Neoadjuvant chemotherapy is considered an effective strategy for patients with advanced
biliary tract cancer for improving R0 resection and prognosis [1]. We report a complete pathological response with remarkable biliary tumor shrinkage
on peroral cholangioscopy (POCS) both before and after neoadjuvant chemotherapy.
A 73-year-old man underwent POCS (SpyGlass DS; Boston Scientific, Marlborough, Massachusetts,
USA) with an initial endoscopic retrograde cholangiopancreatography for suspected
biliary tract cancer. POCS revealed an irregular circumferential granular stricture
with erythematous mucosa and ready oozing within the common hepatic duct, extending
from the bifurcation of the right and left hepatic ducts to the cystic duct ([Fig. 1]
a, [Video 1]). The left intrahepatic bile duct and anterior segment were normal; however, the
root of B4 and the posterior segment had a persistent, irregular granular stricture
with erythematous mucosa from the hilar region, indicative of tumor invasion. Biopsies
of the right and left hepatic duct bifurcation showed adenocarcinoma ([Fig. 2]).
Fig. 1 Peroral cholangioscopy findings before (a) and after (b) neoadjuvant chemotherapy. a An irregular circumferential granular stricture with erythematous mucosa and ready
oozing were seen at the bifurcation. b The irregularly granulated stricture and redness at the bifurcation improved, and
white bile ducts were seen.
Peroral cholangioscopy findings following eight cycles of gemcitabine and cisplatin
plus S-1 therapy revealed delineated whitened bile ducts, marked by improvement in
the granulated stricture and redness.Video 1
Fig. 2 Before neoadjuvant chemotherapy, a biopsy of the bile duct at the right and left hepatic
duct bifurcation showed invasive adenocarcinoma with desmoplastic reaction (arrows).
Subsequent POCS findings following eight cycles of gemcitabine and cisplatin plus
S-1 revealed delineated whitened bile ducts, marked by improvement in the irregularly
granulated stricture and redness at the bifurcation ([Fig. 1]
b, [Video 1]). The erythematous tone of the common hepatic duct had also improved, with concomitant
fibrosis. A section of the common hepatic duct showed a raised lesion unilaterally
([Video 1]; arrow) and thick tortuous vessels ([Video 1]; arrowhead), suggestive of tumor invasion; however, a biopsy showed fibrous scar
formation, indicating a chemotherapeutic effect on the tumor ([Fig. 3]).
Fig. 3 After neoadjuvant chemotherapy, a biopsy of the bile duct at the right and left hepatic
duct bifurcation showed fibrous scar formation with no viable carcinoma cells (*).
No epithelial cells remained on the luminal side (arrow).
An extended right hepatectomy was performed with R0 resection (stage 0, pTisN0M0).
Subsequent histopathological analyses confirmed Evans’s grade IV findings, indicating
that no viable tumor cells were present [2].
The sensitivity and specificity of POCS as a diagnostic technique are reported to
be 94.7% and 92.6%, respectively [3]. However, the evaluation of progression after neoadjuvant chemotherapy is difficult
and requires careful judgment based on the POCS diagnosis.
Endoscopy_UCTN_Code_CCL_1AZ_2AC
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
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