Case 9729 Hilar cholangiocarcinoma: role of multidetector CT in preoperative evaluation Athina C. Tsili1, Maria I. Argyropoulou1, George Glantzounis2, Alexandra Ntorkou1, Nafsika Simou3, Michalis Fatouros2, Konstantinos Tsampoulas1 1Department of Clinical Radiology 2Department of Surgery 3Department of Pathology University Hospital of Ioannina, Greece. University Hospital of Ioannina, Clinical Radiology, Dept. Of Radiology; Pl. Pargis 2 45332 Ioannina, Greece; Email:
[email protected] University Hospital of Ioannina Section: Abdominal Imaging Published: 2011, Dec. 13 Patient: 56 year(s), male
Clinical History A 56-year old man was referred for painless obstructive jaundice and pruritus. Laboratory analysis showed elevated hepatic enzymes and raised CA 19-9 levels. Sonography of the abdomen revealed dilatation of the intrahepatic bile ducts and a normal diameter of the distal part of the common bile duct.
Imaging Findings Multidetector CT examination including unenhanced scanning, with a detector collimation of 16x1.5 mm and triphasic contrast-enhanced CT at 25 sec (arterial phase), 45 sec (CT cholangiography) and 70 sec (portal phase), with a detector collimation of 16x0.75 mm was
performed. Mild intrahepatic bile duct dilatation was detected, abruptly terminating in a level above the hepatic hilum, within an ill-defined mass, moderately and heterogeneously enhancing (Fig. 1). The proximal part of the common bile duct had a focally thickened wall, hyperdense relative to liver. The CT findings were suggestive for the presence of cholangiocarcinoma, of both infiltrating and mass-forming type. CT angiography revealed patency of the proper and main hepatic arteries (Fig. 2). Portal phase showed narrowing of the right portal vein, a finding suggestive for neoplastic infiltration (Fig. 3). The patient underwent a right hepatectomy, cholecystectomy, resection of the extrahepatic biliary tree, and biliary-enteric anastomosis (hepatico-jejunostomy). Histopathology confirmed the CT findings (Fig. 4).
Discussion Background Hilar cholangiocarcinoma or Klatskin tumour is a primary malignancy typically originating at the confluence of the right and left hepatic ducts within the porta hepatis [1, 2]. Prognosis is poor, with a 5-year survival rate of 0%, if it is unresectable and 25-40% after curative resection. Less than 50% of patients are candidates for curative resection, because of the tendency for invasion of the adjacent organs, including the large portal veins and hepatic arteries. Imaging plays an important role in determining whether a patient is suitable for a complicated surgery, as in this patient. Cholangiocarcinoma is classified into three types, based on macroscopic appearance: periductal infiltrating, mass-forming, and intraductal [1]. Periductal infiltrating is the commonest form involving the hilar area. More than one type may coexist in a single patient. Imaging Perspective Multidetector CT (MDCT), with multiphasic imaging (CT angiography and cholangiography), multiplanar reformations and three-dimensional (3D) reconstructions represents an excellent imaging modality for the assessment of the soft-tissue extent of hilar cholangiocarcinoma and its relationship with hepatic vessels [3-7]. The classical CT signs of the infiltrating type of cholangiocarcinoma include a focally, irregularly thickened ductal wall, usually hyperdense when compared to hepatic parenchyma [1-7]. Other signs include asymmetric upstream dilatation of the intrahepatic ducts with isodensity relative to water, unless stone or sludge coexists, combined with nondilated extrahepatic ducts and diffuse enhancement around hilum. These features were met in this patient, and proved in accordance with the operative and the histopathologic findings. Tumour resectability is based on the following criteria: site and type of biliary obstruction, as proposed by Bismuth classification, relationship of the tumour and blood vessels at porta hepatis, signs of neoplastic invasion of the second-order branch of the bilateral hepatic ducts, tumour invasion of the proper, right and left hepatic arteries, invasion of both the right and left branches of the portal vein, signs of distant metastasis or retroperitoneal lymph node metastasis [3-7]. The detection rate for cholangiocarcinoma and the assessment of tumour resectability by MDCT is reported up to 100% and 75-92%, respectively [3]. CT signs for diagnosing invasion of the hepatic vessels include irregularity of the endoluminal surface, straightening, narrowing or occlusion, contour deformity and more than 50% of the vessel circumference detected in contact with the neoplasm. MDCT with angiography with 3D reconstructions allows an accurate delineation of the relationship of the tumour and hepatic vasculature providing important preoperative information of tumour respectability [3-7].
Final Diagnosis Hilar cholangiocarcinoma
Differential Diagnosis List Inflammatory stricture, Including primary and secondary sclerosing cholangitis, Mirizzi syndrome , Xanthogranulomatous cholangitis, Biliary sarcoidosis, Hepatocellular carcinoma, Intrabiliary metastases, Biliary tract melanoma, Lymphoma, Leukaemia, Carcinoid tumour
Figures Figure 1 CT examination
(a) Non-contrast CT image, coronal reformation depicts a soft-tissue mass (arrow, CT density: 45HU) in the hepatic hilum and dilated intrahepatic bile ducts. Common bile duct wall is thickened (arrowhead) and hyperdense relative to liver. © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Biliary Tract / Gallbladder; Liver; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Dilatation; Neoplasia;
(b) CT cholangiography, coronal reformation shows heterogeneous enhancement of the mass (arrow, CT density: 100 HU) and focal thickening of the wall of the proximal common bile duct (arrowhead). © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Biliary Tract / Gallbladder; Liver; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Dilatation; Neoplasia;
(d) CT cholangiography, transverse reformation shows enhancement and focal thickening of the wall of the proximal common bile duct (arrowhead), a finding suggestive for the presence of infiltrating cholangiocarcinoma. © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Dilatation; Neoplasia;
(e) CT cholangiography, transverse reformation shows normal appearance and diameter of the distal part of the common bile duct (arrowhead). © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Cholangiography; Special Focus: Neoplasia; Figure 2 CT examination
(a) Reconstructed 3D CT angiography, transverse plane depicts normal celiac, right and left hepatic arteries. © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Arteries / Aorta; Liver; Imaging Technique: CT-Angiography; Procedure: Computer Applications-3D;
Special Focus: Neoplasia;
(b) Reconstructed 3D CT angiography, coronal plane depicts patency of the right and left hepatic arteries (arrowhead). © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Arteries / Aorta; Imaging Technique: CT-Angiography; Procedure: Computer Applications-3D; Special Focus: Neoplasia; Figure 3 CT examination
(a) Reconstructed 3D CT portovenogram, transverse plane depicts narrowing of the right portal vein (pointer), a finding suggestive for neoplastic invasion. This was confirmed both surgically and pathologically. © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Portal system / Hepatic veins;
Imaging Technique: CT; Procedure: Computer Applications-3D; Contrast agent-intravenous; Special Focus: Neoplasia;
(b) Reconstructed 3D CT portovenogram, coronal plane shows normal main trunk of the portal vein (arrowhead) and narrowing of the right portal vein (pointer). © Ntorkou A, Department of Radiology, Ioannina, Greece
Area of Interest: Portal system / Hepatic veins; Imaging Technique: CT; Procedure: Computer Applications-3D; Contrast agent-intravenous; Special Focus: Neoplasia; Figure 4 Histologic sections
Histology revealed a moderately differentiated adenocarcinoma (asterisk) in the perihilar region (H-E X200). © Ntorkou A, Department of Radiology, Ioannina, Greece.
Area of Interest: Abdomen;
Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
The tumour invades the adjacent hepatic parenchyma (asterisk, H-E X200 ). © Ntorkou A, Department of Clinical Radiology, Ioannina, Greece.
Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
Perineural invasion (arrow) was identified (H-E X200). © Ntorkou A, Department of Clinical Radiology, Ioannina, Greece.
Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
The tumour invades the muscular wall of the right portal vein (arrow, H-E X200 ). © Ntorkou A, Department of Clinical Radiology, Ioannina, Greece.
Area of Interest: Abdomen; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
MeSH Neoplasms [C04] New abnormal growth of tissue. Malignant neoplasms show a greater degree of anaplasia and have the properties of invasion and metastasis, compared to benign neoplasms. Diagnostic Imaging [E01.370.350] Any visual display of structural or functional patterns of organs or tissues for diagnostic evaluation. It includes measuring physiologic and metabolic responses to physical and chemical stimuli, as well as ultramicroscopy.
References [1] Han JK, Choi BI, Kim AY, et al (2002) Cholangiocarcinoma: pictorial essay of CT and cholangiographic findings Radiographics 22:173-187. [2] Han JK, Choi BI, Kim TK, et al (1997) Hilar cholangiocarcinoma: thin-section spiral CT findings with cholangiographic correlation Radiographics 17:1475-1485. [3] Chen HW, Pan AZ, Zhen ZJ, et al (2006) Preoperative evaluation of respectability of Klatskin tumot with 16-MDCT angiography and cholangiography AJR 186:1580-1586. [4] Choi JY, Kim MJ, Lee JM, et al (2008) Hilar cholangiocarcinoma: role of preoperative imaging with sonography, MDCT, MRI, and direct cholangiography AJR 191:1448-1457. [5] Park HS, Lee JM, Choi JY, et al (2008) Preoperative evaluation of bile duct cancer: MRI combined with MR cholangiopancreatography versus MDCT with direct cholangiography AJR
190:396-405. [6] Lee HY, Kim SH, Lee JM, et al (2006) Preoperative assessment of respectability of hepatic hilar cholangiocarcinoma: combined CT and cholangiography with revised criteria Radiology 239:113-121. [7] Ahmetoglu A, Kosucu P, Kul S, et al (2004) MDCT cholangiography with volume rendering for the assessment of patients with biliary obstruction AJR 183:1327-1332.
Citation Athina C. Tsili1, Maria I. Argyropoulou1, George Glantzounis2, Alexandra Ntorkou1, Nafsika Simou3, Michalis Fatouros2, Konstantinos Tsampoulas1 1Department of Clinical Radiology 2Department of Surgery 3Department of Pathology University Hospital of Ioannina, Greece. University Hospital of Ioannina, Clinical Radiology, Dept. Of Radiology; Pl. Pargis 2 45332 Ioannina, Greece; Email:
[email protected] (2011, Dec. 13) Hilar cholangiocarcinoma: role of multidetector CT in preoperative evaluation {Online} URL: http://www.eurorad.org/case.php?id=9729
