Biliary cancers: imaging diagnosis. Study of 30 cases N Hammoune, S Semlali, M Eddarai, T. Amil, M Zentar, S. El Kandri,, M Benameur,, S Chaouir. Radiology Department. Mohamed V Military Hospital. Rabat- Morocco
Introduction Biliary cancers: carcinoma of the gallbladder as well as the intrahepatic, hilar and extrahepatic bile ducts. Familiarity with the imaging characteristics of gallbladder and biliary duct cancers is important to expedite the diagnosis and appropriate treatment.
Methods and Materials: In this study, we analyzed the diagnosis imaging of 30 consecutive patients with biliary cancers (gallbladder, intra and extra hepatic bile duct) All patients underwent ultrasonography and multidetector-ct. Endoscopic retrograde cholangiography (ERC) in 12 cases MR cholangiopancreatography in 10 cases
Results Characteristics of the series They were 19 men and 11 women, with an average age of 62 years. The tumor was revealed by : Cholestatic jaundice Abdominal pain weight loss
Results Imaging Dilation of the intrahepatic bile ducts: n =28 hilaire process: n = 10 intra-hepatic Process: n = 7 gallbladder Process: n =6 liver metastasis: (n=6) vascular invasion: (n=6) peritoneal effusion: (n=1) abdominal wall invasion: (n= 1)
Results Anatomopathologic study The anatomopathologic confirmation was obtained in all the cases: Hilar and intrahepatic cholangiocarcinoma n=17. Extrahepatic biliary duct carcinoma n=9. carcinoma of the gallbladder in 6 patients.
Discussion
1-Gallbladder carcinoma Malignant tumor of the biliar tract occurs in adults> 60 years, Female prevalence sex ratio: 3 / 1 manifested by: right-sided epigastric pain, weight loss jaundice. poor prognosis.
1-gallbladder carcinoma Three forms in imaging: Endoluminal mass filling the gallbladder light, often irregular limited, a gallstone disease was found in 30 to 50%. Parietal thickening thickened located, irregular, clearly visible from the bottom gallbladder, sometimes is difficult to distinguish a cholecystitis Polypoid mass endoluminal: echogenic albeit limited bottom gallbladder. echogenic mass,
Gallbladder carcinoma. Abdominal CT: Heterogeneous lesion process of the gallbladder with anterior abdominal wall extension.
Gallbladder carcinoma. Abdominal CT: organic process filling the gallbladder, with antral stomach extension and circumferential thickening. There exists also a thrombosis of the portal vein and mesenteric higher.
1-Gallbladder carcinoma Ultrasonography (US) and computed tomography (CT) are primary imaging modalities. The assessment of loco-regional extension searches: Hepatic involvement by contiguity or metastases. Biliary tract involvement : a mass of hilar or pedicle with dilation of the intrahepatic bile ducts (contra- indicate the surgical gesture). Lymph nodes. Extension to the digestive tract or more rarely the pancreas.
2- Intra-hepatic Cholangiocarcinoma Carcinoma with varying degrees of differentiation. Particular ground: sclerosing cholangitis, Caroli's disease, intra-hepatic gallstone. Clinic nonspecific: : abdominal pain, weakness, jaundice.
2- Intra-hepatic Cholangiocarcinoma CT: Hypodense lesion not encapsulated +/- calcification Peripheral centripetal enhancement, fine and not very intense on the portal and arterial time. It is sometimes visible only on the late section. MRI: Non-encapsulated lesion, with lobules contours, hypointense en T1-weighted, with a variable signal in T2-weighted. Associated signs: engainement vessels porte without thrombosis and extension to the inferior vena cava.
2- Intra-hepatic Cholangiocarcinoma Particular forms: Cystic degeneration is rare. CT scan : hypodense lesion with a fleshy portion which enhances after injection of contrast. The cholangiocarcinoma producing mucins abundantly: Is manifested by angiocholitis signs. Imaging: important dilation of the intra and extra-hepatic bile ducts. Peripheral Cholangiocarcinoma endobiliaire is rare. Cystic and tubular dilatation of the bile intra-hepatic without tumour.
Intrahepatic Cholangiocarcinoma with cystic degeneration Abdominal enhanced CT scan: bintrahepatic cystic mass with dilation of the intrahepatic bile ducts. Peripheral cholangiocarcinoma: Enhancedbbbbb-CT scan: heterogeneous tissue lesion and dilation of the intrahepatic bile ducts:
3-Hilar and principal bile duct Cholangiocarcinoma Carcinoma developed from the epithelium of the principal biliary tract or their convergence. Adult between 50 and 60 years, Bad prognosis Revealed by jaundice gradually increasing, more rarely angiocholitis. Ultrasound: Dilation of the bile ducts isoechogenic or hypoechogenic mass identified in 80% of cases.
3-Hilaire and principal bile duct Cholangiocarcinoma CT Isodense Lesion before injection of product of contrast Variable Enhancement with the arterial and late phase. MRI Highlight biliary obstruction. Specify the level of obstruction. Not-union of the two hepatic ducts right and left makes the diagnosis. The tumour was enhanced after injection of contrast.
3-Hilaire and Principal bile duct Cholangiocarcinoma Assessment of extension: Vascular Invasion Duct Invasion (classification of Bismuth and Cornet) Hepatic Metastases Lymphadenopathy Carcinose peritoneal
Hilar Cholangiocarcinoma: axial abdominal CT scan with contrast enhancing showing hilar tissular mass with dilation of bile ductbbbbb
Hilar cholangiocarcinoma- Axial and coronal reconstruction abdominal CT enhanced scan : nodular lesion in the principal bile duct (arrows) with dilation of biliary ducts
Hilaire Cholangiocarcinoma CT and MR-Cholongiography Cholongiography: Hypodense tissue process in CT and hypointense en T1- weighted with thrombosis of the portal vein
a b Hilar cholangiocarcinoma- Abdominal CT scan and MRI showing a biliary hilar process with bilation of biliary ducts c
Conclusion CT and MRI are the primary imaging modalities used for the assessment of biliary cancers. Multidector computed tomographic and magnetic resonance appearances of biliary cholangiocarcinomas and their extend are presented.
References 1. Vilgrain V, Menu Y. Imagerie du foie, des voies biliaires, du pancréas et de la rate. Flammarion 2002: 205-26. 2. Leclerc JC, Cannard L, Lefèvre F et Al. Imagerie des voies biliaires intrahépatiques en cholangiographie-irm en coupes épaisses. J Radiol 2001; 82 : 151-60. 3. Gautier AL, Vilgrain V, Fléjou JF et al. Imagerie du cholangiocarcinome périphérique. Comparaison avec l anatomie pathologique. J Radiol 1997; 7 8 : 234-8. 4. Becker CD. Scanner multidétecteur face à l IRM dans les maladies des voies biliairesj Radiol 2003,84;473-9. 5. Arrivé L. Imagerie des voies biliaires. Compte rendu de la réunion de la section Île-de-France de la Société Française de Radiologie. J Radiol 2005;86:431-7.