CLINICAL HISTORY
A 48-year-old male with no significant past medical history presented with acute cholecystitis. An open cholecystectomy was performed, and six weeks later the patient had continued right upper quadrant abdominal pain and jaundice. Re-operation disclosed a partially obstructing neoplasm of the common bile duct for which a T-tube was placed. One month later the patient was readmitted and underwent a pancreaticoduodenectomy.
LABORATORY DATA
Alkaline phosphatase 1400 IU/L
Bilirubin 14 mg/dl
ANCILLARY STUDIES
Preoperative cholangiogram demonstrating a filling defect in the mid portion of the common bile duct. (Figure 1)
GROSS PATHOLOGY
Opened common bile duct from Whipple resection with intraluminal mass. (Figure 2)
Gross picture demonstrating cut section of mass and common bile duct. (Figure 3)
MICROSCOPIC PATHOLOGY
Microscopic whole-mount section of tumor and attachment to common bile duct. (Figure 4)
Sheets of malignant cells (Figure 5) with scattered mitotic figures (H&E 400x).
Inset: Malignant cells along the mucosal-submucosal junction in the adjacent mucosa (S-100 100x).
ADDITIONAL STUDIES
Special Stains/Immunohistochemistry
Tumor cells staining positive for HMB-45 (HMB-45 400x). (Figure 6)
Additionally, the tumor cells showed strong positivity for vimentin and S-100. The tumor cells showed no reactivity to synaptophysin, chromogranin, beta hCG, desmin, EMA, PLAP, Factor VIII, CD45, CD45RO, CD20, CD30, PAS with diastase, mucin, keratin AE1, and keratin AE3.
Electron Microscopy
Electron microscopy of tumor cells demonstrating pre-melanosomes. (Figure 7)
Clinical Workup
A comprehensive clinical workup failed to reveal any additional lesions in other anatomic sites.
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