15.||Alexander IA,Thomson KK,Klune GA. Primary common bile duct carcinoid: demonstration by computed tomography, ultrasonography and angiographyAustralasian RadiologyYear: 19863034373524535|
|16.||Gastinger I,Schütze U,Beetz G,Lippert H. Obstructive jaundice caused by a carcinoid tumor of the hepatocholedochal ductZentralblatt fur ChirurgieYear: 198711218117011752-s2.0-00234872343687265|
|17.||Reinhardt D,Thiele H,Weber JC,Hofmann WJ. Carcinoid of the ductus choledochus. A rare cause of obstructive jaundiceChirurgYear: 198859106836872-s2.0-00240996953058409|
|18.||Chittal SM,Ra PM. Carcinoid of the cystic ductHistopathologyYear: 19891566436462-s2.0-00248482012606458|
|19.||Fujita N,Mochizuki F,Lee S,et al. Carcinoid tumor of the bile duct: case reportGastrointestinal RadiologyYear: 19891421511542-s2.0-00245045202651196|
|20.||Bickerstaff DR,Ross WB. Carcinoid of the biliary tree: a case report and review of the literatureJournal of the Royal College of Surgeons of EdinburghYear: 198732148512-s2.0-00231322863031287|
|21.||Brown WM,Henderson JM,Kennedy JC. Carcinoid tumor of the bile duct. A case report and literature reviewAmerican SurgeonYear: 19905663433462-s2.0-00251210782190510|
|22.||Bumin C,Ormeci N,Dolapci M,Gungor S. Carcinoid tumor of the biliary ductInternational SurgeryYear: 19907542622642-s2.0-00256651412292489|
|23.||Fellows IW,Leach IH,Smith PG,Toghill PJ,Doran J. Carcinoid tumour of the common bile duct—a novel complication of von Hippel-Lindau syndromeGutYear: 19903167287292-s2.0-00253309692379881|
|24.||Besznyák I,Tasnádi G,Hirsch T,Köves I,Schaff Z,Lapis K. Hepato-lobectomy for carcinoid tumor of the hepatic ductOrvosi HetilapYear: 1991132115915942-s2.0-00264267562008303|
|25.||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 literatureAmerican Journal of Clinical PathologyYear: 19919633413442-s2.0-00260098431877530|
|26.||Barron-Rodriguez LP,Manivel JC,Mendez-Sanchez N,Jessurun J. Carcinoid tumor of the common bile duct: evidence for its origin in metaplastic endocrine cellsAmerican Journal of GastroenterologyYear: 1991868107310762-s2.0-00257919851858744|
|27.||Newman K,Vates T,Duffy L,Anderson K. Pancreatoduodenectomy with preservation of the stomach and pylorus: a safe and effective alternative in childrenJournal of Pediatric SurgeryYear: 19922710133413352-s2.0-00266569371357128|
|28.||Dixon JM,Chapman RW,Berry AR. Carcinoid tumour of the ampulla of Vater presenting as acute pancreatitisGutYear: 19872810129612972-s2.0-00232327933678958|
|29.||Rugge M,Sonego F,Militello C,Guido M,Ninfo V. Primary carcinoid tumor of the cystic and common bile ductsAmerican Journal of Surgical PathologyYear: 19921688028072-s2.0-00267763351497121|
|30.||Gembala RB,Arsuaga JE,Friedman AC,et al. Carcinoid of the intrahepatic ductsAbdominal ImagingYear: 19931832422442-s2.0-00272766248508084|
|31.||Mandujano-Vera G,Angeles-Angeles A,De la Cruz-Hernandez J,Sansores- Perez M,Larriva-Sahd J. Gastrinoma of the common bile duct: immunohistochemical and ultrastructural study of a caseJournal of Clinical GastroenterologyYear: 19952043213242-s2.0-00290114067665823|
|32.||Sankary HN,Foster P,Frye E,Williams JW. Carcinoid tumors of the extrahepatic bile duct: an unusual cause of bile duct obstructionLiver Transplantation and SurgeryYear: 1995121221232-s2.0-00292580589346553|
|33.||Hao L,Friedman AL,Navarro VJ,West B,Robert ME. Carcinoid tumor of the common bile duct producing gastrin and serotoninJournal of Clinical GastroenterologyYear: 199623163652-s2.0-00300159658835905|
|34.||Kopelman D,Schein M,Kerner H,Bahuss H,Hashmonai M. Carcinoid tumor of the common bile ductHPB SurgeryYear: 199610141432-s2.0-00298070649187551|
|35.||Belli G,Rotondano G,D’Agostino A,Marano I. Primary extrahepatic bile duct carcinoidsHPB SurgeryYear: 1996921011052-s2.0-00299646098871251|
|36.||Bembenek A,Lotterer E,Machens A,et al. Neuroendocrine tumor of the common heaptic duct: a rare cause of extrahepatic jaundice in adolescenceSurgeryYear: 199812367127152-s2.0-00318402339626325|
|37.||Nahas SC,Lourencao JL,Gazoni E,Mott de B C,Borba MR,Pinto Filho JO,et al. Carcinoid tumors of the common bile duct: report of a caseRevista Do Hospital Das Clinicas Da Faculdade De Medicina Da Universidade De Sao PauloYear: 19985326289659740|
|38.||Ross AC,Hurley JB,Hay WB,Rusnak CH,Petrunia DM. Carcinoids of the common bile duct: a case report and literature reviewCanadian Journal of SurgeryYear: 199942159632-s2.0-0033010750|
|39.||Chamberlain RS,Blumgart LH. Carcinoid tumors of the extrahepatic bile duct. A rare cause of malignant biliary obstructionCancerYear: 1999861959196510570419|
|40.||Hermina M,Starling J,Warner TF. Carcinoid tumor of the cystic ductPathology Research and PracticeYear: 1999195107077092-s2.0-0032882991|
|41.||Chan C,Medina-Franco H,Bell W,Lazenby A,Vickers SM. Carcinoid tumor of the hepatic duct presenting as a Klatskin tumor in an adolescent and review of world literatureHepato-GastroenterologyYear: 200047325195212-s2.0-003400006010791227|
|42.||Maitra A,Krueger JE,Tascilar M,et al. Carcinoid tumors of the extrahepatic bile ducts: a study of seven casesAmerican Journal of Surgical PathologyYear: 20002411150115102-s2.0-003375924311075851|
|43.||Juturi JV,Maghfoor I,Doll DC,Evans ML. A case of biliary carcinoid presenting with pancreatitis and obstructive jaundiceAmerican Journal of GastroenterologyYear: 20009510297329742-s2.0-003379447911051379|
|44.||Turrión VS,Salas C,Alvira LG,Jimenez M,Lucena JL,Ardaiz J. Carcinoid tumour of the common bile duct: an exceptional indication for liver transplantationTransplantation ProceedingsYear: 20023412642652-s2.0-003622380211959276|
|45.||Pawlik TM,Shah S,Eckhauser FE. Carcinoid tumor of the biliary tract: treating a rare cause of bile duct obstructionAmerican SurgeonYear: 2003692981012-s2.0-003731596712641346|
|46.||Podnos YD,Jimenez JC,Zainabadi K,et al. Carcinoid tumors of the common bile duct: report of two casesSurgery TodayYear: 20033375535552-s2.0-003869051414507005|
|47.||Volpe CM,Pryor JP,Caty M,Doerr RJ. An adolescent with bile duct carcinoid tumorMedical and Pediatric OncologyYear: 20034021371382-s2.0-003729210212461807|
|48.||Menezes AAC,Diver AJ,McCance D,Diamond T. Carcinoid tumour of the extrahepatic bile duct—report of a case and literature reviewUlster Medical JournalYear: 200473159622-s2.0-314266497715244130|
|49.||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 findingsOncology ReportsYear: 20051335435462-s2.0-1504435644515706430|
|50.||Hubert C,Sempoux C,Berquin A,Deprez P,Jamar F,Gigot JF. Bile duct carcinoid tumors: an uncommon disease but with a good prognosis?Hepato-GastroenterologyYear: 20055264104210472-s2.0-2174443792216001626|
|51.||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 reviewVirchows ArchivYear: 200644911041112-s2.0-3374563330816670930|
|52.||Kim DH,Song MH,Kim DH. Malignant carcinoid tumor of the common bile duct: report of a caseSurgery TodayYear: 20063654854892-s2.0-3364635048716633759|
|53.||Caglikulekci M,Dirlik M,Aydin O,et al. Carcinoid tumour of the common bile duct: report of a case and a review of the literatureActa Chirurgica BelgicaYear: 200610611121152-s2.0-3364502699316612931|
|54.||Honda H,Hayashi S,Sekiguchi Y,Tsukadaira T,Nakamura K. A case of the extrahepatic bile duct carcinoid tumorNihon Shokakibyo Gakkai ZasshiYear: 200610310116911752-s2.0-3375037710217023761|
|55.||Todoroki T,Sano T,Yamada S,et al. Clear cell carcinoid tumor of the distal common bile ductWorld Journal of Surgical OncologyYear: 20075, article 62-s2.0-33846951511|
|56.||Sethi H,Madanur M,Srinivasan P,Portmann B,Heaton N,Rela M. Non-functioning well-differentiated neuroendocrine tumor of the extrahepatic bile duct: an unusual suspect?Hepatobiliary and Pancreatic Diseases InternationalYear: 2007655495522-s2.0-3494884566517897922|
|57.||Stavridi F,Chong H,Chan S,et al. Neuroendocrine tumour of the cystic duct: a case report and literature reviewJournal of Gastrointestinal CancerYear: 200738132332-s2.0-5914910431519065721|
|58.||Jiménez R,Beguiristain A,Ruiz-Montesinos I,et al. Intrahepatic biliary carcinoidAmerican Journal of Clinical OncologyYear: 20083155215222-s2.0-5524910805718838892|
|59.||Ferrone CR,Tang LH,D’Angelica M,et al. Extrahepatic bile duct carcinoid tumors: malignant biliary obstruction with a good prognosisJournal of the American College of SurgeonsYear: 200720523573612-s2.0-3444763280317660084|
|60.||Nafidi O,Nguyen BN,Roy A. Carcinoid tumor of the common bile duct: a rare complication of von Hippel-Lindau syndromeWorld Journal of GastroenterologyYear: 2008148129913012-s2.0-4054911498518300362|
|61.||Gusani NJ,Marsh JW,Nalesnik MA,Tublin ME,Gamblin TC. Carcinoid of the extra-hepatic bile duct: a case report with long-term follow-up and review of literatureAmerican SurgeonYear: 200874187902-s2.0-4074912018618274439|
|62.||Schmitt TM,Bonatti H,Hagspiel KD,Iezzoni J,Northup P,Pruett TL. Carcinoid of the bile duct bifurcationJournal of the American College of SurgeonsYear: 20082062p. 3992-s2.0-38349096172|
|63.||Costantini M,Montalti R,Rossi G,et al. Adenocarcinoid tumor of the extrahepatic biliary tractInternational Journal of Surgical PathologyYear: 20081644554572-s2.0-5214910563118480386|
|64.||Felekouras E,Petrou A,Bramis K,et al. Malignant carcinoid tumor of the cystic duct: a rare cause of bile duct obstructionHepatobiliary and Pancreatic Diseases InternationalYear: 2009866406462-s2.0-7384913943520007084|
|65.||Price TN,Thompson GB,Lewis JT,Lloyd RV,Young WF. Zollinger-Ellison syndrome due to primary gastrinoma of the extrahepatic biliary tree: three case reports and review of literatureEndocrine PracticeYear: 20091577377492-s2.0-7744908497919491075|
|66.||Tonnhofer U,Balassy C,Reck CA,Koller A,Horcher E. Neuroendocrine tumor of the common hepatic duct, mimicking a choledochal cyst in a 6-year-old childJournal of Pediatric SurgeryYear: 2009446e23e252-s2.0-6694912496719524713|
|67.||Zhan J,Bao G,Hu X,et al. Carcinoid tumor of the common bile duct in children: a case reportJournal of Pediatric SurgeryYear: 20104510206120632-s2.0-7795780265720920731|
|68.||Squillaci S,Marchione R,Piccolomini M,et al. Well-differentiated neuroendocrine carcinoma (malignant carcinoid) of the extrahepatic biliary tract: report of two cases and literature reviewAPMISYear: 201011885435562-s2.0-7795475388820666735|
|69.||Tsalis K,Vrakas G,Geroukis T,Cheva A,Roidos GN,Lazarides C. Primary neuroendocrine tumor of the extrahepatic biliary tree mimicking Klatskin tumorJournal of Gastrointestinal and Liver DiseasesYear: 20101933413422-s2.0-7865010377520922208|
|70.||Lee JH,Lee KG,Oh YH,Paik SS,Park HK,Lee KS. Carcinoid tumors of the extrahepatic biliary tract: report of four casesSurgery TodayYear: 20114134304352-s2.0-7995593121921365432|
|71.||Athanasopoulos PG,Arkadopoulos N,Stafyla V,et al. A rare combination of an endocrine tumour of the common bile duct and a follicular lymphoma of the ampulla of Vater: a case report and review of the literatureWorld Journal of Surgical OncologyYear: 20119, article 42-s2.0-78651286293|
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