practical approaches to biliary tract imaging · practical biliary tract imaging: converting subtle...
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PRACTICAL APPROACHES TO BILIARY TRACT IMAGING
Richard Baron, M.D., University of Chicago
PRACTICAL APPROACHES TO BILIARY TRACT IMAGING
• Differentiating complicated gallbladder inflammation from neoplasm
• Detecting and staging cholangiocarcinoma
GB Carcinoma
Metastatic Melanoma
Staging GB Carcinoma
• Liver Involvement– Direct Invasion
• Regional Lymph Nodes– Pancreatico-duodenal– Node to the foramen of
Winslow• Peritoneal spread
• Distant hematogenousspread (liver, lung) uncommon
Gallbladder Adenomyomatosis
smooth muscle proliferationRokitansky-Aschoff sinusesSegmental, may be diffuse
can be difficult to differentiate from carcinoma
• Cholecystitis(often normal appearance)
Gallstoneswall thickeningpericholecystic halopericholecystic fluidpainful percussiongallbladder distension
• Complicated Cholecystitis
Marked wall thickeningLarger fluid collections
(assymetric)Gas in gallbladder lumen
or wallSloughed mucosa
GB Carcinoma vs. Complicated Cholecystitis?
Complicated Cholecystitis: sloughed mucosa
Complicated Cholecystitis: emphysematous
Complicated Cholecystitis vs. GB Carcinoma
• Symmetric wall thickening
• Halo around GB• Excessive fluid• Striated GB wall
• Assymetric wall thickening
• Replacement of GB lumen
• Liver invasion
Cholangiocarcinoma• Gross pathologic structure
– Annular, constricting– Infiltrative and expanding– Intraluminal, polypoid
• Underlying histologic stroma– Fibrous versus glandular stroma
• Locations– Intrahepatic, Proximal CBD, Distal
• Associations: PSC, Choledochal cysts; infections, chemical toxins
Key Clinical Settings for Chol-Ca:PSC (sclerosing cholangitis
Choledochal Cysts Fluke infestationTHICK SLAB THIN SLAB
Cholangiocarcinoma: Enhancement Characteristics
• Unenhanced CT: hypoattenuating• Arterial Phase CT/MR: minimally
enhancing (often peripheral rim enhancement )
• Portal Venous Phase CT/MR: continued enhancement (towards center)
• Equilibrium Phase: Delayed retention throughout if fibrous dominant stroma
Cholangiocarcinoma
Cholangiocarcinoma: Fibrous Stroma
Cholangiocarcinoma: Glandular Stroma
Spectrum of CholangiocarcinomaPathology
Fibrous Stroma Glandular Stroma
Mixed Stroma
Value of Delay Equilibrium Phase
Delay (mins)
6-10 11-15 16-20 21-25 26-30 31-36
Tumor enhancement 5 12 9 6 2 1No tumor enhancement 1 5 2 2 1 1
Total 6 17 11 8 3 2
CCA: Delay Contrast FindingsLacomis, Baron, Oliver, et al. Radiology 1997;203:998-104
Cholangiocarcinoma: duct wall thickening
Cholangiocarcinoma
Intraductal Papillary Tumor : Morphology
Lim JH , Baron R. ECR 2009
a. Polypoid tumor
b. Mucosal spreading growth
c. Castlike intraductal tumor
d. Cystic tumor
Clinical significance
• Treatment planning: resection
• Prediction of Prognosis: excellent
Papillary Cholangiocarcinoma
Cholangiocarcinoma:Superficial Spreading
Cholangiocarcinoma:Cast-Like
Mucin Producing Cholangiocarcinomawith cystic change
one two three four
Practical Biliary Tract Imaging: Converting Subtle to Obvious
• Optimize imaging techniques to optimize underlying pathologic features
• Understanding arterial, portal, and delay enhancement characteristics of biliarytumors
• Putting images in perspective with clinical setting