Contemporary Imaging of Biliary Malignancy and Preoperative Evaluation

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1 Contemporary Imaging of Biliary Malignancy and Preoperative Evaluation Linda Pantongrag-Brown, MD Advanced Diagnostic Imaging, Ramathibodi Hospital, Bangkok, Thailand

2 Malignancy of biliary tract Cholangiocarcinoma GB carcinoma Ampulla carcinoma Hennedige et al. Cancer Imaging 2014

3 Outline Cellular origin and evolution of CHCA Pre-malignant changes and imaging Classification of CHCA and imaging Pre-operative evaluation of hilar CHCA Conclusions

4 WATERFALL, SELANGOR, MALAYSIA PHOTOGRAPH BY DASHUKI MOHD

5 Stem cell niches in the intra- and extra-hepatic biliary tree Cardinale, V. et al. (2012) The biliary tree a reservoir of multipotent stem cells Nat. Rev. Gastroenterol. Hepatol. doi: /nrgastro

6 Cardinale V et al, WJGO 2012

7 Evolution of cholangiocarcinoma Infection (OV in Thailand), inflammation, hyperplasia ( predisposing factors ) Premalignant changes of bile duct epithelium (current concept) - Biliary Intraepithelial Neoplasia (Bil-IN) - Intraductal Papillary Neoplasm of Biliary Tract (IPN-B) Invasive Tubular Adenocarcinoma

8 Global incidence of CCA Incidence of CCA Sripa et al, trends in parasitology 2012

9 COLD LIGHT OF DAY PHOTOGRAPH BY ANDREW GEORGE, NATIONAL GEOGRAPHIC YOUR SHOT

10 Biliary Intraepithelial Neoplasia (Bil-IN) Bil-IN I Bil-IN II Bil-IN III CCA Nakanuma, World J Hepatol 2009

11 Precancerous Lesion Biliary Intraepithelial Neoplasia (Bil-IN) Normal Bil-IN Bil-IN Bil-IN Invasive carcinoma from BilIN Invasive carcinoma from BilIN

12 POWERPOINT SLIDE SHOW MUST BE STARTED TO SEE THE IMAGES INSERTED

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14 Smooth thickening of right main and common hepatic duct

15 S Mildly dilated and thickened wall of right main hepatic Rt. main hepatic duct

16 S Rt. hepatic duct: Biliary Intraepithelial Neoplasia II-III (Bil-IN II-III) with OV (Opisthorchis Viverini) eggs

17 Nakanuma et al, WHO classification Intraductal Papillary Neoplasm of Biliary Tract (IPNB) Biliary Papilloma Papillary Carcinoma of bile duct Mucin producing bile duct tumor Intraductal growth-type cholangiocarcinoma Intraductal Papillary Neoplasm of Biliary Tract (IPNB)

18 Morphogenesis and Biological Behaviour of IPN-B friable Equivalent to pancreas IPMN Mucin producing

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20 Stalk Head

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22 Intraductal papillary neoplasm of bile duct (IPNB) with large amount of mucin within the dilated right IHD

23 Intraductal papillary neoplasm (IPN), low to high grade dysplasia

24 Conventional CCA Mucinous type CCA De Novo Cholangiocarcinoma Nakanuma etworld J Hepatol October 31; 1(1):

25 IN THE FROSTY AIR PHOTOGRAPH BY GVIDO SATORI, NATIONAL GEOGRAPHIC YOUR SHOT

26 Surgical classifications Extrahepatic CHCA Originate from CHD, CBD Intrahepatic hilar CHCA (Klatskin tumor) Originate from RHD, LHD, CHD bifurcation Intrahepatic peripheral CHCA Originate from secondary bifurcation of RHD/LHD 22/01/61

27 Morphological classifications (growth pattern) (Liver Cancer Study Group of Japan, 1997) Mass-forming type (Exophytic) Periductal infiltrating type Intraductal type (polypoid) Combined type 22/01/61

28 Mass-forming CHCA Usually large by the time of presentation US: varied echogenicity CT/MR: A: mass with peripheral, rim enhancement (viable tumor) V: reticular internal enhancement D: gradual and prolonged enhancement (central fibrosis) Associated with capsular retraction, dilatation of upstream bile ducts 22/01/61

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30 Typical mass-forming CHCA 1. Arterial rim enhancement 2. Reticular internal enhancement 3. Associated bile duct dilatation

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32 Typical mass-forming CHCA gradual and prolonged delayed enhancement subcapsular retraction

33 pre A phase V phase 20 min HB phase T2

34 Periductal infiltrating CHCA A small fibrotic tumor causes segmental dilatation of the bile ducts. Periductal infiltrating CHCA at hilar = Klatskin tumor CT/MRI: Periductal or wall enhancement Duct narrowing 22/01/61

35 22/01/61

36 Periductal infiltrating hilar CHCA = Klatskin tumor 22/01/61

37 Intraductal CHCA Better prognosis than other types because of intraluminal location CT/MR: segmental or lobar biliary dilatation with intraluminal polypoid lesion Mucinous subtype shows large growth expanding the lumen secondary to mucin 22/01/61

38 22/01/61 Mucin producing intraductal CHCA

39 Intraductal CHCA

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41 Intraductal hilar CHCA 22/01/61

42 PLAIN VIEW PHOTOGRAPH BY MARTIN BISOF, NATIONAL GEOGRAPHIC YOUR SHOT

43 Hilar CHCA (Unresectable Criteria) Bismuth IV Invasion of MPV, HA, IVC Atrophy of contralateral lobe (small residual volume) Metastasis 22/01/61

44 Bismuth-Corlette Type I Tumor involves only CHD below confluence of left and right ducts

45 Bismuth-Corlette Type II Tumor involves biliary confluence but no invasion of 2 nd branch IHD

46 Bismuth-Corlette Type III-A Tumor involves biliary confluence + and 2 nd branch of right IHD

47 Bismuth-Corlette Type III-B Tumor involves biliary confluence + and 2nd branch of left IHD

48 Bismuth-Corlette Type IV Tumor involves biliary confluence + 2 nd branches of right and left IHDs

49 Steps of assessment for resectability 1. Bile duct margin Bismuth classification 2. Vascular margin MPV, HA, IVC 3. Lymph nodes regional LN along hepatoduodenal ligament (resectable) juxta LN at CHA, celiac axis (usually contraindicate) distant LN at para-aortic, retroperitoneal, and diaphragmatic (unresectable) 4. Distant metastases peritoneum, lungs, bone

50 1. Assess bile duct margin Bismuth 3A: Potentially resectable

51 2. Assess vascular margin: HA, MPV, IVC potentially resectable

52 3. Assess LN Several equivocal nodes

53 PET /CT: accuracy for N staging = 76-85%

54 Unresectable Bismuth staging: 3A Vascular involvement: eligible for right hepatectomy Nodal staging: distal LN metastasis by PET/CT TNM: T3 N1 M1 Stage IV Treatment option: Chemotherapy + palliative treatment

55 PATAGONIAN PARADISE PHOTOGRAPH BY ROGER SMITH, NATIONAL GEOGRAPHIC YOUR SHOT

56 Conclusions Progenitor cells of CHCA are from Canals of Hering and peribilary glands. Bil-IN and IPNB are premalignant tumors of CHCA. Bil-IN leads to conventional CHCA. IPNB leads to conventional CHCA and mucinous CHCA. CHCA is usually classified by its morphology (mass-forming, infiltrating, and intraductal). CT and MRI is the imaging of choice to diagnose and determine resectability.

57 Acknowledgement Dr. Surachate Siripongsakun Chulabhorn institution (research site for CHCA in BKK)

58 SHAKE THE DUST OFF PHOTOGRAPH BY SARAVUT WHANSET, NATIONAL GEOGRAPHIC YOUR SHOT