State of the Art Imaging for Hepatic Malignancy: My Assignment

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1 State of the Art Imaging for Hepatic Malignancy: My Assignment CT vs MR vs MRCP Which one to choose for HCC vs Cholangiocarcinoma What special protocols to use for liver tumors Role of PET and Duplex US in these patients Evaluating resectability in hilar cholangiocarcinoma Diagnostic accuracy of radiologic imaging for Cholangiocarcinoma and Hepatoma

2 Noninvasive Imaging techniques Ultrasonography MDCT MDCT with PET CT MRCP PET scanning

3 Cholangiocarcinoma: Facts Arises from bile duct epithelium 2 nd most common primary hepatobiliary cancer after hepatoma Usually an adenocarcinoma (95% of cases) Peak prevalence in 7 th decade of life More common in patients with PSC, choledochal cyst, familial polyposis, congenital hepatic fibrosis and exposure to thorotrast

4 Cholangiocarcinoma: Classification Intrahepatic (peripheral) Perihilar Extrahepatic

5 Cholangiocarcinoma: Role of Imaging Noninasive diagnosis and characterization of Cholangiocarcinoma Confirmation of diagnosis Pretherapeutic staging and assessment of resectability Screening of high risks patients

6 Transabdominal Ultrasound: Evaluation of Cholangiocarcinoma Good screening technique to detect biliary obstruction and defining level of obstruction Cause of obstruction (tumor) may be difficult to see Mass forming cholangiocarcinoma may be hard to visualize and echo pattern can be hyperechoic, hypoechois or mxed echogenicity Limited value for staging extent of disease in porta and extraportal zones

7 MDCT/CTA: Evaluation of Cholangiocarcinoma Ideal for initial evaluation of suspected cholangiocarcinoma Cholangiocarcinoma may appear hypodense on early phase imaging and may become hyperdense on later phase imaging Provides CTA angiographic map of the liver used for therapy planning Excellent for detecting extrahepatic disease

8 MDCT Technique for the Liver Study Protocol ml of Omnipaque-350 Injection rate 4-5 cc/sec thru 18g needle

9 MDCT Technique for the Liver Dual phase imaging protocol Arterial phase imaging (30 sec) Venous phase imaging (60-65 sec) Delayed phase imaging (4 minute delay) 3D Post Processing protocol Volume rendering MIP imaging

10 MRI Imaging of the Liver: Cholangiocarcinoma Mass forming cholangiocarcinoma are hypointense to isointense on T1 weighted MR images and hyperintense on T2 weighted images With Gd enhancement the periphery of the lesion may enhance early and the central portion of the lesion will enhance on delayed phase images

11 MRI Imaging of the Liver: Cholangiocarcinoma T2 weighted MR cholangiography is excellent for defining site of ductal obstruction and upstream biliary obstruction The lesions may be hypo- or hyperintense on MR cholangiography.

12 Diagram illustrates a suggested algorithm for the diagnosis and treatment of cholangiocarcinomas. Sainani N I et al. Radiographics 2008;28:

13 MDCT vs MRI In evaluating the biliary duct extension of hilar cholangiocarcinoma, MDCT and MRC (Magnetic Resonance Cholangiography) showed similar accuracies and agreement. Biliary Ductal Involvement of Hilar Cholangiocarcinoma: Multidetector Computed Tomography Versus Magnetic Resonance Cholangiography Cho et al. J Comput Assist Tomogr 2007; 31:72-78

14 Hilar Cholangiocarcinoma: Facts AKA Klatskin tumors Adenocarcinoma of the duct bifurcation in the porta but now include CBD cancers These tumors can spread locally with vascular invasion, adenopathy, peritoneal infiltration not uncommon.

15 In nonoperated patients, there was excellent agreement between Magnetic Resonance Cholangiography and direct cholangiography in evaluating biliary ductal extension, with agreement up to 94.7% Biliary Ductal Involvement of Hilar Cholangiocarcinoma: Multidetector Computed Tomography Versus Magnetic Resonance Cholangiography Cho et al. J Comput Assist Tomogr 2007; 31:72-78

16 The degree of enhancement on delayed phase CT is a useful indicator for prediction of the prognosis of patients with mass forming Intrahepatic Cholangicarcinoma (ICC). Delayed-Phase Dynamic CT Enhancement as a Prognostic Factor for Mass-forming Intrahepatic Cholangiocarcinoma Asayama Y et al. Radiology 238:

17 Cholangiocarcinoma Encases the Portal Vein-

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20 Dilated Enhancing Strictured CBD: Cholangiocarcinoma

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22 Enhancing CBD c/w Cholangiocarcinoma

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24

25

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27 Cholangiocarcinoma with PV Encased

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29 Klatskin Tumor

30 Cholangiocarcinoma

31 HCC (MRI) T2 HAP PVP

32 HCC in Cirrhosis HAP PVP Delayed

33 HCC HAP PVP

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