Case Presentation
Liver Nodules after Percutaneous Transhepatic Biliary Drainage: A Case Series
Hadjimichael E1,2, Fielding DE1,2, Ilyas M1,2,3, Zaitoun AM1,2, Lobo DN2* and Kaye PV1,2
1Department of Cellular Pathology, University of Nottingham, UK
2Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR), Nottingham Biomedical
Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, UK
3Division of Cancer and Stem Cells, School of Medicine, University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, UK
*Corresponding author: Lobo DN, Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, Queen’s Medical Centre, Nottingham NG7 2UH, UK
Published: 11 May, 2018
Cite this article as: Hadjimichael E, Fielding DE, Ilyas
M, Zaitoun AM, Lobo DN, Kaye PV.
Liver Nodules after Percutaneous
Transhepatic Biliary Drainage: A Case
Series. Clin Oncol. 2018; 3: 1457.
Abstract
Although liver granulomata mimicking metastatic nodules have been reported previously, these
have not been related to previous percutaneous transhepatic cholangiography and biliary drainage.
We describe four cases where necrotising granulomata, apparently secondary to previous PTBD,
have necessitated liver biopsy and frozen section examination at the time of subsequent planned
cancer resection, to exclude tumour metastases. Necrotising granulomata were diagnosed on frozen
section in 3 patients, but in one, frozen section offered a diagnosis of malignancy with necrosis, but
paraffin sections showed features of a necrotising granuloma. Knowledge of this potential pitfall,
with surgeons and pathologists being aware of these lesions caused by PTC, should help prevent
misinterpretation.
Keywords: Pancreaticobiliary cancer; Liver nodules; percutaneous transhepatic cholangiography; Liver granulomata; Metastases; Frozen section
Introduction
Percutaneous Transhepatic Cholangiography (PTC) is an interventional radiological technique for both diagnostic imaging and therapeutic decompression (Percutaneous Transhepatic Biliary Drainage - PTBD) of the proximal biliary tract in patients with proximal biliary obstructionor when Endoscopic retrograde cholangiopancreatography (ERCP) fails in patients with distal obstruction. Recognized complications of PTC include sepsis, haemorrhage and pneumothorax. We describe four cases where necrotising granulomata, apparently secondary to previous PTBD, have necessitated liver biopsy and frozen section examination at the time of subsequent planned cancer resection, to exclude tumour metastases.
Case Presentation
Patient 1
A 59-year-old woman who presented with obstructive jaundice due to a pancreatic
cancerunderwent PTC and stenting after having an unsuccessful attempt at ERCP. A
pancreaticoduodenectomy was planned, but during the intra operative assessment, a sub capsular
liver lesion was identified and a biopsy was taken for frozen section examination querying liver
metastasis from a pancreatic cancer. A significant level of difficulty was associated with the
interpretation of the frozen histology, and malignancy with necrosis was considered. Hence,
resection was not performed. However, the paraffin sections of the lesion showed necrosis
surrounded by epithelioid histiocytes and macrophages, histological appearances consistent with a
necrotising granuloma. The patient subsequently underwent a successful pacreaticoduodenectomy
a few weeks later, with the diagnosis being well differentiated adenocarcinoma of the pancreas.
Patients 2-4
A 44-year-old man, a 40-year old man and a 60-year-old woman who presented with obstructive
jaundice and weight loss had PTC and stenting after a failed ERCP. During the intraoperative
assessment for a planned pancreaticoduodenectomy, sub capsular liver lesion was identified
in each of the three patients and a frozen section was sent querying either a scar or metastatic
disease. The frozen section from each patient showed the presence of a necrotising granuloma and
a subsequent paraffin section confirmed the presence of a well-defined granuloma. The first two
patients underwent a successful pancreaticoduodenectomy with
adenocarcinoma of the ampulla and adenocarcinoma of the distal
bile duct being final diagnoses respectively. In the fourth patient, the
pancreaticoduodenectomy was abandoned as trial dissection revealed
that the tumour was locally advanced and, therefore, unrespectable.
Discussion
Common aetiologies of liver granulomata include tuberculosis, sarcoidosis, primary biliary cirrhosis, drug reactions and foreign bodies. Liver granulomata mimicking liver metastases have been reported previously although; these cases were not related to PTC1, 2. The present series comprises the first reported cases of necrotising granulomata in the liver secondary to prior instrumentation of the liver and leading to intraoperative histological assessment. Irrespective of the cause in the cases mentioned, this entity is highlighted as a potential pitfall in frozen section interpretation, which can lead to over staging of otherwise respectable disease having a significant effect on patient’s management. Several reasons can contribute to false interpretation of this lesion as malignant including the macroscopic appearance of a sub capsular liver lesion, the presence of a known primary malignancy that is being operated, localised necrosis, macrophages and histiocytes that can mimic single tumour cells and finally time pressure. In addition, these histological findings could lead to another misleading interpretation including a possible diagnosis of infection such as tuberculosis. Knowledge of this potential pitfall, with surgeons and pathologists being aware of these lesions caused by PTC, should help prevent misinterpretation.