A rare case of cholangiosarcoma metastatic to the pleura, diagnosed the old way

A. Zetos^a (Dr), I. Michailidou*^a (Dr), V. Petta^a (Dr), S. Kaltsas^b (Dr), K. Fragia-Tsivou^c (Dr), D. Bisirtzoglou^a (Dr)

^a Agios Savvas General Oncological Hospital of Athens, Athens, GREECE ; ^b Lamia General Hospital, Lamia, GREECE ; ^c HBD HistoBioDiagnosis, Athens, GREECE

* gataplan@gmail.com

Backround: Cholangiocarcinomas (CCAs) are diverse biliary epithelial tumors involving the biliary tree. They have extremely aggressive metastatic behaviour resulting in a very poor prognosis. Metastasis are usually observed at intrahepatic site, local and distal lymphnodes and peritoneum. Pulmonary and pleural metastasis are very rare. Abrams needle biopsy is a “blind” or closed pleural biopsy used since 1955, which tends to be abandoned, but still in use in our department.

Case report: We describe the case of an 82 years-old male, who was diagnosed with mediastinal lymphadenopathy and pleural effusion after an accident. The patient had a history of cholangiocarcinoma treated with surgery after induction chemotherapy with oxaliplatin/5FU, two years ago. The patient was submitted to bronchoscopy and mediastinal lymphnodes sampling with EBUS, which was negative for malignancy. A pleural biopsy with Abrams needle followed and the histology was positive for metastatic adenocarcinoma from the biliary tract.

Conclusion: Pleural dissemination of cholangiocarcinoma is rare and diagnosis is usually relied on video-assisted thoracoscopic surgery. The sensitivity of Abrams biopsies for malignancy ranges between 27% and 60%, and, in the largest review of 2,893 Abrams samples, the diagnostic yield for malignancy is 57%. Still, in experienced hands, it can help diagnose exudative lymphocytic pleural effusions when image-guided techniques are unavailable or if the patient is not unable to tolerate thoracoscopy and also as a first-line diagnostic tool in resource-poor settings. In our case, a rare disease was diagnosed in an old-fashioned way, reminding us it is a skill not to be abandoned.

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Okuda MD. Clinical Aspects of Intrahepatic Bile Duct Carcinoma.Cancer 1977; 39:232-245

Bibby AC et al.Pleural biopsies in undiagnosed pleural effusions;Abrams vs image guided vs thoracoscopic biopsies.Curr Opin Pulm Med.2016 Jul (4):392-8

Disclosure of funding source(s): none