A Case of Common Bile Duct Cancer That Completely Responded to Combination Chemotherapy of Gemcitabine and TS-1
A 65-year-old male was admitted for abdominal pain and fever, which started 2 weeks ago. He was previously healthy without any specific past medical history. Abdominal physical examination revealed tenderness without rebound tenderness on epigastrium. Laboratory finding demonstrated white blood cells 12.3×103/µL, hemoglobin 11.6 g/dL, platelets 309×103/µL, total bilirubin 0.7 mg/dL, alkaline phosphatase 117 IU/L, aspartate aminotransferase 26 IU/L, alanine aminotransferase 33 IU/L, high sensitivity C-reactive protein 22.1 mg/dL, carcinoembryonic antigen 2.0 ng/mL, carbohydrate antigen 19-9 7.6 U/mL, and alphafetoprotein 1.3 ng/mL. Hepatitis B surface antigen was negative and hepatitis C virus antibody was positive. Abdominal computed tomography (CT) showed about 9 cm lobulating low attenuating mass with peripheral rim enhancement in the left lobe of the liver, which was thought to be mature pyogenic liver abscess (). He started antibiotics therapy with ceftriaxone and metronidazole, and underwent percutaneous drainage tube insertion using 10.2 Fr pigtail catheter into the liver abscess. Two days later fever subsided and a week later he was discharged with oral antibiotics. One month later, follow-up liver CT scan showed 1.5 cm enhancing lesion in distal CBD with progression of biliary dilatation, suggesting distal CBD cancer (). Thus biopsy was performed at CBD via endoscopic retrograde cholangiopancreatography (), which revealed adenocarcinoma (). Additional CT scan () and magnetic resonance imaging (MRI) () showed multiple small nodules in right hepatic lobe and metastatic adenocarcinoma was confirmed from frozen slide of sono-guided liver biopsy (). Since the patient was inoperable, he underwent combination chemotherapy with gemcitabine 1,600 mg intravenous infusion on day 1 and S-1 (tegafur+gimeracil+oteracil) 500 mg twice a day for 14 days with 1-week rest as one course. Serial CT scans checked every three cycles showed gradual regression of the metastatic nodules in liver (). After nine courses of chemotherapy the hepatic lesion completely disappeared on MRI (). Three weeks later, pylorus preserving pancreaticoduodenectomy was performed. Grossly the resected CBD showed a 1×1 cm sized gray solid mass infiltrating into adjacent soft tissue. Microscopically there were no residual tumor but chronic active cholangitis with multifocal erosion and subepithelial fibrosis in the resected CBD (). Then, 22 days after the operation he was discharged without any complication. For 3 months of follow-up, he did not develop any signs of recurrence and no evidence of recurrence was found in the 3-month postoperative CT scan ().