Delayed diagnosis is a common challenge in cancers such as distal CBD adenocarcinoma and has been shown to significantly worsen prognosis by allowing progression to advanced stages before treatment initiation. This pattern is consistent with that of other gastrointestinal cancers, such as gastric adenocarcinoma, where delays in diagnosis and treatment initiation are linked to reduced survival rates [10]. Similarly, colorectal and pancreatic cancers also demonstrate the detrimental effects of delayed diagnosis, which often leads to advanced tumor stages at the time of detection [11, 12].

The upper abdominal pain is the main presentation for most cases recorded in medical literature [13]. In our case, the patient’s presentation with persistent right upper abdominal pain, jaundice, and significant weight loss over a three-month period before seeking medical care reflected a delayed diagnosis trajectory. This delay in recognizing cancer likely contributed to the advanced stage of the disease upon diagnosis, aligning with findings from similar studies on delayed presentations of bile duct cancers. Early detection and intervention, as seen in the aforementioned studies, are crucial for improving survival outcomes, underscoring the need for timely diagnostic and therapeutic efforts.

Accurate diagnosis of distal CBD adenocarcinoma necessitates the use of precise imaging techniques, which are often challenging owing to the limitations of common diagnostic tools. It is difficult to detect small tumors or distal bile duct lesions using ultrasound, which is commonly used as an initial imaging method, due to limited resolution and interference from bowel gas [14]. In our case, abdominal ultrasonography identified intrahepatic bile duct dilation and a distended CBD with an intraluminal heterogeneous mass. ERCP has been integral in diagnosing pancreatic diseases and obtaining detailed imaging of the pancreatic duct. With advancements in technology, it has evolved into a vital tool for therapeutic stenting and various treatment-oriented applications, including collecting pure pancreatic juice and performing intraductal ultrasonography [15]. Similarly, while ERCP can offer direct visualization and tissue sampling, it carries risks, such as pancreatitis, and may not detect small mucosal lesions [16, 17]. Previous studies have shown that CT imaging has demonstrated high accuracy in distinguishing between benign and malignant periampullary tumors, underscoring its critical role in diagnosis and treatment planning. Additionally, CT scans are valuable in identifying biliary obstruction and evaluating the resectability of lesions, emphasizing its importance in comprehensive vascular assessment [18]. The use of MSCT in our case provided important anatomical insights showing ductal dilation but no visible masses, aligning with the limitations noted in the literature [16, 17]. MRCP, used in our patient to evaluate biliary tree involvement, is highly useful for detecting stenosis, but may lack the specificity to differentiate between benign and malignant strictures [16, 17]. The combined use of multiple imaging modalities, as observed in our patient’s diagnostic workup, can improve diagnostic accuracy and help better evaluate complex cases of bile duct adenocarcinoma.

Percutaneous transhepatic biliary drainage (PTBD) and stenting are effective treatments for malignant obstructive jaundice with minimal complications, making them ideal for elderly patients such as in our patient [19]. Surgical resection, especially through pancreaticoduodenectomy (Whipple procedure), remains the mainstay of treatment for resectable distal CBD adenocarcinomas. However, the use of Roux-en-Y hepaticojejunostomy (RYHJ) to restore bile flow after resection has gained prominence in several studies. One study highlighted the use of RYHJ in patients treated for perihilar cholangiocarcinoma, showing its potential to reduce surgical complexity and prevent adhesions [20]. Similarly, a robotic approach to RYHJ in bile duct cancer patients has been linked to improved postoperative outcomes, including a lower risk of anastomotic strictures and cancer recurrence [21]. In our case, the patient underwent a successful RYHJ following resection of the distal CBD tumor, which contributed to bile flow restoration and significant postoperative improvement. These studies underscore the potential benefits of RYHJ, particularly in complex biliary reconstructions and advanced cancers, as observed in our patient’s favorable postoperative outcomes.

Lymphovascular invasion (LVI) is a critical prognostic factor in bile duct adenocarcinoma that influences both disease-free survival (DFS) and overall survival (OS). Studies have shown that LVI is associated with poorer outcomes in distal cholangiocarcinoma, with patients exhibiting higher LVI levels and significantly reduced survival rates [22]. In our case, histopathological examination revealed lymphovascular invasion within the tumor, which was indicative of a more aggressive disease course. This aligns with findings from pancreatic adenocarcinoma and other gastrointestinal cancers, in which LVI serves as a strong indicator of poor prognosis [23]. The presence of LVI in our case underscores the need for aggressive postoperative treatment strategies including adjuvant therapies to improve survival and reduce recurrence.

Postoperative outcomes for patients with distal CBD adenocarcinoma undergoing pancreaticoduodenectomy have shown improvements in recent years, particularly in terms of reduced blood loss, shorter operation times, and lower infection rates [4]. However, complications, such as postoperative pancreatic fistulas, remain challenging. Our case reflects this reality, as the patient demonstrated significant clinical improvement post-surgery, including normalization of bilirubin levels; however, such outcomes require careful postoperative management. Studies have shown that factors such as advanced tumor stage and high preoperative CA19-9 levels continue to affect survival, highlighting the importance of early detection and comprehensive perioperative care [4]. As observed in our patient, careful management of biliary drainage and minimization of postoperative complications are crucial for achieving a favorable outcome.

Early detection is paramount for improving survival rates and reducing recurrence in bile duct cancers. Advancements in biomarkers, such as circulating tumor DNA and microRNA, show promise for early stage diagnosis, enabling earlier interventions that may result in curative outcomes [24]. In our case, the patient’s prolonged symptoms and delayed diagnosis emphasized the need for better early screening methods. Technologies such as endoscopic ultrasound (EUS) have been shown to reduce recurrence rates by enabling earlier detection and targeted intervention [25]. Early detection, especially in high-risk populations, significantly improves the chances of curative treatment, as demonstrated by studies on cholangiocarcinoma [26]. For our patient, more timely screening could potentially lead to earlier intervention, improving long-term outcomes.

Emerging therapies for the treatment of distal CBD adenocarcinoma, particularly in advanced stages, are beginning to show promising results. Targeted therapies, such as PARP inhibitors for BRCA-mutated tumors and KRAS inhibitors for KRAS-mutant cancers, are being explored to extend progression-free survival [27]. In addition, photodynamic therapy (PDT) combined with RNA-based medicines is emerging as a novel strategy to treat fibrotic tumors such as pancreatic and bile duct cancers [28]. Biomarker-driven therapies are also advancing, with the use of immune checkpoint inhibitors in mismatch repair-deficient tumors and NTRK inhibitors in NTRK fusion-positive tumors; these have seen regulatory approval in specific subtypes, marking steps forward in personalized medicine for these cancers [29]. These advancements highlight the potential of personalized medicine to improve outcomes in patients with advanced CBD adenocarcinomas. While these treatments are still in the early stages, they offer optimism for more effective management of distal CBD adenocarcinomas in the future.