Contemporary Imaging of Biliary Malignancy and Preoperative Evaluation Linda Pantongrag-Brown, MD Advanced Diagnostic Imaging, Ramathibodi Hospital, Bangkok, Thailand
Malignancy of biliary tract Cholangiocarcinoma GB carcinoma Ampulla carcinoma Hennedige et al. Cancer Imaging 2014
Outline Cellular origin and evolution of CHCA Pre-malignant changes and imaging Classification of CHCA and imaging Pre-operative evaluation of hilar CHCA Conclusions
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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:10.1038/nrgastro.2012.23
Cardinale V et al, WJGO 2012
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
Global incidence of CCA Incidence of CCA Sripa et al, trends in parasitology 2012
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Biliary Intraepithelial Neoplasia (Bil-IN) Bil-IN I Bil-IN II Bil-IN III CCA Nakanuma, World J Hepatol 2009
Precancerous Lesion Biliary Intraepithelial Neoplasia (Bil-IN) Normal Bil-IN Bil-IN Bil-IN Invasive carcinoma from BilIN Invasive carcinoma from BilIN
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Smooth thickening of right main and common hepatic duct
S57-421 Mildly dilated and thickened wall of right main hepatic Rt. main hepatic duct
S57-421 Rt. hepatic duct: Biliary Intraepithelial Neoplasia II-III (Bil-IN II-III) with OV (Opisthorchis Viverini) eggs
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)
Morphogenesis and Biological Behaviour of IPN-B friable Equivalent to pancreas IPMN Mucin producing
Stalk Head
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Intraductal papillary neoplasm of bile duct (IPNB) with large amount of mucin within the dilated right IHD
Intraductal papillary neoplasm (IPN), low to high grade dysplasia
Conventional CCA Mucinous type CCA De Novo Cholangiocarcinoma Nakanuma etworld J Hepatol. 2009 October 31; 1(1): 35-42.
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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
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
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
Typical mass-forming CHCA 1. Arterial rim enhancement 2. Reticular internal enhancement 3. Associated bile duct dilatation
Typical mass-forming CHCA gradual and prolonged delayed enhancement subcapsular retraction
pre A phase V phase 20 min HB phase T2
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
22/01/61
Periductal infiltrating hilar CHCA = Klatskin tumor 22/01/61
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
22/01/61 Mucin producing intraductal CHCA
Intraductal CHCA
Intraductal hilar CHCA 22/01/61
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Hilar CHCA (Unresectable Criteria) Bismuth IV Invasion of MPV, HA, IVC Atrophy of contralateral lobe (small residual volume) Metastasis 22/01/61
Bismuth-Corlette Type I Tumor involves only CHD below confluence of left and right ducts
Bismuth-Corlette Type II Tumor involves biliary confluence but no invasion of 2 nd branch IHD
Bismuth-Corlette Type III-A Tumor involves biliary confluence + and 2 nd branch of right IHD
Bismuth-Corlette Type III-B Tumor involves biliary confluence + and 2nd branch of left IHD
Bismuth-Corlette Type IV Tumor involves biliary confluence + 2 nd branches of right and left IHDs
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
1. Assess bile duct margin Bismuth 3A: Potentially resectable
2. Assess vascular margin: HA, MPV, IVC potentially resectable
3. Assess LN Several equivocal nodes
PET /CT: accuracy for N staging = 76-85%
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
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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.
Acknowledgement Dr. Surachate Siripongsakun Chulabhorn institution (research site for CHCA in BKK)
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