A rare case of widely metastatic cholangiocarcinoma presenting as ovarian carcinoma

Metastatic cholangiocarcinoma is a very rare disease. Less than 10% of patients are found to have peritoneal carcinomatosis. We describe an unusual case of obstructive jaundice secondary to cholangiocarcinoma and widespread metastasis who presented initially with ovarian cancer. A 59 year old white female was referred to the gastroenterology service for evaluation of jaundice. She had presented to her physician one month back with complaints of abdominal distention. Work up had revealed bilateral ovarian masses with peritoneal spread. She underwent an exploratory laparotomy 3 weeks prior which revealed ovarian, peritoneal, omental, liver, gallbladder and small bowel tumor studding. Histopathology was consistent with metastatic ovarian cancer. On presentation with jaundice, a CT scan of the abdomen revealed a dilated common bile duct(CBD) and findings consistent with peritoneal carcinomatosis without evidence of gallstones or choledocholithiasis. Her laboratory work up was significant for a serum bilirubin level of 7.3 mg/dl and an alkaline phosphatase seven times upper limits of normal. An ERCP was performed which revealed an irregular 3.5 cm. distal CBD stricture without stones. Brush cytology was obtained and a 68 mm wallstent (Schneider, Minneapolis MN.) was successfully placed across the stricture. The patient clinically improved with resolution of jaundice. Cytology was positive for primary adenocarcinoma of the CBD (cholangiocarcinoma) Review of histopathology specimens from ovarian, peritoneal, omental, liver, gallbladder and small bowel tumor studding was consistent with metastatic cholangiocarcinoma. The initial pathology was misleading since the patient did have a low grade, localized mucinous cystadenocarcinoma of the right ovary. Conclusion: While metastatic cholangiocarcinoma is an extremely rare condition, it needs to be considered when widespread carcinomatosis accompanies biliary obstruction. Unfortunately, the prognosis of such patients is dismal and palliation remains the mainstay of therapy. Medline review failed to reveal any reported cases of ovarian metastasis from cholangiocarcinoma, so this likely represents the first such report.