Magnetic Resonance Imaging of Cholangiocarcinoma

Cholangiocarcinoma arises from the bile ducts and is the most common primary malignancy of the biliary tree. Cholangiocarcinoma is classified according to its growth pattern: mass-forming, periductal-infiltrating, or intraductal-growing type. The majority of cholangiocarcinomas occur at the common hepatic duct (CHD) and its bifurcation, also referred to as Klatskin's tumor, but they also can occur in more peripheral branches within the hepatic parenchyma. Microscopically, cholangiocarcinoma represents an adenocarcinoma with a glandular appearance arising from the epithelium of the bile ducts.

On magnetic resonance (MR) images, cholangiocarcinomas appear hypointense on T1-weighted images, and hyperintense on T2-weighted images. Central hypointensity can be seen on T2-weighted images and correspond to fibrosis. On dynamic MR images, cholangiocarcinomas show moderate peripheral enhancement followed by progressive and concentric filling in the tumor with contrast material. Pooling of contrast within the tumor on delayed MR images is suggestive of peripheral cholangiocarcinoma.

The role of MR imaging in hilar cholangiocarcinoma is to confirm/reach a diagnosis and to assess resectability. Hilar cholangiocarcinoma shows the same signal intensity pattern of peripheral tumors both on T1- and T2-weighted images. On magnetic resonance cholangiopancreatography (MRCP) images, hilar cholangiocarcinoma appears as a moderately irregular thickening of the bile duct wall (≥5 mm) with symmetric upstream dilation of the intrahepatic bile ducts.

The aim of preoperative investigation in Klatskin tumors typically requires the evaluation of the level of biliary obstruction, the intrahepatic tumor spread, and the vascular involvement; it also needs to show any atrophy-hypertrophy complex.

Because of its intrinsic high tissue contrast and multiplanar capability, MR imaging and MRCP are able to detect and preoperatively assess patients with cholangiocarcinoma, investigating all involved structures such as bile ducts, vessels and hepatic parenchyma. The main reason for surgical/imaging discrepancy is represented by the microscopic diffusion along the mucosa and in the perineural space.

KEYWORDS

Cholangiocarcinoma - magnetic resonance imaging - biliary stenosis - biliary neoplasm

REFERENCES

• 1 Manfredi R, Maresca G, Vecchioli A et al.. Cholangiocellular carcinoma. In: Bartolozzi C, Lencioni R Liver Malignancies. Berlin; Springer Verlag 1999
• 2 Ros P R, Buck J L, Comdr L T et al.. Intrahepatic cholangiocarcinoma: radiology-pathologic correlation.  Radiology. 1988;  167 689-693
• 3 Nakajima T, Kondo Y, Miyazaki M, Okui K. A histopathologic study of 102 cases of intrahepatic cholangiocarcinoma: histologic classification and mode of spreading.  Hum Pathol. 1988;  19 1228-1234
• 4 Edmondson H A. Tumors of The Liver and Intrahepatic Bile Ducts: Atlas of Tumor Pathology. Section 7, Fasc. 25. Washington, DC; Armed Forces Institute of Pathology 1958
• 5 Clemett A R. Carcinoma of the major bile ducts.  Radiology. 1965;  84 894-903
• 6 Lim J H. Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings.  AJR Am J Roentgenol. 2003;  181 819-827
• 7 Liver Cancer Study Group of Japan .The General Rules for The Clinical and Pathological Study of Primary Liver Cancer, 4th ed. Tokyo; Kanehara 2000
• 8 Sasaki A, Aramaki M, Kawano K et al.. Intrahepatic peripheral cholangiocarcinoma: mode of spread and choice of surgical treatment.  Br J Surg. 1998;  85 1206-1209
• 9 Yamamoto M, Takasaki K, Yoshikawa T, Ueno K, Nakano M. Does gross appearance indicate prognosis in intrahepatic cholangiocarcinoma?.  J Surg Oncol. 1998;  69 162-167
• 10 Isaji S, Kawarada Y, Taoka H et al.. Clinicopathological features and outcome of hepatic resection for intrahepatic cholangiocarcinoma in Japan.  J Hepatobiliary Pancreat Surg. 1999;  6 108-116
• 11 Sano T, Kamiya J, Nagino M et al.. Macroscopic classification and preoperative diagnosis of intrahepatic cholangiocarcinomas in Japan.  J Hepatobiliary Pancreat Surg. 1999;  6 101-107
• 12 Klatskin G. Adenocarcinoma of the hepatic duct at its bifurcation within the porta hepatis: an unusual tumor with distinctive clinical and pathological features.  Am J Med. 1965;  38 241-256
• 13 Rosai J. Ackerman's Surgical Pathology, 8th ed. St. Louis; Mosby 1996
• 14 Bhuiya M R, Nimura Y, Kamiya J et al.. Clinicopathologic studies on perineural invasion of bile duct carcinoma.  Ann Surg. 1992;  215 344-349
• 15 Weinbren K, Mutum S S. Pathological aspects of cholangiocarcinoma.  J Pathol. 1983;  139 217-238
• 16 Thorsen M K, Quiroz F, Lawson T L et al.. Primary biliary carcinoma: CT evaluation.  Radiology. 1984;  152 479-483
• 17 Nesbit G M, Johnson C D, James E M et al.. Cholangiocarcinoma: diagnosis and evaluation of resectability by CT and sonography as procedures complementary to cholangiography.  AJR Am J Roentgenol. 1988;  151 933-938
• 18 Yoon K H, Han H K, Kim C G et al.. Malignant papillary neoplasms of intrahepatic bile ducts: CT and histopathologic features.  AJR Am J Roentgenol. 2000;  175 1135-1139
• 19 Adjei O N, Tamura S, Sugimara H et al.. Contrast enhanced MR imaging of intrahepatic cholangiocarcinoma.  Clin Radiol. 1995;  50 6-10
• 20 Soyer P A, Bluemke D A, Sibert A et al.. MR imaging of intrahepatic cholangiocarcinoma.  Abdom Imaging. 1995;  20 126-130
• 21 Grazioli L, Morana G, Federle M P et al.. Focal nodular hyperplasia: morphologic and functional information from MR imaging with gadobenate dimeglumine.  Radiology. 2001;  221 731-739
• 22 Choi B I, Kim T K, Han J K. MR imaging of clonorchiasis and cholangiocarcinoma.  J Magn Reson Imaging. 1998;  8 359-366
• 23 Kim T K, Choi B I, Han J K et al.. Peripheral cholangiocarcinoma of the liver: two-phase helical CT findings.  Radiology. 1997;  204 539-543
• 24 Lee W J, Lim H K, Jang K M et al.. Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnoses.  Radiographics. 2001;  21(Spec. No.) S97-S116
• 25 Robledo R, Muro A, Prieto M L. Extrahepatic bile duct carcinoma: U.S. characteristics and accuracy in demonstration of tumors.  Radiology. 1996;  198 869-873
• 26 Manfredi R, Masselli G, Maresca G et al.. MR imaging and MRCP of hilar cholangiocarcinoma.  Abdom Imaging. 2003;  28 319-325
• 27 Nichols D A, MacCarty R L, Gaffey T A. Cholangiographic evaluation of bile duct carcinoma.  AJR Am J Roentgenol. 1983;  141 1291-1294
• 28 Lopera J E, Soto J A, Munera F. Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions.  Radiology. 2001;  220 90-96
• 29 Zidi S H, Prat F, Le Guen L, Rondeua Y, Pelletier G. Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures.  Gut. 2000;  46 103-106
• 30 Dooms G C, Kerlan R K, Hricak H, Wall S D, Margulis A R. Cholangiocarcinoma: imaging by MR.  Radiology. 1986;  159 89-94
• 31 Fulcher A S, Turner M A. HASTE MR cholangiography in the evaluation of hilar cholangiocarcinoma.  AJR Am J Roentgenol. 1997;  169 1501-1505
• 32 Guthrie J A, Ward J, Robinson P J. Hilar cholangiocarcinoma: T2-weighted spin-echo and gadolinium enhanced FLASH MR imaging.  Radiology. 1996;  201 347-351
• 33 Whithey W S, Herfkens R J, Brooke J R et al.. Dynamic breath-hold multiplanar spoiled gradient-recalled MR imaging with gadolinium enhancement for differentiating hepatic hemangiomas from malignancy at 1.5T.  Radiology. 1993;  189 863-870
• 34 Adam A, Benjamin I S. The staging of cholangiocarcinoma.  Clin Radiol. 1992;  46 299-303
• 35 Looser C, Stain S L, Baer H U, Triller J, Blumgart L H. Staging of hilar cholangiocarcinoma by ultrasound and duplex sonography: a comparison with angiography and operative findings.  Br J Radiol. 1992;  65 871-877
• 36 Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma.  Ann Surg. 1992;  215 31-38
• 37 Manfredi R, Brizi M G, Masselli G, Vecchioli A, Marano P. Malignant biliary hilar stenosis: MR cholangiopancreatography compared with direct cholangiography [in Italian].  Radiol Med (Torino). 2001;  102 48-54
• 38 Reinhold C, Bret P. Current status of MR cholangiopancreatography.  AJR Am J Roentgenol. 1996;  166 1285-1295
• 39 Triller J, Looser C, Baer H U, Blumgart L H. Hilar cholangiocarcinoma: radiological assessment of resectability.  Eur Radiol. 1994;  4 9-17
• 40 Nichols D A, MacCarty R L, Gaffey T A. Cholangiographic evaluation of bile duct carcinoma.  AJR Am J Roentgenol. 1983;  141 1291-1294