International Surgery Synchronous double cancer of the common bile duct and the ampulla of Vater without pancreaticobiliary maljunction: A case report

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1 International Surgery Synchronous double cancer of the common bile duct and the ampulla of Vater without pancreaticobiliary maljunction: A case report --Manuscript Draft-- Manuscript Number: Full Title: Article Type: Keywords: Corresponding Author: INTSURG-D R1 Synchronous double cancer of the common bile duct and the ampulla of Vater without pancreaticobiliary maljunction: A case report Case Report Synchronous nepoplasm; Common bile duct; Ampulla of Vater Sadaaki Yamazoe, M.D., Ph.D. Department of Surgical Oncology (First Department of Surgery) Osaka City University Graduate School of Medicine Osaka, JAPAN Corresponding Author Secondary Information: Corresponding Author's Institution: Department of Surgical Oncology (First Department of Surgery) Osaka City University Graduate School of Medicine Corresponding Author's Secondary Institution: First Author: Ryota Tanaka, M.D. First Author Secondary Information: Order of Authors: Ryota Tanaka, M.D. Sadaaki Yamazoe, M.D., Ph.D. Ryosuke Amano, M.D., Ph.D Kenjiro Kimura, M.D., Ph.D. Go Ohira, M.D., Ph.D. Keiichiro Hirata, M.D., Ph.D. Kohei Nishio, M.D. Kotaro Miura, M.D., Ph.D Masaichi Ohira, M.D., Ph.D. Kosei Hirakawa, M.D., Ph.D. Order of Authors Secondary Information: Abstract: Introduction: Synchronous double cancers in the biliary system are rare. Double cancer of the CBD and the ampulla of Vater without PBM is extremely rare; to our knowledge, only seven cases have been reported previously. Here we report a case of synchronous double cancer of the CBD and the ampulla of Vater without PBM. Case presentation: A 63-year-old man was referred to our hospital with epigastric pain and jaundice. Computed tomography (CT) showed dilatation of both intrahepatic and intrapancreatic bile ducts, and slightly enhanced tumor in the middle part of the CBD and the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) showed a tuberous filling defect in the middle part of the CBD and an exposed tumor of the ampulla of Vater. Conclusion: Under a diagnosis of synchronous double cancer of the middle bile duct and the ampulla of Vater, pancreaticoduodenectomy was performed. Histopathologically, the ampulla of Vater tumor was well-differentiated tubular adenocarcinoma while the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation

2 middle bile duct tumor was moderately-differentiated tubular adenocarcinoma. Normal mucosa was interposed between both tumors. These findings suggest that they were two primary tumors. Double cancer of the CBD and the ampulla of Vater without PBM is extremely rare. We report a case of synchronous double cancer of the CBD and the ampulla of Vater without PBM. Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation

3 Title Page Click here to download Title Page renamed_07a5c.docx Synchronous double cancer of the common bile duct and the ampulla of Vater without pancreaticobiliary maljunction: A case report. The foot of the title. Synchronous biliary double cancers. Ryota Tanaka, Sadaaki Yamazoe, Ryosuke Amano, Kenjiro Kimura, Go Ohira, Keiichiro Hirata, Kohei Nishio, Kotaro Miura, Masaichi Ohira, Kosei Hirakawa Department of Surgical Oncology (First Department of Surgery), Osaka City University Graduate School of Medicine, Osaka, Japan The authors declare that they have no disclaimers and are not supported by any grants, equipment and drugs regarding this manuscript. Corresponding author: Sadaaki Yamazoe Department of Surgical Oncology Osaka City University Graduate School of Medicine Asahi-machi, Abeno-ku, Osaka , Japan Tel: ; Fax: zoesada@yahoo.co.jp The authors declare that they have no competing interests.

4 Manuscript Click here to download Manuscript renamed_691e5.docx Introduction Synchronous double cancers in the biliary system are rare. Most such cases are double cancers occurring in the common bile duct (CBD) and the gallbladder, and are associated with pancreaticobiliary maljunction (PBM). Double cancer of the CBD and the ampulla of Vater without PBM is extremely rare; to our knowledge, only seven cases have been reported previously, three in the English literature and four in the Japanese literature. Here we report a case of synchronous double cancer of the CBD and the ampulla of Vater without PBM. Case report A 63-year-old Japanese man was admitted to our hospital with upper abdominal pain and jaundice in June Laboratory results included the following: white blood cells 5700 /μl, C-reactive protein 0.37 mg/dl, total bilirubin 3.5 mg/dl, aspartate aminotransferase 61 U/L, alanine aminotransferase 91 U/L, alkaline phosphatase 388 IU/L, γ-glutamyltransferase 156 IU/L, amylase 144 IU/L, creatinine 1.37 mg/dl, carcinoembryonic antigen 2.6 mg/dl, and carbohydrate antigen 53 IU/L.

5 Abdominal CT showed dilatation of the intrahepatic and intrapancreatic bile ducts, and slightly enhanced tumor in the middle part of the CBD and the ampulla of Vater (Fig. 1A and 1B). Gastrointestinal endoscopy revealed an exposed and protruded tumor of the ampulla of Vater. Endoscopic retrograde cholangiopancreatography (ERCP) showed the absence of PBM and dilatation of the upper and lower part of the CBD with stenosis in the middle part (Fig. 1C). Intraductal ultrasonography (IDUS) showed wall thickening in the middle part of bile duct (Fig. 1D). Histopathological examination of biopsy specimens revealed that the middle bile duct tumor was moderately-differentiated adenocarcinoma and the ampulla of Vater tumor was well-differentiated adenocarcinoma. Thus, preoperatively we diagnosed synchronous double cancer of the CBD and the ampulla of Vater. Subtotal stomach-preserving pancreaticoduodenectomy and regional lymph node dissection were performed. Macroscopically, there were two separate tumors; one in the CBD and the other in the ampulla of Vater (Fig. 2). Histopathological examination revealed a synchronous double adenocarcinoma of the CBD and the ampulla of Vater with no communication in either the mucosal or submucosal layer between the two tumors. Subsequently, pathological findings for each

6 tumor confirmed the results of biopsy specimen examination (Fig. 3,4). Discussion Biliary cancers with PBM are thought to develop multi-centrically because continuous reflux of pancreatic juice into the bile duct induces chronic inflammation and metaplastic epithelial changes 1). Synchronous double cancer in the biliary tract without PBM is very rare: the only seven cases to have been reported previously, to our knowledge, are summarized in Table 1 2)-8). Preoperative diagnosis of double cancer in the biliary tract is generally difficult and was made in only two of the previously-reported cases. In each of these cases, accurate diagnosis was made preoperatively because the tumor in the CBD had formed into an expansive papillary lesion that was relatively large, and CT showed a slightly enhanced tumor in the CBD. In our case, the diagnosis of double cancer was made preoperatively because abdominal CT showed dilatation of the intrahepatic and intrapancreatic bile ducts with stenosis in the middle part of bile duct. CT showed extension in the two locations, which indicated that there were two stenotic lesions in the biliary system;

7 therefore, we suspected the presence of a double cancer and could accurately diagnose the situation preoperatively. To select optimal treatment, it is important to make an accurate preoperative diagnosis. Biliary tract cancer may develop multi-centrically with or without PBM. Careful preoperative evaluation is required as there is a possibility of double cancer even though there are no abnormalities of the biliary tract per se. Our case can be considered a synchronous double cancer using the criteria of Warren and Gates 9). It is difficult to identify a double cancer when the two tumors are in close proximity or are attached. In such cases, immunohistochemical staining, for CEA and p53 for example, and determination of DNA ploidy patterns are useful for making an exact diagnosis 10),11). In the current case, the two tumors were separate with different histopathological diagnoses, suggesting that they were two primary cancers. :

8 References_ 1. Fujii T, Kaneko T, Sugimoto H, Okochi O, Inoue S, Takeda S. Metachronous double cancer of the gallbladder and common bile duct. J Hepatobiliary Pancreat Surg. 2004;11(4): Koga H, Furukawa M, Nakata T, Kusano T, Watabe S, Yamada M. A case of simultaneous occurrence of double cancer of the ampulla of Vater and bile duct (in Japanese). Tan to Sui (J Biliary Tract Panc) 1993;14(2): Nishihara K, Tsuneyoshi M, Shimura H, Yasunami Y. Three synchronous carcinomas of the ampulla of Vater, common bile duct and pancreas. Patho Inter. 1994;44(4): Koinuma K, Murai S, Amemiya T, Hara T, Akamatu H, Koizumi K. A case of synchronous double cancer in the biliary tract (in Japanese). Nihon Rinsyogeka Gakkaishi (J Jpn Surg Assoc). 1999;60(3): Hirono S, Tani M, Terasawa H, Kawai M, Ina S, Uchiyama K. A collision tumor composed of cancers of the bile duct and ampulla of Vater Immunohistochemical analysis of a rare entity of double cancer. Hepato-Gastroenterology.

9 2008;55(84): Shibutani M, Teraoka H, Kawasaki T, Sakashita K, Kanehara I, Chikugo T. A case of synchronous double cancer in the biliary tract of the extrahepatic bile duct and the ampulla of Vater (in Japanese). Shujyutu (Surgery). 2011;65(11): Ryu T, Takami Y, Wada Y, Saitsu H. A case of synchronous double cancer of the common bile duct and the ampulla of Vater (in Japanese). Nihon Rinsyogeka Gakkaishi (J Jpn Surg Assoc). 2011;72(12): Wohlauer MV, McManus MC, Brauer B, Hedges J, Gajdos C. Synchronous Presentation of Ampullary Adenocarcinoma and Common Bile Duct Cancer: Report of a Case and Review of Literature. J Pancreas. 2012;13(5): Warren S, Gates O. Multiple primary malignant tumors. A survey of the literature and a statistical study. Am J Cancer. 1932;16(6): Hori H, Ajiki T, Fujita T, Okazaki T, Suzuki Y, Kuroda Y. Double cancer of gall bladder and bile duct not associated with anomalous junction of the pancreaticobiliary duct system. Jpn J Clin Oncol. 2006;36(10): Ogawa A, Sugo H, Takamori S, Kojima K, Fukasawa M, Beppu T. Double cancers

10 in the common bile duct: molecular genetic findings with an analysis of LOH. J Hepatobiliary Pancreat Surg. 2001;8(4):

11 Figure Legends Figure 1. A,B: Abdominal enhanced computed tomography (CT) showed dilatation of the intrahepatic bile duct and slightly enhanced tumor in the middle common bile duct and the ampulla of Vater. C: Endoscopic retrograde cholangiopancreatography (ERCP) showed contrast medium disruption between the middle and distal bile duct. D: Intraductal ultrasonography (IDUS) confirmed wall thickening in the middle bile duct. Figure 2. Macroscopically, there was a nodular tumor in the middle bile duct and a papillary tumor in the ampulla of Vater, which did not communicate. Figure 3. The middle bile duct tumor was a moderately-differentiated adenocarcinoma by hematoxylin-eosin (H&E) staining. Figure 4. The ampulla of Vater papillary tumor was a well-differentiated adenocarcinoma by H&E staining. Table 1. Cases of synchronous multiple cancer of the common bile duct (CBD) and the ampulla of Vater without pancreaticobiliary maljunction. Bp: perihilar bile duct, Bd: distal bile duct, Ad: major duodenal papilla, A: ampulla of

12 Vater, PD: pancreaticoduodenectomy, PPPD: pylorus preserving pancreatoduodenectomy, SSPPD: subtotal stomach-preserving pancreaticoduodenectomy, PV: portal vein

13 Table Click here to download Table double cancer%2c table.xlsx Table1. Cases of synchronous multiple cancer of the common bile duct (CBD) and the ampulla of V Author Age/Sex Location Pathology Depth Stage Koga('93) 2) 76/F Bd well T4 III Ad muc T3 IIB Nishihara('94) 3) 51/M Bd papillary T1 IA Bd papillary T1 IA A papillary T1 IA Koinuma('99) 4) 72/M Bd moderate T2 IB Ad moderate T1 IA Hirono('08) 5) 75/M Bd well T2 IB A papillary T2 IB Shibutani('11) 6) 75/F Bp poorly T4 III Ad well T1 IA Ryu('11) 7) 74/F Bd moderate T1 IA Ad moderate T1 IA Wohlauer('12) 8) 76/F Bd moderate T1 IA Ad moderate T1 IA Our case('13) 63/M Bd moderate T1 IA Ad well T1 IA Bp: perihilar bile duct, Bd: distal bile duct, Ad: major duodenal papilla, A: ampulla of Vater PD: pancreaticoduodenectomy, PPPD: pylorus preserving pancreatoduodenectomy SSPPD: subtotal stomach-preserving pancreaticoduodenectomy, PV: portal vein

14 Vater without pancreaticobiliary maljunction Operation PD PD Outcome 10months dead 26months alive PPPD PPPD PD (PV resection) PD PD SSPPD 25months alive 12months alive 7months dead alive 12months alive

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