Case Report Klatskin Tumor

Introduction
Cholangiocarcinoma is a derived-Cholangio cell transformation malignancy,

which is a an epithelial cell originated from intra and extra hepatic bilier duct.
Hilar Cholangiocarcinoma is classified as intra-hepatic and extra hepatic, also
divided into proximal (hilum), middle and distal. Hilar Cholangiocarcinoma is
termed as klatskin tumor. It is primary malignancy that spread through bilier
duct.1,2
Dr. G. Klastkin, an internal specialist from the United States, in 1965, first
describe the tumor in 1965 and found in 13 cases. dr. Gerald Klatskin, also
described a sclerosis adenocarcinoma which known in the literature as Klatskin
tumors
Klastkin tumour has been found 6 or 7 decades and more than 90% of the
cases show jaundice. Because of the rarity and the complexity of the anatomy
involved in this tumor, the diagnosis and management must be done
multidisplinery include GEH and surgeons digestiv.4
Klatskin tumor typically show symptoms of biliary obstruction with jaundice and
pale bowel movements like putty. The combination of serum tumor markers, ie
carbohydrate antigen (CA 19-9) and carcinogens embryonic antigen (CEA), has
been recommended as one of the elements in the enforcement of diagnosis
tumor.1,5,6
Although the exact cause is unknown klatskins tumor, a number of pathological
conditions either acute or chronic damage of the biliary tract epithelium can
trigger a malignansi.1
If found a suspected case an extrahepatic cholangiocarcinoma, Magnetic
Resonance Imaging examination / cholangiography (MRI / MRC) is the gold
standard for evaluating the state of the tumor and therapy planning. In 40-70%
of patients with suspected an extrahepatic cholangiocarcinoma, confirmed by a
combination of brush cytology and biopsy clamp but generally illustrates the
sensitivity is relatively low (<50%). Although Direct cholangiography is an
examination of the gold standard that has been set to determine Klatskin staging
of the tumor, but in recent years non-invasive examinations such as the MRCP
(Magnetic Resonance Cholangio Pancreatography) are preferred for enforcement
diagnosis.3,5
Klatskin tumor prognosis in general is bad, because most of these tumors can
not do surgery until the diagnosis is established. Surgical exploration curative
resection action can only be performed if the radiology bring the picture
potensial.6,7
The average survival of patients with tumors that do not resektabel Klatskin after
palliative drainage is six to nine months, most patients die of recurrent bacterial
cholangitis and or due to a malfunction hati.3,7,8
Case
Female patients, aged 56 years old Acehnese came to RSUZA on October 16,
2016 with a chief complaint of yellow eyes since one month ago ,. Patients also
felt her look yellow since 2 minggu.Mual and vomiting since 2 minggu.muntah
patient complained of food, appetite is still there. Sometimes complained of

abdominal pain in the right upper abdomen. Patients also complained of itching
in the body begin to be felt in the last 2 weeks. Urination dark yellow like tea 1
month, defecate pale as putty, also complained in the last 1 month. Weight loss
for 2 months 10 kg.4 days ago the patient started complaining of fever, high
fever perceived and sometimes down to a normal temperature.
Patients and their families do not have a history of jaundice, hepatitis,
gallstones, and diseases prior malignancy.
In common vital signs Blood pressure 140 / 80mmHg, pulse 100x / minute,
respiratory 18x / min and temperature: 38,5'C, physical examination of the
patient, looked jaundice in the sclera ', jaundice jaundice sublingual inferior
eyelid and conjunctival pallor. tenderness in the right upper abdomen.
Lymphadenopathy ditemukan.Tidak not found enlarged spleen.
Results of laboratory tests obtained: Hb 11.9 g / dl, leukocytes 18.6x103, total
bilirubin 26.5 mg / dL, direct bilirubin 19.7 mg / dl, AST 218 U / I, ALT 91 U / I, Ca
19- 9 53.85 with negative HBsAg and serum urea normal renal function is 39
mg / dl. and serum creatinine 0.9 mg / dL, albumin 2,07mg / dl.
The liver ultrasound visible mass in the hilum of the liver, pancreas normal size,
did not seem the masses. conclusions obstruction of the biliary system and the
intra and extra hepatic hillus suspect masses in the liver tumor klatskin
impression. CT Scan of the abdomen contrast and non-contrast giving the
impression of a lesion in the right lobe of the liver and pancreas fairy mass in the
pancreas as well as pressing the GB wall thickening klatskins suspect a tumor
with infiltration into GB.
During the initial treatment of patients diagnosed with biliary sepsis +
Obstructive Jaundice ec dd / Ca ampulla Vaterii 1., 2. CBD Stone, 3. Ca Caput
Pancreas, 4. Cholangio Sarcoma. Patients treated at HCU for 6 days, during
treatment in the HCU patients underwent ultrasound examination of the
abdomen Furthermore, after the ultrasound examination of the abdomen and CT
Scan Abdomen diagnosed klatskin tumor and therapy Diet Sonde 6x200cc, IV
meropenem 1 g / 8 hours, Urdafalk, sistenol 3x500mg and patients consulted to
the surgery department for further action. From the digestive surgery
department planned surgery performed for drainage. Management of patients
has been conducted laparotomy and biopsy. Biopsy results with the preparation
of the omentum appears malignant glands bulat- oval shape with enlarged
nucleus cuboidal epithelial linings, pleomorphic, hyperchromatic, some rough
chromatin, child mennonjol core, eosinophilic cytoplasm. Angiolimfatik invasion
can be identified. Conclusion Metastatic adenocarcinoma
Discussion
The incidence of cholangiocarcinoma approximately 2% of all cancer diagnoses
and 25-30% of the bile duct cancer is a tumor Klatskin. Two-thirds of the cases
occurred in patients aged over 65 years and comparison of similar events in both
men and women.
In this case the patient was a woman aged 56 years.
This disease often show symptoms such as obstructive jaundice ( 90% of cases)
and abdominal pain in the right upper quadrant (40-50% of cases). Complaints of
itching was reported in 30-70% of patients. Other symptoms that often appear
include weight loss (40-50% of cases), fever (20% of cases) and nausea.
Enlargement of the gall bladder is not found in patients with tumor Klatskin
because it depends on the level of obstruction supracystic.4,10 Because there
were no early symptoms, Klatskin tumors are often diagnosed at an advanced
stage, when the clinical symptoms of jaundice seen jelas.11 These patients
hospitalized with complaints yellow and right upper quadrant abdominal pain
during the last two months, itching in the body, weight loss body, nausea,
urinate yellow like tea, and defecate pale as putty.
Biochemical laboratory parameters showed cholestatic pattern. Impaired liver
function as a result of cholestasis and is an important risk factor in liver resection
besar.12 In these cases the laboratory results found that total bilirubin level of
26.5 mg / dl, bilirubin direct 19.70 mg / dl, AST 218 U / I , alanine
aminotransferase 91 U / I, U / I and negative HBsAg.
Diagnosis of this disease should be enforced degan basic radiological
examinations such as Magnetic Resonance Imaging (MRI) and Computed
Tomography (CT). Examination with multi-slice CT using contrast with ultra-thin
sections can show Klatskin tumor with a sensitivity of up to 100%. The image
generated on a CT scan depends on the location and morphology of the tumor.
The key to the diagnosis of extrahepatic lesions or confluent lesions is to look at
the common bile duct dilatation at the site of the tumor. Tumor mass at the level
of biliary obstruction can be seen with a CT-Scan, but the likelihood is small and
is not identified. For cases like this, a rough assessment of ductal dilatation
without mass sightings, may lead to the correct diagnosis for tumors Klatskin.
Location and extent of the tumor can be assessed on MRI with a sensitivity of
94% and a specificity of 100%. On the evaluation results can be found Klatskin
tumor intrahepatic biliary dilatation, normal gallbladder or collapse and
extrahepatic biliary, and pancreatic normal.9
In this case, ultrasound examination with the conclusion Liver Biliary obstruction
system as well as intra and extra hepatic hilum suspect masses in the liver
tumor klastkin impression. CT Scan of the abdomen contrast and non-contrast
describes an impression isodense lesions in CHD with dilatation IHBD and
contracted EHBD with GB and GB wall thickening klatskins suspect a tumor with
infiltration into GB.
Etiology klatskin tumor until now unknown. Chronic inflammatory processes,
such as primary sclerosing cholangitis (PSC) or chronic parasitic infection
suspected to have a role in inducing hyperplasia. Chronic proliferation is thought
to have a role in inducing hyperplasia, cellular proliferation and especially
malignant transformation. While gallstones, chronic hepatitis and cirrhosis is not
a risk factor for this disease.
There are several procedures for the determination of staging for
Cholangiocarcinoma. The most commonly used are based on the criteria of
pathological American Joint Committee on Cancer (AJCC) TNM classification
Bismuth and Corlette that divides based pada`keterlibatan tumor in BismuthCorlette empedu.Klasifikasi channel divides into several types as follows:
1. Bismuth-Corlette type I
Hepatic duct tumor is confined to the communists, under the branches. Patients
can be treated with resection along the duct rekonstruski bilaris because the
ramifications are still normal
2. Bismuth-Corlette type II
Tumor lesion extends to the branching early estuary right and left hepatic ducts.
These tumors still has the potential to be resected.
3. Bismuth-Corlette type III-A and III-b
Lesions III-a type of tumor extends to the right hepatic duct and type III-b
extends to the left hepatic duct. Patients can be treated with resection of the
right lobe of the liver.
4. Bismuth-Corlette type IV
Tumor lesion extends to the right and left hepatic ducts. This tumor can not be
resected
This case is Bismuth Corlette Klatskin tumor type II
Klatskin tumor growth is relatively slow, especially in tumors that still invade
locally. However, the progression of metastasis is not uncommon progression of
the disease can be quickly in some cases. Infiltration by bile duct cancer include
spreading longitudinally and vertically. Longitudinally deployment refers to the
spread of tumors throughout the bile duct and spread of vertically refers to the
direct invasion to the area around the pancreas or duodenum, hepatic artery and
portal vein. Direct invasion into the liver parenchyma, if the cancer cells in the
distal bile duct invade directly into the pancreas or duodenum.16
In case, a CT scan of the abdomen contrast and non-contrast describes an
impression isodense lesions in CHD with dilatation IHBD and contracted EHBD
with GB and GB wall thickening klatskins suspect a tumor with infiltration into
GB.
Evaluating tumor and drainage methods depending on the type of Bismuth.
Selection of tumor resection with negative margins of resection is the best option
with long-term survival rate. However, only 10% to 20% of patients who are
eligible for curative resection. Most patients can only be granted drainage
therapy paliatif.17
Tumors originating from the mid-CBD could spread to the liver or pancreas and
can even be wider than the tumor inoperable until lagi.18 palliative treatment
with endoscopic or percutaneous biliary drainage still can not be considered
optimal and Klatskin tumor is still a disease that is difficult to cured. In patients
with inoperable, treatment is intended only purpose is to relieve the symptoms
of jaundice its course and to improve the quality and quantity of survival
Lee et al (2007) mentions Endoscopic Retrograde Biliary Drainage (ERBD) is
recommended as the first choice of palliative drainage procedure jaundice in
tumor klatskin Bismuth type II or III, while for Bismuth type IV is the best choice
of internal biliary stenting via the percutaneous transhepatic biliary drainage.11
In the case of action has been taken hepatic resection + biopsy, external
draignase and omental biopsy. Omental biopsy results concluded a metastatic
adenocarcinoma.
Conclusion
Female patients, aged 56 years old Acehnese came to RSUZA on October 16,
2016 with a chief complaint of yellow eyes, patients also feel healthy and look
yellow since 2 minggu.Mual and vomiting, abdominal pain sometimes
complained of in the right upper abdomen. Itching all over the body Urination
dark yellow as concentrated tea, bowel pale as putty, weight loss 10 kg in two
months. fever 4 days ago perceived higher and some- \ times down to a normal
temperature. From laboratory tests showed elevated levels of direct bilirubin
19.7 mg / dl, ultrasound results showed klatskin impression tumor and the results
ct scan shows the results of a klatskins tumor infiltration into GB and
adenocarcinoma biopsy results

Case Report Klatskin Tumor

Uploaded by

Copyright:

Available Formats

Case Report Klatskin Tumor

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Report Klatskin Tumor

Uploaded by

Copyright:

Available Formats

Introduction

Cholangiocarcinoma is a derived-Cholangio cell transformation malignancy,

patient complained of food, appetite is still there. Sometimes complained of

You might also like