This is case of a lady with known progressive metastatic cholangiocarcinoma, having failed first-line chemotherapy. She presented to our emergency department with RUQ pain, fevers and vomiting. CT showed gastric outlet obstruction secondary to a 5x3cm collection at the porta hepatis compressing the duodenum, with a further 11x9cm collection at the gallbladder fossa.

The patient underwent endoscopic ultrasound (EUS) with fine needle aspiration (FNA) and biopsy. Extrinsic compression of D1/D2 secondary to a heterogenous hilar mass was noted on endoscopy. There was no associated high-grade obstruction as the echoendoscope was able to traverse through to D2 and there was minimal fluid contents in the stomach. This was fine-needle biopsied and the fluid was aspirated with an attempt to decrease the size of the mass (diagnostic and partially therapeutic).

Fine-needle biopsy histopathology report:

MACROSCOPIC (BIOPSY)

• Multiple (>10) fragments of tan tissue ranging in size from 1 up to 12mm in maximum extent

MICROSCOPIC (BIOPSY)

• Sections show fine cores composed of dense fibrous connective tissue infiltrated by moderately differentiated adenocarcinoma
• Morphological features are non-specific but would be consistent with metastatic cholangiocarcinoma

Fine-needle aspiration cytology report:

MACROSCOPIC (ASPIRATE)

• Received 20mL of cloudy yellow fluid

MICROSCOPIC (ASPIRATE)

• Specimen contains numerous neutrophils and a small amount of blood with some bi- and multinuclear histiocytes
• This is consistent with an acute inflammatory reaction
• No malignant cells are seen

The patient is now under the care of medical oncologists to trial second- and third-line chemotherapy.