A 55-year-old female presented to the Department of Gastroenterology (Shanghai East Hospital, Shanghai, China) with complaint of right upper abdominal pain lasting over a 2 mo period that was accompanied by pain in the right back and aggravated after eating greasy diet. The patient’s symptoms started 2 mo prior, with recurrent episodes of right upper abdominal pain. The patient had been diagnosed with breast cancer 3 years prior but had an unremarkable medical history otherwise. Physical examination revealed mild tenderness in the right upper quadrant of the abdomen. Superficial protuberant erythema with clear margins were observed on the left neck and chest; the patient indicated a burning sensation and slight tenderness associated with the erythema. Laboratory tests upon admission showed elevated gamma-glutamyl transpeptidase (238 IU/L; normal range: 10-60 IU/L) but normal level of alkaline phosphatase (67 IU/L) and negative findings for inflammatory biomarkers. All blood tumor markers (alpha-fetoprotein: 2.01 ng/mL; carcinoembryonic antigen: 1.71 ng/mL; cancer antigen-125: 12.1 U/mL; cancer antigen-199: 9.26 U/mL; and cancer antigen-135: 14.3 U/mL) were within normal ranges. Magnetic resonance cholangiopancreatography revealed enlarged head of the pancreas, narrowed CBD within the pancreas head, and slightly dilated upper bile ducts. Ultrasound gastroscopy revealed changes indicative of chronic pancreatitis, widening of the bile duct wall, and immunoglobulin G (IgG)4-related cholangitis. Subsequent laboratory tests, however, showed the IgG-4 level to be within the normal range, excluding the possibility of IgG4-related cholangitis. Abdominal enhanced magnetic resonance imaging showed that the wall of the CBD was thickened and became obviously enhanced with contrast agent. The coronal view showed dilation of the upper segment of the CBD, with rough tissue wall and narrowing of the lower segment. Nodular thickening was also seen (localized) in the lower segment of the CBD. Endoscopic retrograde cholangiopancre-atography (ERCP) showed an obstruction at the end of the CBD. Biopsies were taken from the affected tissues (CBD end and symptomatic skin lesions; Figure ). Bone scan showed metastases in the left third rib and the eighth vertebral body. Histopathology results for the biopsied CBD and skin of left neck and chest were: Cytokeratin 7 (+); trans-acting T-cell-specific transcription factor (+); estrogen receptor (ER) (-); progesterone receptor (PR) (-); and human epidermal growth factor receptor-2 (HER2) (-). Morphological characteristics were assessed, and a cancer embolus was found in the skin vasculature.