Debulking surgery for non-radically resectable intraductal papillary neoplasm of the bile duct: Three case reports and literature review

Figure 1 Preoperative abdominal contrast-enhanced computed tomography, abdominal contrast-enhanced magnetic resonance imaging, and magnetic resonance cholangiopancreatography of patients. A: Preoperative abdominal contrast-enhanced computed tomography (CT) images of patient 1 showing schistosomiasis-related cirrhosis, diffuse intrahepatic bile duct dilatation, and atrophy of the left lateral and right posterior lobes. Multiple intraductal papillary lesions show mild arterial phase enhancement; B: The lesions show relative hypoattenuation in the portal venous phase; C: The lesions show persistent hypoattenuation in the delayed phase; D: The papillary lesions of patient 2 appear mildly hyperintense on T2-weighted imaging; E: Preoperative abdominal contrast-enhanced CT images of patient 2 showing schistosomiasis-related cirrhosis with intrahepatic bile duct dilatation and multiple intraductal papillary lesions. The lesions show mild enhancement in the arterial phase; F: The lesions show relative hypoattenuation in the portal venous; G: The lesions showdelayed phases; H: The papillary lesions of patient 2 appear hypointense on T1-weighted imaging of Preoperative abdominal contrast-enhanced magnetic resonance imaging (MRI); I: The papillary lesions show mild enhancement in the arterial phase; J: The lesions have low signal intensity in the venous phase; K: Diffusion-weighted imaging of patient 2 revealed mild hyperintensity; L: Preoperative three-dimensional reconstruction of patient 2 shows a total liver volume of 1632.1 ml; M: Preoperative contrast-enhanced CT images of patient 3 reveal bile duct dilatation with atrophy of the left and caudate lobes and intraductal papillary masses in the left lobe; the lesions show mild enhancement in the arterial phase; N: The lesions show relative hypoattenuation in the portal venous phase; O: The lesions show relative hypoattenuation in the delayed phases; P: T2-weighted image shows multiple intraductal papillary masses; Q: Contrast-enhanced MRI shows mild arterial enhancement; R: Contrast-enhanced MRI shows low signal intensity in the portal venous phase; S: Magnetic resonance cholangiopancreatography confirms diffuse dilatation of the intrahepatic and extrahepatic bile ducts.

Figure 2 Gross specimen, pathology of patients. A: Gross specimen of patient 1 showing markedly dilated bile ducts filled with mucin and a papillary mass; pathology of patient 1 (B-D); B: Papillary architecture with fibrovascular cores on histopathological examination [hematoxylin and eosin (HE) × 100]; C: Schistosomiasis-related hepatic changes (HE × 200); D: Tumor involvement at the resection margin (HE × 200); E: Preoperative three-dimensional reconstruction of patient 3 shows a total liver volume of 1088.8 mL; pathology of patient 2 (F-H); F: A representative histopathological section showing an extensive intraductal papillary tumor with high-grade intraepithelial neoplasia (HE × 100); G: High-grade intraepithelial neoplasia at the bile duct resection margin (HE × 100); H: Schistosomiasis-related cirrhotic changes (HE × 200); pathology of patient 3 (I-K); I: Positive bile duct resection margin with papillary lesions and mucinous material; J: Postoperative histopathological examination of the left hepatic lobe reveals an intraductal papillary neoplasm of the bile duct (HE, × 100); K: A 3.0 cm × 2.5 cm × 2.5 cm portion of the mass showing local malignant transformation (HE, × 100).

Figure 3 Postoperative magnetic resonance imaging and cholangioscopy of patient 1 and patient 2. Postoperative magnetic resonance imaging (MRI) of patient 1 (A-C); A: Postoperative magnetic resonance cholangiopancreatography showing dilatation of the intrahepatic and extrahepatic bile ducts; B: T2-weighted image showing a T-tube within the common bile duct; C: T2-weighted imaging showing numerous papillary lesions within the dilated bile ducts of the atrophic right posterior lobe; D and E: Postoperative contrast-enhanced MRI of patient 2 showing residual papillary lesions exhibiting mild arterial enhancement (D) and appearing isointense in the venous phase (E) within dilated bile ducts; F: Percutaneous transhepatic cholangioscopy via T-tube of patient 2 showing bleeding intraductal papillary lesions.