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Radiological diagnosis in cholangiocarcinoma: Application of computed tomography, magnetic resonance imaging, and positron emission tomography

https://doi.org/10.1016/j.bpg.2015.02.004Get rights and content

Abstract

The purpose of radiological imaging in patients with suspected or known cholangiocarcinoma (CCA) is tumour detection, lesion characterization and assessment of resectability. Different imaging modalities are implemented complementary in the diagnostic work-up. Non-invasive imaging should be performed prior to invasive biliary procedures in order to avoid false positive results. For assessment of intraparenchymal tumour extension and evaluation of biliary and vascular invasion, MRI including MRCP and CT are the primarily used imaging modalities. The role of PET remains controversial with few studies showing benefit with the detection of unexpected metastatic spread, the differentiation between benign and malignant biliary strictures, and for discriminating post therapeutic changes and recurrent CCA.

Section snippets

Radiological imaging in cholangiocarcinoma

Cholangiocarcinoma (CCA) is the second most prevalent liver cancer after hepatocellular cancer (HCC) and accounts for approximately 3% of all gastrointestinal tumours [1]. According to the localization, CCA can be distinguished into intra- and extrahepatic origin, whereby the latter includes hilar tumours, a particular tumour entity owing to its localization which is also referred to as Klatskin tumour [2]. The main purpose of noninvasive radiological imaging in patients with suspected or known

Imaging features and characterization of cholangiocarcinoma

Based on morphologic growth characteristics, CCA can be classified as either mass-forming, periductal infiltrating or intraductal type, as suggested by the Liver Cancer Study Group of Japan [19], with each type having its own characteristic imaging features [4]. Imaging, be it CT, MRI or PET, is recommended before invasive biliary procedures (e.g. stent placement), as any manipulation can cause mild inflammation of the bile duct walls and subsequently increased contrast enhancement, which may

Initial tumour detection

While in the era of single slice CT reported sensitivities for tumour detection were only up to 69% [37], [38], current MDCT with isotropic submillimeter voxel sizes allow for reliable detection of essentially all lesions larger than 1 cm. Valls and colleagues reviewed the CT scans of 24 patients with peripheral CCA ranging from 1.2 to 17 cm. All lesions were visible at CT; associated bile duct dilatation was present in 13 patients (52%) and retraction of the liver capsule in nine patients

Staging

Radiological staging in patients with CCA includes assessment of local tumour extension and intrahepatic spread, as well as detection of lymph node metastasis (N-staging) and distant tumour spread (M-staging). In case of intrahepatic CCA it has been shown that preoperative staging may fail to detect satellite lesions in up to 37% [52].

When the local resectability is assessed, the detection of lymph node metastasis needs to be addressed. Lymphadenopathy of the portocaval and porta hepatis nodes

Current imaging guidelines

According to the current International Liver Cancer Association (ILCA) guideline on CCA, radiological studies are necessary for assessment of local tumour extent, regional or distant spread and staging and resectability, which is best accomplished using CT and/or MRI [68]. In non-cirrhotic patients in whom a decision has been made to proceed with surgical resection, a presumed radiographic diagnosis (CT or MRI) is sufficient (recommendation B1). However, in most patients a pathological

Conflict of interest

FW: institutional research support not related to the topic: DFG, BMBF, Siemens Healthcare, Promedicus Ltd.

Acknowledgement

None.

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