Magnetic Resonance Imaging of Cholangiocarcinoma

 

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Cholangiocarcinoma arises from the bile ducts and is the most common primary malignancy of the biliary tree. Cholangiocarcinoma is classified according to its growth pattern: mass-forming, periductal-infiltrating, or intraductal-growing type. The majority of cholangiocarcinomas occur at the common hepatic duct (CHD) and its bifurcation, also referred to as Klatskin's tumor, but they also can occur in more peripheral branches within the hepatic parenchyma. Microscopically, cholangiocarcinoma represents an adenocarcinoma with a glandular appearance arising from the epithelium of the bile ducts.

On magnetic resonance (MR) images, cholangiocarcinomas appear hypointense on T1-weighted images, and hyperintense on T2-weighted images. Central hypointensity can be seen on T2-weighted images and correspond to fibrosis. On dynamic MR images, cholangiocarcinomas show moderate peripheral enhancement followed by progressive and concentric filling in the tumor with contrast material. Pooling of contrast within the tumor on delayed MR images is suggestive of peripheral cholangiocarcinoma.

The role of MR imaging in hilar cholangiocarcinoma is to confirm/reach a diagnosis and to assess resectability. Hilar cholangiocarcinoma shows the same signal intensity pattern of peripheral tumors both on T1- and T2-weighted images. On magnetic resonance cholangiopancreatography (MRCP) images, hilar cholangiocarcinoma appears as a moderately irregular thickening of the bile duct wall (≥5 mm) with symmetric upstream dilation of the intrahepatic bile ducts.

The aim of preoperative investigation in Klatskin tumors typically requires the evaluation of the level of biliary obstruction, the intrahepatic tumor spread, and the vascular involvement; it also needs to show any atrophy-hypertrophy complex.

Because of its intrinsic high tissue contrast and multiplanar capability, MR imaging and MRCP are able to detect and preoperatively assess patients with cholangiocarcinoma, investigating all involved structures such as bile ducts, vessels and hepatic parenchyma. The main reason for surgical/imaging discrepancy is represented by the microscopic diffusion along the mucosa and in the perineural space.

REFERENCES

• 1 Manfredi R, Maresca G, Vecchioli A et al.. Cholangiocellular carcinoma. In: Bartolozzi C, Lencioni R Liver Malignancies. Berlin; Springer Verlag 1999
  Google Scholar
• 2 Ros P R, Buck J L, Comdr L T et al.. Intrahepatic cholangiocarcinoma: radiology-pathologic correlation.  Radiology. 1988;  167 689-693
  CrossrefPubMedGoogle Scholar
• 3 Nakajima T, Kondo Y, Miyazaki M, Okui K. A histopathologic study of 102 cases of intrahepatic cholangiocarcinoma: histologic classification and mode of spreading.  Hum Pathol. 1988;  19 1228-1234
  PubMedGoogle Scholar
• 4 Edmondson H A. Tumors of The Liver and Intrahepatic Bile Ducts: Atlas of Tumor Pathology. Section 7, Fasc. 25. Washington, DC; Armed Forces Institute of Pathology 1958
  Google Scholar
• 5 Clemett A R. Carcinoma of the major bile ducts.  Radiology. 1965;  84 894-903
  PubMedGoogle Scholar
• 6 Lim J H. Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings.  AJR Am J Roentgenol. 2003;  181 819-827
  PubMedGoogle Scholar
• 7 Liver Cancer Study Group of Japan .The General Rules for The Clinical and Pathological Study of Primary Liver Cancer, 4th ed. Tokyo; Kanehara 2000
  Google Scholar
• 8 Sasaki A, Aramaki M, Kawano K et al.. Intrahepatic peripheral cholangiocarcinoma: mode of spread and choice of surgical treatment.  Br J Surg. 1998;  85 1206-1209
  CrossrefPubMedGoogle Scholar
• 9 Yamamoto M, Takasaki K, Yoshikawa T, Ueno K, Nakano M. Does gross appearance indicate prognosis in intrahepatic cholangiocarcinoma?.  J Surg Oncol. 1998;  69 162-167
  CrossrefPubMedGoogle Scholar
• 10 Isaji S, Kawarada Y, Taoka H et al.. Clinicopathological features and outcome of hepatic resection for intrahepatic cholangiocarcinoma in Japan.  J Hepatobiliary Pancreat Surg. 1999;  6 108-116
  CrossrefPubMedGoogle Scholar
• 11 Sano T, Kamiya J, Nagino M et al.. Macroscopic classification and preoperative diagnosis of intrahepatic cholangiocarcinomas in Japan.  J Hepatobiliary Pancreat Surg. 1999;  6 101-107
  CrossrefPubMedGoogle Scholar
• 12 Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis: an unusual tumor with distinctive clinical and pathological features.  Am J Med. 1965;  38 241-256
  CrossrefPubMedGoogle Scholar
• 13 Rosai J. Ackerman's Surgical Pathology, 8th ed. St. Louis; Mosby 1996
  Google Scholar
• 14 Bhuiya M R, Nimura Y, Kamiya J et al.. Clinicopathologic studies on perineural invasion of bile duct carcinoma.  Ann Surg. 1992;  215 344-349
  PubMedGoogle Scholar
• 15 Weinbren K, Mutum S S. Pathological aspects of cholangiocarcinoma.  J Pathol. 1983;  139 217-238
  PubMedGoogle Scholar
• 16 Thorsen M K, Quiroz F, Lawson T L et al.. Primary biliary carcinoma: CT evaluation.  Radiology. 1984;  152 479-483
  PubMedGoogle Scholar
• 17 Nesbit G M, Johnson C D, James E M et al.. Cholangiocarcinoma: diagnosis and evaluation of resectability by CT and sonography as procedures complementary to cholangiography.  AJR Am J Roentgenol. 1988;  151 933-938
  PubMedGoogle Scholar
• 18 Yoon K H, Han H K, Kim C G et al.. Malignant papillary neoplasms of intrahepatic bile ducts: CT and histopathologic features.  AJR Am J Roentgenol. 2000;  175 1135-1139
  PubMedGoogle Scholar
• 19 Adjei O N, Tamura S, Sugimara H et al.. Contrast enhanced MR imaging of intrahepatic cholangiocarcinoma.  Clin Radiol. 1995;  50 6-10
  PubMedGoogle Scholar
• 20 Soyer P A, Bluemke D A, Sibert A et al.. MR imaging of intrahepatic cholangiocarcinoma.  Abdom Imaging. 1995;  20 126-130
  PubMedGoogle Scholar
• 21 Grazioli L, Morana G, Federle M P et al.. Focal nodular hyperplasia: morphologic and functional information from MR imaging with gadobenate dimeglumine.  Radiology. 2001;  221 731-739
  PubMedGoogle Scholar
• 22 Choi B I, Kim T K, Han J K. MR imaging of clonorchiasis and cholangiocarcinoma.  J Magn Reson Imaging. 1998;  8 359-366
  PubMedGoogle Scholar
• 23 Kim T K, Choi B I, Han J K et al.. Peripheral cholangiocarcinoma of the liver: two-phase helical CT findings.  Radiology. 1997;  204 539-543
  PubMedGoogle Scholar
• 24 Lee W J, Lim H K, Jang K M et al.. Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnoses.  Radiographics. 2001;  21(Spec. No.) S97-S116
  PubMedGoogle Scholar
• 25 Robledo R, Muro A, Prieto M L. Extrahepatic bile duct carcinoma: U.S. characteristics and accuracy in demonstration of tumors.  Radiology. 1996;  198 869-873
  PubMedGoogle Scholar
• 26 Manfredi R, Masselli G, Maresca G et al.. MR imaging and MRCP of hilar cholangiocarcinoma.  Abdom Imaging. 2003;  28 319-325
  CrossrefPubMedGoogle Scholar
• 27 Nichols D A, MacCarty R L, Gaffey T A. Cholangiographic evaluation of bile duct carcinoma.  AJR Am J Roentgenol. 1983;  141 1291-1294
  PubMedGoogle Scholar
• 28 Lopera J E, Soto J A, Munera F. Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions.  Radiology. 2001;  220 90-96
  PubMedGoogle Scholar
• 29 Zidi S H, Prat F, Le Guen L, Rondeua Y, Pelletier G. Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures.  Gut. 2000;  46 103-106
  CrossrefPubMedGoogle Scholar
• 30 Dooms G C, Kerlan R K, Hricak H, Wall S D, Margulis A R. Cholangiocarcinoma: imaging by MR.  Radiology. 1986;  159 89-94
  PubMedGoogle Scholar
• 31 Fulcher A S, Turner M A. HASTE MR cholangiography in the evaluation of hilar cholangiocarcinoma.  AJR Am J Roentgenol. 1997;  169 1501-1505
  PubMedGoogle Scholar
• 32 Guthrie J A, Ward J, Robinson P J. Hilar cholangiocarcinoma: T2-weighted spin-echo and gadolinium enhanced FLASH MR imaging.  Radiology. 1996;  201 347-351
  PubMedGoogle Scholar
• 33 Whithey W S, Herfkens R J, Brooke J R et al.. Dynamic breath-hold multiplanar spoiled gradient-recalled MR imaging with gadolinium enhancement for differentiating hepatic hemangiomas from malignancy at 1.5T.  Radiology. 1993;  189 863-870
  PubMedGoogle Scholar
• 34 Adam A, Benjamin I S. The staging of cholangiocarcinoma.  Clin Radiol. 1992;  46 299-303
  CrossrefPubMedGoogle Scholar
• 35 Looser C, Stain S L, Baer H U, Triller J, Blumgart L H. Staging of hilar cholangiocarcinoma by ultrasound and duplex sonography: a comparison with angiography and operative findings.  Br J Radiol. 1992;  65 871-877
  PubMedGoogle Scholar
• 36 Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma.  Ann Surg. 1992;  215 31-38
  CrossrefPubMedGoogle Scholar
• 37 Manfredi R, Brizi M G, Masselli G, Vecchioli A, Marano P. Malignant biliary hilar stenosis: MR cholangiopancreatography compared with direct cholangiography [in Italian].  Radiol Med (Torino). 2001;  102 48-54
  PubMedGoogle Scholar
• 38 Reinhold C, Bret P. Current status of MR cholangiopancreatography.  AJR Am J Roentgenol. 1996;  166 1285-1295
  PubMedGoogle Scholar
• 39 Triller J, Looser C, Baer H U, Blumgart L H. Hilar cholangiocarcinoma: radiological assessment of resectability.  Eur Radiol. 1994;  4 9-17
  PubMedGoogle Scholar
• 40 Nichols D A, MacCarty R L, Gaffey T A. Cholangiographic evaluation of bile duct carcinoma.  AJR Am J Roentgenol. 1983;  141 1291-1294
  PubMedGoogle Scholar

Riccardo ManfrediM.D. 

“A. Gemelli” University Hospital

8 L.go A. Gemelli, Rome, Italy 00168

Email: rmanfredi@rm.unicatt.it