Rationale and Objectives
To evaluate the magnetic resonance (MR) findings of bile duct tumor thrombi (BDTT) and intraductal growing-type cholangiocarcinoma (IDG-type CC), especially focusing on the distal segment of intrabiliary tumors.
Materials and Methods
Twenty-nine cases of hepatocellular carcinoma with BDTT and 17 cases of IDG-type CC were available for retrospective review. The following MR findings were evaluated: presence of necrosis and T1-weighted (T1W) hyperintense signal on the surface of the distal segment of intrabiliary tumors, bile duct wall thickening adjacent to the tumor, dilation of bile duct of the tumor-bearing segment, location and maximum diameter of intraductal mass, and presence of a hepatic parenchymal mass.
Results
There was significant difference in T1W hyperintense signal on the surface of the distal segment of intrabiliary tumors between BDTT and IDG-type CC ( P < .05). The T1W hyperintense signal detected in BDTT was identified as bile layering (9/25) or hemobilia (16/25) pathologically. For the diagnosis of BDTT, the sensitivity and specificity of T1W hyperintense signal was 86.2% and 100%, respectively. There was significant difference in necrosis at the distal end of intrabiliary tumors and presence of hepatic parenchymal mass between BDTT and IDG-type CC ( P < .05). However, no statistical significance was found in bile duct dilation, the absence of wall thickening, the location of intraductal mass, or the maximum diameter of intrabiliary mass between the two groups ( P > .05).
Conclusions
The T1W hyperintense signal on the distal segment of intrabiliary mass was because of concentrated bile deposits or hemobilia. The sign of T1W hyper signal on the distal segment is valuable to differentiate BDTT and IDG-type CC.
Hepatocellular carcinoma (HCC) is one of the most common types of malignant abdominal tumors. Jaundice is common in HCC and the incidence is approximately 19% to 40% . The etiology of jaundice is primarily from diffuse tumor infiltration of the liver parenchyma, hilar invasion accompanied by compression of the bile duct, or progressive terminal liver failure . HCC can invade the bile duct and form intrabiliary tumor thrombi . Patients with this type of HCC normally have obstructive jaundice as their initial complaint. Bile duct tumor thrombi (BDTT) formation is presented in 0.8% to 12.9% of surgically resected HCC . Magnetic resonance (MR) imaging is a commonly used diagnostic imaging modality for the detection of hepatic and biliary tumors. The MR manifestation of HCC with BDTT has been reported in the literature . BDTT presents as an intrabiliary cordlike or castlike soft-tissue mass with dilated distal bile duct. However, bile duct wall thickening or tumor invasion beyond bile duct wall is not accompanied in most of the BDTT . On the dynamic-enhanced MR images, early enhancement of BDTT can be detected in the arterial phase . These MR features are very similar to those of intraductal growing-type cholangiocarcinoma (IDG-type CC), which also known as early bile duct carcinoma . These two entities (BDTT and IDG-type CC) are distinct in terms of treatment strategies and prognosis. The prognosis of patients with BDTT is generally poor even with aggressive operative approach, whereas good surgical outcomes can be obtained in IDG-type CC patients after complete resection . For an intrabiliary mass with small hepatic tumor or undetectable liver parenchyma tumor, special emphasis should be placed on discriminating BDTT and IDG-type CC .
Although the MR manifestation of BDTT has been described in detail in the literature, the pathologic change and MR findings of distal segment of BDTT have been rarely reported in the literature. T1-weighted (T1W) hyperintense signal on the surface of distal segment of BDTT has been reported in the literature and is believed to be caused by hemobilia . However, to the best of our knowledge, the pathologic changes and the implications of T1W hyperintense signal on the surface of distal segment of BDTT have not been reported in the literature. To evaluate its significance in the diagnosis of BDTT, we retrospectively reviewed 29 cases of HCC with BDTT and compared the pathologic changes and MR findings of the distal segment of BDTT with those of 17 cases of IDG-type CC. This study mainly focused on the distal segment of BDTT and IDG-type CC.
Materials and methods
Study Population
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MR Imaging
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Table 1
Parameters for MR Imaging
MRI Scanner and Sequence TR/TE (ms) Flip Angle Section Thickness Section Spacing Field of View FST Matrix Size Breath-hold NA 1.5T Gyroscan Intera Axial T1W FFE 260.0/5.0 80° 4.0–6.0 mm 2 mm 360 mm Proset 264 × 207 Yes 1 Axial T2W TSE 1600.0/70.0 90° 4.0–6.0 mm 2 mm 360 mm SPIR 292 × 209 No 3 Coronal T1W FFE 192.0/5.0 80° 5.0 mm 1 mm 400 mm Proset 256 × 204 Yes 1 1.5T Signa HDxt Axial T1W FSPGR 90.0/1.2 80° 6.0 mm 1 mm 350 mm CHESS 320 × 224 Yes 1 Axial T2W FSE 6000.0/86.0 90° 6.0 mm 1 mm 350 mm CHESS 288 × 224 No 2 Coronal T1W FSPGR 75.0/1.3 80° 7.0 mm 1 mm 380 mm CHESS 384 × 224 Yes 1
CHESS, chemical shift selective; FFE, fast field echo; FSE, fast spin echo; FSPGR, fast spoiled gradient echo; FST, fat suppression technique; Proset, principle of selective excitation technique; NA, number of acquisition; SPIR, spectral presaturation inversion recovery; TE, echo time; TR, repetition time; TSE, turbo spin echo.
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Image Evaluation and Pathologic Analysis
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Statistical Analysis
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Results
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Table 2
MRI Findings at the Distal Segment of Intrabiliary Mass in BDTT and IDG-type CC Patients
Findings BDTT ( n = 29) IDG-type CC ( n = 17)P Value T1W hyperintense signal ∗ <.001 Present 25 0 Absent 4 17 Necrosis at the distal end of intrabiliary mass ∗ .001 Present 14 0 Absent 15 17 Bile duct wall thickening adjacent to the tumor † .343 Present 2 3 Absent 27 14 Dilation of bile duct of the tumor-bearing segment † .131 Present 29 15 Absent 0 2 Location of intraductal mass ∗ .885 Extrahepatic duct 22 14 Intrahepatic duct 7 3 Hepatic parenchymal mass ∗ <.001 Present 24 3 Absent 5 14 Maximum diameter of intrabiliary mass ‡ 2.0 ± 0.7 cm 2.2 ± 0.5 cm .366
BDTT, bile duct tumor thrombi; IDG-type CC, intraductal growing-type cholangiocarcinoma.
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Discussion
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References
1. Qin L.X., Ma Z.C., Wu Z.Q., et. al.: Diagnosis and surgical treatments of hepatocellular carcinoma with tumor thrombosis in bile duct: experience of 34 patients. World J Gastroenterol 2004; 10: pp. 1397-1401.
2. Qin L.X., Tang Z.Y.: Hepatocellular carcinoma with obstructive jaundice: diagnosis, treatment and prognosis. World J Gastroenterol 2003; 9: pp. 385-391.
3. Huang J.F., Wang L.Y., Lin Z.Y., et. al.: Incidence and clinical outcome of icteric type hepatocellular carcinoma. J Gastroenterol Hepatol 2002; 17: pp. 190-195.
4. Yeh C.N., Jan Y.Y., Lee W.C., et. al.: Hepatic resection for hepatocellular carcinoma with obstructive jaundice due to biliary tumor thrombi. World J Surg 2004; 28: pp. 471-475.
5. Shiomi M., Kamiya J., Nagino M., et. al.: Hepatocellular carcinoma with biliary tumor thrombi: aggressive operative approach after appropriate preoperative management. Surgery 2001; 129: pp. 692-698.
6. Gabata T., Terayama N., Kobayashi S., et. al.: MR imaging of hepatocellular carcinomas with biliary tumor thrombi. Abdom Imaging 2007; 32: pp. 470-474.
7. Tseng J.H., Hung C.F., Ng K.K., et. al.: Icteric-type hepatoma: magnetic resonance imaging and magnetic resonance cholangiographic features. Abdom Imaging 2001; 26: pp. 171-177.
8. Liu Q., Chen J., Li H., et. al.: Hepatocellular carcinoma with bile duct tumor thrombi: correlation of magnetic resonance imaging features to histopathologic manifestations. Eur J Radiol 2010; 76: pp. 103-109.
9. Kim J.E., Lee J.M., Kim S.H., et. al.: Differentiation of intraductal growing-type cholangiocarcinomas from nodular-type cholangiocarcinomas at biliary MR imaging with MR cholangiography. Radiology 2010; 257: pp. 364-372.
10. Lim J.H., Jang K.T., Choi D., et. al.: Early bile duct carcinoma: comparison of imaging features with pathologic findings. Radiology 2006; 238: pp. 542-548.
11. Lee D.H., Lee J.M., Kim K.W., et. al.: MR imaging findings of early bile duct cancer. J Magn Reson Imaging 2008; 28: pp. 1466-1475.
12. Long X.Y., Li Y.X., Wu W., et. al.: Diagnosis of bile duct hepatocellular carcinoma thrombus without obvious intrahepatic mass. World J Gastroenterol 2010; 16: pp. 4998-5004.
13. Liu Q.Y., Huang S.Q., Chen J.Y., et. al.: Small hepatocellular carcinoma with bile duct tumor thrombi: CT and MRI findings. Abdom Imaging 2010; 35: pp. 537-542.
14. Lee N.K., Kim S., Lee J.W., et. al.: MR appearance of normal and abnormal bile: correlation with imaging and endoscopic finding. Eur J Radiol 2010; 76: pp. 211-221.
15. Yu X.H., Xu L.B., Liu C., et. al.: Clinicopathologic characteristics of 20 cases of hepatocellular carcinoma with bile duct tumor thrombi. Dig Dis Sci 2011; 56: pp. 252-259.
16. Jung A.Y., Lee J.M., Choi S.H., et. al.: CT features of an intraductal polypoid mass: differentiation between hepatocellular carcinoma with bile duct tumor invasion and intraductal papillary cholangiocarcinoma. J Comput Assist Tomogr 2006; 30: pp. 173-181.
17. Kim N.R., Kim S.H., Lee J.M., et. al.: Sonographic features of an intraductal polypoid mass: differentiation between hepatocellular carcinoma and intraductal cholangiocarcinoma. J Ultrasound Med 2004; 23: pp. 1283-1291.
18. Ikenaga N., Chijiiwa K., Otani K., et. al.: Clinicopathologic characteristics of hepatocellular carcinoma with bile duct invasion. J Gastrointest Surg 2009; 13: pp. 492-497.
19. Satoh S., Ikai I., Honda G., et. al.: Clinicopathologic evaluation of hepatocellular carcinoma with bile duct thrombi. Surgery 2000; 128: pp. 779-783.
20. Wang Y.D., Xue H.Z., Jiang Q.F., et. al.: Surgical operation and re-operation for hepatocellular carcinoma with bile duct thrombosis. Chin Med J (Engl) 2010; 123: pp. 2163-2170.
21. Kitagawa K., Yamakado K., Nakatsuka A., et. al.: Selective transcatheter hepatic arterial chemoembolization for hemobilia from hepatocellular carcinoma: report of three cases. J Vasc Interv Radiol 1999; 10: pp. 1357-1360.
22. Kojiro M., Kawabata K., Kawano Y., et. al.: Hepatocellular carcinoma presenting as intrabile duct tumor growth: a clinicopathologic study of 24 cases. Cancer 1982; 49: pp. 2144-2147.
23. Lim J.H.: Cholangiocarcinoma: morphologic classification according to growth pattern and imaging findings. AJR Am J Roentgenol 2003; 181: pp. 819-827.
24. Lim J.H., Park C.K.: Pathology of cholangiocarcinoma. Abdom Imaging 2004; 29: pp. 540-547.
25. Choi B.I., Lee J.M., Han J.K.: Imaging of intrahepatic and hilar cholangiocarcinoma. Abdom Imaging 2004; 29: pp. 548-557.
26. Lee Y.J., Kim S.H., Lee J.Y., et. al.: Differential CT features of intraductal biliary metastasis and double primary intraductal polypoid cholangiocarcinoma in patients with a history of extrabiliary malignancy. AJR Am J Roentgenol 2009; 193: pp. 1061-1069.