J Korean Soc Radiol.  2019 May;80(3):394-411. 10.3348/jksr.2019.80.3.394.

Recent Updates in the Imaging Diagnosis of Cholangiocarcinoma

Affiliations
  • 1Department of Radiology, Seoul National University Hospital, Seoul, Korea. hijijin@gmail.com

Abstract

Cholangiocarcinoma is a disease entity with a wide spectrum of imaging, histological, and clinical features as well as treatment options. At present, imaging studies are essential for the detection, characterization, staging, and resectability assessment of cholangiocarcinoma. This review article describes the imaging features of intrahepatic and perihilar cholangiocarcinoma and the considerations for interpretation of these features. In addition, we introduce the latest concepts regarding the classification system, carcinogenesis process, premalignant lesions, and treatment approaches for cholangiocarcinoma.


MeSH Terms

Bile Ducts
Carcinogenesis
Cholangiocarcinoma*
Classification
Diagnosis*
Diagnostic Imaging
Klatskin Tumor

Figure

  • Fig. 1. Images from a 48-year-old woman with intrahepatic mass-forming type cholangiocarcinoma. A-C. Axial CT images show a solid mass in segment 4 of the liver. The mass demonstrates peripheral enhancement (arrowheads) in the arterial phase (A) and progressive centripetal enhancement in the portal-venous phase (B) and delayed phase (C). Note the dilated intrahepatic ducts peripheral to the mass.

  • Fig. 2. Images from a 60-year-old man with intrahepatic mass-forming type cholangiocarcinoma and underlying chronic hepatitis B. This patient had previously undergone hepatic resection for hepatocellular carcinoma. A-D. On gadoxetic acid-enhanced MRI, a 1-cm nodular lesion (arrows) is seen adjacent to the margin of hepatic resection. The mass shows nodular hyper-enhancement (not-rim) in the arterial phase (A) and lacks washout in the portal venous phase (B). During the transitional phase (C) and hepatobiliary phase (D), the nodule shows hypointensity relative to the liver parenchyma. Surgical resection and histology confirmed the diagnosis of cholangiocarcinoma.

  • Fig. 3. Images from a 54-year-old man with intrahepatic, intraductal-growing type cholangiocarcinoma. A. On the portal venous phase image using contrast-enhanced T1-weighted MRI, an intraductal tumor (arrow) is seen in B3. The affected segment of the bile duct and upstream duct are dilated. Another small intraductal tumor (arrowhead), or skip lesion, is also identified. B. Three-dimensional MR cholangiopancreatography shows segmental filing defects (arrows) in the intrahepatic duct. C. A contrast-enhanced CT image shows the intraductal tumor (arrow) with a mild degree of enhancement. D. CT cholangiography using minimum intensity projection and curved multiplanar reconstruction demonstrates the intraductal

  • Fig. 4. Images from a 57-year-old man with periductal infiltrating type perihilar cholangiocarcinoma. This patient underwent an extended right hemihepatectomy with curative intent. However, there was microscopic tumor involvement in the proximal margin of resection (left hepatic duct). A. Three-dimensional MR cholangiopancreatography shows dilatation of bilateral intrahepatic ducts and separation of the right anterior and posterior ducts (arrowheads) while the left second confluence is preserved, suggesting Bismuth-Corlette classification type IIIA. B. The axial portal venous phase image with contrast-enhanced T1-weighted MRI shows thickening of the hilar bile ducts with enhancement. Separation of right anterior and posterior ducts is seen (arrowheads). C. On the diffusion-weighted image obtained with a b value of 800 sec/mm2, the perihilar cholangiocarcinoma shows restricted diffusion. The area of restricted diffusion along the bile duct is almost identical to that of the enhanced wall thickening found on contrast-enhanced T1-weighted MRI (arrowheads).

  • Fig. 5. Images from a 61-year-old woman with perihilar cholangiocarcinoma of mixed mass-forming and periductal infiltrating type. A, B. Axial portal venous phase CT images show enhancing wall thickening of both the right hepatic duct (arrowhead, A) and the left hepatic duct (arrowhead, B). B. An intrahepatic mass (white arrow) connected to the perihilar tumor is seen in the left lobe of the liver. Invasion of the tumor has caused segmental narrowing of the proximal left portal vein (black arrow).

  • Fig. 6. Images from a 90-year-old woman with mucin-hypersecreting intraductal papillary neoplasm of the bile duct. A. Two-dimensional MR cholangiopancreatography shows fusiform dilatation of the extrahepatic duct. A small filling defect (arrow) is seen in the common hepatic duct due to a solid intraductal tumor. Both the upstream and downstream bile ducts are dilated. B. Axial contrast-enhanced T1-weighted MRI demonstrates an enhancing intraductal tumor (arrow). C. A photograph of the gross specimen shows intraductal papillary tumors (arrows) in the common hepatic duct.

  • Fig. 7. Images from a 42-year-old man with a surgically confirmed cyst-forming IPNB. A. An axial heavily T2-weighted image shows a lobulated cystic mass in segment 4 of the liver with internal septa and mural nodules (arrows). The intrahepatic bile ducts are not dilated. B. On a diffusion-weighted image (b value = 1000 sec/mm2), the mural nodules show restricted diffusion (i.e. high signal intensity) (arrows). C. On gross specimen, the communication between the bile duct and cystic mass is identifiable (arrow). Histological examination confirms the diagnosis of IPNB with high-grade intraepithelial neoplasia. IPNB = intraductal papillary neoplasm of the bile duct.


Reference

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