cholangiocarcinoma pictorial essay of ct and cholangiographic findings

Cholangiocarcinoma: Pictorial essay of CT and cholangiographic findings

• Boramae Radiology
• SNUCM Radiology
• SNUBH Radiology
• SNUCM Surgery

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Cholangiocarcinomas that involve areas from the peripheral intrahepatic duct to the distal common duct have similar morphologic features, and traditional classification schemes based on the location of the involved ducts sometimes overlap. Nevertheless, cholangiocarcinoma is usually classified as either intrahepatic or extrahepatic, and intrahepatic cholangiocarcinoma is further classified as either peripheral or hilar. However, the distinction between peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma is largely based on the site of origin. Therefore, in some tumors that arise peripheral to the secondary bifurcation of one of the hepatic ducts, clear differentiation between the two types of cholangiocarcinoma is not always possible. In addition, the distinction between hilar cholangiocarcinoma and extrahepatic cholangiocarcinoma is not clearly defined. The different biologic behaviors of the tumors seem to be caused by their varying locations and their size at the time of diagnosis. Further molecular or biochemical investigation is needed to support the "field theory," which states that all cholangiocarcinomas are biologically the same tumor originating from the same biliary epithelium.

• Bile duct radiography, 76.122
• Bile ducts, CT, 76.1211
• Bile ducts, neoplasms, 76.321
• Bile ducts, stenosis or obstruction

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T1 - Cholangiocarcinoma

T2 - Pictorial essay of CT and cholangiographic findings

AU - Han, Joon Koo

AU - Choi, Byung Ihn

AU - Kim, Ah Young

AU - An, Su Kyung

AU - Lee, Joon Woo

AU - Kim, Tae Kyung

AU - Kim, Sun Whe

N2 - Cholangiocarcinomas that involve areas from the peripheral intrahepatic duct to the distal common duct have similar morphologic features, and traditional classification schemes based on the location of the involved ducts sometimes overlap. Nevertheless, cholangiocarcinoma is usually classified as either intrahepatic or extrahepatic, and intrahepatic cholangiocarcinoma is further classified as either peripheral or hilar. However, the distinction between peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma is largely based on the site of origin. Therefore, in some tumors that arise peripheral to the secondary bifurcation of one of the hepatic ducts, clear differentiation between the two types of cholangiocarcinoma is not always possible. In addition, the distinction between hilar cholangiocarcinoma and extrahepatic cholangiocarcinoma is not clearly defined. The different biologic behaviors of the tumors seem to be caused by their varying locations and their size at the time of diagnosis. Further molecular or biochemical investigation is needed to support the "field theory," which states that all cholangiocarcinomas are biologically the same tumor originating from the same biliary epithelium.

AB - Cholangiocarcinomas that involve areas from the peripheral intrahepatic duct to the distal common duct have similar morphologic features, and traditional classification schemes based on the location of the involved ducts sometimes overlap. Nevertheless, cholangiocarcinoma is usually classified as either intrahepatic or extrahepatic, and intrahepatic cholangiocarcinoma is further classified as either peripheral or hilar. However, the distinction between peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma is largely based on the site of origin. Therefore, in some tumors that arise peripheral to the secondary bifurcation of one of the hepatic ducts, clear differentiation between the two types of cholangiocarcinoma is not always possible. In addition, the distinction between hilar cholangiocarcinoma and extrahepatic cholangiocarcinoma is not clearly defined. The different biologic behaviors of the tumors seem to be caused by their varying locations and their size at the time of diagnosis. Further molecular or biochemical investigation is needed to support the "field theory," which states that all cholangiocarcinomas are biologically the same tumor originating from the same biliary epithelium.

KW - Bile duct radiography, 76.122

KW - Bile ducts, CT, 76.1211

KW - Bile ducts, neoplasms, 76.321

KW - Bile ducts, stenosis or obstruction

UR - http://www.scopus.com/inward/record.url?scp=0036370243&partnerID=8YFLogxK

U2 - 10.1148/radiographics.22.1.g02ja15173

DO - 10.1148/radiographics.22.1.g02ja15173

M3 - Article

C2 - 11796906

AN - SCOPUS:0036370243

SN - 0271-5333

JO - Radiographics

JF - Radiographics

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Cholangiocarcinoma: pictorial essay of CT and cholangiographic findings.

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• Kim TK | 0000-0001-5193-1428
• Lee JW | 0000-0002-7106-5229

Radiographics : a Review Publication of the Radiological Society of North America, Inc , 01 Jan 2002 , 22(1): 173-187 https://doi.org/10.1148/radiographics.22.1.g02ja15173   PMID: 11796906 

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References 

Articles referenced by this article (12)

Sherlock S, Dooley J.10th ed. London, England: Blackwell, 1997; 642-649.

Tomkins rk, saunders kd, roslyn jj, et al.1990; 211:614-621., intrahepatic peripheral cholangiocarcinoma: comparison of dynamic ct and dynamic mri..

Zhang Y , Uchida M , Abe T , Nishimura H , Hayabuchi N , Nakashima Y

J Comput Assist Tomogr, (5):670-677 1999

MED: 10524843

MR cholangiopancreatography in malignant biliary obstruction.

Pavone P , Laghi A , Passariello R

Semin Ultrasound CT MR, (5):317-323 1999

MED: 10527137

Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures.

Zidi SH , Prat F , Le Guen O , Rondeau Y , Pelletier G

Gut, (1):103-106 2000

MED: 10601064

Choi BI, Han JK, Kim TK.In: Gazelle SG, eds.New York, NY: Thieme, 1998; 630-676.

Choi bi, han jk, kim tk.in: meyers ma, eds.philadelphia, pa: lippincott-raven, 1998; 503-516., liver cancer study group of japan.tokyo, japan: kanehara, 1997; 6-8., peripheral cholangiocarcinoma of the liver: two-phase spiral ct findings..

Kim TK , Choi BI , Han JK , Jang HJ , Cho SG , Han MC

Radiology, (2):539-543 1997

MED: 9240550

Clonorchiasis: sonographic findings in 59 proved cases.

Lim JH , Ko YT , Lee DH , Kim SY

AJR Am J Roentgenol, (4):761-764 1989

MED: 2646867

Citations & impact 

Impact metrics, citations of article over time, article citations, degradation of azgp1 suppresses apoptosis and facilitates cholangiocarcinoma tumorigenesis via trim25..

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Three-dimensional visualization and evaluation of hilar cholangiocarcinoma resectability and proposal of a new classification.

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Feydy A , Vilgrain V , Denys A , Sibert A , Belghiti J , Vullierme MP , Menu Y

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Imaging of Cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common primary hepatobiliary tumour, and it is increasing in incidence. Imaging characteristics, behaviour, and therapeutic strategies in CC differ significantly, depending on the morphology and location of the tumour. In cross-sectional imaging, CCs can be classified according to the growth pattern (mass-forming, periductal infiltrating, intraductal) and the location (intrahepatic, perihilar, extrahepatic/distal). The prognosis of CC is unfavourable and surgical resection is the only curative treatment option; thus, early diagnosis (also in recurrent disease) and accurate staging including the evaluation of lymph node involvement and vascular infiltration is crucial. However, the diagnostic evaluation of CC is challenging due to the heterogeneous nature of the tumour. Diagnostic modalities used in the imaging of CC include transabdominal ultrasound, endosonography, computed tomography, magnetic resonance imaging with cholangiopancreatography, and hybrid imaging such as positron emission tomography/computed tomography. In this review, the potential of cross-sectional imaging modalities in primary staging, treatment monitoring, and detection of recurrent disease will be discussed.

Introduction

Cholangiocarcinoma (CC) is the most frequent malignant tumour of the biliary tract, accounting for 10-20% of all primary liver tumours [ 1 , 2 ]. The vast majority (95%) of CC are adenocarcinomas with a high proportion of fibrous stroma [ 3 , 4 ]. The prevalence of CC shows geographic variations, with the highest prevalence being found in Southeast Asia [ 2 ]. In the US, the incidence of CC has been steadily increasing over the past decades, varying from 0.72 to 0.88 per 100,000 [ 5 ]. Despite recent advances in patient care, surgical resection of the tumour remains the only potentially curable therapy, leading to a 5-year survival of 30-35% [ 6 ]. CC may occur at any segment of the bile duct, i.e. from the terminal ductules to the ampulla of Vater. Therefore, intrahepatic (iCC) and extrahepatic (eCC) tumour localizations are differentiated, and the iCC is subdivided into peripheral and perihilar CC (pCC), the latter also being called Klatskin tumour. In detail, 6-8% of CC are localized peripherally, 50-67% perihilar, and 27-42% occur extrahepatically [ 7 ]. Up to now, the aetiology of CC is not fully understood, but several risk factors like primary sclerosing cholangitis (PSC), liver fluke infestations ( Opisthorchis viverrini , Clonorchis sinensis ), hepatolithiasis, Thorotrast exposure, and choledochal cysts have been identified [ 8 ]. In accordance with the morphologic classification system proposed by the Liver Cancer Study Group of Japan [ 9 ], iCC can be classified into three types based on the dominating morphologic feature: mass-forming (the most common), periductal infiltrating, and intraductal growth (fig. ​ (fig.1). 1 ). Additionally, the growth pattern of eCC is commonly classified as nodular, sclerosing, or papillary [ 10 ]. Imaging modalities like ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and also positron emission tomography/computer tomography (PET/CT) are of particular importance in the diagnosis, primary staging, and restaging of CC.

Schematic illustration of the three most common morphologic features of iCC according to the Liver Cancer Study Group of Japan [ 13 ].

When clinical and laboratory findings are suggestive of CC, transabdominal US is commonly used in the initial phase of CC diagnostics. The technique is helpful to investigate the cause of bile duct obstruction and to characterize liver lesions. Recent technical advances, including transabdominal and endoscopic US applications, and also the use of contrast-enhanced US indicate great potential for the evaluation of both luminal and extraluminal masses in CC diagnosis. A detailed discussion of the role of US in the diagnosis of CC, however, is beyond the scope of this review as it is mainly focusing on the cross-sectional imaging techniques CT, MRI, and PET/CT. When CC is suspected in US due to dilatation of the intrahepatic biliary or an intrahepatic mass, further investigations are generally performed with a second-level imaging modality such as CT or MRI.

Computed Tomography

CT is performed in up to 90% of suspected CC, offering the opportunity of assessing the full extension of the tumour and determining potential surgical resectability. Additionally, pathological details, such as vascular infiltration and the presence of lymph node metastasis, can be estimated. In primary staging of CC, multiphase CT scanning protocols are recommended. By means of pre-contrast scanning (fig. ​ (fig.2A), 2A ), intraductal stones (as one of the risk factors of CC) can be identified [ 11 , 12 ]. In the arterial phase, the exact arterial anatomy of the liver and surrounding structures can be displayed, allowing for planning the surgical method in detail (fig. ​ (fig.2B). 2B ). In the portal venous phase (fig. ​ (fig.2C), 2C ), CC mainly show incomplete rim-like contrast enhancement at the tumour periphery and low intratumoural attenuation, increasing the precision in estimating the tumour size and the detection of satellite nodules [ 13 ]. In late-phase scans (5-10 min after contrast injection), a late enhancement of the tumour can be observed, representing the amount of fibrous stroma. In case of tumour necrosis and/or mucin-containing cells, the delayed enhancement may disappear [ 14 ]. Due to the volumetric scanning technique, CT images can be used in preoperative management to estimate the liver volume and potential liver remnants, avoiding postoperative small-for-size-syndrome [ 15 , 16 ]. Based on this information, alternative surgical procedures like ‘associating liver partition and portal vein ligation for staged hepatectomy’ (ALPPS) can be considered [ 17 ]. As already described, the main morphologic pattern of iCC can be characterized as mass-forming, periductal infiltrating, and intraductal growth which can be visualized using CT imaging.

CT images of an iCC. A In non-contrast enhanced images, a hypodense area is present in liver segment V-VI/VII-VIII. B Tumour vascularity can be visualized in major intensity projections of arterial-phase images. C The exact tumour size with peripheral enhancement and typical hypodense areas in the lesion centre are shown in portal-venous phase CT images.

Mass-forming iCC usually appears as a homogeneous low-attenuating mass on non-contrast-enhanced scans. After contrast media injection, an irregular peripheral enhancement with only minor enhancement in the centre of the tumour can be observed [ 13 ]. The degree of central contrast enhancement is increasing from arterial- to late-phase images and depends on the amount of central tumour fibrosis. Additional findings like capsular retraction and dilatation of bile ducts distal to the mass are typical. Narrowing of portal or hepatic veins is observed less frequently. Vascular invasion typically leads to lobar or segmental atrophy of the liver [ 18 ]. Periductal infiltrating iCC is characterized by a growth pattern along the bile duct without mass formation. The involved bile ducts can be dilated or narrowed but show diffuse periductal thickening with increased enhancement from arterial- to delayed-phase CT. Usually, a dilatation of the distal bile ducts is present [ 13 ]. Intraductal growth of iCC is primarily characterized by an irregular duct calibre. Usually, focal duct ectasia with or without a visible intraductal mass can be detected. In case of intraductal mass, a hypoattenuation with irregular margins can be observed on pre-contrast imaging, showing increasing contrast enhancement in portal venous- and delayed-phase images [ 13 ]. Imaging-based preoperative differentiation of growth pattern of eCC into nodular, sclerosing, and papillary remains challenging and does not seem to be of primary importance concerning the surgical strategy [ 19 ].

Primary Staging of Intrahepatic Cholangiocarcinoma

The literature on staging iCC by CT is poor. Prognosis of iCC depends on the tumour size, lymph node metastasis, quantity of hepatic tumours or intrahepatic metastasis, and vascular invasion. In comparison with MRI, CT seems to be more sensitive in detecting vascular involvement and extrahepatic invasion; therefore, it may be advantageous in the primary staging of iCC [ 20 ]. Additionally, CT might be more accurate than MRI in predicting the resectability of iCC, with an accuracy of up to 88% and a negative predictive value of 85-100% [ 21 ].

Primary Staging of Perihilar Cholangiocarcinoma

Based on 16 articles, a meta-analysis from 2012 estimated the accuracy of CT in staging pCC [ 22 ]. When judging the ductal extent of the tumour, CT showed an overall diagnostic accuracy of 86% (95% confidence interval (CI): 77-92%). Portal vein involvement was detected by CT with a sensitivity of 89% (95% CI: 80-94%) and a specificity of 92% (95% CI: 85-96%). CT diagnosis of hepatic artery involvement showed a sensitivity of 84% (95% CI: 63-94%) and a specificity of 93% (95% CI: 69-99%). The accuracy of CT in detecting lymph node metastasis seems to be limited, with a reported sensitivity of 61% (95% CI: 28-86%) and a specificity of 88% (95% CI: 74-95%). Concerning the evaluation of distant metastasis, CT showed a sensitivity of 67% and a specificity of 94%. So far, there are only a few studies which directly compare the accuracy of CT and MRI in the staging of pCC with controversial findings. In one study, the accuracy of estimating the intraductal tumour size was a little higher for MRI (71%) than for CT (64%) [ 23 ]. A second study favoured CT with an accuracy of 80% (MRI 75%) for the estimation of the intraductal tumour size [ 24 ].

Primary Staging of Extrahepatic Cholangiocarcinoma

In the staging of eCC, determining the exact tumour localization and its longitudinal and lateral expansion is of primary importance as the surgical resection method and the patient's prognosis both depend on these factors. Tumour localization is commonly described by using the modified Bismuth-Corlette classification (type I involves the common hepatic duct, type II involves the hepatic duct bifurcation, types IIIA and IIIB involve the right and left hepatic ducts, respectively, and type IV involves both the right and left hepatic ducts) [ 25 ]. Following the current T staging based on the seventh edition of the American Joint Committee on Cancer (AJCC) staging system [ 26 ], proximal and distal eCC are differentiated and T1 tumours are limited to the bile duct, whereas T2 tumours extend beyond the wall of the bile duct. With imaging (CT, MRI) and even in histopathology, the exact determination of the border of the bile duct is difficult [ 27 ]. Therefore, an accurate preoperative distinction of T1 and T2 tumours does not seem to be possible. Up to now, little is known about the exact accuracy of CT in the staging of eCC. The main issue constitutes the determination of tumour spread outside the wall of the bile duct, potentially affecting adjacent structures like the portal vein and hepatic artery, the hepatoduodenal ligament, and the head of the pancreas in T3 and T4 tumours. Preoperative CT-based three-dimensional space (3D) angiography and multiphase fusion imaging technique may be helpful in planning the surgical intervention, potentially minimizing operating time, the extent of surgical resection, and blood loss [ 28 ].

In mass-forming iCC, the degree of enhancement on delayed-phase CT scans seems to be a potential prognostic indicator. Asayama et al. [ 29 ] postulated a worse prognosis for patients with an intratumoural enhancement greater than two thirds on the delayed images. Two studies including 42 and 70 patients with iCC and operative resection showed strong correlations between augmented arterial tumour enhancement in preoperative CT, histopathological vascularity, and higher survival rate. Histological examination of these tumours demonstrated a smaller amount of fibrotic tissue and necrosis but a higher cellularity [ 30 , 31 ]. The estimated overall accuracy of CT in evaluating tumour resectability ranges between 60 and 75% [ 32 , 33 ].

Recurrent Disease

The probability of local recurrence and distant metastasis in iCC is high. Hyder et al. [ 34 ] analysed recurrence patterns of 301 patients who underwent surgical resection of iCC between 1990 and 2011. During the follow-up of 31 months, 53.5% patients developed recurrent, 60.9% intrahepatic, 21% extrahepatic, and 18.6% simultaneous intra- and extrahepatic disease [ 34 ]. Most frequently, metastases are found in the lungs (24%), peritoneum (18%), and bones (14%) [ 35 ]. Therefore, follow-up restaging CT in CC patients has to cover the thorax and main part of the skeletal system.

Novel Computed Tomography Techniques

Contrast-enhanced dual-energy CT (DECT) offers the opportunity of calculating virtual non-enhanced images, thus allowing the detection of bile duct stones without pre-contrast scanning [ 36 ]. Additionally, hepatic calcifications can be accurately diagnosed when using this technique. Due to the utilization of iodine mapping and monoenergetic extrapolation, the detectability of vascularity of the liver and thrombosis can be improved [ 37 , 38 ]. Marin et al. [ 39 ] showed a significant improvement of the conspicuity of hypervascular liver tumours by using low-keV (kilo electron volt) monoenergetic reconstructions. Analysing the virtual spectral curves from monoenergetic reconstructions of focal liver lesions might be helpful in differentiating benign from malign liver tumours [ 40 ]. Potential risk factors of CC like steatosis and iron overload can be estimated by employing dedicated DECT post-processing techniques [ 41 , 42 ]. Functional imaging of volume perfusion CT (VPCT) can help to assess the exact vascularization of the tumour in CC. Compared with the normal parenchyma, CC usually shows increased hepatic arterial perfusion, increased blood volume, and decreased portal perfusion [ 43 , 44 ]. Due to novel treatment regimens such as anti-angiogenetic drugs or targeted therapies, VPCT might be a helpful monitoring tool for judging treatment response by revealing changes in tumour vascularization in the absence of significant changes in tumour size [ 18 ]. Novel techniques in CT post-processing like frequency-selective non-linear blending may offer additional benefits in the diagnosis of CC [ 45 ].

Magnetic Resonance Imaging

In recent years, the field of abdominal MRI experienced a tremendous development, resulting in more reliable imaging sequences and increased image quality, which in turn led to improved tumour detectability, for instance in the case of liver tumours [ 46 ]. In comparison to other imaging techniques, MRI enables higher tissue contrast. According to current guidelines, MRI is the modality of choice for the diagnosis and staging of CC [ 47 ].

For the assessment of CC, comprehensive imaging protocols not only including the liver but also covering the biliary tract and pancreas should be applied in order to rule out other malignancies such as pancreatic head adenocarcinoma. A typical MRI protocol for the assessment of CC encompasses magnetic resonance cholangiopancreatography (MRCP), conventional T1- and T2-weighted sequences, as well as diffusion-weighted imaging (DWI) and dynamic contrast-enhanced (DCE) MRI [ 48 ]. Furthermore, MRI with hepatocyte-specific contrast agents is often performed for the assessment of CC [ 49 ].

MRCP is a non-contrast MRI technique for assessing the biliary system [ 50 ]. In fact, MRCP is the most accurate non-invasive imaging technique for the assessment of the biliary system [ 51 ]. It allows accurate tumour assessment in both proximal and distal bile ducts [ 51 ]. For appropriate depiction of the biliary system in MRCP, heavily T2-weighted sequences with very long echo time are obtained, resulting in high (i.e. hyperintense) fluid signal in the bile ducts and low (i.e. suppressed) background signal [ 48 ]. MRCP sequences are usually acquired using a combination of thick-slab radial T2 sequences and thin 3D T2 sequences. The thick-slab sequences provide a good overview of the biliary system with a good suppression of the surrounding tissue, whereas the thin 3D T2 sequences provide high spatial resolution and allow for the detection of small abnormalities in the bile ducts such as small masses and/or strictures [ 48 ].

In addition to MRCP, which is useful for depicting intraductal CC tumour growth, DWI, DCE-MRI, and late-phase sequences with hepatocyte-specific contrast agents are helpful in the assessment of extraductal tumour growth as well as in the depiction of tumour masses within dilated bile ducts [ 48 , 52 ].

MRI, especially in combination with MRCP, has a high diagnostic accuracy for the assessment of CC. Park et al. [ 53 ] showed that MRCP and MRI revealed a comparable diagnostic accuracy with invasive cholangiography combined with CT imaging for the detection of CC.

Preoperative MRI is commonly performed in patients with CC in order to assess the extent, resectability, and vascular involvement of the tumour. It is also employed for road mapping of the hepatic vessels and for visualization of vascular anatomic variants. Accurate preoperative assessment of liver vasculature has been shown to significantly affect the surgical outcome in patients with CC [ 54 ].

Besides the preoperative staging and follow-up imaging of CC, MRI and MRCP play a central role in the surveillance of patients with an increased risk of CC, e.g. those with PSC. The lifetime incidence of CC in patients with PSC ranges from 5 to 10% [ 48 ]. According to recent recommendations, MRI including MRCP is appropriate for the surveillance of those patients [ 55 ].

Magnetic Resonance Imaging of Mass-Forming Cholangiocarcinoma

Mass-forming CC are often seen in iCC and usually appear as T1 iso- or hypointense as well as T2 hyperintense [ 56 ]. Contrast enhancement of mass-forming iCC is variable. The most frequent pattern is peripheral enhancement on early images, which progresses on late images [ 57 ] (fig. ​ (fig.3). 3 ). Contrast enhancement patterns depend on the tumour size, structure, and composition; small tumours with less fibrotic tissue may show homogeneous enhancement, whereas large fibrotic tumours may only enhance in late images.

MRI of a 64-year-old female patient with mass-forming CC of the right liver lobe. The CC appears hyperintense on T2-weighted images with diffusion restriction on DWI and shows a typical contrast enhancement pattern on the DCE-MRI.

When using hepatocyte-specific contrast agent, mass-forming iCC often has a cloud-like appearance with a central hyperintense area and a rim with lower signal intensity [ 58 ].

Extrahepatic ductal CC can also appear as a mass mimicking pancreatic adenocarcinoma. In these cases, assessment of the pancreatic duct on MRCP can help to differentiate both tumour entities.

Magnetic Resonance Imaging of Periductal Cholangiocarcinoma

Periductal growth is usually seen in pCC and eCC [ 59 ]. Periductal CC grows alongside the wall of the bile duct, resulting in wall thickening and narrowing of the affected segment and dilation of the proximal intrahepatic bile ducts as seen on T2-weighted images and MRCP (fig. ​ (fig.4) 4 ) [ 60 ]. Periductal CC usually shows slow contrast enhancement, which is best seen in late contrast-enhanced images [ 59 ].

A Coronal T2-weighted image and B MRCP of a 75-year-old female patient with periductal CC. The MRCP shows narrowing of the proximal biliary ducts (arrow) and dilation of the intrahepatic ducts.

Magnetic Resonance Imaging of Intraductal Cholangiocarcinoma

Similar to mass-forming CC, intraductal CC begins to enhance on early post-contrast images, with peak enhancement on late post-contrast images [ 18 ]. MRCP is very suitable for the detection of intraductal CC, with a higher diagnostic accuracy when compared to CT [ 18 , 48 ].

Positron Emission Tomography/ Computed Tomography

Primary staging.

PET/CT is increasingly being recognized as a diagnostic tool in order to provide valuable information for the evaluation of CC. Regarding primary tumour detection in PET/CT, a meta-analysis of 1,232 patients in 23 studies provided high sensitivities of 95% and specificities of 83% for iCC [ 61 ], with a decrease to 84% and 76% in sensitivity and to 95% and 74% in specificity being found when evaluating pCC and eCC, respectively. This indicates a dependency of primary tumour evaluation on tumour localization. Other studies provide even lower sensitivities of 55% for primary staging of pCC in 18 F-FDG ( 18 F-fluorodeoxyglucose) PET/CT [ 62 ]. Other false-negative issues include infiltrative growth, periductal sclerosing, and tumours with a high fraction of mucin [ 63 ]. The diagnostic performance of 18 F-FDG PET/CT in primary tumour evaluation of CC, however, depends on several aspects. First of all, there may be false-positive results due to concomitant inflammatory changes of the bile ducts, caused either by tumour-induced bile retention or chemotherapy or following invasive procedures such as implantation of intraluminal bile duct stents. Furthermore, 18 F-FDG PET/CT is limited in detecting small tumours, as only tumours > 1 cm in diameter are eligible for confident detection by this method [ 64 , 65 ]. Additionally, the different histopathological subtypes and the anatomical location of the tumour need to be considered when performing 18 F-FDG PET/CT.

Several studies indicate that in eCC especially, late 18 F-FDG PET imaging (image acquisition after injection 120 min and longer) could be helpful in differentiating benign bile duct strictures from malignant tumours. This theory is based on the continuous uptake of 18 F-FDG in malignant cells over 3 h, whereas benign diseases tend to show a decline in 18 F-FDG uptake over time. This approach might be a helpful tool when using semiquantitative [ 66 ] or visual assessment [ 67 ], with a small increase in diagnostic sensitivity (76 vs. 79%) and accuracy (76 vs. 80%) being found, whereas specificity remained the same (80%) in 39 patients, thereof 34 patients with CC [ 66 ]. Although some studies indicate a correlation between tumour-to-normal liver ratio (TNR) and standardized uptake values (SUV) in 18 F-FDG PET/CT (65 patients, thereof 47 CC patients) [ 68 ], other studies could not confirm this finding and did not find any correlation between tumour marker levels and SUV values (65 patients with ICC) [ 69 ]. However, it is worth noting that 18 F-FDG PET/CT-induced therapy regimens have been reported in 17-24% [ 69 ], indicating a substantial merit of this hybrid technique regarding the correct evaluation of N and M staging. Determination of N staging is crucial because it correlates with the 5-year survival rates which vary from 27% for N1 (regional lymph nodes in the hepatoduodenal ligament) to 50% for N0 [ 70 ]. Special emphasis lies on the detection of the N2 stage (lymph nodes periaortic, pericaval, or adjacent to the mesenteric or celiac artery), as these are being considered as a contraindication for tumour resection [ 70 ]. 18 F-FDG PET/CT showed a significantly higher specificity (88.2 vs. 64.7%) and accuracy (75.9 vs. 60.9%) for N staging in comparison to CT alone (sensitivity: PET/CT 80% vs. CT 20%; specificity: 92.3 vs. 86.4%, respectively) [ 63 , 71 ]. However, Kluge et al. [ 72 ] examined the role of PET in the diagnosis and staging of CC and did not confirm a positive N staging in their collective of 26 patients; they did mention the significant influence of 18 F-FDG PET on M staging (metastases in liver, peritoneal cavity, distant lymph nodes, lung, bones, and brain), though. As advanced biliary cancer shows huge metabolic differences between the tumours [ 73 ] and detection of peritoneal carcinomatosis is difficult even in 18 F-FDG PET/CT imaging, the additional information of 18 F-FDG PET/CT regarding primary staging of CC in general was relatively low in comparison to conventional imaging including diagnostic laparoscopy [ 22 ]. However, the usefulness of preoperative 18 F-FDG PET/CT in CC for N and M staging is stated in the National Comprehensive Cancer Network (NCCN) guidelines [ 74 ].

In conclusion, the evaluation of tumour resectability by means of different imaging methods reveals that CT imaging is the standard, with high reported sensitivities and specificities (for pCC: sensitivity 91-97%, specificity 63-75%) but with limitations in small hepatic lesions and small lymph node metastasis, where PET/CT seems a promising diagnostic tool. MRI provides comparable results (sensitivity 90-97%, specificity 60-81%), with limitations concerning the evaluation of the vessel involvement with a decreased sensitivity of 73% [ 75 ].

Even in the 30% of patients with apparently primarily resectable tumours according to imaging, tumour recurrence occurs in up to 60-80% in the following 5 years [ 76 ]. The localization of tumour recurrence is mainly next to the resection zone and the hilum including locoregional lymph nodes [ 77 ]. Standardized imaging follow-up includes conventional imaging with CT or MRI [ 78 ]. In case of elevated tumour markers but negative conventional imaging, 18 F-FDG PET is helpful in the detection of recurrence (sensitivity 89%, specificity 100%; study with 33 patients) [ 79 ], with even higher values in 18 F-FDG PET/CT ( 18 F-FDG PET/CT sensitivity 94%, specificity 100% vs. CT sensitivity 82%, specificity 43%; study with 16 patients). Seo et al. [ 65 ] suggested that PET/CT may also provide prognostic information as tumour recurrence could be predicted by 18 F-FDG PET/CT. This hypothesis is based on a study that found a lower disease-free survival if the primary tumour showed high metabolic activity with a cut-off value of SUV mean 8.5 (study based on 27 patients with iCC). Another study (25 patients) with distal bile duct adenocarcinoma revealed total lesion glycolysis (TLG) as a better prognostic marker in primarily resected patients than SUV max [ 80 ]. Onal et al. [ 81 ] reported that 18 F-FDG PET/CT may be useful for radiation planning, with a possible dose reduction for adjacent organs at risk of 17% (right kidney, liver; study in 15 patients with eCC).

In conclusion, 18 F-FDG PET/CT seems to be a promising diagnostic tool in the primary staging of CC regarding N and M status. 18 F-FDG PET/CT plays a major role in the detection of tumour recurrence where this hybrid modality has great potential for differentiating between post-therapeutic changes (including fibroses due to radiotherapy) and tumour recurrence (fig. ​ (fig.5) 5 ) [ 82 ]. Moreover, PET/CT may be useful for the monitoring of treatment response, as metabolic changes may precede the anatomical ones [ 83 , 84 ] (fig. ​ (fig.6, 6 , ​ ,7 7 ).

18 F-FDG-PET/CT for restaging of a 46-year-old male patient with iCC after chemotherapy. Hypodense iCC ( A ) with high tracer uptake indicating high metabolism of the lesion ( B ). After systemic therapy, central necrosis occurred ( C ) which cannot be visualized in CT alone ( D ).

45-year-old male patient. Status post hemihepatectomy for pCC 3 years ago. In CT, a small hypodense liver lesion adjacent to surgical clips is seen ( A ) with elevated 18 F-FDG uptake ( B ) indicative for tumour recurrence. In addition to the local recurrence, two paracardial lymph nodes ( C ) show high FDG uptake in PET, which is suspicious for lymph node metastases ( D ).

49-year-old female patient after resection of pCC. In follow-up imaging, post-therapeutic changes were noticed at the resection margin (slight hyperintensity in the T2-weighted images of MRI; arrow). A Adjacent to surgical clips which are visible in CT ( B ). However, differentiation between local fibrotic changes and tumour recurrence was not possible based on the morphologic appearance in CT and MRI alone. In the fused 18 F-FDG-PET/CT, focal 18 F-FDG uptake was found in the corresponding area indicating tumour recurrence at the resection margin ( C ).

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The authors declare that no conflicts of interest exist.

Imaging of intrahepatic and hilar cholangiocarcinoma

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• Published: 08 June 2004
• Volume 29 , pages 548–557, ( 2004 )

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• B. I. Choi 1 ,
• J. M. Lee 1 &
• J. K. Han 1  

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PR Ros JL Buck ZD Goodman et al. (1988) ArticleTitle Intrahepatic cholangiocarcinoma: radiologic-pathologic correlation Radiology 67 689–693

Google Scholar  

T Nakajima Y Kondo M Miyazaki K Okui (1988) ArticleTitle A histopathologic study of 102 cases of intrahepatic cholangiocarcinoma: histologic classification and mode of spreading Hum Pathol 19 1228–1234 Occurrence Handle 1:STN:280:BiaD3cnmtlA%3D Occurrence Handle 2844646

CAS   PubMed   Google Scholar  

Y Nakanuma H Minato T Kida T Terada (1994) Pathology of cholangiocellular carcinoma T Tobe H Kameda M Okudaira M Ohto (Eds) Primary liver cancer in Japan Springer-Verlag Tokyo 39–50

AR Clemett (1985) ArticleTitle Carcinoma of the major bile ducts Radiology 84 894–903

WJ Lee HK Lim KM Jang et al. (2001) ArticleTitle Radiologic spectrum of cholangiocarcinoma: emphasis on unusual manifestations and differential diagnosis Radiographics 21 97–116

JK Han BI Choi AY Kim et al. (2002) ArticleTitle Cholangiocarcinoma: pictorial essay of CT and cholangiographic findings Radiographics 22 173–187 Occurrence Handle 11796906

PubMed   Google Scholar  

Y Zhang M Uchida T Abe et al. (1999) ArticleTitle Intrahepatic peripheral cholangiocarcinoma: comparison of dynamic CT and dynamic MRI J Comput Assist Tomogr 23 670–677 Occurrence Handle 10.1097/00004728-199909000-00004 Occurrence Handle 1:STN:280:DyaK1Mvlt1Cktg%3D%3D Occurrence Handle 10524843

Article   CAS   PubMed   Google Scholar  

P Pavon A Laghi R Passariello (1999) ArticleTitle MR cholangiopancreatography in malignant biliary obstruction Semin Ultrasound CT MR 20 317–323 Occurrence Handle 10.1016/S0887-2171(99)90063-X Occurrence Handle 10527137

Article   PubMed   Google Scholar  

SH Zidi F Prat O Le Guen et al. (2000) ArticleTitle Performance characteristics of magnetic resonance cholangiography in the staging of malignant hilar strictures Gut 46 103–106 Occurrence Handle 10.1136/gut.46.1.103 Occurrence Handle 1:STN:280:DC%2BD3c%2FmvFGjuw%3D%3D Occurrence Handle 10601064

InstitutionalAuthorName Liver Cancer Study Group of Japan (2000) The general rules for the clinical and pathological study of primary liver cancer, 4th ed Kanehara Tokyo

A Sasaki M Aramaki K Kawano et al. (1998) ArticleTitle Intrahepatic peripheral cholangiocarcinoma: mode of spread and choice of surgical treatment Br J Surg 85 1206–1209 Occurrence Handle 10.1046/j.1365-2168.1998.00815.x Occurrence Handle 1:STN:280:DyaK1cvitlOrsA%3D%3D Occurrence Handle 9752860

M Yamamoto K Takasaki T Yoshikawa et al. (1998) ArticleTitle Does gross appearance indicate prognosis in intrahepatic cholangiocarcinoma J Surg Oncol 69 162–167 Occurrence Handle 10.1002/(SICI)1096-9098(199811)69:3<162::AID-JSO8>3.0.CO;2-L Occurrence Handle 1:STN:280:DyaK1M%2FmtV2gtQ%3D%3D Occurrence Handle 9846503

S Isaji Y Kawarada H Taoka et al. (1999) ArticleTitle Clinicopathological features and outcome of hepatic resection for intrahepatic cholangiocarcinoma in Japan J Hepatobil Pancreat Surg 6 108–116 Occurrence Handle 10.1007/s005340050092 Occurrence Handle 1:STN:280:DyaK1MzivFemuw%3D%3D

Article   CAS   Google Scholar  

JH Lim (2003) ArticleTitle Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings AJR 181 819–827 Occurrence Handle 12933488

BI Choi JH Park YI Kim et al. (1988) ArticleTitle Peripheral cholangiocarcinoma and clonorchiasis: CT findings Radiology 169 149–153 Occurrence Handle 1:STN:280:BieA3snktlQ%3D Occurrence Handle 2843940

TK Kim BI Choi JK Han et al. (1997) ArticleTitle Peripheral cholangiocarcinoma of the liver: two-phase helical CT findings Radiology 204 539–543 Occurrence Handle 1:STN:280:ByiA1c3lsVI%3D Occurrence Handle 9240550

BI Choi JK Han TK Kim (1998) Diagnosis and staging of cholangiocarcinoma by computed tomography MA Meyers (Eds) Neoplasms of the digestive tract: imaging, staging and management Lippincott-Raven Philadelphia 503–516

BI Choi JK Han YM Shin et al. (1995) ArticleTitle Peripheral cholangiocarcinoma: comparison of MRI with CT Abdom Imaging 20 357–360 Occurrence Handle 1:STN:280:BymD2crgsVY%3D Occurrence Handle 7549743

MF Fan Y Yamashita M Harada et al. (1993) ArticleTitle Intrahepatic cholangiocarcinoma: spin-echo and contrast-enhanced dynamic MR imaging AJR 161 313–317 Occurrence Handle 1:STN:280:ByyA38rltFA%3D Occurrence Handle 8392787

JE Hamrick-Turner PL Abbitt PR Ros (1992) ArticleTitle Intrahepatic cholangiocarcinoma: MR appearance AJR 158 77–79 Occurrence Handle 1:STN:280:By2D1c7lsFc%3D Occurrence Handle 1309221

H Honda H Onitsuka K Yasumori et al. (1993) ArticleTitle Intrahepatic peripheral cholangiocarcinoma: two-phased dynamic incremental CT and pathological correlation J Comput Assist Tomogr 17 397–402 Occurrence Handle 1:STN:280:ByyB28%2Fhs1Y%3D Occurrence Handle 8388005

JM Lacomis RL Baron JH, III Oliver et al. (1997) ArticleTitle Cholangiocarcinoma: delayed CT contrast enhancement patterns Radiology 203 98–104 Occurrence Handle 1:STN:280:ByiB3s3ktVI%3D Occurrence Handle 9122423

BI Choi JK Han JM Cho et al. (1995) ArticleTitle Characterization of focal hepatic tumors: value of two-phase scanning with spiral computed tomography Cancer 76 2434–2442 Occurrence Handle 1:STN:280:BymB38zjtVc%3D Occurrence Handle 8625068

P Soyer DA Bluemke C Vissuzaine et al. (1994) ArticleTitle CT of hepatic tumors: prevalence and specificity of retraction of the adjacent capsule AJR 162 1119–1122 Occurrence Handle 1:STN:280:ByuB3MbjtFU%3D Occurrence Handle 8165994

HA Edmondson PE Steiner (1954) ArticleTitle Primary carcinoma of the liver: a study of 100 cases among 48,900 necropsies Cancer 7 462–503 Occurrence Handle 13160935

K Okuda Y Kubo N Okazaki et al. (1977) ArticleTitle Clinical aspects of intrahepatic bile duct carcinoma including hilar carcinoma: a study of 7 autopsy proven cases Cancer 39 232–246 Occurrence Handle 1:STN:280:CSiD1cbit1M%3D Occurrence Handle 64293

AC Friedman S Frazier TM Hendrix PR Ros (1994) Focal disease. Part I. The liver AC Friedman AH Dachman (Eds) Radiology of the liver, biliary tract, and pancreas Mosby St Louis 169–327

P Soyer DA Bluemke R Reichle et al. (1995) ArticleTitle Imaging of intrahepatic cholangiocarcinoma. 2. Hilar cholangiocarcinoma AJR 165 1433–1436 Occurrence Handle 1:STN:280:BymD2s3mvFY%3D Occurrence Handle 7484580

JH Lim C Yi HK Lim et al. (2002) ArticleTitle Radiological spectrum of intraductal papillary tumors of the bile ducts Korean J Radiol 3 57–63 Occurrence Handle 11919480

JW Lee JK Han TK Kim et al. (2000) ArticleTitle CT features of intraductal intrahepatic cholangiocarcinoma AJR 175 721–725 Occurrence Handle 1:STN:280:DC%2BD3cvnsFaruw%3D%3D Occurrence Handle 10954456

YS Kim ST Myung SY Kim et al. (1998) ArticleTitle Biliary papillomatosis: clinical, cholangiographic and cholangioscopic findings Endoscopy 30 763–767 Occurrence Handle 1:STN:280:DyaK1M7ivFGgtw%3D%3D Occurrence Handle 9932755

KH Yoon HK Han CG Kim et al. (2000) ArticleTitle Malignant papillary neoplasms of intrahepatic bile ducts: CT and histopathologic features AJR 175 1135–1139 Occurrence Handle 1:STN:280:DC%2BD3cvpvVyqsw%3D%3D Occurrence Handle 11000178

JH Lim MH Kim TK Kim et al. (2003) ArticleTitle Papillary neoplasms of the bile duct that mimic biliary stone disease Radiographics 23 447–455 Occurrence Handle 12640158

JK Han BI Choi TK Kim et al. (1997) ArticleTitle Hilar cholangiocarcinoma: thin-section spiral CT findings with cholangiographic correlation Radiographics 17 1475–1485 Occurrence Handle 1:STN:280:DyaK1c%2FlvFynug%3D%3D Occurrence Handle 9397459

BI Choi JK Han TK Kim (1998) Benign and malignant tumors of the biliary tree SG Gazelle (Eds) Hepatobiliary and pancreatic radiology Thieme New York 630–676

LA Wetter EJ Ring CA Pellegrini LW Way (1991) ArticleTitle Differential diagnosis of sclerosing cholangiocarcinoma of the common hepatic ducts (Klatskin tumors) Am J Surg 161 57–63 Occurrence Handle 10.1016/0002-9610(91)90361-G Occurrence Handle 1:STN:280:By6C3czjvFw%3D Occurrence Handle 1846276

LE Hann KV Greatrex AM Bach et al. (1997) ArticleTitle Cholangiocarcinoma at the hepatic hilus: sonographic findings AJR 168 985–989 Occurrence Handle 1:STN:280:ByiB2czjt1U%3D Occurrence Handle 9124155

JT Ferrucci (1994) ArticleTitle Liver tumor imaging: current concepts Radiol Clin North Am 32 39–54 Occurrence Handle 1:STN:280:ByuC3M3hvVU%3D Occurrence Handle 8284360

SC Stain HU Baer AR Dennison LH Blumgart (1992) ArticleTitle Current management of hilar cholangiocarcinoma Surg Gynecol Obstet 175 579–588 Occurrence Handle 1:STN:280:ByyD2sbmtlA%3D Occurrence Handle 1280374

H Honda Y Matsuura H Onitsuka et al. (1992) ArticleTitle Differential diagnosis of hepatic tumors (hepatoma, hemangioma, and metastasis) with CT: value of two-phase incremental imaging AJR 159 735–740 Occurrence Handle 1:STN:280:By2H3M7gs1U%3D Occurrence Handle 1326884

A Adam IS Benjamin (1992) ArticleTitle The staging of cholangiocarcinoma Clin Radiol 46 299–303 Occurrence Handle 1:STN:280:ByyD1MbntF0%3D Occurrence Handle 1334451

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Choi, B., Lee, J. & Han, J. Imaging of intrahepatic and hilar cholangiocarcinoma. Abdom Imaging 29 , 548–557 (2004). https://doi.org/10.1007/s00261-004-0188-1

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• Cholangiocarcinomas
• Cholangiocellular carcinoma (CCC)
• Bile duct cancer

Cholangiocarcinomas  (commonest type of bile duct cancers ) are malignant epithelial tumours arising from the biliary tree , excluding the gallbladder or ampulla of Vater . Cholangiocarcinoma is the third most common primary hepatobiliary malignancy after hepatocellular carcinoma (HCC)  and gallbladder cancer 23 . They tend to have a poor prognosis and high morbidity. 

On this page:

Epidemiology, clinical presentation, radiographic features, radiology report, treatment and prognosis, differential diagnosis.

• Related articles

Cases and figures

Imaging differential diagnosis.

Although overall cholangiocarcinoma is rare, there are significant regional variations in incidence with much higher rates seen in Southeast Asia and the Middle East 2 . The incidence ranges from 0.3 to 6 per 100,000 inhabitants per year 14 . 

They usually present in the elderly, with a mean age of 65 years 7 . There may be a slight male predilection.

Cholangiocarcinomas correspond to ~15% of all primary liver tumours and to ~3% of all gastrointestinal malignancies 14 . 

Risk factors

A number of risk factors for cholangiocarcinoma have been identified, and bile stasis and chronic inflammation of the biliary epithelium are identified as common features among many of them 1,2,9,14 :

Caroli disease  /  choledochal cysts : lifetime risk of 10-15%  2

choledocholithiasis : more than cholelithiasis   10,11

primary sclerosing cholangitis (PSC) : especially in Western countries

recurrent pyogenic cholangitis : especially in Southeast Asia

cirrhosis 14

toxins: e.g.  thorotrast , dioxin, polyvinylchloride, heavy alcohol use

viral infections: e.g.  HIV ,  hepatitis B ,  hepatitis C ,  EBV

Inflammatory bowel disease (IBD)   17

fibropolycystic liver disease 18,19

liver fluke infestation: Opisthorchis spp. and Clonorchis spp.  18,20

hepatolithiasis 18,21

​ Regarding inflammatory bowel disease, cholangiocarcinoma develops in one in every 100 to 200 patients, which means they have a 4 times greater risk than IBD-free patients. Individuals with ulcerative colitis are at higher risk of having cholangiocarcinoma in comparison to those with Crohn disease 17 .

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Typically, the presentation is with painless jaundice .

Cholangiocarcinomas may be classified anatomically as follows 16 :

intrahepatic (10% of cases)

extrahepatic

perihilar (70%): occur between the secondary biliary radicles and proximal to the cystic duct insertion

tumours involving the confluence of the right and left hepatic ducts are frequently referred to as Klatskin tumours , although use of the eponym is going out of favour in both the radiology and the clinical literature 22

distal (20%): distal to the cystic duct insertion

NB: There is variability in nomenclature in the literature, as perihilar cancers often span the vague and variable boundary between intrahepatic and extrahepatic bile ducts. For example, intrahepatic cholangiocarcinomas are sometimes subclassified into peripheral and hilar types 16 .

Some institutions are discouraging the use of the terms Klatskin tumour and extrahepatic cholangiocarcinoma in favour of perihilar and distal cholangiocarcinoma in an attempt to standardise the classification and provide useful clinical information. Indeed, the International Liver Cancer Association guidelines on "Diagnosis and management of intrahepatic cholangiocarcinoma" published in 2014 discourage using the term Klatskin tumour altogether 22 .

Perihilar cholangiocarcinomas are commonly subclassified by their anatomic extent according to the Bismuth-Corlette classification  (described separately).

Classification

Prognostic staging uses the TNM system , depending on location:

intrahepatic cholangiocarcinoma (staging)

perihilar cholangiocarcinoma (staging)

distal cholangiocarcinoma (staging)

The previously mentioned Bismuth-Corlette anatomic classification is used for operative planning but is limited in predicting prognosis 16 .

Macroscopic appearance

Cholangiocarcinomas are typically sclerotic masses without haemorrhage or macroscopic necrosis 2 . In general, the active tumour is at the periphery, with the central portions replaced by fibrosis, accounting for the capsular retraction that may be seen in intrahepatic tumours.

The macroscopic appearance is further described according to the Liver Cancer Study Group of Japan classification 15,16 :

mass-forming : definite mass in the liver parenchyma

periductal-infiltrating : extends longitudinally along the bile duct, often causing peripheral bile duct dilation

intraductal : proliferates in the lumen of the bile duct-like a papilla or tumour thrombus

Mass-forming

Intrahepatic exophytic nodular (peripheral) tumours are most commonly of the mass-forming type 3 . They demonstrate variable amounts of central fibrosis, usually marked.

Periductal infiltrating

Periductal infiltrating intrahepatic tumours are most common at the hilum (comprise over 70% of hilar-perihilar cholangiocarcinomas), known as Klatskin tumours 3 , but can also be seen in combination with mass-forming tumours within the liver. Growth along the walls of the duct may narrow or dilate the duct.

Intraductal

Intraductal tumours comprise 8-18% of resected cholangiocarcinomas 3  and a much smaller number of all cholangiocarcinomas (as most are inoperable). They are characterised by alterations in duct calibre, usually duct ectasia with or without a visible mass. If a mass is visible it may be mural or polypoid in shape 2 . The duct dilatation is thought to be due to abundant mucin production. This entity is thought to be similar to the pancreatic intraductal papillary mucinous neoplasms (IPMN) .

Microscopic appearance

Histologically, cholangiocarcinomas are divided into well, moderately, and poorly differentiated adenocarcinomas 2 . In specimens of bile ducts from patients with hepatolithiasis, biliary intraepithelial neoplasia (BilIN) is a common finding and is considered to be a precursor lesion of cholangiocarcinoma. It is typically a microscopic lesion with a flat or micropapillary dysplastic epithelium. It is synonymous with carcinoma in situ 2 .

The appearance will vary according to the growth pattern. 

Mass-forming : tumours will be a homogeneous mass of intermediate echogenicity with a peripheral hypoechoic halo of compressed liver parenchyma. They tend to be well delineated but irregular in outline and are often associated with capsular retraction 2  which, if present, helps distinguish cholangiocarcinomas from other hepatic tumours .

Periductal infiltrating : tumours typically are associated with altered calibre bile duct (narrowed or dilated) without a well-defined mass.

Intraductal : tumours are characterised by alterations in duct calibre, usually duct ectasia with or without a visible mass. If a polypoid mass is seen, it is usually hyperechoic compared to surrounding liver 2 .

Contrast-enhanced ultrasound

Contrast-enhanced ultrasound may aid with the diagnosis of cholangiocarcinoma 8 :

arterial phase

peripheral irregular rim-like enhancement

heterogeneous central hypoenhancement

portal venous phase / delayed phase

decreased echogenicity relative to background liver ("wash out")

Mass-forming : these are typically homogeneously low in attenuation on non-contrast scans, and demonstrate heterogeneous minor peripheral enhancement with gradual centripetal enhancement 2,3 . The rate and extent of enhancement depend on the degree of central fibrosis 2 .  Again, capsular retraction may be evident. Calcification may be seen in ~20% 24 . The bile ducts distal to the mass are typically dilated.

Although narrowing the portal veins, or less frequently hepatic veins, is seen, unlike hepatocellular carcinoma, cholangiocarcinoma only rarely forms a tumour thrombus 2 .

Lobar or segmental hepatic atrophy is usually associated with vascular invasion 6 . 

Periductal infiltrating : intrahepatic tumours appear as regions of duct wall thickening or of the periductal parenchyma, with altered calibre of the involved duct (usually narrowed). These are most common at the hepatic hilum. They tend to be longer than benign strictures (i.e. approximately 20 mm in length) and show contrast enhancement. There is usually some proximal (i.e. peripheral) dilatation of the biliary tree .

Intraductal : these are characterised by alterations in duct calibre, usually duct ectasia with or without a visible mass. If a polypoid mass is seen, it is hypoattenuating on pre-contrast imaging and demonstrates enhancement 2 .

MRI is the imaging modality of choice as it can best visualise all three of the tumour mass, the biliary ducts, and the blood vessels, all of which are essential for determining resectability (see below). Appearances on MR are similar to those described above for CT, except that MR is more sensitive to contrast enhancement 3  and bile duct visualisation.

DWI/ADC : a peripherally hyperintense "target" appearance on DWI favours cholangiocarcinoma over hepatocellular carcinoma

Direct cholangiography

Direct cholangiography is a blanket term for any imaging obtained with intra-biliary tree contrast and includes:

All these modalities not only allow evaluation of the biliary tree but are invaluable in planning treatment and assessing for resectability.

The following reporting checklist pertains to hilar/perihilar cholangiocarcinoma, as it is anatomically close to the large bile ducts and blood vessels, crucial to the determination of resectability:

bile ducts (see Bismuth-Corlette classification )

is the tumour confined to the common or hepatic bile duct?

is there extension to the right or left hepatic duct or both?

does the tumour involve second-order radicles and on which side?

portal vein : does the tumour abut/encase the main/right/left portal vein and to what extent?

hepatic artery

is the common hepatic artery / hepatic artery proper involved and to what extent?

is the right / left hepatic artery involved and to what extent?

any variant arterial anatomy ?

lymph nodes: enlarged regional (N1) or distant (N2) lymph nodes?

assess for distal metastases

The most important factor in prognosis is whether or not the tumour can be resected. Unfortunately, when discovered, most cases are too advanced for curative resection. Even with resection, the prognosis is poor, with a 5-year survival of only 10-44% 4 , with the prognosis favouring extrahepatic tumours (around 30% 5-year survival vs 15% for intrahepatic tumours).

The pattern of metastatic spread includes 1 :

intrahepatic vascular involvement with numerous local metastases 

regional lymph nodes (50% at autopsy)

haematogenous (50% at autopsy)

bones, especially vertebrae

adrenal glands

Surgical resectability

An increase in margin-negative resection rates and, hence, survival can be achieved by resection of the ipsilateral hepatic lobe. In the interest of leaving the patient with a large enough contralateral lobe, portal vein branch embolisation of the lobe intended for resection 4-6 weeks before surgery can induce hypertrophy of the contralateral lobe. It should be noted that when attempting resection, tumour size in itself is unimportant.

A hilar-perihilar tumour is considered unresectable in the following cases 12 :

Bismuth type IV: bilateral secondary biliary radicle involvement

main portal vein encasement/occlusion

atrophy of a liver lobe with contralateral portal vein or hepatic artery encasement

atrophy of a liver lobe with contralateral secondary biliary radicle involvement

involvement of both hepatic arteries

The differential diagnosis depends on whether the tumour is intrahepatic or extrahepatic and on the growth pattern.

For a mass-forming cholangiocarcinoma consider the following:

liver metastases

central necrosis (high T2 signal) is more common

hepatocellular carcinoma (HCC)

tumour thrombus more common

capsular retraction uncommon

may appear very similar

other primary liver tumours

hepatic abscess

For a periductal infiltrating cholangiocarcinoma consider the following:

benign stricture

usually short-segment 

regular margin, but there are exceptions to this

symmetric narrowing

no ductal enhancement

no lymph node enlargement

no periductal soft-tissue mass

periportal lymphangitic metastasis 2

For an intraductal cholangiocarcinoma consider:

intraductal invasion by hepatocellular carcinoma (HCC)

extraductal mass

hepatolithiasis

no enhancement

higher attenuation

biliary cystadenoma or cystadenocarcinoma

intratumoural cysts do not communicate with the biliary tree

Quiz questions

• 1. Vinay Kumar, Abul K. Abbas, Nelson Fausto. Robbins and Cotran Pathologic Basis of Disease. (2005) ISBN: 9780721601878 - Google Books
• 2. Chung Y, Kim M, Park Y et al. Varying Appearances of Cholangiocarcinoma: Radiologic-Pathologic Correlation. Radiographics. 2009;29(3):683-700. doi:10.1148/rg.293085729 - Pubmed
• 3. Han J, Choi B, Kim A et al. Cholangiocarcinoma: Pictorial Essay of CT and Cholangiographic Findings. Radiographics. 2002;22(1):173-87. doi:10.1148/radiographics.22.1.g02ja15173 - Pubmed
• 4. Josef E. Fischer, Kirby I. Bland, Mark P. Callery. Mastery of Surgery. (2006) ISBN: 9780781771658 - Google Books
• 5. C.D. Johnson, I. Taylor. Recent Advances in Surgery 27. (2004) ISBN: 9781853155710 - Google Books
• 6. Vilgrain V. Staging Cholangiocarcinoma by Imaging Studies. HPB (Oxford). 2008;10(2):106-9. doi:10.1080/13651820801992617 - Pubmed
• 7. Sainani N, Catalano O, Holalkere N, Zhu A, Hahn P, Sahani D. Cholangiocarcinoma: Current and Novel Imaging Techniques. Radiographics. 2008;28(5):1263-87. doi:10.1148/rg.285075183 - Pubmed
• 8. Malhi H, Grant E, Duddalwar V. Contrast-Enhanced Ultrasound of the Liver and Kidney. Radiol Clin North Am. 2014;52(6):1177-90. doi:10.1016/j.rcl.2014.07.005 - Pubmed
• 9. Welzel T, Graubard B, El-Serag H et al. Risk Factors for Intrahepatic and Extrahepatic Cholangiocarcinoma in the United States: A Population-Based Case-Control Study. Clin Gastroenterol Hepatol. 2007;5(10):1221-8. doi:10.1016/j.cgh.2007.05.020 - Pubmed
• 10. Nordenstedt H, Mattsson F, El-Serag H, Lagergren J. Gallstones and Cholecystectomy in Relation to Risk of Intra- and Extrahepatic Cholangiocarcinoma. Br J Cancer. 2012;106(5):1011-5. doi:10.1038/bjc.2011.607 - Pubmed
• 11. Cai H, Kong W, Chen C et al. Cholelithiasis and the Risk of Intrahepatic Cholangiocarcinoma: A Meta-Analysis of Observational Studies. BMC Cancer. 2015;15(1):831. doi:10.1186/s12885-015-1870-0 - Pubmed
• 12. Caserta M, Sakala M, Shen P, Gorden L, Wile G. Presurgical Planning for Hepatobiliary Malignancies: Clinical and Imaging Considerations. Magn Reson Imaging Clin N Am. 2014;22(3):447-65. doi:10.1016/j.mric.2014.04.003 - Pubmed
• 13. Itri J & de Lange E. Extrahepatic Cholangiocarcinoma: What the Surgeon Needs to Know RadioGraphics Fundamentals | Online Presentation. Radiographics. 2018;38(7):2019-20. doi:10.1148/rg.2018180067 - Pubmed
• 14. Banales J, Marin J, Lamarca A et al. Cholangiocarcinoma 2020: The Next Horizon in Mechanisms and Management. Nat Rev Gastroenterol Hepatol. 2020;17(9):557-88. doi:10.1038/s41575-020-0310-z - Pubmed
• 15. Yamasaki S. Intrahepatic Cholangiocarcinoma: Macroscopic Type and Stage Classification. J Hepatobiliary Pancreat Surg. 2003;10(4):288-91. doi:10.1007/s00534-002-0732-8 - Pubmed
• 16. Joo I, Lee J, Yoon J. Imaging Diagnosis of Intrahepatic and Perihilar Cholangiocarcinoma: Recent Advances and Challenges. Radiology. 2018;288(1):7-13. doi:10.1148/radiol.2018171187 - Pubmed
• 17. Dohan A, Faraoun S, Barral M et al. Extra-Intestinal Malignancies in Inflammatory Bowel Diseases: An Update with Emphasis on MDCT and MR Imaging Features. Diagn Interv Imaging. 2015;96(9):871-83. doi:10.1016/j.diii.2015.02.009 - Pubmed
• 18. Vinay Kumar, Abul K. Abbas, Jon C. Aster. Robbins & Cotran Pathologic Basis of Disease. (2020) ISBN: 9780323531139 - Google Books
• 19. Tanaka M, Tanaka H, Tsukuma H, Ioka A, Oshima A, Nakahara T. Risk Factors for Intrahepatic Cholangiocarcinoma: A Possible Role of Hepatitis B Virus. J Viral Hepat. 2010;17(10):742-8. doi:10.1111/j.1365-2893.2009.01243.x - Pubmed
• 20. Tyson G & El-Serag H. Risk Factors for Cholangiocarcinoma. Hepatology. 2011;54(1):173-84. doi:10.1002/hep.24351 - Pubmed
• 21. Donato F, Gelatti U, Tagger A et al. Intrahepatic Cholangiocarcinoma and Hepatitis C and B Virus Infection, Alcohol Intake, and Hepatolithiasis: A Case-Control Study in Italy. Cancer Causes Control. 2001;12(10):959-64. doi:10.1023/a:1013747228572 - Pubmed
• 22. Bridgewater J, Galle P, Khan S et al. Guidelines for the Diagnosis and Management of Intrahepatic Cholangiocarcinoma. J Hepatol. 2014;60(6):1268-89. doi:10.1016/j.jhep.2014.01.021 - Pubmed
• 23. Lopes Vendrami C, Magnetta M, Mittal P, Moreno C, Miller F. Gallbladder Carcinoma and Its Differential Diagnosis at MRI: What Radiologists Should Know. Radiographics. 2021;41(1):78-95. doi:10.1148/rg.2021200087 - Pubmed
• 24. Patnana M, Menias C, Pickhardt P et al. Liver Calcifications and Calcified Liver Masses: Pattern Recognition Approach on CT. AJR Am J Roentgenol. 2018;211(1):76-86. doi:10.2214/ajr.18.19704 - Pubmed

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• Intraductal papillary neoplasm of the bile duct
• Bile duct enhancement (differential)
• Klatskin tumour
• Hepatic capsular retraction (mnemonic)
• Hepatic capsular retraction
• Intrahepatic cholangiocarcinoma (staging)
• Courvoisier sign (hepatobiliary)
• Double duct sign
• Central scar in hepatic lesions
• Medical abbreviations and acronyms (C)
• Centrifugal (inside-out) enhancement of liver hemangioma
• Recurrent pyogenic cholangiohepatitis
• Skull metastases
• Leptomeningeal metastases
• Exophytic hepatic mass
• Metastases to the thyroid
• Bile duct duplication
• Pancreatic ductal adenocarcinoma
• Klatskin tumor
• Distal cholangiocarcinoma
• Cerebral metastasis - cholangiocarcinoma
• Mass forming cholangiocarcinoma
• Cholangiocarcinoma with cerebral metastases
• Intraductal growing–type cholangiocarcinoma
• Ductal cholangiocarcinoma
• Hepatic arterial infusion pump chemotherapy
• Extrahepatic cholangiocarcinoma
• Choledocholithiasis causing intrahepatic biliary duct dilation
• Unresectable cholangiocarcinoma - Yttrium-90 microsphere radioembolisation
• Oriental cholangiohepatitis
• Opisthorchis sinensis liver fluke egg (photo)
• Intrahepatic cholangiocarcinoma
• Question 1837
• Question 382

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• cholesterol polyps
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• benign gallbladder tumours
• benign vs malignant features
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