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Image of the Month—Diagnosis
Arch Surg. 2006;141:316.
Answer: Papillary Adenoma of the Cystic Duct
Papillary adenoma is one of the most common benign neoplasms of the gallbladder. In a study by Christensen and Ishak,1 28% of the 180 benign tumors were papillary adenoma. Other benign tumors include adenomatous hyperplasia, inflammatory pseudotumors, and gastric heterotopia. There is, however, to our knowledge, only 1 previous case report2 of papillary adenoma of the cystic duct, which occurred in a 72-year-old woman who presented with a 3-month history of recurrent biliary colic. In our case, tarry stools in a teenager constituted the initial presenting symptom. Preoperative diagnosis was unlikely in both cases. The diagnoses were made only after examination of the resected specimens. In our patient, intraoperative findings showed regional lymphadenopathy near the common bile duct and a gallbladder and common bile duct of normal size. A frozen pathologic specimen of a sampled lymph node showed inflammation only. Malignancy could not be excluded. Cholecystectomy, resection of the common bile duct, lymph node dissection, and choledochojejunostomy with Roux-en-Y anastomosis were performed. Histologic examination confirmed a papillary adenoma. Our patient had an uneventful recovery.
Papillary adenoma in the biliary tree may occur singly or be part of a multiple papillomatosis syndrome with low-grade malignant potential.3-4 Inflammatory pseudotumors of the gallbladder are reactive lesions without distinctive gross features. The symptoms often resemble those of chronic cholecystitis. The diagnosis is based on histologic features such as epithelial hyperplasia and chronic inflammatory cell infiltrations. The diagnosis of adenomatous hyperplasia is likewise determined from microscopic features, being characterized by a proliferation of epithelial and smooth muscle elements without infiltration of chronic inflammatory cells. Cystic duct carcinoma is also rare, with only 26 reported cases.5 The ages of those patients ranged from 38 to 80 years, with an average age of 63 years. Most of the common clinical symptoms are those associated with cystic duct obstruction.5 Our patient was only 15 years old, making malignancy less likely. It is difficult, however, to rule out malignancy intraoperatively in a setting of regional lymphadenopathy. A more radical resection, therefore, was performed. The regional lymphadenopathy may have been due to irritation caused by blood in the common bile duct.
AUTHOR INFORMATION
Correspondence: Po-Huang Lee, MD, PhD, Department of Surgery, National Taiwan University Hospital, No. 7, Chung San South Road, Taipei 100, Taiwan (miningho{at}ntu.edu.tw; pohuang{at}ha.mc.ntu.edu.tw).
Accepted for Publication: May 2, 2005.
REFERENCES
1. Christensen AH, Ishak KG. Benign tumors and pseudotumors of the gallbladder: report of 180 cases. Arch Pathol. 1970;90:423-432.
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2. Loh A, Kamar S, Dickson GH. Solitary benign papilloma (papillary adenoma) of the cystic duct: a rare cause of biliary colic. Br J Clin Pract. 1994;48:167-168.
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3. Gertsch P, Thomas P, Baer H, Lerut J, Zimmermann A, Blumgart LH. Multiple tumors of the biliary tract. Am J Surg. 1990;159:386-388.
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4. Neumann RD, LiVolsi VA, Rosenthal NS, Burrell M, Ball TJ. Adenocarcinoma in biliary papillomatosis. Gastroenterology. 1976;70:779-782.
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5. Galler L, Feinberg GL, Scarano JJ. Case report: cystic duct carcinoma. N J Med. 1991;88:337-339.
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SECTION EDITOR: GRACE S. ROZYCKI, MD
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