Breathhold unenhanced and gadolinium-enhanced magnetic resonance tomography and magnetic resonance cholangiography in hilar cholangiocarcinoma

Staging cholangiocarcinoma by imaging studies

Cholangiocarcinoma (CCA) is an adenocarcinoma that arises from the bile duct epithelium and is observed in the entire biliary tree (intrahepatic, hilum, and extrahepatic distal). The staging of this tumor differs depending on location. The role of imaging in the staging of hilar CCA is to assess the extent of ductal involvement by the tumor, hepatic artery, or portal venous involvement, the functional status and volumetric assessment of the underlying liver, and the regional or distant tumor extension. Complete assessment is done by combining magnetic resonance (MR) cholangiography and multidetector computed tomography (CT). Multidetector CT, in particular, is accurate for resectability and the negative predictive value (patients with disease classified as unresectable and in whom unresectability has been confirmed) is quite high: 85-100%. The role of imaging in the staging of intrahepatic CCA is to evaluate resectability based on the tumor itself, vascular involvement, regional and distal extension, and volumetric assessment of the contralateral liver, and to determine the prognostic factors. These factors are mainly: tumor size, the presence of satellite nodules, vascular involvement, and lymph nodes. CT and MR imaging (MRI) are keys and their results are comparable. In distal extrahepatic CCA due to tumor location, staging is focused mainly on the adjacent vessels (portal vein and hepatic artery), the hepatoduodenal ligament, the proximal and distal biliary extent, and pancreatic invasion. CT and MRI are mandatory.

Diagnostic and surgical approaches in hilar cholangiocarcinoma

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.