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Lee CW, Son HJ, Woo JY, Lee SH. Is Prone Position [ 18F]FDG PET/CT Useful in Reducing Respiratory Motion Artifacts in Evaluating Hepatic Lesions? Diagnostics (Basel) 2023; 13:2539. [PMID: 37568906 PMCID: PMC10417611 DOI: 10.3390/diagnostics13152539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Prone position is useful in reducing respiratory motion artifacts in lung nodules on 2-Deoxy-2-[18F] fluoro-D-glucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT). However, whether prone position PET/CT is useful in evaluating hepatic lesions is unknown. Thirty-five hepatic lesions from 20 consecutive patients were evaluated. The maximum standardized uptake value (SUVmax) and metabolic tumor volume (MTV) of both standard supine position PET/CT and additional prone position PET/CT were evaluated. No significant difference in SUVmax (4.41 ± 2.0 vs. 4.23 ± 1.83; p = 0.240) and MTV (5.83 ± 6.69 vs. 5.95 ± 6.24; p = 0.672) was observed between supine position PET/CT and prone position PET/CT. However, SUVmax changes in prone position PET/CT varied compared with those in supine position PET/CT (median, -4%; range: -30-71%). Prone position PET/CT was helpful when [18F]FDG uptake of the hepatic lesions was located outside the liver on supine position PET/CT (n = 4, SUVmax change: median 15%; range: 7-71%) and there was more severe blurring on supine position PET/CT (n = 6, SUVmax change: median 11%; range: -3-32%). Unlike in lung nodules, prone position PET/CT is not always useful in evaluating hepatic lesions, but it may be helpful in individual cases such as hepatic dome lesions.
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Affiliation(s)
- Chung Won Lee
- Department of Radiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea;
| | - Hye Joo Son
- Department of Nuclear Medicine, Dankook University Medical Center, Cheonan 31116, Republic of Korea;
| | - Ji Young Woo
- Department of Radiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea;
| | - Suk Hyun Lee
- Department of Radiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea;
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Han C, Ling X, Sheng L, Yang M, Lin R, Ding Z. Distal extrahepatic cholangiocarcinoma mimicking groove pancreatitis: A case report and literature review. Front Oncol 2022; 12:948799. [PMID: 36237325 PMCID: PMC9553287 DOI: 10.3389/fonc.2022.948799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThe differential diagnosis between cholangiocarcinoma and groove pancreatitis is quite challenging. Groove pancreatitis is commonly misdiagnosed as periampullary tumors. We reported a case of distal extrahepatic cholangiocarcinoma mimicking groove pancreatitis.Case reportA 57-year-old male patient was transferred to our hospital after endoscopic retrograde cholangiopancreatography (ERCP) with stent placement in the common bile duct due to obstructive jaundice at a local hospital. Groove pancreatitis was considered based on the clinical manifestations and multiple examinations [including computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and endoscopic ultrasonography (EUS)]. The patient’s symptoms and laboratory results almost returned to normal after conservative treatments. Interestingly, his symptoms and laboratory results worsened after the stent was removed. We performed a second EUS process and found a lesion in the lower common bile duct. Finally, the patient underwent pancreatoduodenectomy, and the diagnosis was confirmed as moderately differentiated adenocarcinoma of the common bile duct.ConclusionOur case highlights the fact that distal extrahepatic cholangiocarcinoma, which is a malignant disease, can mimic a benign condition like groove pancreatitis. Our case also raises the concern that performing stent placement through ERCP to relieve jaundice without a clear diagnosis could interfere with further evaluation of the disease.
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Affiliation(s)
- Chaoqun Han
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liping Sheng
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Yang
- Division of Pathology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Lin
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Zhen Ding, ; Rong Lin,
| | - Zhen Ding
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Zhen Ding, ; Rong Lin,
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Lim HJ, Park MS, Kim YE. Diffuse Large B-Cell Lymphoma in the Portal Vein. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2020; 81:707-713. [PMID: 36238629 PMCID: PMC9431918 DOI: 10.3348/jksr.2020.81.3.707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/19/2019] [Accepted: 11/08/2019] [Indexed: 11/18/2022]
Abstract
Tumor thrombus in the portal vein without any liver parenchymal abnormality is extremely rare. In the liver, the primary tumor most frequently presenting with intravascular tumor thrombi is hepatocellular carcinoma and lymphoma is rarely considered. Even though thrombosis occurs quite often in lymphoma, cases of tumor thrombus are rare and cases of tumor thrombus in the portal vein are even rarer. Only four cases of lymphoma with portal vein tumor thrombosis have been reported to date and all cases were the result of direct extensions of a dominant nodal or extra-nodal mass. To our knowledge, there has been no report on diffuse large B-cell lymphoma (DLBCL) presenting only within the lumen of the portal vein and not intravascular B-cell lymphoma. We present the first case of DLBCL presenting only within the lumen of the portal vein in an immunocompetent patient.
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Affiliation(s)
- Hyun Ji Lim
- Department of Radiology, Seoul Medical Center, Seoul, Korea
| | - Mi-Suk Park
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yeo-Eun Kim
- Department of Radiology, Seoul Medical Center, Seoul, Korea
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Chapman MH, Thorburn D, Hirschfield GM, Webster GGJ, Rushbrook SM, Alexander G, Collier J, Dyson JK, Jones DE, Patanwala I, Thain C, Walmsley M, Pereira SP. British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of primary sclerosing cholangitis. Gut 2019; 68:1356-1378. [PMID: 31154395 PMCID: PMC6691863 DOI: 10.1136/gutjnl-2018-317993] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 02/21/2019] [Accepted: 03/24/2019] [Indexed: 12/11/2022]
Abstract
These guidelines on the management of primary sclerosing cholangitis (PSC) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included medical representatives from hepatology and gastroenterology groups as well as patient representatives from PSC Support. The guidelines aim to support general physicians, gastroenterologists and surgeons in managing adults with PSC or those presenting with similar cholangiopathies which may mimic PSC, such as IgG4 sclerosing cholangitis. It also acts as a reference for patients with PSC to help them understand their own management. Quality of evidence is presented using the AGREE II format. Guidance is meant to be used as a reference rather than for rigid protocol-based care as we understand that management of patients often requires individual patient-centred considerations.
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Affiliation(s)
- Michael Huw Chapman
- GI Division, UCL Hospitals NHS Foundation Trust, London, UK
- Liver Unit, Royal Free London NHS Foundation Trust, London, UK
| | | | - Gideon M Hirschfield
- Toronto Centre for Liver Disease, University Health Network and University of Toronto, Toronto, Canada
| | | | - Simon M Rushbrook
- Department of Hepatology, Norfolk and Norwich University Hospitals NHS Trust, Norwich, UK
| | | | | | - Jessica K Dyson
- Hepatology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - David Ej Jones
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Imran Patanwala
- Gastroenterology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
- University of Liverpool, Liverpool, UK
| | | | | | - Stephen P Pereira
- GI Division, UCL Hospitals NHS Foundation Trust, London, UK
- Institute for Liver & Digestive Health, University College London, London, UK
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Yaprak O, Acar S, Ertugrul G, Dayangac M. Role of pre-transplant 18F-FDG PET/CT in predicting hepatocellular carcinoma recurrence after liver transplantation. World J Gastrointest Oncol 2018; 10:336-343. [PMID: 30364796 PMCID: PMC6198297 DOI: 10.4251/wjgo.v10.i10.336] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 05/27/2018] [Accepted: 06/14/2018] [Indexed: 02/05/2023] Open
Abstract
The last two decades have seen a paradigm shift in the selection of patients with hepatocellular carcinoma (HCC) for liver transplantation. Microvascular invasion and differentiation have been the most significant factors affecting post-transplant recurrence; however, because of inherent disadvantages of pre-transplant biopsy, histological criteria never gained popularity. Recently, the selection criteria evolved from morphological to biological criteria, such as biomarkers and response to loco-regional therapy. With the introduction of multimodality imaging, combination of computed tomography with nuclear medicine imaging, particularly, 18F-fluorodeoxyglucose positron emission tomography fulfilled an unmet need and rapidly became a critical component of HCC management. This review article will focus on the use of 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography in the pre-transplant evaluation of HCC patients with special discussion on its ability to predict HCC recurrence after liver transplantation.
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Affiliation(s)
- Onur Yaprak
- Medipol University Hospital, Center for Organ Transplantation, Istanbul 34214, Turkey
| | - Sencan Acar
- Atasehir Memorial Hospital, Center for Organ Transplantation, Istanbul 34758, Turkey
| | - Gokhan Ertugrul
- Medipol University Hospital, Center for Organ Transplantation, Istanbul 34214, Turkey
| | - Murat Dayangac
- Medipol University Hospital, Center for Organ Transplantation, Istanbul 34214, Turkey
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Regulation of HK2 expression through alterations in CpG methylation of the HK2 promoter during progression of hepatocellular carcinoma. Oncotarget 2018; 7:41798-41810. [PMID: 27260001 PMCID: PMC5173097 DOI: 10.18632/oncotarget.9723] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/23/2016] [Indexed: 02/07/2023] Open
Abstract
Hexokinase 2 (HK2) is a rate-determining enzyme in aerobic glycolysis, a process upregulated in tumor cells. HK2 expression is controlled by various transcription factors and epigenetic alterations and is heterogeneous in hepatocellular carcinomas (HCCs), though the cause of this heterogeneity is not known. DNA methylation in the HK2 promoter CpG island (HK2-CGI) and its surrounding regions (shore and shelf) has not previously been evaluated, but may provide clues about the regulation of HK2 expression. Here, we compared HK2 promoter methylation in HCCs and adjacent non-cancerous liver tissues using a HumanMethylation450 BeadChip array. We found that, while the HK2-CGI N-shore was hypomethylated, thereby enhancing HK2 expression, the HK2-CGI was itself hypermethylated in some HCCs. This hypermethylation suppressed HK2 expression by inhibiting interactions between HIF-1α and a hypoxia response element (HRE) located at -234/-230. HCCs that were HK2negative and had distinct promoter CGI methylation were denoted as having a HK2-CGI methylation phenotype (HK2-CIMP), which was associated with poor clinical outcome. These findings indicate that HK2-CGI N-shore hypomethylation and HK2-CGI hypermethylation affect HK2 expression by influencing the interaction between HIF 1α and HRE. HK2-CGI hypermethylation induces HK2-CIMP and could represent a prognostic biomarker for HCC.
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Catalano O, Sandomenico F, Vallone P, Setola SV, Granata V, Fusco R, Lastoria S, Mansi L, Petrillo A. Contrast-Enhanced Ultrasound in the Assessment of Patients with Indeterminate Abdominal Findings at Positron Emission Tomography Imaging. ULTRASOUND IN MEDICINE & BIOLOGY 2016; 42:2717-2723. [PMID: 27495384 DOI: 10.1016/j.ultrasmedbio.2016.06.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/01/2016] [Accepted: 06/08/2016] [Indexed: 06/06/2023]
Abstract
Widespread use of fluorodeoxyglucose-positron emission tomography (PET) in cancer imaging may result in a number of indeterminate and false-positive findings. We investigated the role of contrast-enhanced ultrasound (CEUS) as a second-level option after inconclusive PET. We reviewed CEUS images acquired over 4 y, selecting the examinations performed specifically to better assess an unclear PET image. Final diagnosis was confirmed by biopsy, surgery, further imaging or follow-up. Seventy CEUS examinations were performed after a PET scan (44 PET examinations, 19 PET-computer tomography [CT] examinations and 7 PET-CECT examinations). The target organ was the liver in 54 cases, spleen in 12, gallbladder in 2 and pancreas and kidney in one each. In 6 of 70 cases, CEUS was performed because of a negative PET (no uptake) despite an abnormal finding on the CT images of the PET-CT study; CEUS allowed a correct diagnosis in all of these. In 20 of 70 cases, the PET findings were categorized as indeterminate and non-specific (non-specific fluorodeoxyglucose uptake in PET report with no standardized uptake value given); CEUS reached a correct diagnosis in 19 of the 20 cases with one false negative. In 34 of 70 cases, PET was indeterminate, but specific (fluorodeoxyglucose uptake with a standardized uptake value provided); CEUS reached a correct diagnosis in 30 of these 34 cases. In 10 of 70 cases, PET was categorized as determinate but to be investigated because of discrepancy with clinical or imaging findings; CEUS a definitive diagnosis in 9 of 10 cases. CEUS proved to be effective option in the assessment of cancer patients with indeterminate PET findings.
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Affiliation(s)
- Orlando Catalano
- Department of Radiology, National Cancer Institute, Fondazione Pascale, Naples, Italy.
| | - Fabio Sandomenico
- Department of Radiology, National Cancer Institute, Fondazione Pascale, Naples, Italy
| | - Paolo Vallone
- Department of Radiology, National Cancer Institute, Fondazione Pascale, Naples, Italy
| | | | - Vincenza Granata
- Department of Radiology, National Cancer Institute, Fondazione Pascale, Naples, Italy
| | - Roberta Fusco
- Department of Radiology, National Cancer Institute, Fondazione Pascale, Naples, Italy
| | - Secondo Lastoria
- Department of Nuclear Medicine, National Cancer Institute, Fondazione Pascale, Naples, Italy
| | - Luigi Mansi
- Department of Nuclear Medicine, Second University of Naples, Naples, Italy
| | - Antonella Petrillo
- Department of Radiology, National Cancer Institute, Fondazione Pascale, Naples, Italy
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Pang EH, Harris AC, Chang SD. Approach to the Solitary Liver Lesion: Imaging and When to Biopsy. Can Assoc Radiol J 2016; 67:130-48. [DOI: 10.1016/j.carj.2015.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 07/06/2015] [Accepted: 07/28/2015] [Indexed: 02/07/2023] Open
Abstract
The characterization and management of focal liver lesions is a commonly encountered problem in radiology. While the imaging findings will often be diagnostic, in equivocal cases the decision of how to proceed may be challenging. The primary modalities for liver lesion characterization are multiphase contrast-enhanced computed tomography and magnetic resonance imaging. Most lesions have typical imaging features, and when taken in conjunction with patient demographics and biochemistry the diagnosis can usually be made. Ancillary imaging modalities such as contrast-enhanced ultrasound and hepatobiliary specific contrast agents are also useful. Cirrhotic livers present a challenge due to the spectrum of benign, dysplastic, and malignant nodules that can occur. The report should include information necessary for accurate staging, and published standardized reporting guidelines should be taken into consideration. A decision to proceed to biopsy should be made only after multidisciplinary review of the case. If biopsy is required, fine needle aspiration is usually sufficient, though core needle biopsy may be required in certain circumstances.
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Affiliation(s)
| | - Alison C. Harris
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Silvia D. Chang
- Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
This review article is focused on the role of FDG PET/CT in diagnosing and characterizing hepatic incidentalomas. A large variety of unsuspected lesions can be detected in the liver both with ultrasound and CT performed for other reasons; the prevalence of liver incidentalomas increases in patients with chronic liver disease or preexisting oncologic history. The major challenge is to discriminate benign from malignant lesions. There is a large body of literature indicating that FDG PET/CT is a useful tool to this purpose even if it is unspecific (ie, it cannot differentiate a primary tumor from a secondary lesion). Occasionally, FDG PET/CT can be useful for biopsy guidance.
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11
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Mertens J. Clinical diagnosis and management of perihilar cholangiocarcinoma. Clin Liver Dis (Hoboken) 2014; 3:60-64. [PMID: 30992887 PMCID: PMC6448701 DOI: 10.1002/cld.328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Joachim Mertens
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland.
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12
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FDG and other radiopharmaceuticals in the evaluation of liver lesions. Clin Transl Imaging 2014. [DOI: 10.1007/s40336-014-0059-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Gores GJ, Darwish Murad S, Heimbach JK, Rosen CB. Liver transplantation for perihilar cholangiocarcinoma. Dig Dis 2013; 31:126-9. [PMID: 23797134 DOI: 10.1159/000347207] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Perihilar cholangiocarcinoma is a complex and devastating disease. Its complexity in part arises from the difficulty of establishing a diagnosis, especially in primary sclerosing cholangitis (PSC) patients. We have found fluorescent in situ hybridization (FISH) of cytologic specimens to be helpful in establishing a diagnosis of cholangiocarcinoma. In particular, FISH polysomy is useful in establishing a diagnosis of this malignancy. Endoscopic ultrasound with fine needle aspirates of regional lymph nodes has high utility in identifying patients who have advanced disease with lymph node metastases. Patients who are resectable by conventional surgical techniques are referred for surgery. However, patients who are not resectable or who have PSC and meet highly selective criteria become eligible for liver transplantation. The protocol employs external beam radiation therapy followed by brachytherapy, and then capecitabine until a staging laparotomy is performed. There is a high dropout rate while patients await liver transplantation of approximately 30% at 12 months, due to tumor progression. Overall, survival rates are approximately 65-70% at 5 years. The disease recurrence rate is 20%. Patients who have masses greater than 3 cm or who do not meet the criteria identified above have worse outcomes. These survival rates are better than those following surgical resection. Vascular complications occur frequently after liver transplantation. Portal venous anastomotic strictures are very common and can be managed by stent placement. In summary, neoadjuvant chemoradiation plus liver transplantation achieves excellent survival for patients with early-stage perihilar cholangiocarcinoma.
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Affiliation(s)
- Gregory J Gores
- William J. von Liebig Transplant Center, Mayo College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Tabibian JH, Lindor KD. Challenges of Cholangiocarcinoma Detection in Patients with Primary Sclerosing Cholangitis. JOURNAL OF ANALYTICAL ONCOLOGY 2012; 1:50-55. [PMID: 31897266 PMCID: PMC6939639 DOI: 10.6000/1927-7229.2012.01.01.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Primary sclerosing cholangitis (PSC) is a chronic, cholestatic, idiopathic liver disease characterized by fibro-obliterative inflammation of the hepatic bile ducts. In a clinically significant proportion of patients, PSC progresses to cirrhosis, end-stage liver disease, and in some cases, cholangiocarcinoma (CCA). The development of CCA in PSC is unpredictable, its surveillance and diagnosis complex, and its treatment options limited unless detected early. Herein we provide a focused review of the current literature regarding CCA surveillance in patients with PSC and discuss the diagnostic and management challenges that exist. Where evidence is limited, we present our perspective and approach as well as directions for future research.
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Affiliation(s)
- James H. Tabibian
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Keith D. Lindor
- Executive Vice Provost, Health Solutions, Arizona State University, P.O. Box 877805, Tempe, AZ 85287-7805, USA
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Abstract
Cholangiocarcinoma is the most frequent biliary malignancy. It is difficult to diagnose owing to its anatomic location, growth patterns and lack of definite diagnostic criteria. Currently, cholangiocarcinoma is classified into the following types according to its anatomic location along the biliary tree: intrahepatic, perihilar or distal extrahepatic cholangiocarcinoma. These cholangiocarcinoma types differ in their biological behavior and management. The appropriate stratification of patients with regard to the anatomic location and stage of cholangiocarcinoma is a key determinate in their management. Staging systems can guide this stratification and provide prognostic information. In addition, staging systems are essential in order to compare and contrast the outcomes of different therapeutic approaches. A number of staging systems exist for cholangiocarcinoma-several early ones have been updated, and new ones are being developed. We discuss the emerging diagnostic criteria as well as the different staging systems for cholangiocarcinoma, and provide a critical appraisal regarding these advances in biliary tract malignancies.
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