A 60-year-old woman presented at our hospital with abnormal liver function tests discovered 2 weeks earlier on physical examination. Enhanced abdominal computed tomography (CT) scans revealed a space-occupying lesion at the hepatic hilum that was presumably considered hilar cholangiocarcinoma. The patient was admitted to our hospital on February 21, 2019. The patient denied any prior abdominal surgery or trauma. No abnormalities were found on physical examination.
Laboratory investigations included liver function enzymes and tumor markers: alanine aminotransferase (ALT) 187 U/L (normal: 7-55 U/L), aspartate aminotransferase (AST) 111 U/L (normal: 8-48 U/L), alkaline phosphatase (ALP) 737 U/L (normal: 40-129 U/L), gamma-glutamyltransferase (gamma-GT) 1,074 U/L (normal: 8-61 U/L), total bilirubin (TBil) 28.5 mumol/L (normal: 4-19 mumol/L), direct bilirubin (DBil) 13.7 mumol/L (normal: 0-5 mumol/L), albumin 44.5 g/L (normal: 30-50 g/L), CA19-9 50.01 U/ml (normal: 0-37 U/ml), CA125 12.18 U/ml (normal: 0-35 U/ml), alpha fetoprotein 8.63 ng/ml (normal: <20 ng/mL), and CEA 1.93 ng/ml (normal: 0-2.5 ng/mL).
Abdominal enhanced CT scan (Figure 1A) revealed a 10 x 17 mm mass in the hepatic hilum with an unclear boundary. In the arterial phase (Figure 1B), the mass showed obvious enhancement. The intrahepatic bile duct showed obvious dilation, and the mass surrounded the cystic duct. The wall of the gallbladder appeared thickened, but there was no significant enlargement. No enlarged lymph nodes were noted in the retroperitoneum. Furthermore, 3D reconstruction revealed a space-occupying lesion at the hilar bile duct, invading the right branch of the portal vein. Furthermore, the postoperative left residual liver volume (RLV) was estimated to be only 27.6% (Figure 1C).
After a multidisciplinary team (MDT) discussion, the location of the tumor was considered unordinary, and, since a biopsy would have been highly risky, the pathological nature of the tumor was difficult to establish preoperatively. Thus, preoperative diagnosis was considered to be hilar cholangiocarcinoma based on enhanced CT scans. However, direct surgical intervention (right hepatectomy) would be inappropriate due to insufficient residual liver volume. The patient thus underwent preoperative percutaneous transhepatic cholangiodrainage (PTCD) on March 1, 2019, followed by percutaneous transhepatic portal vein embolization (PVE) on March 4, 2019, to improve residual liver volume.
One month later, the patient was admitted again for surgery. Preoperative laboratory investigations revealed elevated liver function enzymes (ALT 131 U/L, AST 256 U/L, ALP 188 U/L, gamma-GT 209 U/L), while bilirubin and tumor markers were all within the normal range. A contrast-enhanced CT (Figure 2A) of the abdomen revealed improvement in the dilation of the hepatic duct, while the volume of the left hepatic liver had increased by 55.57% (Figure 2B). Magnetic resonance cholangiopancreatography (MRCP) (Figure 2C) indicated an irregular shadow at the porta hepatitis with a vague boundary and involving the cystic duct. The gallbladder was not enlarged, but the walls were significantly thickened.
On April 11, 2019, the patient underwent surgery. Intraoperatively, the gallbladder was severely attached to the liver. The gallbladder had atrophied with a hardened texture (Figure 3A). The tumor invaded the hilar bile duct and the right branch of the portal vein. Lymph node enlargement at the hepatoduodenal ligament was observed. Based on the intraoperative findings, gallbladder carcinoma was considered. The surgical intervention included laparoscopic cholecystectomy, laparoscopic right extended hepatectomy, and laparoscopic hepatoduodenal ligament lymph node dissection. A cholangiojejunostomy was then performed. Intraoperative freezing biopsy showed no cancer cells at the level of the resected left bile duct and cystic duct.
Postoperative pathological examination revealed that the mucosa of the gallbladder was grayish-white with a hard texture. Fibrous tissue hyperplasia of the gallbladder wall with hyaline degeneration was seen together with chronic interstitial inflammatory cell infiltration and focal multinucleated giant cell aggregation. A nodule, 1.4 x 1.0 cm in size, with a grayish-whitcross-sectionon (Figure 3B), was seen at the neck of the gallbladder. Pathological analysis and immunohistochemistry validated the diagnosis of traumatic neuroma through spindle cells (Figure 3C) and S-100 positivity (Figure 3D). Four resected lymph nodes showed reactive hyperplasia. The final validated diagnosis was traumatic neuroma of the gallbladder, chronic cholecystitis, fibrosis of the gallbladder wall, hyaline degeneration, and gallstones. The patient recovered well after the operation, without complications, and was discharged from the hospital. There was no obvious discomfort in the postoperative follow-up.