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Hilar Cholangiocarcinoma: Role of Preoperative Imaging with Sonography, MDCT, MRI, and Direct Cholangiography

¹ Department of Radiology, Research Institute of Radiological Science, Institute of Gastroenterology, Yonsei University Health System, Seodaemun-ku Shinchon-dong 134, Seoul, 120-752, Republic of Korea.
² Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea.

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —63-year-old man with hilar cholangiocarcinoma. Intercostal sonographic scan through common hepatic duct shows well-defined soft-tissue intraductal mass (white arrow) within dilated intrahepatic duct (black arrow). S8 = segment VIII.

View larger version (197K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —63-year-old man with hilar cholangiocarcinoma. Contrast-enhanced CT scan barely depicts intraductal papillary tumor (arrow). Papillary tumor is more easily seen with sonography than with CT.

View larger version (57K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —63-year-old man with hilar cholangiocarcinoma. Drawing depicts intraductal papillary-type cholangiocarcinoma at hepatic hilum.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D —63-year-old man with hilar cholangiocarcinoma. Photograph of surgical specimen shows papillary tumor (arrow).

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —58-year-old man with hilar cholangiocarcinoma. Subcostal oblique gray-scale sonographic scan through porta hepatis shows abrupt narrowing of right intrahepatic duct (black arrows) secondary to infiltrating tumor (white arrow).

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —58-year-old man with hilar cholangiocarcinoma. Drawing shows periductal infiltrating-type cholangiocarcinoma.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2C —58-year-old man with hilar cholangiocarcinoma. Contrast-enhanced CT scan shows tumor (white arrows) infiltrating right portal vein (black arrow).

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —55-year-old man with hilar cholangiocarcinoma. Contrast-enhanced sonographic scan shows extent of tumor at hilum (black arrows). Right hepatic artery (white arrows) and dilated duct (arrowhead) are enhanced.

View larger version (171K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —55-year-old man with hilar cholangiocarcinoma. CT scan shows hilar mass (black arrow) and dilated right hepatic duct (white arrow).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —60-year-old woman with hilar cholangiocarcinoma. Radial intraductal sonographic image shows circumferential wall thickening (arrows).

View larger version (201K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —60-year-old woman with hilar cholangiocarcinoma. Coronal T2-weighted MR image shows bile duct wall thickening (arrows).

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —60-year-old woman with hilar cholangiocarcinoma. Cholangiogram shows stenosis in proximal and mid portions of extrahepatic duct (arrow).

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —67-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 3a. Oblique axial reformatted (A), oblique coronal reformatted (B and C), and curved planar (D) MDCT scans along bile duct show tumor involves primary confluence (white arrow, A–C) and right secondary confluence (arrow, D). Right hepatic artery (black arrows, C) is invaded by tumor.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —67-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 3a. Oblique axial reformatted (A), oblique coronal reformatted (B and C), and curved planar (D) MDCT scans along bile duct show tumor involves primary confluence (white arrow, A–C) and right secondary confluence (arrow, D). Right hepatic artery (black arrows, C) is invaded by tumor.

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —67-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 3a. Oblique axial reformatted (A), oblique coronal reformatted (B and C), and curved planar (D) MDCT scans along bile duct show tumor involves primary confluence (white arrow, A–C) and right secondary confluence (arrow, D). Right hepatic artery (black arrows, C) is invaded by tumor.

View larger version (173K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —67-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 3a. Oblique axial reformatted (A), oblique coronal reformatted (B and C), and curved planar (D) MDCT scans along bile duct show tumor involves primary confluence (white arrow, A–C) and right secondary confluence (arrow, D). Right hepatic artery (black arrows, C) is invaded by tumor.

View larger version (192K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —67-year-old man with Klatskin's tumor, type 3a. Early arterial (A), late arterial (B), and portal venous (C and D) phase CT scans. Late arterial phase is used to maximize enhancement of tumor in hilar region (arrow, B). Portal venous phase is suitable for evaluating portal vein, adjacent liver invasion, and lymph node metastasis (arrows, D).

View larger version (196K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —67-year-old man with Klatskin's tumor, type 3a. Early arterial (A), late arterial (B), and portal venous (C and D) phase CT scans. Late arterial phase is used to maximize enhancement of tumor in hilar region (arrow, B). Portal venous phase is suitable for evaluating portal vein, adjacent liver invasion, and lymph node metastasis (arrows, D).

View larger version (185K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —67-year-old man with Klatskin's tumor, type 3a. Early arterial (A), late arterial (B), and portal venous (C and D) phase CT scans. Late arterial phase is used to maximize enhancement of tumor in hilar region (arrow, B). Portal venous phase is suitable for evaluating portal vein, adjacent liver invasion, and lymph node metastasis (arrows, D).

View larger version (189K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6D —67-year-old man with Klatskin's tumor, type 3a. Early arterial (A), late arterial (B), and portal venous (C and D) phase CT scans. Late arterial phase is used to maximize enhancement of tumor in hilar region (arrow, B). Portal venous phase is suitable for evaluating portal vein, adjacent liver invasion, and lymph node metastasis (arrows, D).

View larger version (55K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T1 tumors are confined to right, left, or confluence of bile ducts without portal venous involvement in liver atrophy.

View larger version (53K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T1 tumors are confined to right, left, or confluence of bile ducts without portal venous involvement in liver atrophy.

View larger version (50K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T2 tumors have same attributes as T1 tumors but are accompanied by ipsilateral liver atrophy.

View larger version (64K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7D —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T2 tumors have same attributes as T1 tumors but are accompanied by ipsilateral liver atrophy.

View larger version (59K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7E —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T3 tumors have same classifiers as T1 tumors but have ipsilateral portal venous atrophy without main portal vein involvement. Patients with T3 tumors are considered poor candidates for surgery. However, some Bismuth type 4 tumors with favorable anatomic features or short-segment invasion of main portal vein may not be absolute contraindication to curative resection.

View larger version (55K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7F —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T3 tumors have same classifiers as T1 tumors but have ipsilateral portal venous atrophy without main portal vein involvement. Patients with T3 tumors are considered poor candidates for surgery. However, some Bismuth type 4 tumors with favorable anatomic features or short-segment invasion of main portal vein may not be absolute contraindication to curative resection.

View larger version (61K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7G —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T3 tumors have same classifiers as T1 tumors but have ipsilateral portal venous atrophy without main portal vein involvement. Patients with T3 tumors are considered poor candidates for surgery. However, some Bismuth type 4 tumors with favorable anatomic features or short-segment invasion of main portal vein may not be absolute contraindication to curative resection.

View larger version (57K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7H —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T3 tumors have same classifiers as T1 tumors but have ipsilateral portal venous atrophy without main portal vein involvement. Patients with T3 tumors are considered poor candidates for surgery. However, some Bismuth type 4 tumors with favorable anatomic features or short-segment invasion of main portal vein may not be absolute contraindication to curative resection.

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7I —Modified T categorization in American Joint Committee on Cancer system proposed by Memorial Sloan–Kettering group [21]. Drawings show T3 tumors have same classifiers as T1 tumors but have ipsilateral portal venous atrophy without main portal vein involvement. Patients with T3 tumors are considered poor candidates for surgery. However, some Bismuth type 4 tumors with favorable anatomic features or short-segment invasion of main portal vein may not be absolute contraindication to curative resection.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —62-year-old woman with hilar cholangiocarcinoma. Oblique coronal MDCT scan shows relation between hilar tumor (thick black arrow) and left hepatic artery (white arrow). Hepatic metastasis is present in segment IV (thin black arrow).

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —62-year-old woman with hilar cholangiocarcinoma. Oblique axial MDCT scan shows tumor involvement along biliary tree (arrows).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —64-year-old woman with Klatskin's tumor. Oblique coronal MDCT scans show endoscopic retrograde biliary drainage tube (arrow) in bile duct makes it difficult to evaluate biliary extension of tumor.

View larger version (119K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —64-year-old woman with Klatskin's tumor. Oblique coronal MDCT scans show endoscopic retrograde biliary drainage tube (arrow) in bile duct makes it difficult to evaluate biliary extension of tumor.

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —55-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 4. Two-dimensional MR cholangiopancreatographic image shows hilar bile duct tumor.

View larger version (198K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —55-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 4. T2-weighted images show tumor encasement of right hepatic artery (arrow, B) and hepatic parenchymal invasion (arrowhead, C).

View larger version (183K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —55-year-old man with hilar cholangiocarcinoma, Bismuth-Corlette type 4. T2-weighted images show tumor encasement of right hepatic artery (arrow, B) and hepatic parenchymal invasion (arrowhead, C).

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —54-year-old man with Klatskin's tumor, type 4. Two-dimensional thick-slab RARE (A) and maximum-intensity-projection (B) MR cholangiopancreatographic images obtained with 3D navigator-triggered turbo spin-echo technique show malignant hilar obstruction.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —54-year-old man with Klatskin's tumor, type 4. Two-dimensional thick-slab RARE (A) and maximum-intensity-projection (B) MR cholangiopancreatographic images obtained with 3D navigator-triggered turbo spin-echo technique show malignant hilar obstruction.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —67-year-old man with Klatskin's tumor. Three-dimensional dynamic T1-weighted gradient-echo MR image in arterial phase shows relation between right hepatic artery (white arrows) and tumor (black arrow).

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —67-year-old man with Klatskin's tumor. Three-dimensional dynamic T1-weighted gradient-echo MR images in portal venous phase show infiltrating tumor (arrow, C and D) and lymph node metastasis at porta hepatis (arrows, E).

View larger version (176K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —67-year-old man with Klatskin's tumor. Three-dimensional dynamic T1-weighted gradient-echo MR images in portal venous phase show infiltrating tumor (arrow, C and D) and lymph node metastasis at porta hepatis (arrows, E).

View larger version (175K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12D —67-year-old man with Klatskin's tumor. Three-dimensional dynamic T1-weighted gradient-echo MR images in portal venous phase show infiltrating tumor (arrow, C and D) and lymph node metastasis at porta hepatis (arrows, E).

View larger version (182K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12E —67-year-old man with Klatskin's tumor. Three-dimensional dynamic T1-weighted gradient-echo MR images in portal venous phase show infiltrating tumor (arrow, C and D) and lymph node metastasis at porta hepatis (arrows, E).

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12F —67-year-old man with Klatskin's tumor. MR cholangiopancreatographic image shows tumor involvement of primary confluence of bile duct (arrow).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —61-year-old man with Bismuth-Corlette type 4 cholangiocarcinoma. Percutaneous cholangiogram shows bilateral tumor involvement of secondary confluence level (arrows).

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —61-year-old man with Bismuth-Corlette type 4 cholangiocarcinoma. Percutaneous cholangiogram shows metallic biliary stents inserted into bilateral hepatic ducts as palliative treatment.

View larger version (152K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —63-year-old man with Bismuth-Corlette type 4 cholangiocarcinoma. Percutaneous cholangiogram through left hepatic duct does not depict right hepatic duct proximal to occlusion.

View larger version (174K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —63-year-old man with Bismuth-Corlette type 4 cholangiocarcinoma. Maximum intensity projection of MR cholangiopancreatographic image clearly shows bilateral dilated hepatic ducts proximal to hilar mass (arrows).

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