AJR 2005; 184:1572-1577
© American Roentgen Ray Society
Hilar and Suprapancreatic Cholangiocarcinoma: Value of 3D Angiography and Multiphase Fusion Images Using MDCT
Masafumi Uchida1,
Masatoshi Ishibashi1,
Naofumi Tomita1,
Masaharu Shinagawa1,
Naofumi Hayabuchi1 and
Kouji Okuda2
1 Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi,
Kurume City, Fukuoka 830-0011, Japan.
2 Department of Surgery, Division of Hepatic Surgery, Kurume University School
of Medicine, Kurume City, Fukuoka 830-0011, Japan.
Received August 26, 2004;
accepted after revision October 18, 2004.
Address correspondence to M. Uchida
(krumf{at}med.kurume-u.ac.jp).
Abstract
OBJECTIVE. We evaluated the feasibility of creating 3D and
multiphase fusion images of cholangiocarcinoma. The 3D renderings of the
biliary tree provide valuable information for planning surgery, including the
location of the obstruction and its relationship to the surrounding
vessels.
CONCLUSION. Our data emphasize that 3D and multiphase fusion images
may be an accurate and routinely applicable tool for the diagnosis and
therapeutic management of patients with biliary system abnormalities.
Introduction
In the biliary system, the degree of risk involved in bile duct resection
depends primarily on the location of the tumor, its size, whether it has
invaded vascular structures, and parenchymal function. Cholangiocarcinoma,
which tends to spread along the artery and portal vein, is likely to spread
outside the wall of the bile duct
[1]. A recently developed 3D
imaging technique allows us to detect the extent of tumor invasion and the
relationship of the tumor to the vessels and the bile duct system. Scanning
the entire biliary system in three or more phases can be performed easily with
the current MDCT, and recent advances have now made it possible to produce
multiphase fusion images [2].
In this article, we show the utility of 3D angiography and multiphase fusion
images of hilar and suprapancreatic cholangiocarcinoma.
Imaging Technique
CT images were acquired on a LightSpeed Ultra system (GE Healthcare).
Scanning was performed using a pitch of 1.35:1, a 0.7-sec scanning time per
rotation, a table speed of 13.5 mm/rotation, and a detector configuration of
1.25 x 8 mm. A power injector was used to administer iopamidol (370 mg
I/mL) through a 20-gauge high-pressure IV catheter at a rate of 4 mL/sec. The
total volume was 1.5–2.0 mL per kilogram of body weight. The scanning
time was determined using a test injection of 15 mL of contrast medium
administered at a rate of 4 mL/sec.
The arterial phase images were obtained 5 sec after the peak aortic
enhancement time; portal phase images, 20 sec after the peak aortic
enhancement time; and venous phase images, 70 sec after the peak aortic
enhancement time. Furthermore, in the patients in whom percutaneous
transhepatic bile drainage was performed for obstructive jaundice, contrast
medium was injected both IV and through a percutaneous transhepatic bile
drainage tube.
The CT data for each phase were retrospectively reconstructed with a
standard algorithm at a reconstruction interval of 0.63–1.25 mm with a
1.25-mm section thickness. The raw data were transferred automatically to a
workstation (Zio M-900, Amin) in a 512 x 512 pixel format via Ethernet.
The three- or four-phase source 2D CT images were reviewed and analyzed for 3D
reconstruction using the workstation.
CT Angiography
Numerous studies have reported that 3D CT arteriography is as accurate as
angiography for the assessment of hepatobiliary arterial anatomy
[3,
4]. Indeed, in the present
study, Figures 1A,
1B,
1C,
1D,
1E,
1F and
2A,
2B,
2C,
2D show a concise depiction of
the artery compared with digital subtraction angiography and enabled us to
evaluate the variation in the artery in both cases.
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Fig. 1A. —73-year-old woman with mass in common bile duct. On the basis
of all the images, it was decided that surgery should be performed. Resection
of extrahepatic bile duct was performed, and surgical removal of tumor was
confirmed to be sufficient. Portal phase CT image shows hypervascular mass
(arrow) within dilated area of common bile duct.
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Fig. 1B. —73-year-old woman with mass in common bile duct. On the basis
of all the images, it was decided that surgery should be performed. Resection
of extrahepatic bile duct was performed, and surgical removal of tumor was
confirmed to be sufficient. Cholangiogram obtained during endoscopic
retrograde cholangiography shows irregular filling defect in common bile
duct.
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Fig. 1C. —73-year-old woman with mass in common bile duct. On the basis
of all the images, it was decided that surgery should be performed. Resection
of extrahepatic bile duct was performed, and surgical removal of tumor was
confirmed to be sufficient. Curved planar reformation image through common
bile duct clearly shows hypervascular tumor (arrow) in common bile
duct. Tumor was dilating bile duct in this case but was not invasive of portal
vein. This image depicts bile duct tumor and its relationship with surrounding
structures better than corresponding endoscopic retrograde cholangiography
image (B).
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Fig. 1D. —73-year-old woman with mass in common bile duct. On the basis
of all the images, it was decided that surgery should be performed. Resection
of extrahepatic bile duct was performed, and surgical removal of tumor was
confirmed to be sufficient. Three-dimensional image of hepatic artery on
arterial phase CT shows posterior segmental artery (arrow) in liver,
which appears to arise from gastroduodenal artery (arrowhead).
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Fig. 1E. —73-year-old woman with mass in common bile duct. On the basis
of all the images, it was decided that surgery should be performed. Resection
of extrahepatic bile duct was performed, and surgical removal of tumor was
confirmed to be sufficient. Digital subtraction angiographic image shows
posterior segmental artery (arrow) arising from gastroduodenal artery
(arrowhead). This was confirmed by our CT angiography findings.
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Fig. 1F. —73-year-old woman with mass in common bile duct. On the basis
of all the images, it was decided that surgery should be performed. Resection
of extrahepatic bile duct was performed, and surgical removal of tumor was
confirmed to be sufficient. Multiphase fusion image composed of vessels,
liver, and other organs depicts relationship between portal vein (dark
blue) and artery in hilus of liver. This image was useful for vascular
treatment during surgery. Pink = artery, light blue = vein.
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Fig. 2A. —63-year-old woman with mass in hepatic hilum. In this case,
right hemihepatectomy was performed. Portal phase CT image shows ill-defined
hypoattenuating mass adjacent to hepatic hilum (arrow).
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Fig. 2B. —63-year-old woman with mass in hepatic hilum. In this case,
right hemihepatectomy was performed. Volume-rendering CT arteriography image
clearly shows that right hepatic artery arises from aorta (arrow) and
lateral segmental artery arises from left gastric artery.
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Fig. 2C. —63-year-old woman with mass in hepatic hilum. In this case,
right hemihepatectomy was performed. Multiphase fusion image composed of
vessels and liver shows structure surrounding portal vein (black
arrow and dark blue) into liver, right hepatic artery (white
arrow), and left hepatic artery (black arrowhead). Furthermore,
it helped surgeons to understand flow into liver through lateral segmental
artery (white arrowhead). Pink = artery, light blue = vein.
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Fig. 2D. —63-year-old woman with mass in hepatic hilum. In this case,
right hemihepatectomy was performed. Multiphase fusion image depicts
localization of major accessory hepatic vein (arrow). Obtained before
surgery, this image aided in treatment of hepatic vein during right
hepatectomy. Pink = artery, light blue = vein.
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CT portography can be performed using the images from the portal phase, and
CT venography can be performed using the images from the venous phase. Because
enhancement of the hepatic vein is insufficient during the portal phase, the
image was produced during the venous phase. MDCT is useful for depicting the
portal and hepatic venous anatomy
[5]. Figures
3A,
3B,
3C,
3D and
4A,
4B,
4C show a concise depiction of
the portal and hepatic veins and enabled us to evaluate for tumor invasion in
these cases. The involvement of the portal vein, splenic vein, or superior
mesenteric vein is classically a contraindication for surgery. The depiction
of the hepatic vein using CT venography may aid surgical planning because it
helps surgeons select hepatectomy of either the right or left lobe of the
liver [6].
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Fig. 3A. —68-year-old woman with mass in common bile duct. Surgery was
judged to be possible and resection of extrahepatic bile duct was performed on
the basis of the imaging findings. Percutaneous transhepatic bile drainage was
performed via IV injection and percutaneous transhepatic bile drainage tube of
contrast medium to treat obstructive jaundice. Portal phase CT image shows
well-enhanced mass in common bile duct (arrow).
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Fig. 3B. —68-year-old woman with mass in common bile duct. Surgery was
judged to be possible and resection of extrahepatic bile duct was performed on
the basis of the imaging findings. Percutaneous transhepatic bile drainage was
performed via IV injection and percutaneous transhepatic bile drainage tube of
contrast medium to treat obstructive jaundice. Curved planar reformation image
through common bile duct clearly shows well-enhanced, thickened bile duct wall
and hypervascular mass in common bile duct (arrow). Tumor is separate
from portal vein and was not invasive of portal vein.
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Fig. 3C. —68-year-old woman with mass in common bile duct. Surgery was
judged to be possible and resection of extrahepatic bile duct was performed on
the basis of the imaging findings. Percutaneous transhepatic bile drainage was
performed via IV injection and percutaneous transhepatic bile drainage tube of
contrast medium to treat obstructive jaundice. Three-dimensional CT
cholangiography image of bile duct system depicts bile duct systems clearly
and shows complete occlusion of common bile duct (arrow).
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Fig. 3D. —68-year-old woman with mass in common bile duct. Surgery was
judged to be possible and resection of extrahepatic bile duct was performed on
the basis of the imaging findings. Percutaneous transhepatic bile drainage was
performed via IV injection and percutaneous transhepatic bile drainage tube of
contrast medium to treat obstructive jaundice. Multiphase fusion image
composed of vessels shows relationship between portal vein (dark
blue) and artery (pink) and could be understood before surgery.
Image depicts noninvasive finding (arrowhead) in portal vein around
tumor. Light blue = vein.
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Fig. 4A. —69-year-old man with mass in hepatic hilum. This case was
considered to be inoperable because of liver and portal vein invasion. Portal
phase CT image shows ill-defined, hypoattenuating mass in hepatic hilum
(white arrows) and area adjacent to liver associated with ill-defined
hypoattenuating mass (black arrows). Indeed, this resulted in direct
invasion of liver.
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Fig. 4B. —69-year-old man with mass in hepatic hilum. This case was
considered to be inoperable because of liver and portal vein invasion. This
case underwent percutaneous transhepatic bile drainage due to obstructive
jaundice via IV injection and percutaneous transhepatic bile drainage tube of
contrast medium. This 3D image of bile duct system, created by cholangiogram
CT, shows complete occlusion of common hepatic bile duct (arrow) and
marked narrowing of right hepatic duct (arrowhead).
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Fig. 4C. —69-year-old man with mass in hepatic hilum. This case was
considered to be inoperable because of liver and portal vein invasion.
Multiphase fusion images composed of vessels, bile duct, and liver aid in
understanding surrounding structure of bile duct, hepatic artery, and portal
vein (dark blue). This image does not suggest invasive finding in
hepatic artery but depicts narrowing (arrows) of portal vein that is
suspected to occur with invasion. Pink = artery.
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Multiphase Fusion Images
The entire biliary system can easily be scanned with the current MDCT using
three or more phases, and recent advances have made the workstation capable of
producing a fusion image made from images obtained during each phase. This
technique was named "multiphase fusion imaging." Three-dimensional
volume rendering was performed on acquisitions from each phase, and 3D images
were constructed from the scans using all voxels higher than the selected
minimum threshold of 160 H. The bone was removed manually from the 3D
images.
Multiphase fusion images are produced by combining each volume data set
based on the fusion of each 3D image. Although the workstation is capable of
rotation or magnification of the multiphase fusion image, it is limited in
that it cannot alter the window and level settings. Because each phase is
combined on the basis of the individual image, we believe that it has not been
affected by another phase. The operator determines the color in the images
during each phase. Although approximately 10% of the patients in our study had
imperfect breath-holding, the striking image was produced by manually
correcting anatomic structures using software.
Multiphase fusion images are able to depict the following vascular
components in one image: artery, portal vein, hepatic vein, and biliary tract.
Figures 1F,
2C,
2D,
3D, and
4C show the use of the
multiphase fusion images to depict the vessels, liver, and other organs. These
images clearly show the relationships between the vessels. The resultant image
makes it easy to evaluate the surrounding structure. The image does not
display the tumor because depicting both the tumor and vascular component may
make it difficult to understand the anatomic structure of the vascular
components.
Surgeons imagine the complex structure of the vascular components based on
the digital subtraction angiography or cholangiography findings. The
multiphase fusion image is superior to the surgeons' knowledge of the vascular
components based on imaging. In particular, the multiphase fusion image is
able to depict the complex structure of the vascular components of the hilus
of the liver. We believe that simulation or navigation based on this image can
be improved using a field of 3D images
[7].
Conclusion
Current applications of the 3D angiography and multiphase fusion imaging
technique using MDCT have focused primarily on the simultaneous visualization
of superficial and deep structures to depict the spatial relationships between
tumor lesions inside the bile duct and the surrounding vascular structures and
to show the internal details of vessels. With the use of a multiphase fusion
image, concise observation was achieved before surgery and the complicated
structures could be understood more easily on the multiphase fusion image than
on images obtained using conventional radiologic examinations. We believe that
these images are helpful to the surgeon in localizing lesions and in
minimizing operating time, the extent of surgical resection, and blood
loss.
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Abstract
Introduction
