Baylor University Medical Center Proceedings April 2017 - 190

Bile duct lymphoma disguised as cholangiocarcinoma
Charis Durham, MD, Deepna Jaiswal, DO, and Lucas Wong, MD

a

b

Figure 1. Magnetic resonance imaging of the abdomen-(a) a dual-echo image and (b) a T2-weighted image-showing intrahepatic and extrahepatic biliary
dilation and an abnormal enhancement at the bifurcation of the common hepatic duct (arrow). This finding is often correlated with hilar cholangiocarcinoma, also
known as Klatskin tumor.

We present a case of intrabiliary primary B-cell lymphoma masked as
a cholangiocarcinoma in an HIV-positive patient. The two entities have
similar symptoms, laboratory findings, and imaging findings but require
very different treatments. The case highlights the need to confirm the
diagnosis by biopsy.

H

IV-associated primary non-Hodgkin's lymphoma of
the bile duct is an uncommon presentation of obstructive jaundice, with few published cases (1). With similar
symptoms and laboratory and imaging findings, bile
duct lymphoma and cholangiocarcinoma can be almost identical (2). Since cholangiocarcinoma is far more prevalent than
primary bile duct lymphoma, a presumed diagnosis of cholangiocarcinoma is often made before biopsy confirmation (3)-an
approach that raises concern since the two malignancies require
radically different treatment.
CASE REPORT
A 61-year-old HIV-infected man with a CD4 count of
77 mL presented to the emergency department with nausea,

190

vomiting, epigastric pain, jaundice, and pruritus. He also
reported dark urine and light-colored stools. Laboratory workup
was consistent with obstructive jaundice. Magnetic resonance
imaging of the abdomen showed intrahepatic and extrahepatic
biliary dilation and an abnormal enhancement at the bifurcation
of the common hepatic duct, suggestive of cholangiocarcinoma
(Klatskin tumor) (Figure 1). Endoscopic retrograde cholangiopancreatography demonstrated nodular, erythematous walls and
high-grade bile duct stricture. He underwent sphincterotomy
and stenting. Biopsy of the bile duct was positive for CD20,
BCL-2, BCL-6, two-paired box protein Pax-5, CD10, and
B-cell lymphoma 6 protein, with antigen Ki-67 demonstrating >90% confirmation of high-grade large B-cell lymphoma
(Figure 2). Immunoperoxidase stains for c-Myc demonstrated
staining in >30% of the cells. Positron emission tomography-
computed tomography showed hypermetabolic activity in the
From the Department of  Internal Medicine (Durham) and the Division of
Hematology/Oncology (Jaiswal, Wong), Baylor Scott and White Health, Temple,
Texas.
Corresponding author: Charis G. Durham, MD, Baylor Scott and White Health,
315 W. Elm Avenue, Temple, TX 76501 (e-mail: Charis.Durham@bswhealth.org).
Proc (Bayl Univ Med Cent) 2017;30(2):190-191



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