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Williams AS, Sikes MA, Liu S. An Unusual Case of Intrahepatic Stone Masquerading as Cholangiocarcinoma. ACG Case Rep J 2025; 12:e01607. [PMID: 39916889 PMCID: PMC11801792 DOI: 10.14309/crj.0000000000001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Accepted: 01/07/2025] [Indexed: 02/09/2025] Open
Abstract
A cancer of the biliary tree, cholangiocarcinoma (CCA) often presents with painless jaundice, right upper quadrant abdominal pain, and unintended weight loss. Serologic testing to include cancer antigen 19-9 (CA 19-9) is elevated in CCA but can also be elevated in inflammatory processes in the biliary system. Diagnosis is difficult and even with advanced imaging techniques false-positives may occur. We present a case of a patient with elevated CA 19-9 and biliary stricture concerning for CCA but was due to hepatic stone. It demonstrates the challenge of correctly diagnosing CCA and an instance of nonmalignant elevation of CA 19-9.
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Affiliation(s)
| | - Michael A. Sikes
- Department of Gastroenterology, Naval Medical Center San Diego, San Diego, CA
| | - Scott Liu
- Department of Gastroenterology, Naval Medical Center San Diego, San Diego, CA
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Wadhwa V, Patel N, Grover D, Ali FS, Thosani N. Interventional gastroenterology in oncology. CA Cancer J Clin 2023; 73:286-319. [PMID: 36495087 DOI: 10.3322/caac.21766] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
Abstract
Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.
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Affiliation(s)
- Vaibhav Wadhwa
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nicole Patel
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Dheera Grover
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Faisal S Ali
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), Division of Gastroenterology Hepatology and Nutrition, University of Texas Health Science Center, McGovern Medical School, Houston, Texas, USA
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Drenth J, Barten T, Hartog H, Nevens F, Taubert R, Torra Balcells R, Vilgrain V, Böttler T. EASL Clinical Practice Guidelines on the management of cystic liver diseases. J Hepatol 2022; 77:1083-1108. [PMID: 35728731 DOI: 10.1016/j.jhep.2022.06.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 02/07/2023]
Abstract
The advent of enhanced radiological imaging techniques has facilitated the diagnosis of cystic liver lesions. Concomitantly, the evidence base supporting the management of these diseases has matured over the last decades. As a result, comprehensive clinical guidance on the subject matter is warranted. These Clinical Practice Guidelines cover the diagnosis and management of hepatic cysts, mucinous cystic neoplasms of the liver, biliary hamartomas, polycystic liver disease, Caroli disease, Caroli syndrome, biliary hamartomas and peribiliary cysts. On the basis of in-depth review of the relevant literature we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with cystic liver disease.
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Krupa Ł, Staroń R, Dulko D, Łozińska N, Mackie AR, Rigby NM, Macierzanka A, Markiewicz A, Jungnickel C. Importance of Bile Composition for Diagnosis of Biliary Obstructions. Molecules 2021; 26:7279. [PMID: 34885858 PMCID: PMC8659177 DOI: 10.3390/molecules26237279] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 01/01/2023] Open
Abstract
Determination of the cause of a biliary obstruction is often inconclusive from serum analysis alone without further clinical tests. To this end, serum markers as well as the composition of bile of 74 patients with biliary obstructions were determined to improve the diagnoses. The samples were collected from the patients during an endoscopic retrograde cholangiopancreatography (ERCP). The concentration of eight bile salts, specifically sodium cholate, sodium glycocholate, sodium taurocholate, sodium glycodeoxycholate, sodium chenodeoxycholate, sodium glycochenodeoxycholate, sodium taurodeoxycholate, and sodium taurochenodeoxycholate as well as bile cholesterol were determined by HPLC-MS. Serum alanine aminotransferase (ALT), aspartate transaminase (AST), and bilirubin were measured before the ERCP. The aim was to determine a diagnostic factor and gain insights into the influence of serum bilirubin as well as bile salts on diseases. Ratios of conjugated/unconjugated, primary/secondary, and taurine/glycine conjugated bile salts were determined to facilitate the comparison to literature data. Receiver operating characteristic (ROC) curves were determined, and the cut-off values were calculated by determining the point closest to (0,1). It was found that serum bilirubin was a good indicator of the type of biliary obstruction; it was able to differentiate between benign obstructions such as choledocholithiasis (at the concentration of >11 µmol/L) and malignant changes such as pancreatic neoplasms or cholangiocarcinoma (at the concentration of >59 µmol/L). In addition, it was shown that conjugated/unconjugated bile salts confirm the presence of an obstruction. With lower levels of conjugated/unconjugated bile salts the possibility for inflammation and, thus, neoplasms increase.
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Affiliation(s)
- Łukasz Krupa
- Teaching Hospital No 1, Department of Gastroenterology and Hepatology with Internal Disease Unit, Chopina 2, 35-055 Rzeszów, Poland; (Ł.K.); (R.S.)
- Medical Department, University of Rzeszów, Kopisto 2a, 35-310 Rzeszów, Poland
| | - Robert Staroń
- Teaching Hospital No 1, Department of Gastroenterology and Hepatology with Internal Disease Unit, Chopina 2, 35-055 Rzeszów, Poland; (Ł.K.); (R.S.)
- Medical Department, University of Rzeszów, Kopisto 2a, 35-310 Rzeszów, Poland
| | - Dorota Dulko
- Department of Colloid and Lipid Science, Faculty of Chemistry, Gdańsk University of Technology, Narutowicza 11/12, 80-233 Gdańsk, Poland; (D.D.); (N.Ł.); (A.M.)
| | - Natalia Łozińska
- Department of Colloid and Lipid Science, Faculty of Chemistry, Gdańsk University of Technology, Narutowicza 11/12, 80-233 Gdańsk, Poland; (D.D.); (N.Ł.); (A.M.)
| | - Alan R. Mackie
- School of Food Science & Nutrition, University of Leeds, Leeds LS2 9JT, UK; (A.R.M.); (N.M.R.)
| | - Neil M. Rigby
- School of Food Science & Nutrition, University of Leeds, Leeds LS2 9JT, UK; (A.R.M.); (N.M.R.)
| | - Adam Macierzanka
- Department of Colloid and Lipid Science, Faculty of Chemistry, Gdańsk University of Technology, Narutowicza 11/12, 80-233 Gdańsk, Poland; (D.D.); (N.Ł.); (A.M.)
| | - Aleksandra Markiewicz
- Laboratory of Translational Oncology Intercollegiate, Faculty of Biotechnology, University of Gdańsk and Medical University of Gdańsk, 80-211 Gdańsk, Poland;
| | - Christian Jungnickel
- Department of Colloid and Lipid Science, Faculty of Chemistry, Gdańsk University of Technology, Narutowicza 11/12, 80-233 Gdańsk, Poland; (D.D.); (N.Ł.); (A.M.)
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Kingham TP, Aveson VG, Wei AC, Castellanos JA, Allen PJ, Nussbaum DP, Hu Y, D'Angelica MI. Surgical management of biliary malignancy. Curr Probl Surg 2021; 58:100854. [PMID: 33531120 PMCID: PMC8022290 DOI: 10.1016/j.cpsurg.2020.100854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023]
Affiliation(s)
| | - Victoria G Aveson
- New York Presbyterian Hospital-Weill Cornel Medical Center, New York, NY
| | - Alice C Wei
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Peter J Allen
- Duke Cancer Center, Chief, Division of Surgical Oncology, Duke University School of Medicine, Durham, NC
| | | | - Yinin Hu
- Division of Surgical Oncology, University of Maryland, Baltimore, MD
| | - Michael I D'Angelica
- Memorial Sloan Kettering Cancer Center, Professor of Surgery, Weill Medical College of Cornell University, New York, NY..
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Abou-Alfa GK, Jarnagin W, El Dika I, D'Angelica M, Lowery M, Brown K, Ludwig E, Kemeny N, Covey A, Crane CH, Harding J, Shia J, O'Reilly EM. Liver and Bile Duct Cancer. ABELOFF'S CLINICAL ONCOLOGY 2020:1314-1341.e11. [DOI: 10.1016/b978-0-323-47674-4.00077-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Suthar M, Purohit S, Bhargav V, Goyal P. Role of MRCP in Differentiation of Benign and Malignant Causes of Biliary Obstruction. J Clin Diagn Res 2015; 9:TC08-12. [PMID: 26675498 DOI: 10.7860/jcdr/2015/14174.6771] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 09/03/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Differentiation of the benign and malignant etiology of biliary obstruction is difficult. We studied the diagnostic accuracy of MRCP (Magnetic Resonance Cholangio-pancreatography) in differentiating between benign and malignant causes of biliary obstruction. AIM To evaluate the role of Magnetic Resonance Cholangio-Pancreatography in differentiating benign from malignant causes of biliary obstruction using surgical, ERCP or histopathological findings as gold standard. MATERIALS AND METHODS Seventy five patients with clinical and laboratory finding suggestive of biliary obstruction underwent MRI/MRCP. The final diagnosis was based on either surgical findings, histopathology of resected specimen or ERCP findings. Diagnostic effectivity of MRCP was calculated which included sensitivity, specificity and accuracy. Statistical analysis was done by using chi-square test and p value was calculated. RESULTS Out of 75 cases, there were 54 benign and 21 malignant cases. Mean age of patients with malignant obstruction was more than benign with slight male preponderance. The diagnostic accuracy of MRCP in differentiating benign from malignant biliary obstructive diseases in correlation with surgical, ERCP and histopathological outcome was 93.3%, sensitivity 85.7%, specificity 96.3%. It was found that irregular, asymmetric and long segment narrowing was more common in malignant stricture. CONCLUSIONS MRCP is the investigation of choice for suspected choledocholithiasis, choledochal cyst and primary sclerosing cholangitis. A benign stricture can be differentiated from a malignant one if it shows regular, symmetric and short segment narrowing. Irregular, asymmetric and long segment narrowing was more commonly found in malignant stricture.
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Affiliation(s)
- Meena Suthar
- Resident, Department of Radiodiagnosis, Santokba Durlabhji Memorial Hospital Cum Medical Research Institute , Jaipur, Rajasthan, India
| | - Sunita Purohit
- Professor and Head, Department of Radiodiagnosis, Santokba Durlabhji Memorial Hospital Cum Medical Research Institute , Jaipur, Rajasthan, India
| | - Vivek Bhargav
- Consultant Radiologist, Okay Diagnostic Center, SDMH Jaipur, Rajasthan, India
| | - Pradeep Goyal
- Consultant Radiologist, Okay Diagnostic Center, SDMH Jaipur, Rajasthan, India
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Kloeckner R, Ruckes C, Kronfeld K, Wörns MA, Weinmann A, Galle PR, Lang H, Otto G, Eichhorn W, Schreckenberger M, Dueber C, Pitton MB. Selective internal radiotherapy (SIRT) versus transarterial chemoembolization (TACE) for the treatment of intrahepatic cholangiocellular carcinoma (CCC): study protocol for a randomized controlled trial. Trials 2014; 15:311. [PMID: 25095718 PMCID: PMC4132905 DOI: 10.1186/1745-6215-15-311] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 07/23/2014] [Indexed: 12/18/2022] Open
Abstract
Background Cholangiocellular carcinoma is the second most common primary liver cancer after hepatocellular carcinoma. Over the last 30 years, the incidence of intrahepatic cholangiocellular carcinoma has risen continuously worldwide. Meanwhile, the intrahepatic cholangiocellular carcinoma has become more common than the extrahepatic growth type and currently accounts for 10-15% of all primary hepatic malignancies. Intrahepatic cholangiocellular carcinoma is typically diagnosed in advanced stages due to late clinical symptoms and an absence of classic risk factors. A late diagnosis precludes curative surgical resection. There is evidence that transarterial chemoembolization leads to better local tumor control and prolongs survival compared to systemic chemotherapy. New data indicates that selective internal radiotherapy, also referred to as radioembolization, provides promising results for treating intrahepatic cholangiocellular carcinoma. Methods/Design This pilot study is a randomized, controlled, single center, phase II trial. Twenty-four patients with intrahepatic cholangiocellular carcinoma will be randomized in a 1:1 ratio to receive either chemoembolization or radioembolization. Randomization will be stratified according to tumor load. Progression-free survival is the primary endpoint; overall survival and time to progression are secondary endpoints. To evaluate treatment success, patients will receive contrast enhanced magnetic resonance imaging every 3 months. Discussion Currently, chemoembolization is routinely performed in many centers instead of systemic chemotherapy for treating intrahepatic cholangiocellular carcinoma confined to the liver. Recently, radioembolization has been increasingly applied to cholangiocellular carcinoma as second line therapy after TACE failure or even as an alternative first line therapy. Nonetheless, no randomized studies have compared radioembolization and chemoembolization. Considering all this background information, we recognized a strong need for a randomized controlled trial (RCT) to compare the two treatments. Therefore, the present protocol describes the design of a RCT that compares SIRT and TACE as the first line therapy for inoperable CCC confined to the liver. Trial registration ClinicalTrials.gov, Identifier: NCT01798147, registered 16th of February 2013.
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Affiliation(s)
- Roman Kloeckner
- Department of Diagnostic and Interventional Radiology, Johannes Gutenberg-University Medical Center, Langenbeckstr, 1, 55131 Mainz, Germany.
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Zhimin G, Noor H, Jian-Bo Z, Lin W, Jha RK. Advances in diagnosis and treatment of hilar cholangiocarcinoma -- a review. Med Sci Monit 2013; 19:648-56. [PMID: 23921971 PMCID: PMC3739601 DOI: 10.12659/msm.889379] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hilar cholangiocarcinoma (HC) is a rare tumor that causes devastating disease. In the late stages, this carcinoma primarily invades the portal vein and metastasizes to the hepatic lobes; it is associated with a poor prognosis. HC is diagnosed by its clinical manifestation and results of imaging techniques such as ultrasound, computed tomography, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiography, and percutaneous transhepatic cholangiography. Preoperative hepatic bile drainage can improve symptoms associated with insufficient liver and kidney function, coagulopathy, and jaundice. Surgical margin-negative (R0) resection, including major liver resection, is the most effective and potentially curative treatment for HC. If the tumor is not resected, then liver transplantation with adjuvant management can improve survival. We conducted a systematic review of developments in imaging studies and major surgical hepatectomy for HC with positive outcomes regarding quality of life.
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Affiliation(s)
- Geng Zhimin
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, P.R. China
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Serrablo A, Tejedor L. Outcome of surgical resection in Klatskin tumors. World J Gastrointest Oncol 2013; 5:147-158. [PMID: 23919109 PMCID: PMC3731528 DOI: 10.4251/wjgo.v5.i7.147] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 03/22/2013] [Accepted: 04/29/2013] [Indexed: 02/05/2023] Open
Abstract
Cholangiocarcinomas are the second most frequent primary hepatic malignancy, and make up from 5% to 30% of malignant hepatic tumours. Hilar cholangiocarcinoma (HCC) is the most common type, and accounts for approximately 60% to 67% of all cholangiocarcinoma cases. There is not a staging system that permits us to compare all series and extract some conclusions to increase the long-survival rate in this dismal disease. Neither the extension of resection, according to the sort of HCC, is a closed topic. Some authors defend limited resection (mesohepatectomy with S1, S1 plus S4b-S5, local excision for papillary tumours, etc.) while others insist in the compulsoriness of an extended hepatic resection with portal vein bifurcation removed to reach cure. As there is not an ideal adjuvant therapy, R1 resection can be justified to prolong the survival rate. Morbidity and mortality rates changed along the last decade, but variability is the rule, with morbidity and mortality rates ranging from 14% to 76% and from 0% to 19%, respectively. Conclusion: Surgical resection continues to be the main treatment of HCC. Negative resection margins achieved with major hepatic resections are associated with improved outcome. Preresectional management with biliary drainage, portal vein embolization and staging laparoscopy should be considered in selected patients. Additional evidence is needed to fully define the role of orthotopic liver transplant. Portal and lymph node involvement worsen the prognosis and long-term survival, and surgery is the only option that can lengthen it. Improvements in adjuvant therapy are essential for improving long-term outcome. Furthermore, the lack of effective chemotherapy drugs and radiotherapy approaches leads us to can consider R1 resection as an option, because operated patients have a longer survival rate than those who not undergo surgery.
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Turaga KK, Tsai S, Wiebe LA, Evans DB, Gamblin TC. Novel multimodality treatment sequencing for extrahepatic (mid and distal) cholangiocarcinoma. Ann Surg Oncol 2012; 20:1230-9. [PMID: 23064778 DOI: 10.1245/s10434-012-2648-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Indexed: 12/15/2022]
Abstract
Neoadjuvant chemoradiation has demonstrated significant advantages in the management of pancreatic adenocarcinoma. A similar tumor in a nearby anatomical location is extrahepatic cholangiocarcinoma, which has proven to be largely unresponsive to current forms of therapy. Neoadjuvant therapy for hilar cholangiocarcinoma has been combined with surgical resection and/or liver transplantation with a 25-33 % complete pathological response rate. We propose a wider application of neoadjuvant chemoradiation for patients with distal cholangiocarcinoma and present our rationale for this form of treatment sequencing.
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Affiliation(s)
- Kiran K Turaga
- Department of Surgery, Dvision of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Magnetic resonance cholangiopancreatography in conjunction with 3D for assessment of different biliary obstruction causes. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2010. [DOI: 10.1016/j.ejrnm.2010.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Aljiffry M, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009. World J Gastroenterol 2009; 15:4240-62. [PMID: 19750567 PMCID: PMC2744180 DOI: 10.3748/wjg.15.4240] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Several advances in diagnosis, treatment and palliation of cholangiocarcinoma (CC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. CC is a relatively rare tumor and the main risk factors are: chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree. While the incidence of intra-hepatic CC is increasing, the incidence of extra-hepatic CC is trending down. The only curative treatment for CC is surgical resection with negative margins. Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy. Magnetic resonance imaging/magnetic resonance cholangiopancreatography, positron emission tomography scan, endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging. Adjuvant therapy, palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC. For most of these patients biliary stenting provides effective palliation. Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief, improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization, hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.
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Chen CH, Yang CC, Yeh YH, Chou DA, Nien CK. Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI. JOURNAL OF CLINICAL ULTRASOUND : JCU 2009; 37:18-25. [PMID: 18726967 DOI: 10.1002/jcu.20523] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
PURPOSE To reappraise the accuracy of transabdominal sonography (US), CT, MRI, and endosonography (EUS) in the diagnosis and staging of ampullary tumors. METHOD We reviewed the medical records and the images of 41 consecutive patients with ampullary tumors. Tumor detection rate and accuracy of TNM (tumor-node-metastasis) staging of malignant tumors were determined. Imaging findings were correlated with histopathologic findings. RESULTS The detection rates for ampullary tumors were 97.6% for EUS, 81.3% for MRI, 28.6% for CT, and 12.2% for US (p < 0.001 for EUS versus CT; p < 0.001 for EUS versus US; p > 0.05 for EUS versus MRI). The accuracy in T staging for ampullary carcinomas was 72.7% for EUS, 53.8% for MRI, and 26.1% for CT (p < 0.01 for EUS versus CT; p > 0.05 for EUS versus MRI). The accuracy in N staging for ampullary carcinomas was 66.7% for EUS, 76.9% for MRI, and 43.5% for CT with no statistically significant difference between the 3 modalities. The sensitivity in detecting malignant lymph nodes was 46.7% for EUS, 25.0% for MRI, and 0% for CT (p < 0.01 for EUS versus CT; p > 0.05 for EUS versus MRI; p > 0.05 for MRI versus CT). Transpapillary stenting, advanced tumor extension (>T2), large tumor size (>2 cm), tumor differentiation, and endoscopic appearance of tumor growth did not significantly influence EUS accuracy in T or N staging (p > 0.05). CONCLUSION EUS was superior to CT and was equivalent to MRI for tumor detection and T and N staging of ampullary tumors. Neither indwelling stents nor tumor size, differentiation, or endoscopic appearance affected the staging accuracy of EUS.
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Affiliation(s)
- Chien-Hua Chen
- Digestive Disease Center, Changhua Show-Chwan Memorial Hospital, Changhua 500, Taiwan
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Aljiffry M, Abdulelah A, Walsh M, Peltekian K, Alwayn I, Molinari M. Evidence-based approach to cholangiocarcinoma: a systematic review of the current literature. J Am Coll Surg 2008; 208:134-47. [PMID: 19228515 DOI: 10.1016/j.jamcollsurg.2008.09.007] [Citation(s) in RCA: 178] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 09/04/2008] [Accepted: 09/09/2008] [Indexed: 12/14/2022]
Affiliation(s)
- Murad Aljiffry
- Department of Surgery, Queen Elizabeth II Health Science Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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Sahni VA, Mortele KJ. Magnetic resonance cholangiopancreatography: current use and future applications. Clin Gastroenterol Hepatol 2008; 6:967-77. [PMID: 18774532 DOI: 10.1016/j.cgh.2008.05.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 05/13/2008] [Accepted: 05/24/2008] [Indexed: 02/07/2023]
Abstract
Magnetic resonance pancreatography (MRCP) is now established as a robust noninvasive tool for the evaluation of biliary and pancreatic pathology. Its diagnostic performance is comparable with endoscopic retrograde cholangiopancreatography without the associated risks. This article aims to familiarize the reader with the technique, clinical indications, and limitations of the investigation. Common pitfalls in interpretation also are addressed. Emerging applications and techniques are discussed that include recent advances in technology and the development of functional imaging.
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Affiliation(s)
- Vikram A Sahni
- Department of Radiology, Division of Abdominal Imaging and Intervention, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Choi JY, Kim MJ, Lee JM, Lee JY, Kim SH, Kim KW, Han JK, Choi BI. Magnetic resonance cholangiography: comparison of two- and three-dimensional sequences for assessment of malignant biliary obstruction. Eur Radiol 2007; 18:78-86. [PMID: 18236046 DOI: 10.1007/s00330-007-0670-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 04/14/2007] [Accepted: 04/19/2007] [Indexed: 12/22/2022]
Abstract
The purpose was to retrospectively compare two-dimensional (2D) magnetic resonance cholangiography (MRC) including breath-hold single-shot rapid acquisition with relaxation enhancement (RARE) and multislice half-Fourier RARE versus navigator-triggered 3D-RARE MRC in the evaluation of biliary malignancy. MRC findings were evaluated in 31 patients with malignant biliary obstruction, including biliary malignancy, gallbladder carcinoma, and ampullary cancer. Two observers independently reviewed the images to assess the overall image quality, artifacts, ductal conspicuity, extent of disease, diagnostic confidence of tumor extent, and origin of tumor. The results were compared with surgical and histopathologic findings. Studies obtained with 3D-MRC were of significantly higher technical quality than those obtained with 2D-MRC. However, the accuracy between two sequences for classification of tumor showed no statistical significance. There was no significant difference between the Az values of 2D- and 3D-MRC for overall tumor extent in bilateral second order branch, intrapancreatic common bile duct (CBD) involvement (Az = 0.889, 0.881 for 2D and Az = 0.903, 0.864 for 3D). Nor was there a significant difference between two sequences in the assessment of the origin of tumor. Although 3D-MRC has superior image quality over 2D-MRC, 3D-MRC showed no statistically significant difference in accuracy compared with 2D-MRC for evaluating the extent of disease in malignant biliary obstructions.
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Affiliation(s)
- Jin-Young Choi
- Department of Diagnostic Radiology, Yonsei University College of Medicine, Seodaemun-ku Shinchon-dong 134, Seoul, 120-752, South Korea
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Halefoglu AM. Magnetic resonance cholangiopancreatography: A useful tool in the evaluation of pancreatic and biliary disorders. World J Gastroenterol 2007; 13:2529-34. [PMID: 17551999 PMCID: PMC4146812 DOI: 10.3748/wjg.v13.i18.2529] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance cholangiopancreatography (MRCP) is being used with increasing frequency as a noninvasive alternative to diagnostic retrograde cholangiopancreatography (ERCP). The aim of this pictorial review is to demonstrate the usefulness of MRCP in the evaluation of pancreatic and biliary system disorders. Because the recently developed techniques allows improved spatial resolution and permits imaging of the entire pancreaticobiliary tract during a single breath hold, MRCP is of proven utility in a variety of pancreatic and biliary disorders. It uses MR imaging to visualize fluid in the biliary and pancreatic ducts as high signal intensity on T2 weighted sequences and is the newest modality for pancreatic and biliary duct imaging. Herein, we present the clinical applications of MRCP in a variety of pancreaticobiliary system disorders and conclude that it is an important diagnostic tool in terms of imaging of the pancreaticobiliary ductal system.
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Affiliation(s)
- Ahmet-Mesrur Halefoglu
- Department of Radiology, Sisli Etfal Training and Research Hospital, Sisli, Istanbul, Turkey.
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21
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JARNAGIN W, D'ANGELICA M, BLUMGART L. Intrahepatic and Extrahepatic Biliary Cancer. SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS 2007:782-826. [DOI: 10.1016/b978-1-4160-3256-4.50063-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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22
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Choi JY, Lee JM, Lee JY, Kim SH, Lee MW, Han JK, Choi BI. Navigator-triggered isotropic three-dimensional magnetic resonance cholangiopancreatography in the diagnosis of malignant biliary obstructions: Comparison with direct cholangiography. J Magn Reson Imaging 2007; 27:94-101. [DOI: 10.1002/jmri.21038] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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23
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DeWitt J, Misra VL, Leblanc JK, McHenry L, Sherman S. EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointest Endosc 2006; 64:325-33. [PMID: 16923477 DOI: 10.1016/j.gie.2005.11.064] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Accepted: 11/27/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND Accurate nonoperative diagnosis of proximal biliary strictures (PBSs) is often difficult. OBJECTIVE To report our experience with EUS-guided FNA (EUS-FNA) of PBSs following negative or unsuccessful results with brush cytology during ERCP. DESIGN Retrospective cohort study. SETTING Single, tertiary referral hospital in Indianapolis, Indiana. PATIENTS Consecutive subjects from January 2001 to November 2004 who underwent EUS-FNA of a PBS documented by ERCP. INTERVENTIONS EUS-FNA of PBS. MAIN OUTCOME MEASURES Performance of EUS-FNA, with the final diagnosis determined by surgical pathology study or the results of EUS-FNA and follow-up. RESULTS A total of 291 biliary strictures undergoing EUS were identified. Of these, 26 (9%) had PBSs and 2 were excluded. EUS-FNA was not attempted in 1 because no mass was visualized. The second had a PBS seen on magnetic resonance cholangiopancreatography, but no ERCP was performed. Twenty-four patients (14 men; mean age, 68 years) underwent EUS-FNA of a PBS following ERCP brush cytology studies that were either negative/nondiagnostic (20) or unable to be performed (4). EUS visualized a mass in 23 (96%) patients, including 13 in whom previous imaging detected no lesion. EUS-FNA (median, 4 passes; range, 1-11) demonstrated malignancy in 17 of 24 (71%) patients with findings showing adenocarcinoma (15), lymphoma (2), atypical cytology (3), or benign cells (4). No complications were noted. Pathology results from 8 of 24 (33%) patients who underwent surgery showed hilar cholangiocarcinoma (6), gallbladder cancer (1), and a benign, inflammatory stricture (1). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS-FNA were 77% (95% confidence interval [CI], 54%-92%), 100% (95% CI, 15%-100%), 100% (95% CI, 83%-100%), 29% (95% CI, 4%-71%), and 79% (95% CI, 58%-93%), respectively. LIMITATIONS Histopathologic correlation of EUS-FNA findings was limited to 8 of 24 (33%) patients who underwent surgery. CONCLUSIONS EUS-FNA is a sensitive method for the diagnosis of PBSs following negative results or unsuccessful ERCP brush cytology. The low negative predictive value does not permit reliable exclusion of malignancy following a negative biopsy.
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Affiliation(s)
- John DeWitt
- Department of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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24
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Kaza RK, Gulati M, Wig JD, Chawla YK. Evaluation of gall bladder carcinoma with dynamic magnetic resonance imaging and magnetic resonance cholangiopancreatography. ACTA ACUST UNITED AC 2006; 50:212-7. [PMID: 16732816 DOI: 10.1111/j.1440-1673.2006.01564.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The objective of this study is to evaluate the efficacy of dynamic MRI with magnetic resonance cholangiopancreatography (MRCP) in the preoperative assessment of gall bladder carcinoma. Magnetic resonance imaging and MRCP were carried out in 15 patients with gall bladder carcinoma before surgery and the imaging findings correlated with surgical and pathological findings. Gall bladder carcinoma manifested as focal or diffuse wall thickening in 73% (11/15) and as a mass replacing the gall bladder in 27% (4/15). All tumours showed enhancement in the early phase, which persisted into the delayed phase. The sensitivity and specificity of MRI with MRCP in detecting hepatic invasion, lymph node metastasis and bile duct invasion was 87.5 and 86%, 60 and 90%, and 80 and 100%, respectively. Magnetic resonance imaging correctly diagnosed duodenal invasion in only 50% and in none of the two patients with peritoneal metastasis. In conclusion, dynamic MRI with MRCP is an accurate and a reliable method of showing gall bladder carcinoma and in assessing its local and regional extent as part of preoperative assessment.
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Affiliation(s)
- R K Kaza
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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25
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Low RN. Magnetic resonance imaging in the oncology patient: evaluation of the extrahepatic abdomen. Semin Ultrasound CT MR 2005; 26:224-36. [PMID: 16152737 DOI: 10.1053/j.sult.2005.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In the oncology patient MR imaging provides excellent depiction of all forms of extrahepatic tumor. Rapid breath-hold imaging techniques are combined with intravenous and intraluminal contrast material to demonstrate tumors of the solid visceral organs, the gastrointestinal tract, peritoneum, mesentery, omentum, bile ducts, lymph nodes, and osseous structures. The unmatched soft tissue contrast of MR imaging allows one to depict subtle tumors involving all of these extrahepatic sites. MR imaging has become an integral and essential element in the management of oncology patients.
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Affiliation(s)
- Russell N Low
- Sharp and Children's MRI Center, 7901 Frost Street, San Diego, CA 92123, USA.
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26
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Abstract
Biliary tract cancer, which consists of gall bladder cancer and cholangio-carcinoma, presents many challenges to practising physicians. It is a relatively rare cancer that often causes a diagnostic dilemma, as its presentation may be similar to that of non-malignant conditions. In many cases, histological or cytological confirmation of a cancer diagnosis is not possible preoperatively. The management of this disease is also complex due to a morbid patient population and limited data on the optimal therapeutic approach. Surgery remains the mainstay of treatment, although the extent of resection required is still debated. The role of adjuvant therapy is also controversial, but a combined modality approach appears to be beneficial in patients with a high risk of recurrence, such as those with node positive tumors or positive resection margins. When surgery is not possible, the prognosis of patients with biliary tract cancer is very poor. In unresectable patients, the combination of chemotherapy and radiotherapy can result in a prolonged survival for some patients. In the palliative setting, biliary stenting and other supportive measures can alleviate symptoms and improve survival. Gemcitabine-based combination chemotherapy may also provide successful palliation and has achieved response rates of approximately 30% and a median survival of > 15 months in one study. Ultimately, treatment decisions should be individualised and participation in clinical trials is encouraged. Further progress in the management of biliary tract cancer is anticipated using biological therapies and continued research is essential to discover the optimal treatment for this challenging disease.
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Affiliation(s)
- Gregory D Leonard
- Memorial Sloan-Kettering Cancer Center, Gastrointestinal Oncology Service, Department of Medicine, 1275 York Avenue, Box 324, New York, New York 10021, USA
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27
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Rao NDLV, Gulati MS, Paul SB, Pande GK, Sahni P, Chattopadhyay TK. Three-dimensional helical computed tomography cholangiography with minimum intensity projection in gallbladder carcinoma patients with obstructive jaundice: comparison with magnetic resonance cholangiography and percutaneous transhepatic cholangiography. J Gastroenterol Hepatol 2005; 20:304-8. [PMID: 15683436 DOI: 10.1111/j.1440-1746.2004.03548.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Computed tomography (CT) is traditionally used for evaluation and staging of gallbladder carcinoma (GC). However, in the subgroup of patients with obstructive jaundice, magnetic resonance cholangiography (MRC) is generally required to assess the level of biliary obstruction. The present study was undertaken to evaluate the diagnostic potential of three-dimensional helical CT cholangiography (3-D CTC) with minimum intensity projection (minIP), to determine the presence and level of biliary obstruction. MATERIALS AND METHODS Twenty-five consecutive patients with proven GC, presenting with clinical and biochemical features of obstructive jaundice, over a 1-year period were included in the study. Dual phase helical CT data was obtained in the arterial and venous phases, respectively, after intravenous contrast injection using a pressure injector. Axial CT data (both arterial and venous phase) was studied for staging and resectability of tumor. Three-dimensional helical CT cholangiography using minIP obtained from the venous phase data set, was used to assess the level of biliary obstruction and isolation of hepatic segmental ducts. Three-dimensional helical CT cholangiography findings were compared with MRC and percutaneous transhepatic cholangiography (PTC) (gold standard). None of the patients were operated on as they were all considered inoperable on axial CT images due to extensive local disease or distant metastasis. RESULTS In all patients, 3-D CTC demonstrated dilated intrahepatic ducts up to tertiary branch level. The 3-D CTC correctly diagnosed the level of biliary obstruction and demonstrated isolated segmental ducts in all patients and correlated well in all cases with MRC and PTC findings in this regard. However, the 3-D CTC did not add any additional information over the axial source images. CONCLUSION Three-dimensional helical CT cholangiography with minIP can correctly determine the level of biliary obstruction in patients with GC and may be a strong competitor with MRC, because it gives equivalent information with regard to the level of ductal obstruction even while being a part of an overall comprehensive CT staging study. Even though 3-D CTC did not provide additional information on top of the source images, the referring physicians found them very useful for conceptualization of the 3-D biliary anatomy.
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Affiliation(s)
- Narayana D L V Rao
- Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, B-3/185 Janak Puri, New Delhi 110-058, India
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Abstract
Cancer arising from the proximal biliary tree, or hilar cholangiocarcinoma, remains a difficult clinical problem. Significant experience with these uncommon tumors has been limited to a small number of centers, which has greatly hindered progress. Complete resection of hilar cholangiocarcinoma is the most effective and only potentially curative therapy, and it now clear that concomitant hepatic resection is required in most cases. Simply stated, long-term survival is generally possible only with an en bloc resection of the liver with the extrahepatic biliary apparatus, leaving behind a well perfused liver remnant with adequate biliary-enteric drainage. Preoperative imaging studies should aim to assess this possibility and must evaluate a number of tumor-related factors that influence resectability. Advances in imaging technology have improved patient selection, but a large proportion of patients are found to have unresectable disease only at the time of exploration. Staging laparoscopy and (13)fluoro-deoxyglucose positron emission tomography (FDG-PET) may help to identify some patients with advanced disease; however, local tumor extent, an equally critical determinant of resectability, may be underestimated on preoperative studies. This paper reviews issues pertaining to diagnosis and preoperative evaluation of patients with hilar biliary obstruction. Knowledge of the imaging features of hilar tumors, particularly as they pertain to resectability, is of obvious importance for clinicians managing these patients.
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Affiliation(s)
| | - Corinne Winston
- Radiology, Memorial Sloan-Kettering Cancer CenterNew York NYUSA
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29
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Fulcher AS. Magnetic resonance cholangiopancreatography: is it becoming the study of choice for evaluating obstructive jaundice? J Clin Gastroenterol 2004; 38:839-40. [PMID: 15492597 DOI: 10.1097/00004836-200411000-00001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Abstract
Cholangiocarcinoma presents a formidable diagnostic and treatment challenge. The majority of patients present with unresectable disease and have a survival of less than 12 months following diagnosis. Progress has been made by the appropriate selection of patients for treatment options including resection, with the routine use of more aggressive resections in order to achieve margin-negative resections. This has resulted in longer survival times for these patients. Neoadjuvant and adjuvant therapies have, for the most part, not improved survival in patients with this tumor, and new strategies are needed to improve this line of therapy. The prognosis for unresectable patients is poor, and palliative measures should be aimed at increasing quality of life first and increasing survival second.
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Affiliation(s)
- Christopher D Anderson
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232-4753, USA
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31
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Hii MWJ, Gibson RN. Role of radiology in the treatment of malignant hilar biliary strictures 1: Review of the literature. ACTA ACUST UNITED AC 2004; 48:3-13. [PMID: 15027913 DOI: 10.1111/j.1440-1673.2004.01233.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Malignant strictures of the biliary tree are an uncommon cause of obstructive jaundice. There are a number of pathological subtypes, but tumours in this region tend to have similar clinical and diagnostic features and therapeutic and prognostic implications. We review the published literature on this topic discussing diagnostic modalities and treatment options with a focus on radiological intervention. Diagnosis currently is best achieved using a range of procedures. Direct cholangiography remains the gold standard in delineating anatomy, but the invasiveness of this procedure limits its use as a purely diagnostic tool. Magnetic resonance technology, in particular magnetic resonance cholangiopancreatography, has an increasing role as accessibility is improved. Treatment of these tumours is difficult. Surgical resection and palliative biliary enteric bypass are the most common methods used with endoscopic and percutaneous therapies reserved for palliating patients not fit for surgery. There is little firm evidence to suggest that any one palliative modality is superior. Interventional radiology is particularly suitable for palliative management of difficult and expansive lesions as the anatomy can preclude easy access by surgical or endoscopic techniques. Good palliative results with minimal mortality and morbidity can be achieved with percutaneous stenting.
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Schwartz LH, Lefkowitz RA, Panicek DM, Coakley FV, Jarnagin W, Dematteo R, Fong Y, Blumgart L. Breath-hold magnetic resonance cholangiopancreatography in the evaluation of malignant pancreaticobiliary obstruction. J Comput Assist Tomogr 2003; 27:307-14. [PMID: 12794591 DOI: 10.1097/00004728-200305000-00002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was designed to determine the effectiveness of magnetic resonance cholangiopancreatography (MRCP) using a breath-hold single-shot fast spin echo (SSFSE) technique in imaging patients with malignant biliary and/or pancreatic duct obstruction. METHODS One hundred thirty-one breath-hold MRCP studies in patients with malignant pancreatic and/or biliary obstruction were evaluated. Pathologic diagnoses included pancreatic cancer, biliary malignancy, gallbladder carcinoma, hepatic neoplasms, malignant lymphadenopathy, and ampullary carcinoma. Two observers independently reviewed the images in a blinded fashion to assess the level of obstruction and the site of underlying tumor. RESULTS The level of obstruction was correctly identified in 104 of 131 cases (79%) by observer 1 and in 107 of 131 cases (82%) by observer 2. The site of underlying tumor was correctly identified in 113 of 131 cases (86%) by observer 1 and in 110 of 131 cases (84%) by observer 2. CONCLUSION Magnetic resonance cholangiopancreatography utilizing the SSFSE technique can accurately assess the level of obstruction and the site of underlying tumor in patients with malignant pancreaticobiliary obstruction, without the risks of cholangiography. This MRCP technique allows for visualization of intra- and extraductal anatomy and pathology.
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Affiliation(s)
- Lawrence H Schwartz
- Department of Radiology, Memmorial Sloan - Kettering Cancer Center, and Weill Medical College of Cornell University, New York, NY 10021, USA.
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Abstract
Carcinoma of the gallbladder is the most common malignant tumour of the biliary tract and a particularly high incidence is observed in Chile, Japan, and northern India. The aetiology of this tumour is complex, but there is a strong association with gallstones. Owing to its non-specific symptoms, gallbladder carcinoma is generally diagnosed late in the disease course, but if a patient with gallstones experiences a sudden change of symptoms, then a cancer diagnosis should be considered. Treatment with radical or extended cholecystectomy is potentially curative, although these procedures are only possible in 10-30% of patients. There is no role for cytoreductive surgery in this disease. If a gallbladder carcinoma is discovered via pathological examination of tissue samples, then the patient should be examined further and should have radical surgery if the tumour is found to be T1b or beyond. Additional port-site excision is necessary if the patient has already had their gallbladder removed during laparoscopy; however, patients with an intact gallbladder who are suspected to have gallbladder carcinoma should not undergo laparoscopic cholecystectomy. Patients with advanced inoperable disease should receive palliative treatment; however, the role of chemotherapy and radiation in these patients needs further evaluation.
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Affiliation(s)
- Sanjeev Misra
- Department of Surgical Oncology, King George's Medical College, Lucknow, India.
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Wagman R, Yorke E, Ford E, Giraud P, Mageras G, Minsky B, Rosenzweig K. Respiratory gating for liver tumors: use in dose escalation. Int J Radiat Oncol Biol Phys 2003; 55:659-68. [PMID: 12573753 DOI: 10.1016/s0360-3016(02)03941-x] [Citation(s) in RCA: 189] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE To determine the clinical impact of the Varian Real-Time Position Monitor (RPM) respiratory gating system for treatment of liver tumors. METHODS AND MATERIALS Ten patients with liver tumors were selected for evaluation of this passive system, which tracks motion of reflective markers mounted on the abdomen with an infrared-sensitive camera. At simulation, a fluoroscopic movie, breathing trace, and CT scans synchronized at end-expiration (E-E) and end-inspiration were acquired in treatment position using the RPM system. Organs and gross tumor volume were contoured on each CT. Each organ's positional change between two scan sets was quantified by calculation of the center of volume shift and an "index coefficient," defined as the volume common to the two versions of the organ to the volume included in at least one (intersection/union). Treatment dose was determined by use of normal tissue complication probability calculations and dose-volume histograms. Gated portal images were obtained to monitor gating reproducibility with treatment. RESULTS Eight patients received 177 treatments with RPM gating. Average superior-to-inferior (SI) diaphragm motion on initial fluoroscopy was reduced from 22.7 mm without gating to 5.1 mm with gating. Comparing end-inspiration to E-E CT scans, average SI movement of the right diaphragm was 11.5 mm vs. 2.2 mm for two E-E CT scans. For all organs, average E-I SI organ motion was 12.8 mm vs. 2.0 mm for E-E studies. Index coefficients were closer to 1.0 for E-E than end-inspiration scans, indicating gating reproducibility. The average SI displacement of diaphragm apex on gated portal images compared with DRR was 2.3 mm. Treatment was prolonged less than 10 minutes with gating. The reproducible decrease in organ motion with gating enabled reduction in gross tumor volume-to-planning target volume margin from 2 to 1 cm. This allowed for calculated dose increases of 7%-27% (median: 21.3%) in 6 patients and enabled treatment in 2. CONCLUSION Gating of radiotherapy for liver tumors enables safe margin reduction on tumor volume, which, in turn, may allow for dose escalation.
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Affiliation(s)
- Raquel Wagman
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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35
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Pamos S, Benages A, Medina E, Martinez Sanjuan V. Prospective evaluation of magnetic resonance cholangiopancreatography in patients with biliary disease: comparative study with conventional ultrasonography and endoscopic retrograde cholangiopancreatography diagnostic algorithm. Dig Liver Dis 2003; 35:186-92. [PMID: 12779073 DOI: 10.1016/s1590-8658(03)00027-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Magnetic resonance cholangiopancreatography is an accurate technique that can replace invasive diagnostic methods of the biliary and pancreatic duct. AIMS Our aim was to assess sensitivity and specificity of magnetic resonance cholangiopancreatography and ultrasonography using the results of endoscopic retrograde cholangiopancreatography as reference, and to establish a diagnostic algorithm under which circumstances magnetic resonance cholangiopancreatography can replace endoscopic retrograde cholangiopancreatography. PATIENTS Eighty-three patients with suspicion of biliary disease based on clinical, biochemical and ultrasonography findings were studied. METHODS Ultrasonography, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography were performed, comparing the results of the techniques for the determination of their sensitivity and specificity. RESULTS Sensitivity and specificity results obtained by magnetic resonance cholangiopancreatography were: 100 and 92.8% when dilated ducts were detected (n=61); 97.4 and 97.2% in the diagnosis of choledocholithiasis (n=38); 100 and 96.7% in malignant lesions (n=14) and 81.8 and 98.4% when biliary ducts were normal. The percentage of images of diagnostic quality was 97.6%. Sensitivity and specificity achieved by ultrasonography was: 100 and 57.1% in detection of dilatation, 71 and 97.2% in choledocholithiasis, 92.8 and 96.7% in malignancy and 66.6 and 96.8% in normal ducts. CONCLUSIONS Magnetic resonance cholangiopancreatography is a technique with high sensitivity and specificity in the evaluation of biliary ducts. Thus, magnetic resonance cholangiopancreatography may replace diagnostic endoscopic retrograde cholangiopancreatography for purely diagnostic purposes, following an initial clinical and ultrasonographic exam.
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Affiliation(s)
- S Pamos
- Department of Digestive Pathology, Hospital General Universitario, Valencia, Spain
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36
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Madura JA, Deziel DJ. The Jaundiced Cancer Patient. Surg Oncol 2003. [DOI: 10.1007/0-387-21701-0_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fernández-Esparrach G, Ginès A, Pellisé M, Bordas JM. [Role of endoscopic ultrasonography in the study of extrahepatic cholestasis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2002; 25:633-638. [PMID: 12459125 DOI: 10.1016/s0210-5705(02)70326-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- G Fernández-Esparrach
- Unitat d'Endoscòpia Digestiva. Institut de Malalties Digestives. Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). Hospital Clínic. Barcelona. España
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38
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Abstract
In summary, over the past decade, MRCP has evolved not only as a feasible means of noninvasively evaluating the pancreaticobiliary tract but also as a technique with documented clinical utility. With the evolution of MRCP, there has been, by necessity, an evolution of ERCP. In fact, at some institutions MRCP has replaced diagnostic ERCP such that ERCP is reserved primarily for therapeutic interventions. When MRCP is performed in conjunction with abdominal MR and MRA, a comprehensive examination results that permits evaluation of the solid organs and vessels of the abdomen as well as the ductal systems.
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Affiliation(s)
- Ann S Fulcher
- Department of Radiology, 401 North 12th Street, Room 3-407B, Post Office Box 980615, Medical College of Virginia of Virginia Commonwealth University, Richmond, VA 23298-0615, USA.
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MacEneaney P, Mitchell MT, McDermott R. Update on magnetic resonance cholangiopancreatography. Gastroenterol Clin North Am 2002; 31:731-46. [PMID: 12481728 DOI: 10.1016/s0889-8553(02)00033-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
MRCP is a useful tool in the diagnosis of a wide variety of pathologic entities including congenital anomalies, biliary obstruction and stricture, biliary calculi, pancreatitis, neoplasms, and trauma. ERCP and MRCP both have important roles in the management of patients with suspected pancreaticobiliary disease. Knowledge of the advantages and disadvantages of each technique is needed to determine the appropriate work-up of patients with these pathologies.
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Affiliation(s)
- Peter MacEneaney
- University of Chicago Hospitals, Department of Radiology, MRI Section, 5841 South Maryland Ave./MC 2026, Chicago, IL 60615, USA.
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Irie H, Honda H, Shinozaki K, Yoshimitsu K, Aibe H, Nishie A, Nakayama T, Masuda K. MR imaging of ampullary carcinomas. J Comput Assist Tomogr 2002; 26:711-7. [PMID: 12439303 DOI: 10.1097/00004728-200209000-00008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE The purpose of this study was to demonstrate the appearance of ampullary carcinomas on MR images. METHODS Sixteen patients with ampullary carcinomas underwent MR imaging. Tumor detectability, signal intensity of the tumor, and enhancement pattern on dynamic study were analyzed. MR cholangiopancreatography (MRCP) findings were assessed and were compared with the endoscopic retrograde cholangiopancreatography (ERCP) findings. RESULTS Signal intensities of the tumor on each image were various. Dynamic study detected all tumors except one, and all detected tumors showed delayed enhancement. MRCP delineated more than half of the tumors as a filling defect within the duodenal fluid and clearly demonstrated pancreaticobiliary ductal. CONCLUSIONS Dynamic study is mandatory in diagnosing ampullary carcinoma, because it can depict most of the tumors, and delayed enhancement of such tumors is characteristic in case of ampullary carcinoma. MRCP can provide reliable information about pancreaticobiliary duct and it can replace diagnostic ERCP.
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Affiliation(s)
- Hiroyuki Irie
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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41
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Affiliation(s)
- Fergus V Coakley
- Department of Radiology, Abnormal Imaging, University of California-San Francisco Medical Center, California 94122, USA
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42
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Abstract
Pancreatic imaging is an essential tool in the early diagnosis and staging of pancreatic disease. This review analyzes the most recent advances in pancreatic imaging. The specific modalities discussed include helical computed tomography (HCT) and multislice CT (MSCT), CT angiography, magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and positron emission tomography (PET). At present, MSCT is generally viewed as the most efficient modality for initial detection and staging of pancreatic carcinoma, with an accuracy rate of about 95% to 97% for initial detection and virtually 100% for staging. CT is also the initial imaging modality used in evaluation of acute pancreatitis. However, recently, MRI has been viewed increasingly as a more precise diagnostic tool in this subgroup of patients. MRCP has been accepted as the primary imaging technique in the diagnosis of chronic pancreatitis. PET imaging, on the other hand, has an increasing role in the staging of pancreatic carcinoma, for which it may be the modality of choice in detection of extrapancreatic metastasis.
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Affiliation(s)
- Chiara Del Frate
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Jarnagin WR, Fong Y, DeMatteo RP, Gonen M, Burke EC, Bodniewicz BS J, Youssef BA M, Klimstra D, Blumgart LH. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001; 234:507-17; discussion 517-9. [PMID: 11573044 PMCID: PMC1422074 DOI: 10.1097/00000658-200110000-00010] [Citation(s) in RCA: 956] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To analyze resectability and survival in patients with hilar cholangiocarcinoma according to a proposed preoperative staging scheme that fully integrates local, tumor-related factors. SUMMARY BACKGROUND DATA In patients with hilar cholangiocarcinoma, long-term survival depends critically on complete tumor resection. The current staging systems ignore factors related to local tumor extent, preclude accurate preoperative disease assessment, and correlate poorly with resectability and survival. METHODS Demographics, results of imaging studies, surgical findings, pathology, and survival were analyzed prospectively in consecutive patients. Using data from imaging studies, all patients were placed into one of three stages based on the extent of ductal involvement by tumor, the presence or absence of portal vein compromise, and the presence or absence of hepatic lobar atrophy. RESULTS From March 1991 through December 2000, 225 patients were evaluated, 77% of whom were seen and treated within the last 6 years. Sixty-five patients had unresectable disease; 160 patients underwent exploration with curative intent. Eighty patients underwent resection: 62 (78%) had a concomitant hepatic resection and 62 (78%) had an R0 resection (negative histologic margins). Negative histologic margins, concomitant partial hepatectomy, and well-differentiated tumor histology were associated with improved outcome after all resections. However, in patients who underwent an R0 resection, concomitant partial hepatectomy was the only independent predictor of long-term survival. Of the 9 actual 5-year survivors (of 30 at risk), all had a concomitant hepatic resection and none had tumor-involved margins; 3 of these 9 patients remained free of disease at a median follow-up of 88 months. The rates of complications and death after resection were 64% and 10%, respectively. In the 219 patients whose disease could be staged, the proposed system predicted resectability and the likelihood of an R0 resection and correlated with metastatic disease and survival. CONCLUSION By taking full account of local tumor extent, the proposed staging system for hilar cholangiocarcinoma accurately predicts resectability, the likelihood of metastatic disease, and survival. Complete resection remains the only therapy that offers the possibility of long-term survival, and hepatic resection is a critical component of the surgical approach.
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Affiliation(s)
- W R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Potter MW, Shah SA, McEnaney P, Chari RS, Callery MP. A critical appraisal of laparoscopic staging in hepatobiliary and pancreatic malignancy. Surg Oncol 2001; 9:103-10. [PMID: 11356338 DOI: 10.1016/s0960-7404(01)00005-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Prognosis for patients with hepatobiliary and pancreatic cancers is dismal. Surgery is the best therapeutic option for those with tumors which have not yet metastasized. Standard radiologic tests such as computed tomography (CT) scan and trans-abdominal ultrasound are useful in identifying patients for whom an attempt at resection would be futile. Staging laparoscopy with laparoscopic ultrasound allows greater precision in identifying those for whom resection would be helpful with less morbidity than an open exploration. Metastatic disease can be identified more precisely than with radiologic tests and can be characterized by biopsy techniques. Palliative procedures are now being performed laparoscopically with low morbidity and short hospital stays. The use of laparoscopy prior to open exploration for patients with hepatobiliary and pancreatic tumors is advantageous.
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Affiliation(s)
- M W Potter
- Department of Surgery, University of Massachusetts Medical School, 01655, Worcester, MA, USA
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45
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Abstract
Current MR imaging technology offers the surgeon diagnostic information about pancreatic diseases. This article reviews the basics of MR imaging formation and the rationale for the different types of imaging sequences that comprise a comprehensive pancreaticobiliary examination. Clinical examples include evaluation of pancreatic neoplasms, acute and chronic pancreatitis, and congenital abnormalities.
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Affiliation(s)
- A J Megibow
- Department of Radiology, New York University Medical Center, New York 10016, USA
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46
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Abstract
Gallbladder cancer often presents with advanced disease. When found early, surgery can be curative for this particular malignancy. Prognostic factors that influence the success of aggressive surgical therapy include depth of invasion, extent of hepatic infiltration, histologic grade, presence of venous, lymphatic or perineural invasion, and lymph node metastasis. Tumors with tumor limited to the subserosal layer, hepatic infiltration that is only 5 mm or less, papillary or well differentiated adenocarcinomas, tumors with no venous, lymphatic or perineural invasion and lymph node metastasis limited to the hepatoduodenal ligament have the best prognosis with surgery (15, 16, 36). Extended cholecystectomy with lymph node dissection has improved the results of treating T2 gallbladder cancers. More extensive resections should keep the above prognostic factors in mind. When surgical resection is not possible, endoscopic stenting of the biliary tree for palliation of obstructive jaundice is effective. Earlier detection or more effective chemotherapy will be needed to significantly improve the prognosis of this disease.
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Affiliation(s)
- L G Dawes
- University of Michigan, Ann Arbor, MI, USA
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Jarnagin WR. Cholangiocarcinoma of the extrahepatic bile ducts. SEMINARS IN SURGICAL ONCOLOGY 2000; 19:156-176. [PMID: 11126380 DOI: 10.1002/1098-2388(200009)19:2<156::aid-ssu8>3.0.co;2-%23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
Abstract
Malignancies of the biliary tree, particularly the extrahepatic bile ducts, remain difficult clinical problems. Because experience with these uncommon tumors has been limited to a small number of centers, meaningful clinical trials have been difficult to perform. Complete resection remains the most effective therapy, but is usually possible in the minority of patients. Palliating the effects of biliary obstruction is thus often the primary therapeutic goal. Chemotherapy and radiation therapy have not been proven to reduce the incidence of recurrence after resection nor to improve survival in patients with unresectable disease. This review focuses on cholangiocarcinoma of the extrahepatic bile ducts.
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Affiliation(s)
- W R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York 10021, USA.
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Hann LE, Winston CB, Brown KT, Akhurst T. Diagnostic imaging approaches and relationship to hepatobiliary cancer staging and therapy. SEMINARS IN SURGICAL ONCOLOGY 2000; 19:94-115. [PMID: 11126385 DOI: 10.1002/1098-2388(200009)19:2<94::aid-ssu3>3.0.co;2-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Diagnostic imaging plays an essential role in management of hepatobiliary tumors. High resolution images provided by computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) allow detection of tumor within the liver. CT arterial portography remains the standard for detection of small lesions in the range of 1.5 cm, but noninvasive techniques such as contrast-enhanced helical CT and MR hold promise for comparable lesion detection. MRI provides lesion characterization for differentiation of benign and malignant tumors. Lesion characterization has been further improved by faster CT and MR techniques that allow imaging in both arterial and portal venous phases for characterization of lesions based on the rate and pattern of enhancement. Functional imaging such as 2-fluoro-2-deoxy-D-glucose-positron-emission tomography (FDG-PET) is increasingly utilized for detection of intrahepatic tumor and extrahepatic disease. Accuracy of FDG-PET for extrahepatic disease is better than conventional imaging and has been shown to change management in a significant number of patients. Imaging is also invaluable for surgical planning. Segmental anatomy is well shown by CT, MRI, and US. CT or MR angiography with newer 3D techniques delineate vascular variants and areas of encasement or occlusion by tumor. Biliary involvement at the hilus may be shown by US and MR cholangiography. Imaging detection of vascular involvement, bile duct extension, and lobar atrophy may alter the surgical approach.
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Affiliation(s)
- L E Hann
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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49
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Abstract
The liver is a common site of metastasis from a variety of tumors. In many cases, liver resection for metastatic cancer provides the only chance for a cure and can be performed with less than 5% mortality and acceptable morbidity. The 5-year survival following liver resection for colorectal metastasis is reported in many large series to be 25% to 37%. The data regarding liver resection for other metastatic tumor types are less clear. However, resection for selected tumors, such as neuroendocrine and renal cell, can provide durable palliation and/or cure. We will review important prognostic factors used to guide the selection of patients for resection of metastatic disease and make recommendations for imaging studies and follow-up routines. The role of adjuvant regional and systemic chemotherapy for resectable metastatic disease is also discussed. Methods for ablating unresectable metastatic tumors may prove to be useful adjuncts to current therapies.
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Affiliation(s)
- M D McCarter
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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50
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Abstract
Malignancies of the biliary tree, particularly the extrahepatic bile ducts, remain difficult clinical problems. Because experience with these uncommon tumors has been limited to a small number of centers, meaningful clinical trials have been difficult to perform. Complete resection remains the most effective therapy, but is usually possible in the minority of patients. Palliating the effects of biliary obstruction is thus often the primary therapeutic goal. Chemotherapy and radiation therapy have not been proven to reduce the incidence of recurrence after resection nor to improve survival in patients with unresectable disease. This review focuses on cholangiocarcinoma of the extrahepatic bile ducts.
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Affiliation(s)
- W R Jarnagin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York 10021, USA.
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