ARTICLE IN PRESS

Current Diagnostic Pathology (2005) 11, 34–43

www.elsevier.com/locate/cdip

MINI-SYMPOSIUM: HEPATOBILIARY PATHOLOGY

Tumours of the biliary system

S. Kakara,, L.J. Burgartb

a
Department of Anatomic Pathology, 113B, VA and UCSF Medical Center, 4150 Clement Street,
San Francisco, CA 94121, USA
b
Anatomic Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA

KEYWORDS Summary Biliary hamartoma, bile-duct adenoma (BDA) and mucinous cystadeno-
Biliary tumours; ma are the most common benign biliary tumours. Hamartomas occur sporadically or
Benign; in association with polycystic liver disease. BDAs may represent a localized response
Malignant; to injury rather than true neoplasms. Cystadenomas are multilocular lesions lined by
Hamartoma; mucinous epithelium, often with cellular ovarian-like stroma. Cytologic atypia may
Von Meyenburg suggest malignant transformation, but stromal invasion must be identified for
complex; diagnosis of cystadenocarcinoma. Cholangiocarcinoma (CC) is the most common
Adenoma; malignant neoplasm. Risk factors include primary sclerosing cholangitis, liver flukes,
Cystadenoma; hepatolithiasis and thorotrast exposure. The tumours show mass-forming, periduc-
Cystadenocarcinoma; tal-infiltrating or intraductal growth patterns. Intrahepatic CC presents as a hepatic
Cholangiocarcinoma; mass and can be confused with hepatocellular carcinoma or metastatic adenocarci-
Dysplasia; noma. Immunohistochemistry and albumin in situ hybridization are helpful in this
Intraductal distinction. The diagnosis of extrahepatic CC can often be elusive due to the marked
papillomatosis stromal desmoplasia, and multiple endoscopic biopsies and brushings may be
required. Loss of p53 is common in mass-forming intrahepatic CC, and K-ras
mutations in periductal-infiltrative extrahepatic tumours. Prognosis is poor, with 5-
year survival of o20%. Lymph-node metastasis and surgical margin status are the
most significant prognostic factors.
& 2004 Elsevier Ltd. All rights reserved.

Benign tumours malformation rather than a neoplasm, and may

occur sporadically or as part of polycystic liver
Biliary hamartoma disease.

Clinical features Pathologic features

Biliary hamartoma (BH), or von Meyenberg com-
plex, is thought to represent a ductal plate
Corresponding author. Tel.: +1 415 221 4810x2619;
fax: +1 415 750 6947.
E-mail address: skakar@itsa.ucsf.edu (S. Kakar).
BHs are small (usually o0.5 cm), gray-white,
irregular, and commonly multifocal. They are often
noticed incidentally in a liver biopsy or at autopsy.
BH consists of numerous small to medium-sized,
irregularly shaped, dilated ductules embedded in a
dense fibrous stroma (Fig. 1). They are located

0968-6053/$ - see front matter & 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cdip.2004.10.007
 ARTICLE IN PRESS
Tumours of the biliary system
within and at the edges of portal tracts. The
ductules are lined by cuboidal to flattened epithe-
lium and may contain eosinophilic debris or
inspissated bile but are not connected with the
biliary system. BHs are not considered premalig-
nant, although rare cases of cholangiocarcinoma
(CC) arising in BH have been reported.1
Bile-duct adenoma
Clinical features
Bile-duct adenoma (BDA) is a less common lesion
than BH. The designation ‘adenoma’ may be a
misnomer as it may not represent a true neoplasm
but a localized ductal proliferation at a site of
previous injury2 or peribiliary gland hamartoma.3
BDAs are usually found incidentally at surgery or
autopsy, and may be sent for frozen section to
exclude metastasis.
Pathologic features
BDA is typically small (o2 cm), firm, gray-white,
well circumscribed, often subcapsular, and can be
single or multiple. The ducts are uniform in size and
with less intervening fibrous stroma compared to
hamartomas. The stroma is typically more abun-
dant centrally than peripherally. The lesional ducts
have round outlines and are lined by bland cuboidal
epithelium without mitotic activity (Fig. 2). Bile is
not present, and the ductules do not communicate
with the biliary tree. Mucinous metaplasia, a1-
antitrypsin droplets, and neuroendocrine differen-
tiation may be seen. The endocrine cell clusters
must not be confused with metastatic carcinoid or
islet cell tumour.4 A rare variant with clear cells has
been described which can be mistaken for primary
or metastatic clear-cell carcinoma.5 Immunohisto-
Figure 1 BH: irregularly dilated ductules embedded in a
dense fibrous stroma.
35
Figure 2 BDA: uniform round ducts lined by bland
cuboidal epithelium.
chemically, BDA expresses both 1F6 and D10
(antigens extracted from bile-duct cell cultures),
a profile similar to bile ductules and canals of
Hering.3
Differential diagnosis
The absence of nuclear atypia, mitoses and
vascular invasion distinguish BDA from adenocarci-
noma. The uniform round outlines of glands,
relatively less stroma, lack of bile, absence of
cystic change, and lack of association with poly-
cystic liver disease separate it from BH. In contrast
to BDA, BHs express D10 but not 1F6.3
Prognosis
BDA is a benign lesion and malignant change is not
known to occur.
Biliary (hepatobiliary) cystadenoma and
cystadenocarcinoma
Clinical features
Biliary cystadenomas are rare lesions, with a higher
incidence in women and histological counterparts
in the pancreas and ovary. It can be associated with
the development of cystadenocarcinoma, which
occurs equally in men and women. The mean age
for cystadenocarcinoma (59 years) is higher than
that for cystadenomas (45 years).6
Pathologic features
Cystadenomas are 5–15-cm multilocular cysts with
a smooth or somewhat trabeculated inner surface.
The cysts are relatively few in number (oligocystic),
tend to be large (macrocystic) and contain fluid of
variable appearance, including serous, mucinous,
gelatinous, occasionally hemorrhagic, or even
purulent. There is no communication between the
cysts and the biliary tree. The presence of large
 ARTICLE IN PRESS
36
polypoid projections or solid masses in the cyst wall
is characteristic of cystadenocarcinoma. The cysts
are lined by a single layer of mucinous epithelial
cells, and small papillary tufts may be present. The
epithelial nuclei are bland and basally located,
without mitotic activity. In women, the cysts are
essentially always associated with a cellular me-
senchymal component resembling ovarian stroma
(Fig. 3). Densely hyalinized stroma often separates
the ovarian-like stroma from the adjacent liver.
The cyst wall may also be focally lined by
macrophages, calcification, or scar-like tissue.
Cystadenocarcinomas arising in this lesion often
have a tubulopapillary, solid or adenosquamous
histology.6 Features such as marked nuclear pleo-
morphism, loss of polarity, mitotic figures, and
multilayering of the epithelium suggest malignant
transformation, and can be designated as in situ
adenocarcinoma, but stromal invasion is necessary
for the diagnosis of cystadenocarcinoma.6 Since
malignant change can be focal, extensive sampling
is recommended.7 The presence of a benign
epithelial component in up to one-third of cysta-
denocarcinomas supports the view that at least
some of them arise from cystadenomas. Immuno-
histochemically, cystadenomas and cystadenocarci-
nomas are identical and mark for cytokeratin,
carcinoembryonic antigen and epithelial membrane
antigen. Scattered chromogranin-positive cells can
occasionally be present.
Prognosis
Cystadenomas are benign tumours and can be
successfully treated by total excision. Cystadeno-
carcinomas can invade the adjacent viscera and
may occasionally spread to the regional lymph
Figure 3 Mucinous cystadenoma: cysts lined by mucinous
epithelium and a cellular mesenchymal component
resembling ovarian stroma.
S. Kakar, L.J. Burgart
nodes, peritoneum and lung.8 Cystadenocarcino-
mas with mesenchymal stroma occur exclusively in
women and behave indolently. In men, these
tumours lack ovarian-like stroma and behave more
aggressively.6
Other benign biliary tumours or tumour-like
conditions
Biliary adenofibroma is a rare entity, with three
reported cases in the literature.9 It consists of
tortuous and branching ductular elements with
microcystic dilatation, cuboidal to flattened lining
epithelium, prominent fibroblastic stroma between
the glands, and immunohistochemical expression of
D10 but not IF6. Hence it shows marked resem-
blance to BH, but is larger and is not associated
with any typical von Meyenburg complexes. It
differs from BDAs, which usually lack cystic config-
uration, have less stroma, and express both 1F6 and
D10. Monosomy 22 has been reported in one case.11
Biliary adenofibroma is considered a benign lesion,
and malignant transformation has not been ob-
served. However, the large size and the reported
presence of positive p53 immunostaining and
tetraploidy raise the possibility of a premalignant
lesion.
Serous cystadenoma is rare in the liver and is
similar to its pancreatic counterpart, consisting of
multiple microcysts lined by bland glycogen-rich
cuboidal epithelium (Fig. 4).6 The cysts lack the
cellular mesenchymal stroma characteristic of
mucinous cystadenoma.
Neuromas of the extrahepatic biliary ducts can
cause obstructive jaundice. They are often trau-
matic in origin, typically after cholecystectomy.12
Figure 4 Serous cystadenoma: multiple microcysts lined
by bland glycogen-rich cuboidal epithelium.
 ARTICLE IN PRESS
Tumours of the biliary system
Histologically, irregular tortuous bundles of nerve
fibers are scattered in the bile-duct submucosa.
Adenomyoma is a hamartomatous lesion that
rarely occurs in the extrahepatic biliary tree,13
being more common in the ampulla. It is char-
acterized by glandular structures with intervening
smooth-muscle bundles.
Solitary or multiple cysts can be seen around
intrahepatic large bile ducts and probably arise
from the peribiliary glands.14 They are lined by
columnar or cuboidal epithelium and do not
communicate with the biliary tree. Peribiliary cysts
can occur in chronic advanced liver disease and
normal livers, but are usually not associated with
polycystic kidney or liver disease.
Malignant tumours
Cholangiocarcinoma
Cholangiocarcinoma (CC) encompasses malignant
tumours arising from the intrahepatic bile ducts
(intrahepatic, peripheral or cholangiocellular CC)
as well as those of perihilar and extrahepatic bile
ducts. Recent epidemiological studies have shown
an increase in the incidence of CC over time. The
exact cause for this increase is unknown, but does
not appear to be entirely explained by greater
recognition of the disease.15 In the United States,
the incidence is approximately 8 per million;
20–30% of the cases are intrahepatic CC, and the
rest occur in an extrahepatic location.16 The
tumour usually occurs in patients above 65 years
of age, and both sexes are equally affected.
Intrahepatic cholangiocarcinoma
Clinical features
Patients often remain asymptomatic until the
tumour is in a late stage, or they may have non-
specific symptoms like abdominal pain, anorexia
and weight loss. Jaundice is uncommon, although
alkaline phosphatase is often elevated. Tumour
markers like CA19-9, CEA and CA-125 can be
elevated. However, these markers are non-specific
and their role in diagnosis is uncertain. CA19-9 is
elevated in up to 85% of patients with CC, but
can also be associated with carcinomas of the
stomach and pancreas and in non-neoplastic
conditions such as obstructive jaundice. Persistent
elevation of CA19-9 even after biliary decompres-
sion suggests malignancy and is used as a screening
tool in patients with primary sclerosing cholan-
gitis (PSC).17
37
Risk factors
Biliary disease. PSC is the most common known
predisposing factor,18–20 with a risk of 1.5% per year
of the disease. Smoking may increase the risk in
association with PSC. Hepatolithiasis is uncommon
in the West but is endemic in portions of Far East
where it can be associated with more than 50% of
intrahepatic CC.21 Rare cases have been reported
with von Meyenberg complexes, choledochal cyst
and Caroli’s disease.22–24
Parasites. CC is associated with two species of
liver fluke, Clonorchis sinensis and Opisthorchis
viverrini.24,25 Both are endemic in South East Asia,
Clonorchis in Hong Kong, southern China and Korea,
and Opisthorchis in Thailand and Laos.
Other. Thorotrast, a contrast medium, was
banned in the 1950s, but the associated risk can
last for several decades.26 In Japan and the Far
East, hepatitis B (around 10%) and hepatitis C
(around 25%) frequently co-exist with CC, raising
suspicion of their role in carcinogenesis. Although
CC typically arises in non-cirrhotic liver, this
concept may need to be revisited in view of a
recent Japanese study which found non-biliary
cirrhosis in nearly 5% of CC.27
Pathologic features
The Liver Cancer Study Group proposes three
macroscopic types: mass-forming, periductal-infil-
trating and intraductal.28 Mass-forming is the most
common appearance of intrahepatic CC and is
characterized by a localized tumour with a distinct
border that grows radially without periductal or
intraductal spread (Fig. 5). The periductal-infiltra-
tive type infiltrates along the bile duct and is often
associated with stricture and involvement of
periductal connective tissue. Both of these types
are usually firm, white-tan lesions due to dense
fibrous stroma. Advanced cases can show mixed
patterns of growth. The intraductal type is dis-
cussed separately. A vast majority (495%) of
tumours are adenocarcinomas. The well-differen-
tiated tumours show tubular, papillary and cord-
like patterns, and cytologic atypia can be minimal.
Intracytoplasmic lumina, focal cribriform architec-
ture, nuclear stratification and intraluminal cellu-
lar debris favour carcinoma over a benign process.
Nucleoli are often less prominent compared to
hepatocellular carcinoma (HCC). Mucin can be
demonstrated in most cases. A prominent desmo-
plastic stroma is characteristic of CC (Fig. 6).
Occasionally, the tumour cells form small, narrow,
tubular structures resembling ductules or canals
of Hering, a pattern referred to as cholangiocel-
lular carcinoma. Other less common micro-
scopic variants include clear-cell, adenosquamous,
 ARTICLE IN PRESS
38
Figure 5 Intrahepatic CC: mass-forming pattern with
radial growth, distinct border, and no periductal or
intraductal spread.
Figure 6 CC with marked desmoplastic stromal response.
squamous, mucinous, signet-ring, sarcomatous,
small-cell and EBV-associated lymphoepithelioma-
like carcinoma.24
Differential diagnosis
HCC. The presence of cirrhosis, elevated a-Feto-
protein (AFP) level and trabecular pattern of
growth favour HCC. However, CC can occur in
cirrhotic livers. The presence of dense fibrotic
stroma favours CC, but sclerosing variants of HCC
also occur. Immunohistochemistry and albumin in
situ hybridization are helpful in differential diag-
nosis. Hep Par 1 has emerged as the most sensitive
(490%) and specific immunohistochemical marker
for HCC.29,30 It can be negative in poorly differ-
entiated and sclerosing HCC, and is usually negative
or weakly positive in CC. Polyclonal CEA shows a
characteristic canalicular pattern in more than 90%
of HCCs as it cross-reacts with biliary glycoprotein.
HCC is non-reactive with monoclonal CEA. CC shows
cytoplasmic pattern with both polyclonal and
S. Kakar, L.J. Burgart
monoclonal CEA.31 However, the canalicular pat-
tern of CEA in HCC can often be difficult to
interpret, and similar patterns have been focally
reported in adenocarcinomas. CD10 staining yields
a canalicular pattern similar to polyclonal CEA in
HCC. It is rarely positive in CC, but has low
sensitivity (around 50%).31 AFP is specific for HCC
if yolk-sac tumour can be excluded, but also has
low sensitivity (20–30%). MOC-31, an antibody
directed against a cell-surface glycoprotein, con-
sistently (80–100%) stains CC, yielding a diffuse
membranous staining pattern. HCC is negative for
MOC-31.31 Albumin in situ hybridization is specific
for hepatocellular differentiation and has high
sensitivity (490%).30,32 CC is consistently negative.
Cytokeratin subsets usually show CK7+/CK20– phe-
notype in CC. HCC is generally CK7–/CK20–, but
focal positive reactions can occur in a minority of
cases. A combination of Hep Par 1 and MOC-31 will
allow the distinction in a vast majority of cases. If
this is inconclusive, additional help with polyclonal
CEA, cytokeratin subsets and albumin in situ
hybridization can be sought.
Metastatic adenocarcinoma (MA). Liver metasta-
sis from primary tumours arising in the pancreas,
colon, stomach, lung and breast can closely mimic
CC. Distinction from metastatic adenocarcinoma
(MA) can be difficult on morphologic grounds. The
presence of tall columnar cells and luminal necrotic
debris favours metastatic colonic carcinoma. Site-
specific immunohistochemical markers such as
thyroid transcription factor-1 for lung, ER and PR
for breast, PSA for prostate and uroplakin for
urinary bladder may be helpful. Non-site-specific
markers such as cytokeratin subsets may yield
useful information. CC is generally CK7+/CK20–,
while metastatic colorectal adenocarcinoma is
CK7–/CK20+ in 490% of cases.33,34 It has been
suggested that immunohistochemistry for Lewis (x),
Leu-M1 and B72.3 can be helpful in distinguishing
CC from MA. Lewis (x) shows cytoplasmic and
membranous reactivity in CC but only cytoplasmic
reactivity in MA. In contrast, Leu-M1 and B72.3 are
more likely to show cytoplasmic staining in CC and
cytoplasmic and membranous staining in MA.35
LeuM1, B72.3 or Lewis (x) has not been incorpo-
rated into our practice at this time.
Treatment and prognosis
Surgical resection of the involved liver segments
offers the only hope of cure, but is successful in a
minority of cases, with 5-year survival rates of
0–43%.36,37 The role of adjuvant chemotherapy
and radiation is not clearly established for intra-
hepatic CC. Liver transplantation has not been
encouraging, with 5-year survival rates o20%.36
 ARTICLE IN PRESS
Tumours of the biliary system
Lymph-node metastasis and status of surgical
margins are the most common factors influencing
outcome. Lymph-node involvement is seen in more
than 50% of patients at presentation.16 Lymphovas-
cular or perineural invasion, intrahepatic satellite
nodules, and bilobar distribution have been shown
to predict poor survival.38 Mass-forming tumours
have a better outcome compared to tumours with a
periductal-infiltrating pattern.28 Tumours with a
marked desmoplastic response may have a higher
incidence of lymphatic invasion, higher prolifera-
tive activity and lower survival.24 Poorly differen-
tiated tumours and variants such as signet-ring and
sarcomatous carcinoma may behave aggressively.
Pathogenesis and molecular abnormalities
The risk factors of CC, such as PSC and parasitic
infestations, have chronic inflammation and cho-
lestasis as their common link. Chronic inflammation
leads to production of cytokines such as interleu-
kin-1 and -6, and interferon-g, some of which have
potent mitogenic effects on biliary epithelial cells.
The proinflammatory cytokines also lead to the
expression of inducible nitric oxide synthase. This
in turn leads to generation of nitric oxide and
reactive oxygen radicals, which can irreversibly
damage the DNA of the epithelial cells. Nitric oxide
also inactivates key DNA-repair proteins by nitro-
sylation, leading to accumulation of potentially
oncogenic mutations.17,36 Nitrosylation of caspase
proteases can inactivate caspase 9 with inhibition
of apoptosis.39 Bile acids can increase the levels of
COX-2 and myeloid-cell leukemia protein 1 in
cholangiocytes; both these molecules can exert
potent anti-apoptotic effects.40 Bile composition is
altered in chronic cholestasis, and levels of reduced
glutathione are reduced. This compromises a key
intracellular defense against oxidative injury.
Hence chronic inflammation and cholestasis exert
a strong proliferative and mutagenic influence on
the biliary epithelium.
Loss of p53 and K-ras mutations are the most
common molecular alterations observed in CC. Loss
of p53 is reported in up to 50% of intrahepatic mass-
forming tumours, and can occur by mutation, LOH
at 17p or MDM2 gene amplification.36 Inactivation
of p53 leads to deregulation of bcl-2, and poten-
tially causes resistance to apoptosis. Loss of bcl-2
correlates with lymph-node metastasis, vascular
invasion and aberrant p53 expression.36 K-ras
mutations usually affect codon 12 and vary widely
with the geographical location and tumour site.
The incidence is up to 100% in England, 50–56% in
Japan and 0–8% in Thailand, possibly reflecting
differences in underlying etiology. K-ras mutations
are more common in periductal-infiltrative tumours
39
in the extrahepatic biliary tree than in mass-
forming intrahepatic CC, while p53 mutations are
more common in the latter.41 Alterations of the p16
gene are also frequent, and promoter hypermethy-
lation may be the most common cause of inactiva-
tion in intrahepatic CC. Loss of p16 may be a useful
diagnostic test for PSC-associated cancer.42 Fre-
quent overexpression of human telomerase reverse
transcriptase is seen in dysplasia and invasive
carcinoma, indicating that it may be an early event
in carcinogenesis. The detection of a telomerase
ladder in biopsy samples has been shown to be an
excellent tool for diagnosis.43 Hepatocyte growth
factor, c-met, is overexpressed in CC and correlates
with tumour differentiation. Other alterations
include mutations of E-cadherin, b-catenin and
DPC-4 genes, HER-2/neu gene amplification and
microsatellite instability.
Carcinoma affecting the extrahepatic biliary
tree
Clinical features
Extrahepatic CC can be divided into tumours arising
close to the hilum of the liver (perihilar CC) or in
the distal portion of the bile duct (distal CC).
Perihilar neoplasms (also known as Klatskin tumour)
constitute nearly two-thirds of all CC. Patients
present with obstructive jaundice, repeated at-
tacks of cholangitis, and a cholestatic biochemical
profile. Persistent elevation of tumour markers like
CA19-9 in the absence of cholangitis can be useful
for diagnosis.
Pathologic features
The tumours may have an infiltrative (70–80%),
nodular (20%) or intraductal (o5%) growth pattern.
The infiltrative and nodular tumours are often
poorly differentiated, tend to spread along the
mucosa and submucosa, and are accompanied by
striking desmoplastic response. Encasement of the
right or left portal vein is present in one-third of
the patients and leads to ipsilateral lobar atrophy.
Lymph-node metastasis occurs in 30–50% of pa-
tients at resection, hilar and pericholedochal lymph
nodes being the most commonly affected. Tumours
arising in the setting of PSC can be multifocal and
associated with dysplasia and carcinoma in situ at
multiple sites. Due to the marked stromal desmo-
plasia, the pathologic diagnosis can often be
elusive, and multiple endoscopic biopsies and
brushings may be required. Pathologic diagnosis
may be possible in only 40–70% of cases. The use of
ancillary techniques—including digital image ana-
lysis and fluorescence in situ hybridization to
 ARTICLE IN PRESS
40
detect aneuploid cells in brushings or biopsy
samples—have been shown to significantly increase
diagnostic sensitivity.44
Treatment and prognosis
Surgical treatment of perihilar CC often requires
partial hepatic resection to achieve negative
margins. Since the caudate lobe drains indepen-
dently, resection of the caudate lobe is also
advocated. Distal lesions are treated by Whipple’s
procedure. The 5-year survival in resectable tu-
mours with negative margins is 20–40%, and the
operative mortality is 10%.45 Negative resection
margins and T1 disease are major predictors of
outcome in resected cases. Tumours with bilateral
extension into segmental biliary radicles, lobar
atrophy with portal vein encasement and metas-
tasis to N2 nodes or distant sites are considered
unresectable. Survival in unresectable or advanced
stage disease is less than 1 year. Tumours arising in
the setting of PSC have a particularly grim outlook,
with a 5-year survival of o10%. Some studies have
shown the beneficial role of radiation and che-
motherapy for palliation and as an adjunct to
surgery, but the results are conflicting.45 CC has
been considered a contraindication for liver trans-
plantation due to rapid recurrence of the disease.
However, recent trials have shown 5-year survival
rates of 80% in early stage disease with neoadju-
vant chemotherapy and radiation, and transplanta-
tion may be beneficial in selected patients.17
Precursor intraductal biliary lesions
Biliary dysplasia (intraepithelial neoplasia/
atypical hyperplasia)
Neoplastic transformation to CC almost certainly
follows the hyperplasia–dysplasia–carcinoma se-
quence. Biliary dysplasia on liver biopsies is very
infrequent but correlates strongly with the pre-
sence of CC in PSC.20 Histologically, it is character-
ized by nuclear stratification, micropapillary and
cribriform patterns, loss of polarity, nuclear en-
largement and hyperchromasia, and irregular nu-
clear contours (Fig. 7). The proliferative activity of
the biliary dysplasia is higher than biliary hyper-
plasia but lower than carcinoma, lending support to
the concept of a progression sequence. The
dysplastic epithelium often expresses carcinoem-
bryonic antigens, CA19-9 and DUPAN-2, as in CC,
although the expression can be focal.46
Intrahepatic bile ducts with stones or liver flukes
often show chronic inflammation, epithelial hyper-
plasia, hyperplasia of intrahepatic peribiliary
glands and fibrosis. Hyperplasia of mucus acini is
S. Kakar, L.J. Burgart
Figure 7 Biliary dysplasia: micropapillary pattern, loss of
polarity, nuclear enlargement and irregular nuclear
contours.
common, and pseudopyloric metaplasia may be
present. This constellation of findings has been
referred to as ‘chronic proliferative cholangitis’.46
In the presence of liver flukes, marked proliferation
of intramural glands in the large intrahepatic ducts
has been referred to as ‘adenomatous hyperplasia
of the bile duct’. Multifocal biliary dysplasia and CC
can occur in these proliferative lesions.
Intraductal papillary neoplasia
Clinical features. Papillary biliary neoplasms are
characterized by intraductal papillary growth with
a fine fibrovascular stalk, and include biliary
(intraductal) papillomatosis as well as CC with
intraductal growth pattern. Intraductal papilloma-
tosis generally involves extensive areas of the
intrahepatic and/or the extrahepatic bile ducts,
with a predilection for the latter. The patients
often present with repeated episodes of acute
cholangitis and obstructive jaundice.
Pathologic features. Biliary papillomatosis is a
premalignant neoplastic proliferation character-
ized by multifocal or diffuse papillary proliferations
of biliary lining cells without invasion or metastasis
(Fig. 8). Tumours are composed of delicate papillae
covered by tall columnar cells with basal nuclei
showing minimal pleomorphism. Most cases are
histologically benign, but foci of biliary epithelial
dysplasia can be present. Frank invasion of the
stalk and underlying periductular tissues must be
seen for a diagnosis of CC. Another pattern of
intraductal papillary neoplasm of the liver is
characterized by mucin hypersecretion and seg-
mental dilatation of the neoplastic and non-
neoplastic biliary tree. The clinical and patho-
logic features of this type of intraductal
biliary neoplasm bear a striking resemblance to
 ARTICLE IN PRESS
Tumours of the biliary system
Figure 8 Biliary papillomatosis characterized by diffuse
intraductal papillary growth pattern.
intraductal pancreatic mucinous tumour.24,47,48 The
dilated ducts are filled with mucus and papillary
excrescences lined by mucinous epithelium. Onco-
cytic and clear cell change may be seen. Gastric
and intestinal metaplasia with goblet cells is also
frequent. Involvement of peribiliary glands is
common. Epithelial dysplasia or carcinoma in situ,
often multifocal, may be present. The invasive
component, when present, may exhibit features of
mucinous carcinoma.
Molecular abnormalities. K-ras mutations have
been observed in biliary papillomatosis; malignant
transformation may be associated with increased
expression of MUC1 and Tn antigen.49 Intraductal
papillary mucinous neoplasms often show reduced
expression of cytokeratin 7 and aberrant expression
of cytokeratin 20 and mucins such as MUC2,
MUC5AC and MUC 6.48 Expression of p53 occurs in
less than one-third of the cases, but is higher in
cases with dysplasia and carcinoma.
Prognosis. Although histologically benign in most
cases, these lesions are not only premalignant but
inherently pernicious due to multicentricity, ten-
dency to recur, and complications such as recurrent
bouts of cholangitis and sepsis. However, even in
the presence of invasion, the outcome is better
than more typical forms of CC.48,50 Lymph-node
metastasis does not occur in the absence of
invasion. Recurrences are observed in around 10%
of intraductal papillary tumours after resection.
Other malignant tumours
Combined hepatocellular and CC (combined
HCC–CC) is a rare tumour that represents o5% of
primary liver tumours. It is more closely related to
41
HCC, as evidenced by its frequent association with
hepatitis B or C virus infection and cirrhosis.51,52
However, these data are based largely on studies in
Asia, and a large study in the US revealed that the
incidence of positive hepatitis B or C serology and
cirrhosis is o15% in combined HCC–CC, which is
similar to CC.53 The diagnosis is based on the
demonstration of both hepatocellular and glandular
differentiation. According to WHO criteria, the
hepatocellular component is identified by trabecu-
lar growth pattern, bile production or intercellular
bile canaliculi. The cholangiocellular component is
identified by definite gland formation or mucin
production. The diagnosis can be confirmed im-
munohistochemically by demonstrating the HCC
component with Hep Par1, AFP and canalicular
polyclonal CEA pattern, and the CC component by
MOC-31, CK7 and CK19. Areas of transition between
HCC and CC are often present. Some tumours may
be composed entirely of cells with features inter-
mediate between HCC and CC, and have been
designated as intermediate carcinomas.54 The
histogenesis of combined HCC–CC remains uncer-
tain. It may be an inadvertent collision of HCC and
CC, or may represent a single tumour with
divergent differentiation.52,55 In the former case,
the tumour would presumably be biclonal, with no
intimate admixture of HCC and CC components.
The latter would presumably arise from a single
clone, with HCC or CC arising first and then
transforming to the other, or originate from
intermediate cells with divergent differentiation.
Combined HCC–CC with intermediate phenotype
are often c-kit positive, supporting the idea of their
origin from progenitor cells.54 Genetic studies have
shown that a majority of the combined HCC–CC
arises from the same clone and share abnormalities
with conventional HCC, such as allelic losses of 4q,
8p, 17p and 13q.55 The prognosis is poor, and the
disease is more aggressive than conventional HCC
or CC. After resection, the 5-year survival is 24%. In
unresectable cases, almost all patients die within 2
years.53
Carcinoid,56 paraganglioma57 and primary malig-
nant melanoma58 can rarely occur in the extra-
hepatic bile ducts. The possibility of metastasis
from another primary site should be excluded
before a diagnosis of primary malignant melanoma
can be made.
Leukemia and malignant lymphoma can involve
the extrahepatic bile ducts and may rarely be the
initial presentation.
Embryonal (botryoid) rhabdomyosarcoma is a
rare neoplasm in the biliary tree, but is the most
common malignant tumour at this site in children.59
Rare cases have been reported in adults. Clinically,
 ARTICLE IN PRESS
42
these tumours present with obstructive jaundice,
fever, weight loss and hepatomegaly. Grossly, the
tumour projects into the biliary tree as soft
polypoid masses. Microscopically, round to spin-
dle-shaped tumour cells are arranged in a variable
admixture of hypercellular and loose myxoid areas.
The tumour cells are often densely packed below
the epithelium (cambium layer). Hyperchromatic
nuclei, eosinophilic cytoplasm and striations may
be visible as evidence of rhabdomyoblastic differ-
entiation. The diagnosis can be confirmed immu-
nohistochemically with muscle markers like desmin
and myogenin. Surgical resection combined with
chemoradiation may achieve long-term survival,
although the outcome is poor in most cases.59
Practice points
 BHs are usually solitary, but when multiple
they should raise the suspicion of polycystic
liver disease
 Extensive sampling is recommended in mu-
cinous cystic tumours as malignant change
can be focal in mucinous cystadenocarcino-
ma
 Immunohistochemistry and albumin in situ
hybridization can be useful in distinguishing
intrahepatic CC from HCC; CC express MOC-
31, CK7 and cytoplasmic CEA, while hepa-
tocellular cacinomas express Hep Par1,
canalicular CEA and AFP
 Pathologic diagnosis of extrahepatic CC can
often be elusive, requiring multiple endo-
scopic samples. The use of ancillary techni-
ques such as digital image analysis and
fluorescence in situ hybridization to detect
aneuploid cells, and demonstration of ge-
netic abnormalities such as p16 loss and
telomerase ladder can increase the diagnos-
tic sensitivity
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Further Reading
10. Varnholt H, Vauthey JN, Cin PD, et al. Biliary adenofibroma:
a rare neoplasm of bile duct origin with an indolent
behavior. Am J Surg Pathol 2003;27:693–8.