Biliary pseudo tumor associated with hepatic atrophy

Extensive ductular proliferation can mimic well-differentiated cholangiocarcinoma, but such pseudo-tumorous lesion has not been well described in the literature. Our study sought to evaluate the clinicopathologic features of such cases.

Four cases with reactive ductular proliferation that mimicked cholangiocarcinoma microscopically and also appeared grossly to form a mass/nodule were identified from 1995 to 2024 at two large academic health institutions. The clinicopathological features were studied in detail.

The study cases included 2 explants, 1 segmental hepatectomy and 1 wedge resection. One of the explants had thrombosis and obstruction of the right portal vein (PV) along with right lobe atrophy. Vascular abnormality was suspected in case 2 but could not be confirmed. However, atrophy of the left lobe along with caudate lobe hypertrophy and preserved right lobe was observed. Both cases had cirrhosis (case 1: HCV infection, case 2: alcoholic liver disease) with portal hypertension. Case 3 and 4 were from patients with metastatic colon cancer who had undergone trans-arterial chemoembolization (TACE). Upon gross examination of the two explants, the atrophic lobes were markedly pale-tan, shrunken, and well-demarcated from the uninvolved lobe mimicking a tumor, while the unaffected lobes were cirrhotic. Histologically the lesions in all cases comprised of marked ductular proliferation that led to an initial consideration of a well-differentiated intrahepatic cholangiocarcinoma. However, these lacked significant cytologic atypia and mitotic activity (ki-67 < 5 %) and had a non-infiltrative growth pattern. In case 3, the ductular proliferation was at the periphery of metastatic focus, while scattered metastatic tumoral glands were encased within proliferating ductules in case 4. The immunostains showed wild-type staining pattern with p53 and retained nuclear expression with p16 and BAP1.

Biliary pseudo-tumors can be seen with lobar or segmental atrophy, likely secondary to ischemic parenchymal injury and can mimic a well-differentiated cholangiocarcinoma grossly as well as microsopically. Awareness of this phenomenon and careful attention to the clinical presentation, radiographic imaging and histology shows subtle differences that can facilitate an accurate diagnosis.