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Nakshabandi AA, Lee JH. Contemporary advances in the endoscopic management of cholangiocarcinoma: a review of accomplished milestones and prospective opportunities. Expert Rev Gastroenterol Hepatol 2023; 17:175-187. [PMID: 36683580 DOI: 10.1080/17474124.2023.2170875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Cholangiocarcinoma, a primary malignancy of epithelial cells of the bile ducts, has been shown to have increasing incidence rates globally. Many of the current advances aim to improve the accuracy of differentiation between benign biliary strictures and cholangiocarcinoma, which include endoscopic techniques, devices, image processing, and the use of genomic sequencing in acquired specimens. AREAS COVERED In this review, the authors explore the historical timeline of changes leading to modern management of cholangiocarcinoma, with special emphasis on endoscopic modalities and novel therapeutic interventions. The authors also expand on the strengths and shortcomings of endoscopic diagnostics and techniques in biliary drainage and finally discuss potential areas to focus for future research and development. EXPERT OPINION Despite the advances in diagnosis and management of cholangiocarcinoma, there remain multiple tasks that are still awaiting to be completed. Next-generation sequencing in the diagnosis of cholangiocarcinoma needs to be further tested, validated, and easily obtainable. Other innovative diagnostic modalities, such as the use of artificial intelligence in cholangioscopy, may provide an effective complementary modality to existing techniques. A consensus on biliary drainage needs to be defined and account for longevity and patient convenience.
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Affiliation(s)
- Ahmad Al Nakshabandi
- Department of Gastroenterology, Hepatology & Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology & Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Garg I, Graham RP, VanBuren WM, Goenka AH, Torbenson MS, Venkatesh SK. Hepatic segmental atrophy and nodular elastosis: imaging features. Abdom Radiol (NY) 2017; 42:2447-2453. [PMID: 28456818 DOI: 10.1007/s00261-017-1164-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE To evaluate the imaging features of hepatic segmental atrophy and nodular elastosis. MATERIALS AND METHODS In this Institutional review board (IRB)-approved, HIPAA-compliant study, we reviewed imaging features in six cases of histologically confirmed hepatic segmental atrophy (HSA) and nodular elastosis (NE). Retrospective review of ultrasound (US) in 2 patients, computed tomography (CT) in 5 patients, magnetic resonance imaging (MRI) in 4 patients, and positron emission tomography (PET) in 2 patients was performed. Location, size, and attenuation/density/signal intensity of these lesions were evaluated. Clinical presentation and coexistent conditions were also recorded. RESULTS All six patients were females. Mean age of presentation was 58.3 years (range 37-80). A single HSA and NE lesion in each patient was found. The mean size of the lesion was 18 mm (range: 3 mm to 36 mm). Most lesions were detected incidentally (5/6). On contrast-enhanced single-phase (portal venous) CT, most lesions were hypodense (4/5) and one lesion was hyperdense to fatty liver parenchyma. On MRI, the lesions were iso- to hyperintense on T2-weighted images, T1 hypointense, and hyperintense on diffusion-weighted images (DWI). Three lesions were hypointense on arterial, portal venous, and delayed phases. One lesion occurring in fatty liver appeared hyperintense on all three phases. Gd-EOB-DTPA-enhanced images were available in 2 patients and lesions were hypointense on the 20-min hepatobiliary phase. On PET, two lesions were isometabolic to the background hepatic parenchyma. On ultrasound, one lesion appeared hypoechoic and another lesion isoechoic to hepatic parenchyma. CONCLUSIONS Hepatic segmental atrophy and nodular elastosis is an uncommon benign lesion and can simulate metastases due to variable imaging features. Lack of FDG uptake on PET/CT may be a clue to the benign nature of the lesion and may suggest the possibility of HSA and NE.
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Ceravolo I, Guerrieri D, De Vargas Macciucca M, De Cristofaro F, Panzironi G. MRI rare finding: Absence of the left liver lobe. Eur J Radiol Open 2017; 4:50-52. [PMID: 28459087 PMCID: PMC5396858 DOI: 10.1016/j.ejro.2017.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/03/2017] [Indexed: 01/18/2023] Open
Abstract
We report a rare case of left liver lobe absence in an 80-year-old male patient discovered during an MRI scan. The main imaging features of this condition are briefly reviewed, together with its pathogenesis and the most common associations and differential diagnoses.
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Affiliation(s)
| | - Daniele Guerrieri
- Department of Radiological, Oncological and Pathological Sciences, University of Rome “Sapienza”, Viale del Policlinico 155, 00161 Rome, Italy
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Fu CJ, Wong YC, Tsang YM, Wang LJ, Chen HW, Ku YK, Wu CH, Chen HW, Kang SC. Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma. Diagn Interv Radiol 2016; 21:361-7. [PMID: 26268303 DOI: 10.5152/dir.2015.14445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma. METHODS Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared. RESULTS A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm3; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm3; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm3; IQR: 136, 371) (both, P = 0.002). CONCLUSION Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma.
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Affiliation(s)
- Chen Ju Fu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, TaoYuan, Taiwan.
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Solodinina EN, Starkov IG, Shumkina LV. [The efficacy of endoscopic endosonography in diagnosis of benign and malignant stenoses of common bile duct]. Khirurgiia (Mosk) 2016:38-43. [PMID: 26977609 DOI: 10.17116/hirurgia2016138-43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To define criteria and to estimate diagnostic significance of endosonography in differential diagnosis of benign and malignant stenoses of common bile duct. MATERIAL AND METHODS We presented the results of survey and treatment of 57 patients with benign and malignant stenoses of common bile duct. The technique of endosonography is described. We have formulated major criteria of differential diagnostics of tumoral and non-tumoral lesion of extrahepatic bile ducts. Comparative analysis of endosonography, ultrasound, computed tomography and magnetic resonance cholangiopancreatography was performed. RESULTS Sensitivity, specificity and accuracy of endosonography in diagnosis of stenosis cause is 97.7%, 100% and 98.2% respectively. So it exceeds the efficacy of other diagnostic X-ray methods. In modern surgical clinic endosonography should be mandatory performed. It is necessary for final diagnostics of cause of common bile duct stenosis especially in case of its low location.
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Lobar and segmental liver atrophy associated with hilar cholangiocarcinoma and the impact of hilar biliary anatomical variants: a pictorial essay. Insights Imaging 2011; 2:525-531. [PMID: 22347972 PMCID: PMC3259339 DOI: 10.1007/s13244-011-0100-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/19/2011] [Accepted: 05/02/2011] [Indexed: 11/24/2022] Open
Abstract
The radiological features of lobar and segmental liver atrophy and compensatory hypertrophy associated with biliary obstruction are important to recognise for diagnostic and therapeutic reasons. Atrophied lobes/segments reduce in volume and usually contain crowded dilated bile ducts extending close to the liver surface. There is often a “step” in the liver contour between the atrophied and non-atrophied parts. Hypertrophied right lobe or segments enlarge and show a prominently convex or “bulbous” visceral surface. The atrophied liver parenchyma may show lower attenuation on pre-contrast computed tomography (CT) and CT intravenous cholangiography (CT-IVC) and lower signal intensity on T1-weighted magnetic resonance imaging (MRI). Hilar biliary anatomical variants can have an impact on the patterns of lobar/segmental atrophy, as the cause of obstruction (e.g. cholangiocarcinoma) often commences in one branch, leading to atrophy in that drainage region before progressing to complete biliary obstruction and jaundice. Such variants are common and can result in unusual but explainable patterns of atrophy and hypertrophy. Examples of changes seen with and without hilar variants are presented that illustrate the radiological features of atrophy/hypertrophy.
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Mohamadnejad M, DeWitt JM, Sherman S, LeBlanc JK, Pitt HA, House MG, Jones KJ, Fogel EL, McHenry L, Watkins JL, Cote GA, Lehman GA, Al-Haddad MA. Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience. Gastrointest Endosc 2011; 73:71-8. [PMID: 21067747 DOI: 10.1016/j.gie.2010.08.050] [Citation(s) in RCA: 177] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 08/28/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Accurate preoperative diagnosis and staging of cholangiocarcinoma (CCA) remain difficult. OBJECTIVE To evaluate the utility of EUS in the diagnosis and preoperative evaluation of CCA. DESIGN Observational study of prospectively collected data. SETTING Single tertiary referral hospital in Indianapolis, Indiana. PATIENTS Consecutive patients with CCA from January 2003 through October 2009. INTERVENTIONS EUS and EUS-guided FNA (EUS-FNA). MAIN OUTCOME MEASUREMENTS Sensitivity of EUS for the detection of a tumor and prediction of unresectability compared with CT and magnetic resonance imaging (MRI); sensitivity of EUS-FNA to provide tissue diagnosis, by using surgical pathology as a reference standard. RESULTS A total of 228 patients with biliary strictures undergoing EUS were identified. Of these, 81 (mean age 70 years, 45 men) had CCA. Fifty-one patients (63%) had distal and 30 (37%) had proximal CCA. For those with available imaging, tumor detection was superior with EUS compared with triphasic CT (76 of 81 [94%] vs 23 of 75 [30%], respectively; P < .001). MRI identified the tumor in 11 of 26 patients (42%; P = .07 vs EUS). EUS identified CCA in all 51 (100%) distal and 25 (83%) of 30 proximal tumors (P < .01). EUS-FNA (median, 5 passes; range, 1-12 passes) was performed in 74 patients (91%). The overall sensitivity of EUS-FNA for the diagnosis of CCA was 73% (95% confidence interval, 62%-82%) and was significantly higher in distal compared with proximal CCA (81% vs 59%, respectively; P = .04). Fifteen tumors were definitely unresectable. EUS correctly identified unresectability in 8 of 15 and correctly identified the 38 of 39 patients with resectable tumors (53% sensitivity and 97% specificity for unresectability). CT and/or MRI failed to detect unresectability in 6 of these 8 patients. LIMITATION Single-center study. CONCLUSION EUS and EUS-FNA are sensitive for the diagnosis of CCA and very specific in predicting unresectability. The sensitivity of EUS-FNA is significantly higher in distal than in proximal CCA.
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Affiliation(s)
- Mehdi Mohamadnejad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Aljiffry M, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009. World J Gastroenterol 2009; 15:4240-62. [PMID: 19750567 PMCID: PMC2744180 DOI: 10.3748/wjg.15.4240] [Citation(s) in RCA: 186] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.
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Abstract
Cholangiocarcinomas arise from the epithelial cells of the bile ducts and are associated with poor prognosis. Despite new diagnostic approaches, the definite diagnosis of this malignancy continues to be challenging. Cholangiocarcinomas often grow longitudinally along the bile duct rather than in a radial direction. Thus, large tumor masses are frequently absent and imaging techniques, including ultrasound, CT, and MRI have only limited sensitivity. Tissue collection during endoscopic (ERCP) and/or percutaneous transhepatic (PTC) procedures are usually used to confirm a definitive diagnosis of cholangiocarcinoma. However, forceps biopsy and brush cytology provide positive results for malignancy in about only 50% of patients. Percutaneous and peroral cholangioscopy using fiber-optic techniques were therefore developed for direct visualization of the biliary tree, yielding additional information about endoscopic appearance and tumor extension, as well as a guided biopsy acquistion. Finally, endoscopic ultrasonography (EUS) complements endoscopic and percutaneous approaches and may provide a tissue diagnosis of tumors in the biliary region through fine-needle aspiration. In the future, new techniques allowing for early detection, including molecular markers, should be developed to improve the diagnostic sensitivity in this increasing tumor entity.
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Weber A, Weyhern CV, Fend F, Schneider J, Neu B, Meining A, Weidenbach H, Schmid RM, Prinz C. Endoscopic transpapillary brush cytology and forceps biopsy in patients with hilar cholangiocarcinoma. World J Gastroenterol 2008; 14:1097-101. [PMID: 18286693 PMCID: PMC2689414 DOI: 10.3748/wjg.14.1097] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the sensitivity of brush cytology and forceps biopsy in a homogeneous patient group with hilar cholangiocarcinoma.
METHODS: Brush cytology and forceps biopsy were routinely performed in patients with suspected malignant biliary strictures. Fifty-eight consecutive patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) including forceps biopsy and brush cytology in patients with hilar cholangiocarcinoma between 1995-2005.
RESULTS: Positive results for malignancy were obtained in 24/58 patients (41.4%) by brush cytology and in 31/58 patients (53.4%) by forceps biopsy. The combination of both techniques brush cytology and forceps biopsy resulted only in a minor increase in diagnostic sensitivity to 60.3% (35/58 patients). In 20/58 patients (34.5%), diagnosis were obtained by both positive cytology and positive histology, in 11/58 (19%) by positive histology (negative cytology) and only 4/58 patients (6.9%) were confirmed by positive cytology (negative histology).
CONCLUSION: Brush cytology and forceps biopsy have only limited sensitivity for the diagnosis of malignant hilar tumors. In our eyes, additional diagnostic techniques should be evaluated and should become routine in patients with negative cytological and histological findings.
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Scaife C. Liver. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Hilar cholangiocarcinoma is a rare tumor. Surgery remains the only treatment to prolong survival. There is a correlation between the extent of diagnostic work-up and the achieved resection rates. Moreover, diagnostic work-up may contribute to an improvement of the surgical technique. Due to the perihilar fibrosis, the extent of the central lesion may be overestimated, which may lead to exclude the patient from potentially curative surgery. En bloc resection is requested to achieve tumor-free resection margins. The prognosis of the patients treated with surgery is strongly influenced by negative resection margins. According to our experience, 5-year survival of 78/111 patients with tumor resection (resection rate 71%) has been 30%. Forty-eight percent of the patients with curative en bloc resection of tumor and liver survived for more than 5 years. Perioperative mortality was 5.1%. The available data are supposed to reflect the results of centers with high caseload and not the general situation.
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Affiliation(s)
- Gerd Otto
- Department of Transplantation and Hepatobiliopancreatic Surgery, Johannes Gutenberg University Mainz, Langenbeckst. 1, 55101 Mainz, Germany.
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Hashimoto M, Heianna J, Yasuda K, Tate E, Watarai J, Shibata S, Sato T, Yamamoto Y. Portal flow into the liver through veins at the site of biliary-enteric anastomosis. Eur Radiol 2005; 15:1421-5. [PMID: 15711839 DOI: 10.1007/s00330-005-2667-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2004] [Revised: 12/25/2004] [Accepted: 12/30/2004] [Indexed: 10/25/2022]
Abstract
The aim of this study was to establish the role played by jejunal veins in hepatopetal flow after biliary-enteric anastomosis and to evaluate the helical CT features of hepatopetal flow through the anastomosis. We retrospectively analyzed helical CT images of the liver in 31 patients with biliary-enteric anastomosis who underwent hepatic angiography with (n=13) or without (n=18) CT arterial portography within 2 weeks of the CT examination during the last 4 years. Arterial portography showed hepatopetal flow through small vessels located (communicating veins) between the elevated jejunal veins and the intrahepatic portal branches in two (9%) of 22 patients with a normal portal system. Helical CT showed focal parenchymal enhancement around the anastomosis in these two patients. All nine patients with extrahepatic portal vein occlusion (100%) had hepatopetal flow through the anastomosis, and four of the nine had decreased portal flow. CT revealed small communicating veins in two of these four patients. In five patients with normal portal perfusion despite extrahepatic portal vein occlusion, CT detected dilated communicating veins and elevated jejunal veins. The presence of communicating veins and/or focal parenchymal enhancement around the anastomosis indicates hepatopetal flow through the elevated jejunal veins.
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Affiliation(s)
- M Hashimoto
- Radiology, Akita University School of Medicine, Japan.
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Abstract
Preoperative imaging with MRI/MRA/MRCP is an accurate non-invasive method for staging cholangiocarcinoma, and determining resectability. It provides information regarding tumor size, extent of bile duct involvement, vascular patency, extrahepatic extension, nodal or distant metastases, and the presence of lobar atrophy. MRCP is better for demonstrating bile ducts distal to the stricture, although with ERCP, therapeutic intervention such as stent placement and biopsy can be performed.
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Affiliation(s)
- Katrina A Vanderveen
- Department of Radiology/MRI B2B311, University of Michigan Hospitals-Ann Arbor, Ann Arbor, MI 48109-0030, USA
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Zhang Y, Uchida M, Abe T, Nishimura H, Hayabuchi N, Nakashima Y. Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI. J Comput Assist Tomogr 1999; 23:670-7. [PMID: 10524843 DOI: 10.1097/00004728-199909000-00004] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this work was to compare dynamic MRI (D-MRI) with dynamic CT (D-CT) for the diagnosis of peripheral cholangiocarcinoma (PCC) of the liver. METHOD Twenty patients with PCC underwent both D-CT and D-MRI during the early, middle, and delayed phase after contrast medium administration. The findings from D-MRI were compared with those from D-CT. RESULTS D-CT and D-MRI exhibited a similar tumoral enhancement pattern, and this enhancement was more conspicuous on D-MRI. A wedge-like enhancement area peripheral to the tumor was observed in 9 (45%) patients on D-CT and 11 (55%) patients on D-MRI. Ductal dilatation was found in 13 (65%) patients on both techniques. Vascular involvement and extrahepatic invasion were seen in nine (45%) and two (10%) patients, respectively. The relationship of the tumor to the vessels and surrounding organs was more easily evaluated on D-CT. CONCLUSION Both D-CT and D-MRI can provide important information for the diagnosis of PCC. D-CT is better than D-MRI for demonstrating vascular involvement and extrahepatic invasion. D-MRI gives more conspicuous enhancement.
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Affiliation(s)
- Y Zhang
- Department of Radiology, Kurume University School of Medicine, Kurume City, Fukuoka, Japan
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Worawattanakul S, Semelka RC, Noone TC, Calvo BF, Kelekis NL, Woosley JT. Cholangiocarcinoma: spectrum of appearances on MR images using current techniques. Magn Reson Imaging 1998; 16:993-1003. [PMID: 9839983 DOI: 10.1016/s0730-725x(98)00135-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study describes the spectrum of appearances of cholangiocarcinoma on magnetic resonance (MR) sequences, including gadolinium-enhanced, fat-suppressed spoiled gradient echo images and MR cholangiography. Fifteen patients were included in the study. Histologic diagnosis was established in 11 patients by surgical resection (6 patients), percutaneous biopsy (4 patients), and open liver biopsy (1 patient). The final diagnosis was determined by correlation of the MR findings with cholangiographic studies and laboratory studies in 4 patients. MR studies were performed at 1.5 T, and the following sequences were obtained: T1-weighted spoiled gradient echo (SGE), T1-weighted fat-suppressed spin echo or SGE, T2-weighted fat-suppressed conventional or turbo spin echo, MR cholangiography, and gadolinium-enhanced T1-weighted fat-suppressed SGE images. The following determinations were made: tumor location, tumor extent, ductal dilatation, ductal wall thickness, signal intensity, enhancement pattern, and associated findings. Mass-like neoplasms were peripheral (6 patients), hilar (1 patient), and extrahepatic (2 patients). Circumferential tumors were hilar (2 patients) and extrahepatic (4 patients). All peripheral tumors were multifocal. Mass-like tumors were well-defined, rounded, and ranged from 1 to 14 cm in diameter. Circumferential tumors had less well-defined margins and measured from 3 to 15 mm in thickness. All mass-like tumors were moderately hypointense on T1-weighted images and mildly to moderately hyperintense on T2-weighted images. The circumferential tumors were iso- to moderately hypointense on T1-weighted images and iso- to mildly hyperintense on T2-weighted images. Mass-like tumors were generally well shown on non-contrast and immediate gadolinium-enhanced images, whereas circumferential tumors were poorly seen on non-contrast images and best shown on gadolinium-enhanced T1-weighted fat-suppressed images. The degree of enhancement ranged from minimal to intense on immediate gadolinium-enhanced images, with all tumors becoming more homogeneous in signal intensity on images obtained between 1 and 5 min following contrast administration. Tumor-containing lymph nodes greater than or equal to 1 cm in diameter were demonstrated in 11 out of 15 patients (73.3%). These were best shown on T2-weighted fat-suppressed images and gadolinium-enhanced fat-suppressed SGE images. MR cholangiography demonstrated the level of obstruction and degree of dilatation of the proximal biliary system in 5 out of 6 patients who underwent MR cholangiography. The spectrum of appearances of cholangiocarcinoma is demonstrable on MR images. Mass-like tumors are well shown on both pre- and post-gadolinium sequences. Circumferential tumors may cause minimally increased duct wall thickness and are most clearly shown on gadolinium-enhanced fat-suppressed SGE images obtained 1 to 5 min following gadolinium administration.
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Affiliation(s)
- S Worawattanakul
- Department of Radiology, University of North Carolina at Chapel Hill, 27599-7510, USA
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Soong TC, Lee RC, Cheng HC, Chiang JH, Tseng HS, Lin CW, Teng MM. Dynamic MR imaging of hepatolithiasis. ABDOMINAL IMAGING 1998; 23:515-9. [PMID: 9841066 DOI: 10.1007/s002619900390] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
BACKGROUND To report the dynamic magnetic resonance (MR) imaging findings of hepatolithiasis. METHODS Dynamic MR images (fast spoiled gradient echo sequence with intravenous injection of gadopentate dimeglumine) and computed tomography, cholangiography, or angiography of nine patients with hepatolithiasis are analyzed. RESULTS All affected hepatic segments showed atrophic changes and contained dilated intrahepatic ducts. These segments showed either iso- or hypointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging. Preferential enhancement was noted throughout all phases of the dynamic study and persisted to delayed T1-weighted imaging in seven patients. In the last two patients, severe atrophic changes made evaluating signal intensity differences and enhancement patterns difficult. CONCLUSION In addition to intrahepatic stones and biliary dilatation, segmental atrophy, signal intensity differences, and preferential and persistent enhancement are important MR findings of hepatolithiasis.
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Affiliation(s)
- T C Soong
- Department of Radiology, Veterans General Hospital-Taipei, Taiwan
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Colli A, Cocciolo M, Mumoli N, Cesarini L, Prisco A, Gaffuri I, Martinez E. Peripheral intrahepatic cholangiocarcinoma: ultrasound findings and differential diagnosis from hepatocellular carcinoma. EUROPEAN JOURNAL OF ULTRASOUND : OFFICIAL JOURNAL OF THE EUROPEAN FEDERATION OF SOCIETIES FOR ULTRASOUND IN MEDICINE AND BIOLOGY 1998; 7:93-9. [PMID: 9614277 DOI: 10.1016/s0929-8266(98)00012-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Peripheral cholangiocarcinoma may be more frequent than expected, and is usually asymptomatic until it is well advanced. Our purpose was to assess the accuracy of ultrasound in differential diagnosis. METHODS We compared the sonographic findings of ten consecutive patients with histologically proven peripheral cholangiocarcinoma with those obtained in 26 consecutive patients with hepatocarcinoma detected in the same period. In every patient we performed an ultrasound-guided biopsy with a fine (22 gauge) cutting needle. RESULTS In all patients with a final diagnosis of peripheral cholangiocarcinoma, the ultrasound scan disclosed multiple well-defined nodules with a hypoechoic or target pattern. Two patients had dilated intrahepatic bile ducts and suspected infiltration of the common duct. No patient had ascites. Only minimal alterations in laboratory examinations were found. Ultrasound-guided fine cutting needle biopsy yielded diagnostic material and allowed the definitive differential diagnosis. CONCLUSION Peripheral cholangiocarcinoma even in Western countries may represent a significant proportion of all primary liver cancers. Due to non-specific symptomatology only intractable and far advanced cases were detected by means of sonography. Ultrasound findings did not differ from those found in cases of metastases from extrahepatic adenocarcinomas or hepatocarcinoma with multinodular pattern (10/26 in our series).
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Affiliation(s)
- A Colli
- Divisione de Medicina, Ospedale 'C. Borella', Giussano (Milan), Italy
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Siegelman ES, Outwater EK, Piccoli CW, Chernesky CE, Mitchell DG. MRI of benign and malignant hepatic lobar atrophy. Clin Imaging 1997; 21:43-50. [PMID: 9117931 DOI: 10.1016/0899-7071(95)00062-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We assessed the magnetic resonance imaging (MRI) features of hepatic lobar atrophy. Two of us reviewed MRIs of the liver in eight patients with benign or malignant forms of lobar atrophy. All atrophic lobes showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images compared with the remainder of the liver, and all showed greater enhancement compared to the nonatrophic lobe. Atrophic lobes have suggestive MRI findings and are similar for both benign and malignant etiologies.
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Affiliation(s)
- E S Siegelman
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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22
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Yoshimitsu K, Honda H, Kaneko K, Kuroiwa T, Fukuya T, Irie H, Kajiyama K, Takenaka K, Masuda K. MR signal intensity changes in hepatic parenchyma with ductal dilation caused by intrahepatic cholangiocarcinoma. J Magn Reson Imaging 1997; 7:136-41. [PMID: 9039604 DOI: 10.1002/jmri.1880070119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
MR images of the liver in 13 patients with surgically proven intrahepatic cholangiocarcinoma were reviewed retrospectively and correlated to the histologic analysis of surgical specimens. We paid special attention to the peripheral liver tissue with ductal dilation but without tumorous involvement. High signal intensity was observed in the hepatic parenchyma with ductal dilation on T1-weighted spin-echo images (8 of 12) and spoiled gradient-recalled echo images (seven of seven), as compared with the contralateral hepatic lobe without duct dilation. The high signal intensity was not suppressed with fat saturation and showed enhancement after administration of contrast (11 of 12). Concurrent portal venous obstruction did not have significant effect on these findings (P < .05). Correlation with pathologic specimens suggested that this enhancement was associated with periportal fibrosis. The etiology of the high signal intensity on unenhanced spin echo or gradient-recalled T1-weighted image remains unclear. Radiologists should recognize these findings and should distinguish these from tumor involvement or the arterial buffer response caused by portal venous obstruction.
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Affiliation(s)
- K Yoshimitsu
- Department of Radiology, Kyushu University Hospital, Fukuoka, Japan
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23
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Vilgrain V, Van Beers BE, Flejou JF, Belghiti J, Delos M, Gautier AL, Zins M, Denys A, Menu Y. Intrahepatic cholangiocarcinoma: MRI and pathologic correlation in 14 patients. J Comput Assist Tomogr 1997; 21:59-65. [PMID: 9022771 DOI: 10.1097/00004728-199701000-00012] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE Our goal was to determine the MR features of intrahepatic cholangiocarcinoma and to correlate them with pathologic findings in a surgical series. METHOD MRI in 14 patients with intrahepatic cholangiocarcinoma who had undergone resection was reviewed. All patients had T1- and T2-weighted SE sequences. Contrast-material-enhanced MRI was performed in 12 cases. Comparison between findings at MRI and pathologic examination was made. RESULTS MRI depicted all the lesions but one satellite nodule of 2 cm diameter. All lesions were hypointense relative to the liver on T1-weighted images. On T2-weighted images, the tumors were predominantly isointense or slightly hyperintense relative to liver parenchyma in nine cases (64%) and were strongly hyperintense in five cases (36%). Central hypointense areas or bands were seen in eight cases. No capsule was detected. On contrast-enhanced MR studies, all lesions had progressive and concentric filling with contrast material. Associated findings such as vascular encasement, focal liver atrophy, or dilatation of intrahepatic bile ducts were observed in 10 cases (71%). Comparison with pathologic examination revealed that lesion signal intensity on T2-weighted MR images was due mostly to the amount of fibrosis, necrosis, and mucous secretion within the lesion. The nine isointense or slightly hyperintense lesions contained abundant fibrosis and had a low content of mucous secretion or necrosis, whereas the five hyperintense lesions contained low or moderate fibrosis and prominent mucous secretion and/or necrosis. CONCLUSION Our study suggests that the MR features of intrahepatic cholangiocarcinoma are well correlated with pathologic findings, but are nonspecific. Associated findings may strengthen the diagnosis of intrahepatic cholangiocarcinoma at MRI.
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Affiliation(s)
- V Vilgrain
- Department of Radiology, Hôpital Beaujon, Clichy, France
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24
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25
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Nakeeb A, Lipsett PA, Lillemoe KD, Fox-Talbot MK, Coleman J, Cameron JL, Pitt HA. Biliary carcinoembryonic antigen levels are a marker for cholangiocarcinoma. Am J Surg 1996; 171:147-52; discussion 152-3. [PMID: 8554130 DOI: 10.1016/s0002-9610(99)80090-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cholangiocarcinoma develops in 5% to 15% of patients with choledochal cysts, sclerosing cholangitis, and intrahepatic stones. The detection of cholangiocarcinoma in patients with premalignant biliary conditions has been difficult. Serum levels of carcinoembryonic antigen (CEA) have been neither sensitive nor specific for the diagnosis of cholangiocarcinoma. However, CEA has been shown to be present in cholangiocarcinomas by immunohistochemical staining. Therefore, we measured the level of CEA excreted in bile in patients with benign strictures, premalignant biliary diseases, and cholangiocarcinoma. PATIENTS AND METHODS Bile was obtained from transhepatic stents in patients with benign biliary strictures (34), choledochal cysts (5), primary sclerosing cholangitis (6), intrahepatic cholelithiasis (5), and perihilar cholangiocarcinoma (25). Samples were analyzed for CEA using a solid phase, two-site immunoenzymetric assay. RESULTS Biliary CEA levels were significantly elevated (P < 0.01) in patients with cholangiocarcinoma (50.2 +/- 5.8 ng/mL) and intrahepatic cholelithiasis (57.4 +/- 10.4 ng/mL) compared with patients with benign strictures (10.1 +/- 3.9 ng/mL). Patients with sclerosing cholangitis (21.6 +/- 3.9 ng/mL) and choledochal cysts (20.0 +/- 16.5 ng/mL) had intermediate levels. In 5 patients undergoing resection of perihilar cholangiocarcinomas, the mean biliary CEA level decreased from a preoperative level of 46.8 +/- 6.7 ng/mL to a postoperative level of 11.3 +/- 5.6 ng/mL (P < 0.02). In 4 patients with progression of cholangiocarcinoma, biliary CEA increased from a mean of 53.3 +/- 6.9 ng/mL to 98.3 +/- 12.2 ng/mL (P < 0.02) over a mean interval of 9.5 months. CONCLUSIONS Increased levels of CEA can be detected in the bile of patients with chlolangiocarcinoma. Monitoring these levels may have a role in the management of cholangiocarcinoma as well as premalignant biliary conditions such as choledochal cysts and sclerosing cholangitis.
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Affiliation(s)
- A Nakeeb
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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26
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Schlund JF, Semelka RC, Kettritz U, Eisenberg LB, Lee JK. Transient increased segmental hepatic enhancement distal to portal vein obstruction on dynamic gadolinium-enhanced gradient echo MR images. J Magn Reson Imaging 1995; 5:375-7. [PMID: 7549197 DOI: 10.1002/jmri.1880050402] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The purpose of the present study was to demonstrate the frequency of occurrence of transient increased segmental hepatic enhancement distal to portal vein obstruction in patients with a lobar (main branch) portal vein obstruction. MR images of all patients with main and lobar branch portal vein obstruction examined by dynamic gadolinium enhanced gradient echo MR images between December 1990 and July 1994 were reviewed retrospectively. All studies included T2-weighted imaging, T1-weighted spoiled gradient echo 'fast low angle shot ([FLASH])', and postgadolinium enhanced FLASH imaging at 1, 45, and 90 sec and 10 min. Fourteen patients were identified with portal vein obstruction which included: six with main portal and right and left branch occlusion, six with right lobar, and two with left lobar. In the six patients with main portal vein obstruction, enhancement on 1-sec postgadolinium FLASH images was homogenous (three patients), diffusely heterogeneous (two patients), or peripherally hyperintense (one patient). In eight of eight patients with isolated obstruction of the right or left lobar portal vein, transient-increased segmental enhancement distal to portal vein occlusion was observed on immediate postcontrast images. Relatively high signal intensity of the involved segments was present on 1-sec images and liver parenchymal enhancement became more homogeneous by 45 to 90 sec in all cases. In conclusion, transient-increased segmental enhancement occurred in eight of eight patients with isolated right or left portal vein occlusion. We postulate that this effect occurs due to increased hepatic arterial blood flow in the presence of portal vein obstruction.
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Affiliation(s)
- J F Schlund
- Department of Radiology, University of North Carolina, School of Medicine, Chapel Hill 27599-7510, USA
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27
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Choi BI, Han JK, Shin YM, Baek SY, Han MC. Peripheral cholangiocarcinoma: comparison of MRI with CT. ABDOMINAL IMAGING 1995; 20:357-60. [PMID: 7549743 DOI: 10.1007/bf00203371] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To evaluate the clinical utility of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis of peripheral cholangiocarcinoma of the liver, 11 patients with pathologically proven peripheral cholangiocarcinoma were examined with both CT and MRI. On CT scans in 10 cases, the tumors appeared as irregular, low-attenuation masses with a wide variation in heterogeneity. Contrast enhancement of the tumors was mild in nine cases and moderate in one case, at the periphery. Tumor was not identified in one case. On T1-weighted MRIs, the tumors showed low intensity in eight cases and isointensity in three cases. On T2-weighted images, the tumors showed high intensity in all 11 cases. Focal dilatation of the intrahepatic bile ducts around the tumor was seen in one case on MRIs and in four cases on CT scans. Portal vein invasion of the tumors was seen in one case, and lymphadenopathy was seen in four cases on both MRIs and CT scans. MRI was slightly superior to CT in detecting the tumors, was inferior to CT in delineating focal ductal dilatation around the tumors, and was equal to CT in assessing extent of the tumors.
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Affiliation(s)
- B I Choi
- Department of Radiology, Seoul National University, College of Medicine, Korea
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Soyer P, Bluemke DA, Sibert A, Laissy JP. MR imaging of intrahepatic cholangiocarcinoma. ABDOMINAL IMAGING 1995; 20:126-30. [PMID: 7787714 DOI: 10.1007/bf00201519] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The purpose of this study was to determine the magnetic resonance (MR) features of intrahepatic cholangiocarcinoma. METHODS MR imaging studies of seven cases of pathologically proven intrahepatic cholangiocarcinoma were retrospectively reviewed. RESULTS On MR images the tumors presented as a single mass (N = 5) or multiple nodules (N = 2), as well-delineated (N = 5) or ill-defined (N = 2), and as nonencapsulated (N = 7). Mean tumor diameter ranged from 6-14 cm (mean, 10 cm). On T1-weighted (TR/TE = 400-600/10-17 msec) images, the tumors were hypointense compared to the liver. The five tumors studied with dynamic MR imaging showed progressive centripetal filling-in after intravenous administration of a gadolinium chelate. On T2-weighted (TR/TE = 2000-2500/80-100 msec) images, all tumors were hyperintense compared to the liver; five were markedly hyperintense and two moderately hyperintense. Vascular encasement, bile duct dilatation within the tumor, and central scar were depicted on MR images in four, three, and two tumors respectively. CONCLUSION The typical MR appearance of intrahepatic cholangiocarcinoma is a large well-delineated nonencapsulated tumor associated with intrahepatic venous encasement.
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Affiliation(s)
- P Soyer
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD 21287-2180, USA
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29
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Affiliation(s)
- H A Pitt
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Adjei ON, Tamura S, Sugimura H, Kihara Y, Yuuki Y, Kakitsubata S, Watanabe K. Contrast-enhanced MR imaging of intrahepatic cholangiocarcinoma. Clin Radiol 1995; 50:6-10. [PMID: 7834978 DOI: 10.1016/s0009-9260(05)82957-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The unenhanced spin-echo T1-weighted images, contrast-enhanced (dynamic and conventional) T1-weighted images and spin-echo T2-weighted images of 19 patients with histologically proven intrahepatic cholangiocarcinoma were reviewed. The results showed that typical intrahepatic cholangiocarcinoma presented as a large mass of low signal intensity on T1-weighted images. On T2-weighted images tumours generally presented as high signal intensity masses. In five patients the tumours exhibited varying degrees of central hypointensity on T2-weighted images. On contrast-enhanced images, large tumours (diameter larger than 4 cm, n = 14) typically showed peripheral enhancement with delayed or incomplete central filling. This pattern was seen most commonly. Smaller tumours (diam. 2-4 cm, n = 5) typically exhibited homogenous enhancement. On dynamic studies, enhancement of the tumours showed a centripetal pattern. Complete enhancement was observed in the small tumours. Among the larger lesions central sparing of the tumours was seen. It is concluded that contrast-enhanced MR imaging is useful in the diagnosis of intrahepatic cholangiocarcinoma. The characteristic enhancing pattern of intrahepatic cholangiocarcinoma was seen less commonly in smaller tumours. Definite differentiation from other liver masses in this case could be less certain.
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Affiliation(s)
- O N Adjei
- Department of Radiology, Miyazaki Medical College, Japan
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Soyer P, Bluemke DA, Hruban RH, Sitzmann JV, Fishman EK. Intrahepatic cholangiocarcinoma: findings on spiral CT during arterial portography. Eur J Radiol 1994; 19:37-42. [PMID: 7859759 DOI: 10.1016/0720-048x(94)00556-r] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
To attempt to determine the characteristic imaging features of intrahepatic cholangiocarcinoma on spiral CT during arterial portography (CTAP), spiral CTAP examinations of 17 patients with pathologically confirmed intrahepatic cholangiocarcinoma were reviewed in consensus by three radiologists. The diameter of the tumors ranged from 1 to 12 cm (mean diameter, 6.6 cm). All tumors (100%) were hypoattenuating masses on spiral CTAP. In 11 cases, the tumor was homogeneous in attenuation (65%). Tumor margins were smooth and regular in 11 cases (65%). Vascular invasion was found in 14 cases (82%). Intrahepatic bile duct dilatation was present in seven cases (41%). This review shows that intrahepatic cholangiocarcinoma is associated with a constellation of findings on spiral CTAP. The presence of a low attenuation homogeneous intrahepatic mass with vascular invasion and intrahepatic bile duct dilatation on spiral CTAP images should raise the possibility of intrahepatic cholangiocarcinoma. However, these findings can be associated with other types of primary and secondary malignant hepatic tumors.
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Affiliation(s)
- P Soyer
- Department of Radiology, Johns Hopkins Hospital, Baltimore, MD 21205-2180
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