Pancreatobiliary Intraductal Papillary Neoplasms

A 70-year-old man presented with a 2-week history of painless jaundice. Blood tests revealed anemia and abnormal liver function tests with markedly increased bilirubin. Serum carcinoembryonic antigen was also increased. At emergency computed tomography scan, a 23-mm expansile cystic lesion in the head of the pancreas was identified. The extraand intrapancreatic common bile duct was dilated and a polypoid growth was seen within its lumen; the wall appeared thickened. Finally, a second polypoid area was seen in the gallbladder measuring approximately 9 mm. The patient was initially stented and subsequently, a Whipple’s procedure was performed. A papillary lesion within the dilated suprapancreatic common bile duct was seen at macroscopy and the bile duct wall appeared thickened; the pancreatic cystic lesion was also evident (Figure 1A and B) as was the gallbladder polyp. Several associated neoplasms were seen at histology (Figure 2A-D). The common bile duct lesion was an intraductal papillary neoplasm of biliary type with high-grade dysplasia and an associated invasive adenocarcinoma infiltrating the main bile duct wall but not the surrounding pancreas. The gallbladder lesion was an intracystic papillary neoplasm of biliary type with high-grade dysplasia. The cystic pancreatic head lesion was a main duct, intraductal papillary mucinous neoplasm of mixed type with mild dysplasia and no evidence of invasive malignancy. The association of gallbladder, bile duct, and pancreas intraductal papillary neoplasms is a rare event. This case exemplifies how terminology is changing. Indeed, new names for old entities have been introduced in the 2010 World Health Organization blue book of neoplasms of the digestive system. The previous edition described these gallbladder/bile duct neoplasms as papillary adenoma/carcinoma or “biliary papillomatosis” when multiple—the name has now changed (even though the World Health Organization book’s microphotograph has not) and these are considered intraductal or intracystic papillary neoplasms. Both similarities and differences between 576960 IJSXXX10.1177/1066896915576960International Journal of Surgical PathologyGrillo et al research-article2015