kartik s. jhaveri , md frcpc director, abdominal …...kartik s. jhaveri , md frcpc director,...

Kartik S. Jhaveri , MD FRCPC

Director, Abdominal MRI

Director, CME Program

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CHOLANGIOCARCINOMA

Adenocarcinoma(mostly) arising from bile duct

epithelium -Liver to Ampulla of Vater

Diverse range of Growth patterns, Location and

Imaging appearances

Diagnostic and Therapeutic Challenges

Rising incidence over the last 3 decades

10-15% of hepatic primary malignancies

Relevance to Liver Transplant Elligibility

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OVERVIEW

DIAGNOSIS STAGING

MRI Protocol Pointers

Classification/Patterns

Surveillance - High Risk

Mimics

Staging Systems

Resectability

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Coronal T2 Axial In/Out phase

Axial Diffusion:

Axial 3D T1

Axial T2

CCA - MR PROTOCOL Radial MRCP

3D T2 MRCP Coronal 3D T1 4

CLASSIFICATION

Location Growth Pattern &

Morphology

ANATOMICAL INFO RISK FACTORS

BIOLOGICAL BEHAVIOUR

PROGNOSIS

ICC

ECC

MASS FORMING

PERIDUCTAL INFILTRATING

INTRADUCTAL

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Mass-Forming Periductal-Infiltrating Intraductal

CLASSIFICATION

CCA MIMICS

CRC Met

HCC

AIP/IgG4

Mirizzi

PSC

Portal Biliopathy

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Mass-Forming Periductal-Infiltrating Intraductal

• Lymphoma

• Mets

• Cast/blood

STAGING-IMPLICATIONS

• Surgery- Resection (or Transplantation) is the “only

effective treatment”.

• 5-year survival - Surgery ~ 10-30%

- No Surgery ~ 0%(Median 6m)

• Surgical Morbidity (>25%) & Mortality (>5%) is HIGH

•Accurate Staging is Critical !

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STAGING SYSTEMS

Bismuth-Corlette ( Perihilar)

TNM

Blumgart(MSKCC)

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STAGING – BISMUTH-CORLETTE

• Type I

CHD within 2cm of Confluence

• Type II

CHD involving both main RHD & LHD

• Type IIIa

Biliary Confluence and Secondary RHD radicle

• Type IIIb

Biliary Confluence and secondary LHD radicle

• Type IV

Bilobar Intrahepatic ducts involves secondary and tertiary radicles

INCOMPLETE SCHEMA AS NO ACCOUNT OF

VASCULAR INVASION ,NODAL STATUS AND

METASTASES

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STAGING-TNM

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AJCC 7th ed

• Pathology Criteria

• Post Op Staging System

• Survival Prediction

• Doesnot Correlate well with Resectability

STAGING- BLUMGART CLASSIFICATION

T1 = Biliary Confluence +/- unilateral extent to

2nd order ducts

T2 = T1 with ipsilateral portal infiltration +/-

ipsilateral lobar atrophy

T3 = Biliary confluence +

Bilateral extent to 2nd order ducts OR

Unilateral extent to 2nd order ducts with

Contralateral portal vein infiltration /

Lobar atrophy / bilateral or main portal vein

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Jarnagin . Ann Surg 1998

Matsuo JACS 2012 Best correlation Resectability(86% Acc)

Modified J-B Classification

Original Jarnagin-Blumgart (MSKCC)

Not useful Predicting Survival

13 Ding et al. World Journal of Surgical Oncology (2015) 13:99

RESECTABILITY

- Longitudinal and Radial Tumor Spread

- Vascular Involvement

- Lymph Node

- Distant Metastases

- Liver Volume

- Other Co-Existent Diseases

Biliary, Arterial and Portal Vein Anomalies

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STAGING- BLUMGART CLASSIFICATION

T1 = Biliary Confluence +/- unilateral extent to

2nd order ducts

T2 = T1 with ipsilateral portal infiltration +/-

ipsilateral lobar atrophy

T3 = Biliary confluence +

Bilateral extent to 2nd order ducts OR

Unilateral extent to 2nd order ducts with

Contralateral portal vein infiltration /

Lobar atrophy / bilateral or main portal vein

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Jarnagin . Ann Surg 1998

Matsuo JACS 2012 Best correlation Resectability(86% Acc)

Q

Is This Tumor Resectable?

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Vasc encase CASE

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CASE

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Surveillance of High-Risk Groups

Primary Sclerosing Cholangitis

Caroli’s Disease

Choledochal Cyst

Fluke Infestations-Clonorchis

Recurrent Pyogenic Cholangitis

Hepatolithiasis

5-15 %

7 %

5 %

PREDISPOSING DISEASE LIFETIME RISK

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PSC

1% Annual Incidence

Detection of CCA in PSC on single exam remains problematic

Serial MR + Tumour Markers (CA 19-9) increases yield

Charatcharoenwitthaya P et al. Utility of serum tumor markers, imaging, and biliary cytology for

detecting cholangiocarcinoma in primary sclerosing cholangitis.. Hepatology. 2008. 48 (4):1106

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PSC-CCA

JULY 2006 JAN 2007

Warning Signs On MR Imaging

•Short Interval Appearance / New area of Biliary Dilatation

•Unequal Regional/Segmental Biliary Dilatation

•Subtle /New Parenchymal Lesion adjacent to Bile ducts

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PSC-CCA

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PSC-CCA

8 MONTHS LATER

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Choledochal Cyst + CCA

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JULY 2008 SEP 2010

SUMMARY

MRI :Diagnosis, Staging & Surveillance

High Quality Imaging Key

Be Aware of Mimics.

Preop Staging/Resectability is Critical

Blumgart(MSKCC) system

CCA in PSC – Challenging

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