Figure 5b. Papillary adenocarcinoma of the extrahepatic duct in a 73-year-old man with a 2-month history of jaundice. (a) US image shows a slightly dilated CBD that contains an echogenic cast. The wall of the bile duct is well preserved and appears as a thin echogenic line (arrow). GB = gallbladder. (b, c) Unenhanced (b) and contrast material-enhanced (c) CT scans show an intraluminal mass in the CBD (arrow). Attenuation of the mass increased from 24 HU on b to 95 HU on c, indicating that the mass represents a tumor attached to the bile duct wall. (d) ERCP image shows multiple large, oval filling defects in the CBD. The filling defects with smooth surfaces (open arrow) are stones, whereas those with papillary surfaces are tumors. The margin of the common hepatic duct (CHD) (solid arrow) is serrated. The bile ducts are dilated as far as the ampulla of Vater. Note the normal duodenal mucosal surface. (e) ERCP image obtained after an attempt to extract the "lumps" with a basket maneuver shows innumerable filling defects of varying size that represent tumor fragments. A stone (open arrow) remains in the bile duct, and only small tissue debris could be removed. The serrated margin of the CHD (solid black arrow) is unchanged (cf d). Note the small and medium-sized filling defects in the second portion of the duodenum (solid white arrows), which represent tumor fragments. Surgery revealed several pigmented stones as well as many tiny (3-5-mm-diameter) fragments of papillary tumor and debris within the extrahepatic ducts. (f) Photomicrograph (original magnification, x40; H-E stain) of tissue debris obtained from the bile ducts at surgery shows innumerable papillary tumor fragments (arrowheads). (g) Low-power photomicrograph (original magnification, x10; H-E stain) of a cut section of the proximal portion of the CHD shows tiny flat papillary carcinomas lining the mucosal surface (curved arrow). A defect caused by bile duct exploration performed during surgery is also seen (straight arrow). Because the superficial papillary tumors were sloughed or denuded before or during surgery, there are no polypoid masses as were seen at US, CT, and ERCP.