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;193:1061-1069. [PMID: 19770330 DOI: 10.2214/ajr.08.2089]

Intrabiliary metastasis of colorectal mucinous adenocarcinoma mimicking choledocholithiasis 18 years after the primary tumor

This case report presents a 62-year-old male who had previously undergone curative colectomy and neoadjuvant chemotherapy in 2005 for colorectal cancer. He presented with jaundice, which was initially attributed to choledocholithiasis. After cholecystectomy and repeat ERCPs, hyperbilirubinemia persisted. There was persistent dilation of the right posterior duct on imaging, concerning for biliary stricture, possibly due to cholangiocarcinoma or intraductal papillary neoplasm. During a right posterior hepatectomy, a peripheral liver lesion was found in association with the dilated bile duct. On frozen evaluation, the lesion was found to be invasive adenocarcinoma. The final pathology was compatible with a metastatic mucinous adenocarcinoma of colonic origin. A repeat colonoscopy was done with no recurrence or new lesion in the colon. This case underscores the challenges associated with diagnosing biliary issues and assessing liver lesions in patients with a remote history of cancer. It raises the question of when and whether, after primary cancer treatment, it becomes safe to explore alternative diagnoses without immediately suspecting metastasis. Another significant challenge arises in ascertaining the most suitable therapeutic approaches for these patients. This is because these extremely late recurrences might be linked to an indolent, slow-growing type of tumor, but also have been linked to cancer stem cells, and as any recurrence, demands attention.

Liver Metastases: Correlation between Imaging Features and Pathomolecular Environments

A wide range of imaging manifestations of liver metastases can be encountered, as various primary cancers preferably metastasize to the liver (organ-specific metastases), with the imaging characteristics largely depending on various primary tumor-specific factors such as histopathologic category, degree of tumor differentiation, histologic behavior, and intratumor alterations. Characteristic imaging features potentially can help provide a more precise diagnosis in some clinical settings. These settings include those of (a) primary cancers of hollow organs such as gastrointestinal organs, the lungs, and the bladder, owing to the appearance of metastases that cannot be applied to the liver, which is a parenchymal organ; (b) unknown primary tumors; (c) more than one primary tumor; (d) another emergent malignancy; and (e) transformation to a different histopathologic tumor subtype. The characteristic features include the target sign on T2-weighted MR images or during the hepatobiliary phase of hypovascular metastasis, the peripheral rim washout sign on delayed phase images, peritumor hyperintensity during the hepatobiliary phase, hypervascular metastasis, a cystic appearance with marked hyperintensity on T2-weighted images, marked hyperintensity on T1-weighted images, calcification, capsular retraction, absence of the vessel-penetrating sign, distribution of liver metastases, and rare intraductal forms of metastases. In addition to various factors associated with the primary cancer, desmoplastic reactions around the tumor-which can be observed in adenocarcinomas with peripheral and peritumor enhancement, distinct arterioportal shunts with metastases from pancreatic ductal carcinoma, and pseudocirrhosis-also can affect these findings. The authors review the characteristic imaging findings of liver metastases from various primary cancers, with a focus on the mechanisms that underlie organ-specific liver metastases. Online supplemental material is available for this article. ^©RSNA, 2022.

Mucin-producing Cystic Hepatobiliary Neoplasms: Updated Nomenclature and Clinical, Pathologic, and Imaging Features

Cystic hepatobiliary neoplasms with mucin-producing epithelium-mucinous cystic neoplasm of the liver (MCN) and intraductal papillary neoplasm of the bile duct (IPNB)-are rare and distinct entities that have unique clinical, pathologic, and imaging features. They are differentiated pathologically by the presence of subepithelial ovarian-like hypercellular stroma (OLS), which is the defining histopathologic feature of MCN. MCN is commonly a benign, large, solitary, symptomatic, multiloculated cystic mass without biliary communication that occurs in middle-aged women. On the other hand, IPNBs are a heterogeneous spectrum of tumors, which are commonly associated with invasive carcinoma, occur in older patients, and can be differentiated from MCN by communication with the biliary tree, intraductal masses, associated biliary ductal dilatation, and absent OLS. Understanding of these rare neoplasms has grown and evolved over time and continues to today, but uncertainty and controversy persist, related to the rarity of these tumors, relatively recent designation as separate entities, inherent clinicopathologic heterogeneity, overlapping imaging features, and the fact that many prior studies likely included MCN and cystic IPNB together as a single entity. Confusion regarding these neoplasms is evident by historical inconsistencies and nonstandardized nomenclature through the years. Awareness of these entities is important for the interpreting radiologist to suggest a particular diagnosis or generate a meaningful differential diagnosis in the appropriate setting, and is of particular significance as MCN and cystic IPNB have overlapping imaging features with other more common hepatobiliary cystic masses but have different management and prognosis. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

Imaging and clinical features of colorectal liver metastases with macroscopic intrabiliary growth

PURPOSE

The purpose of this study was to evaluate imaging and clinical features of colorectal liver metastases complicated with macroscopic intrabiliary growth, and correlate the unusual pattern of spread with treatment and follow-up.

METHODS

A retrospective analysis of the clinical, imaging and follow-up files of all patients with surgically resected colorectal liver metastases from January 2016 to October 2020 was reviewed to identify those with macroscopic intrabiliary growth. Two radiologists evaluated the radiological features of colorectal liver metastasis with macroscopic intrabiliary growth. The histopathological findings and follow-up results were also investigated.

RESULTS

A total of 555 patients were included. Colorectal liver metastasis with macroscopic intrabiliary growth was present in 5 patients (0.9 %). Four patients experienced tumor recurrence or progression after surgical treatment (80 %), and recurrent tumors retained propensity for intraductal growth. CT (n = 6) and MR (n = 6) examinations were performed before 8 operations with the pathological examination confirmed macroscopic intrabiliary colorectal metastases. According to the location, intrabiliary colorectal metastases were classified into two categories: peripheral (n = 3) and central involvement (n = 5). The lengths of tumoral extension into the downstream bile duct were more than those of extension into the upstream bile duct (P = 0.029). On CT images, all cases showed dilated bile ducts filled with soft tissue attenuation presenting moderate (n = 4) or obvious (n = 2) enhancement. On MR images, all intra-hepatic and intrabiliary components of the metastases showed restricted diffusion on diffusion-weighted imaging, and peritumoral wedge-shaped T1-weighted hyperintensity appeared in the cases with obstruction of intrahepatic bile ducts.

CONCLUSIONS

The propensity for colorectal liver metastasis with intrabiliary growth to grow longitudinally and extend beyond the intrahepatic tumor edge elevates the risk of high recurrence after operation. Intrabiliary growth of liver metastasis exhibits characteristic MR and CT imaging features, which help to make an accurate diagnosis and improve treatment plans.

Tumor calcification as a prognostic factor in cetuximab plus chemotherapy-treated patients with metastatic colorectal cancer

Supplemental Digital Content is available in the text.

This study aimed to explore the correlation between survival and tumor calcification in patients with metastatic colorectal cancer who received cetuximab combined with chemotherapy. The study was a single-center retrospective analysis that enrolled 111 patients who had received therapy between April 2011 and October 2016. Tumor calcification and treatment efficacy were evaluated independently by radiologists on the basis of computed tomography scans. Clinical characteristics and follow-up data were collected from electronic medical records. Correlations between tumor calcification and clinical characteristics, tumor response rate, and patient survival were analyzed. Among the 111 enrolled patients, 27 had tumor calcification [27/111 (24.3%)]. The median progression-free survival was significantly longer for patients with tumor calcification than for those without calcification (9.3 vs. 6.2 months, P=0.022). Patients with tumor calcification also had a higher objective response rate (55.6 vs. 31%, P=0.021) and better overall survival (21.9 vs. 16.5 months, P=0.084). The correlation between calcification features and prognosis showed that patients with an increasing number of calcifications after treatment had a significantly longer median overall survival (22.9 vs. 9.1 months, P=0.033). Simultaneously, new liver metastases and multiple calcifications also showed a trend toward better overall survival. There were also no significant correlations between clinical characteristics (sex, age, gene mutation, primary tumor location, pathological type, blood test result) and survival (Supplementary Table 1, Supplemental digital content 1, http://links.lww.com/ACD/A280). Tumor calcification is associated with a better treatment outcome and is a potential prognostic marker.

Diagnostic Accuracy of Cardiac Computed Tomography and 18-F Fluorodeoxyglucose Positron Emission Tomography in Cardiac Masses

OBJECTIVES

This study sought to assess the diagnostic accuracy of cardiac computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) with positron emission tomography/computed tomography (PET/CT) in defining the nature of cardiac masses.

BACKGROUND

The diagnostic accuracy of cardiac CT and ¹⁸F-FDG PET/CT in identifying the nature of cardiac masses has been analyzed to date only in small samples.

METHODS

Of 223 patients with echocardiographically diagnosed cardiac masses, a cohort of 60 cases who underwent cardiac CT and ¹⁸F-FDG PET/CT was selected. All masses had histological confirmation, except for a minority of thrombotic formations. For each mass, 8 morphological CT signs, standardized uptake value (SUV_max, SUV_mean), metabolic tumor volume, and total lesion glycolysis in ¹⁸F-FDG PET were used as diagnostic markers.

RESULTS

Irregular tumor margins, pericardial effusion, invasion, solid nature, mass diameter, CT contrast uptake, and pre-contrast characteristics were strongly associated with the malignant nature of masses. The coexistence of at least 5 CT signs perfectly identified malignant masses, whereas the detection of 3 or 4 CT signs did not accurately discriminate the masses' nature. The mean SUV_max, SUV_mean, metabolic tumor volume, and total lesion glycolysis values were significantly higher in malignant than in benign masses. The diagnostic accuracy of SUV, metabolic tumor volume, and total lesion glycolysis ¹⁸F-FDG PET/CT parameters was excellent in detecting malignant masses. Among patients with 3 or 4 pathological CT signs, the presence of at least 1 abnormal ¹⁸F-FDG PET/CT parameter significantly increased the identification of malignancies.

CONCLUSIONS

Cardiac CT is a powerful tool to diagnose cardiac masses as the number of abnormal signs was found to correlate with the lesions' nature. Similarly, ¹⁸F-FDG PET/CT accurately identified malignant masses and contributed with additional valuable information in diagnostic uncertainties after cardiac CT. These imaging tools should be performed in specific clinical settings such as involvement of great vessels or for disease-staging purposes.

Differences in early imaging features and pattern of progression on CT between intrahepatic biliary metastasis of colorectal origin and intrahepatic non-mass-forming cholangiocarcinoma in patients with extrabiliary malignancy

PURPOSE

To assess the differences in early imaging features and progression pattern on CT between intrahepatic biliary metastasis (IBM) and non-mass-forming cholangiocarcinoma (NMFC) in patients with extrabiliary malignancy.

METHODS

This retrospective study included 35 patients who were surgically and pathologically confirmed with IBM (n = 14) or NMFC (n = 21) at the time of or after surgery for extrabiliary malignancy. Two observers evaluated the following aspects of biliary lesions on initial or follow-up CT images: location, characteristics of intrahepatic duct (IHD) dilatation, presence of duct wall thickening, and periductal infiltration lesion or periductal expansile mass.

RESULTS

All IBMs were associated with colorectal cancer (p = 0.032). As early imaging features on CT, smooth tapered localized IHD dilatation without duct wall thickening and peripheral duct involvement were observed significantly more often in IBM, and IHD dilatation with abrupt tapering or irregularity of transition site and bile duct wall thickening were significantly more common in NMFC (all p < 0.05). Regarding progression pattern, periductal expansile mass was present only in IBM, whereas periductal infiltrative lesion was present only in NMFC (p < 0.001).

CONCLUSION

In the differentiation between IBM and NMFC in patients with extrabiliary malignancy, the differences in early imaging features and progression pattern of the two diseases revealed in this study would be helpful for diagnosis.

Intraductal Papillary Neoplasm of the Bile Duct: Clinical, Imaging, and Pathologic Features

OBJECTIVE

We outline the concept of intraductal papillary neoplasm of the bile duct (IPNB), discuss the morphologic features of IPNB and the differential diagnoses, and describe the radiologic approaches used in multidisciplinary management.

CONCLUSION

The concept of IPNB has been evolving. Because the imaging features of IPNB can be variable, different mimickers according to IPNB subtype can be considered. A multimodality approach is essential to obtain an optimal diagnosis and establish treatment plans.

Contrast-enhanced ultrasound examination of the gallbladder and bile ducts: A pictorial essay

The gallbladder and bile ducts are usually assessed initially with conventional gray-scale ultrasound (US). Contrast enhanced US (CEUS) is used when a diagnosis cannot be reached with conventional US. CEUS is easy to learn and perform. US contrast agents can be safely administered in patients with renal function impairment. In this pictorial essay the physics, examination technique and indications of CEUS for examining the gallbladder and bile ducts are reviewed. Gallbladder indications include elucidating normal variants, differentiating sludge from neoplastic lesions, benign and malignant pathology, infection, wall rupture and hemobilia. In the biliary tree CEUS is used for studying benign and malignant tumors, including metastases and cholangiocarcinoma, as well as intrabiliary injection.

Cronkhite-Canada Syndrome Complicated by Triple Primary Cancers

We herein report a case of Cronkhite-Canada syndrome (CCS) complicated with triple primary cancers. The patient was diagnosed with CCS at 65 years of age. At 76 years of age, one of his colon polyps was diagnosed as adenocarcinoma. At 81 years of age, gastric carcinoma was detected. Weight loss and fatigue appeared one month before he visited our hospital. An examination revealed dilatation of the intrahepatic bile duct. Cholangiocarcinoma was diagnosed as a result of bile duct cytology. Patients with CCS should be monitored carefully for carcinoma of systemic organs as well as the gastrointestinal tract.

Metastatic mucinous adenocarcinoma of the distal common bile duct, from transverse colon cancer presenting as obstructive jaundice

The patient was a 70-year-old male whose chief complaints were obstructive jaundice and weight loss. Abdominal imaging studies showed a 2.5 cm sized mass at the distal common bile duct, which was suggestive of bile duct cancer. Eccentric enhancing wall thickening in the transverse colon was also shown, suggesting concomitant colon cancer. A colonoscopy revealed a lumen-encircling ulcerofungating mass in the transverse colon, that was pathologically proven to be adenocarcinoma. The bile duct pathology was also adenocarcinoma. Pylorus-preserving pancreaticoduodenectomy and extended right hemicolectomy were performed under the diagnosis of double primary cancers. Postoperative histopathologic examination revealed moderately differentiated mucinous adenocarcinoma of transverse colon cancer, and mucinous adenocarcinoma of the distal common bile duct. Immunohistochemical staining studies showed that the bile duct cancer had metastasized from the colon cancer. The patient recovered uneventfully from surgery and will be undergoing chemotherapy for three months.

Imaging of the porta hepatis: spectrum of disease

A wide array of pathologic conditions can arise within the porta hepatis, which encompasses the portal triad (the main portal vein, common hepatic artery, and common bile ducts), lymphatics, nerves, and connective tissue. Major vascular diseases of the portal triad include thrombosis, stenosis, and aneurysm. Portal vein thrombosis can complicate liver cirrhosis and hepatocellular carcinoma and has important therapeutic implications. Hepatic artery thrombosis and stenosis require immediate attention to reduce graft loss in liver transplant recipients. Congenital (eg, choledochal cyst) and acquired (benign and malignant) diseases of the biliary system can manifest as mass lesions in the porta hepatis. Lymphadenopathy can arise from neoplastic and nonneoplastic entities. Uncommon causes of mass lesions arise from nerves (eg, neurofibroma, neurofibrosarcoma) and connective tissue (sarcomas) and are rare. The hepatoduodenal ligament is a peritoneal reflection at the porta hepatis and is an important route for the spread of pancreatic and gastrointestinal cancers. Imaging plays a major role in diagnosis and enables appropriate management. Ultrasonography accurately demonstrates anatomic variations and pathologic conditions and is the initial modality of choice for detection of vascular and biliary lesions. Multidetector computed tomography and magnetic resonance imaging allow characterization and differentiation of various masses in the porta hepatis. Imaging-guided interventions, including embolization and stent placement, also play a key role in disease management.

Bile duct tumors

Bile duct tumors are benign or malignant lesions which may be associated to risk factors or potentially malignant lesions. They constitute an heterogenous entities group with a different biological behavior and prognosis according to location and growth pattern. We revise the role of the radiologist in order to detect, characterize and stage these tumors, specially the importance of their classification when deciding an appropriate management and treatment.

Metastatic common bile duct cancer from pulmonary adenocarcinoma presenting as obstructive jaundice

We report an extremely rare case of metastatic common bile duct cancer from pulmonary adenocarcinoma presenting as obstructive jaundice. The patient was a 76-year-old male, who presented with generalized weakness and right upper quadrant pain. Plain chest X-ray noted multiple small nodules in both lung fields. Abdominal computed tomography scan showed a stricture of the mid common bile duct along with ductal wall enhancement. Endoscopic retrograde cholangiography revealed a concentric, abrupt narrowing of the mid-common bile duct suggestive of primary bile duct cancer. However, pathology comfirmed metastatic common bile duct cancer arising from pulmonary adenocarcinoma with immunohistochemical study with thyroid transcriptional factor-1 (TTF-1).

Intrabiliary growth of colorectal liver metastasis: spectrum of imaging findings and implications for surgical management

OBJECTIVE

The propensity for colorectal liver metastasis to invade the biliary tree is increasingly recognized, placing particular emphasis on the risk of postoperative recurrence. This article illustrates the spectrum of imaging findings when colorectal metastasis invades the biliary tree.

CONCLUSION

Knowledge of the imaging features of intrabiliary invasion by colorectal liver metastasis improves the quality of preoperative staging and is crucial in an era in which nonanatomic wedge resection and radiofrequency ablation are routinely performed.

Radiological diagnosis and staging of hilar cholangiocarcinoma

Hilar cholangiocarcinoma is a rare malignant tumor arising from the epithelium of the bile ducts. Surgery is still the only chance of potentially curative treatment in patients with perihilar cholangiocarcinoma. However, radical resection requires aggressive surgical strategies that should be tailored optimally according to the location, size and vascular invasion of the tumors. Accurate diagnosis and staging of these tumors is therefore critical for optimal treatment planning and for determining a prognosis. Multidetector computed tomography (MDCT), magnetic resonance imaging (MRI) and MR cholangiography are useful tools, both to diagnose and stage hilar cholangiocarcinoma. Modern imaging techniques allow accurate detection of the level of obstruction and the longitudinal and radial spread of the tumor. In addition, high-resolution MDCT and MR provide specific radiographic features to determine vascular involvement of anatomic structures, such as the hepatic artery or the portal vein, which are critical to decide the surgical strategy. Finally, radiological staging allows detection of patients with distant metastasis in the liver or peritoneum who will not benefit from a surgical approach.

The T1W hyperintense signal on the surface of distal segment of bile duct tumor thrombi and its significance

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.

Tumors with macroscopic bile duct thrombi in non-HCC patients: Dynamic multi-phase MSCT findings

Non-hepatocellular carcinoma (non-HCC) with macroscopic bile duct tumor thrombus (BDTT) formation is rare, few radiological studies have been reported. In this case report, we retrospectively analyzed the imaging findings of three cases of non-HCC with macroscopic BDTT on dynamic enhanced multislice computed tomography (MSCT) scan. One case of primary hepatic carcinosarcoma was presented as a solitary, large well-defined tumor with significant necrotic changes. One case of liver metastasis from colon cancer was presented as a lobulated, large ill-defined tumor. One case of intraductal oncocytic papillary neoplasm involved the entire pancreas, presented as a cystic and solid mass with multilocular changes (the individual loculi were less than 5.0 mm in diameter). The bile duct was dilated due to expansible growth of the BDTT in all three patients. The BDTT was contiguous with hepatic or pancreatic tumor, and both of them showed the same enhancement patterns on dynamic contrast-enhanced computed tomography scan: early enhancement in the hepatic arterial phase and a quick wash-out of contrast agent in the portal and equilibrium phases. Macroscopic BDTT in non-HCC patient is rare, dynamic enhanced MSCT scan may be valuable in the diagnosis of non-HCC with BDTT.

Correlation between calcified liver metastases and histopathology of primary colorectal carcinoma in Chinese

The study examined the association between calcified liver metastases and the histopathology of the primary colorectal carcinoma in Chinese. The clinical, pathological and CT data were retrospectively analyzed in 210 patients (mean age: 54.2 years) with liver metastases from colorectal carcinoma. Plain CT scanning and contrast-enhanced scanning were performed in all the patients. For the contrast-enhanced examination, iohexol was injected by using a high pressure syringe at a flow rate of 2.5-3.0 mL/s. The arterial phase lasted approximately 25 s and the portal venous phase about 60 s. All patients had no history of chronic liver diseases and had never received interventional treatments. χ(2)-test was used to analyze the rate of calcification in the liver metastasis from colorectal cancer of different differentiation degrees. Among the 210 cases of liver metastases, 22 patients (10.5%) were found to have calcified liver metastases on CT scan. Two patients with calcified liver metastasis received lumpectomy and developed calcification in recurrent tumors. Another two patients had calcification in newly developed tumor masses. And the calcification in the newly developed masses was similar to that of their primary counterparts in terms of morphology and distribution. On the enhanced CT scan, the tumors exhibited no enhancement during hepatic arterial phase and showed slight rim enhancement during portal venous scan in the 22 cases. The calcification became obscure on contrast-enhanced scans. Histopathologically, the primary tumors were well-differentiated adenocarcinoma in 6 cases, moderately-differentiated adenocarcinoma in 10, poorly-differentiated adenocarcinoma in 4 and mucinous adenocarcinoma in 2 among the 22 cases. No statistical correlation was noted between the incidence of calcified liver metastasis and the pathological subtypes and differentiation degrees of the primary colorectal carcinoma. It was concluded that calcified liver metastases may result from colorectal adenocarcinomata of different differentiation degrees or mucinous adenocarcinomata in Chinese population. There is no correlation between calcification of liver metastases and the pathological subtype of the primary colorectal carcinoma in Chinese, which is different from the findings that calcified metastases were associated with colorectal mucinous adenocarcinoma in other ethnic groups.