Peripheral Cholangiocarcinoma Research Articles

Immediate results of biliodigestive reconstruction in patients with peripheral cholangiocarcinoma with invasion of visceral veins

Objective. To evaluate the immediate results of biliodigestive reconstruction in patients with peripheral cholangiocarcinoma with invasion of the visceral veins.
 Materials and methods. From 2004 to 2018, 28 patients with peripheral cholangiocarcinoma with invasion of the visceral veins were radically operated at the Department of Liver Transplantation and Surgery of the Shalimov National Institute of Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine (now the Shalimov National Scientific Centre of Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine). The main group consisted of 8 (28.6%) patients who underwent biliodigestive reconstruction simultaneously with resection and reconstruction of visceral veins, the control group consisted of 20 (71.4%) patients who underwent resection and reconstruction of visceral veins, and biliodigestive reconstruction was not performed.
 Results. Postoperative clinically significant (grade IIIa­IV according to the Clavien­Dindo classification) complications during the 90­day postoperative period were noted in 12.5% of patients in the main group and 25% of patients in the control group (p=0.002), postoperative liver failure according to the criteria of the International Study Group on Liver Surgery ­ in 25 and 30%, respectively (p=0.415). Repeat surgery was performed in 12.5 and 10% of patients, respectively (p=0.923). There was no postoperative mortality in both study groups.
 Conclusions. The immediate results of biliodigestive reconstruction in patients with peripheral cholangiocarcinoma with invasion of the visceral veins are satisfactory.

A feasibility randomized controlled trial testing the use of indocyanine green fluorescence image-guidance in liver surgery compared to standard liver surgery alone in reducing microscopic positive tumor margin resection rate with an embedded qualitative study: the I-FIGS study protocol

Abstract Indocyanine green fluorescence image-guidance (I-FIGS) is gaining global popularity in liver surgery for various applications. However, its true clinical value in reducing microscopic positive margins (R1-resection rate) remains uncertain. To address this, a multi-center randomized controlled trial (RCT) comparing I-FIGS with standard liver surgery is needed. However, due to a lack of essential information on potential R1 reduction rate, sample size, methodology, intervention delivery and patient experience, a feasibility RCT protocol has been developed to determine the viability of conducting a full-scale RCT. The aim of the study is to conduct a feasibility RCT (fRCT) with an embedded qualitative study to gather all the necessary information for a full-scale RCT. Adult patients undergoing elective liver surgery for colorectal liver metastasis (CRLMs), hepatocellular carcinoma (HCC) or peripheral cholangiocarcinoma will be eligible for the study. Forty patients will be randomly assigned to either the control group (standard liver surgery) or the intervention group (standard liver surgery + I-FIGS). Patients in the I-FIGS group will receive intravenous injection of 0.03–0.05 mg/kg indocyanine green (ICG) dye 2–4 hours before the surgery. Data will be collected on demographics, screening, recruitment and retention rates, adherence to study methods, intraoperative details, postoperative histology, and experiences of both surgeons and patients. Interviews will be conducted with selected patients and surgeons to explore their experiences with the intervention. The protocol has been approved by the West-Midlands-Solihull Research Ethics Committee and registered with ClinicalTrials.gov (NCT05616039). The results will be disseminated through academic publications, congresses, newsletters and other platforms.

Solitary hypovascular hepatic nodules: comparison and differentiation between peripheral nodular cholangiocarcinoma and atypical liver hemangioma with MRI.

Peripheral nodular cholangiocarcinoma (PCC) and hepatic hemangioma (HG) significantly differ in treatment strategies and prognosis. However, they can present similar imaging characteristics, making them difficult to distinguish. The distinction between PCC and atypical HG using pre-operative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) holds substantial significance. Fifty-four cases of solitary hypovascular hepatic nodules (nodules ≤3 cm in diameter and enhancement not exceeding the hepatic parenchyma) confirmed pathologically were collected, including 25 cases of PCC and 29 cases of HG. The clinical and DCE-MRI features were observed, and the apparent diffusion coefficient (ADC) values were compared. The t-test or Fisher's exact test was used to compare the differences between the two groups. Receiver operating characteristic (ROC) curve analysis was performed on the diagnostic results of the two readings before and after the study by three diagnostic physicians. The signal of PCC was more heterogeneous and could be shown as a ring hyperintensity signal on diffusion weighted imaging (DWI). The T2-weighted imaging (T2WI) signal of HG lesions showed a more homogeneous high-intense signal. The ADC value of PCC patients was lower than that of HG patients. Most of the patients in the two groups presented marginal enhancement in the arterial phase with infrequent abnormal perfusion around. The intratumoral vascular traversal signs in the PCC group showed a diagnostic significance. Among the lesions with marginal enhancement at arterial stage, the enhancement in PCC group was more likely to have annular enhancement with the main manifestation of delay reduction and nebulous or separated/astral center. On the other hand, HG tended to be more likely to have nodular enhancement in the arterial phase with delayed invariance at the margins and with no significant enhancement at the center. The area under the curves (AUC) of the three radiologists before and after the two readings were 0.645 and 0.888, respectively. In the differentiation of PCC and atypical liver hemangioma, the presence of a circular hyper-intense signal in DWI, the ADC values, and the pattern and extent of enhancement of marginal and central lesions were of diagnostic significance.

CT and MRI Diagnosis and Clinical Analysis of Intrahepatic Peripheral Cholangiocarcinoma

CT and MRI Diagnosis and Clinical Analysis of Intrahepatic Peripheral Cholangiocarcinoma

Immediate results of surgical treatment of peripheral hepatic cholangiocarcinoma in elderly and senile patients

Objective. To estimate immediate results of surgical treatment of peripheral cholangiocarcinoma in elderly and senile patients.
 Materials and methods. In 2004-2018 yrs period in the Department of Transplantation and Surgery of the Liver of the Shalimov National Institute of Surgery and Transplantology 84 patients, suffering peripheral cholangiocarcinoma, were radically operated: 31 (36.9%) patients older than 60 yrs (the main Group), and 53 (63.1%) patients, younger than 60 yrs (control Group).
 Results. Postoperative clinically significant (IIIa-IV degree in accordance to classification of Clavien-Dindo) complications during 90-days of postoperative period were noted in 29.1% patients of the main Group and in 32.1% patients of a control Group (p=0.262), postoperative hepatic insufficiency, in accordance to The International Study Group of Liver Surgery criteria, - in 16.1 and 22.6% accordingly (p=0.473); reoperation was performed in 9.6 and 9.4% patients, accordingly (p=0.973). The causes of postoperative lethality in 2 patients of the main Group were an acute myocardial infarction (1) and an acute pulmonary thromboembolism (1).
 Conclusion. Hepatic resection is characterized by satisfactory immediate results of treatment of peripheral cholangiocarcinoma in elderly and senile patients, if performed in highly-specialized multidisciplinary centre and thorough selection of patients.

Surgical treatment of peripheral hepatic cholangiocarcinoma with a visceral vein invasion

Objective. To estimate the immediate and late results of surgical treatment in patients, suffering peripheral cholangiocarcinoma with invasion of visceral vein.
 Маterials and methods. Retrospective analysis was accomplished for surgical treatment of 84 patients, suffering peripheral cholangiocarcinoma, in whom radical operations were performed in Department of Transplantation and Hepatic Surgery of Shalimov National Istitute of Surgery and Transplantology in a period from Jan. 2004 tо Dec. 2018 yrs. The investigated group consisted of 28 patients, to whom hepatic resection with simultant resection and plasty of visceral veins for tumoral vascular invasion was performed. Into comparison group 56 patients were included, in whom hepatic resection was not accompanied with vascular resection.
 Results. Trustworthy differences were absent between groups in accordance to following indices: the patients’ age (p=0.16-0.7), gender (p=0.3), physical status (p=0.36), pre- and postoperative stationary stay (p=0.4). In the investigated group there were performed 14.3% hemihepatectomies, 32.1% extended hemihepatectomies and 53.6% threesectioectomies, and in a comparative one - 57.2% (р ≤ 0.001), 14.3% (р = 0.054) and 21.4% (р = 0.002), accordingly. Simultant intervention on biliary ducts was done in 37.5% patients from investigated group and in 25% patients from comparative group (р = 0.305), the adjacent organs resection - in 14.3 and 12.5% (р = 0.819) patients, accordingly. Clinically significant postoperative complications were observed in 25 and 30.4% (р = 0.262) patients, accordingly. In the investigated group postoperative mortality was absent, while in a comparative one it constituted 3.5%. In the investigated group a 3-years and a 5-years total survival was noted in 47 and 35% patients, accordingly, while in a comparison group - in 49% (р = 0.317) and 38% (р = 0.003) patients, accordingly. In investigated group a 3-years and a 5-years survival without a recurrence was noted in 39 and 28% patients, accordingly, and in a comparative group - in 44% (р = 0.04) and 31% (р=0.002) patients, accordingly.
 Conclusion. Іnvasion of peripheral cholangiocarcinoma into visceral veins does not constitute a contraindication for operative treatment, if it is conducted in a highly specialized multidisciplinary centre.

Difference in driver gene expression patterns between perihilar and peripheral intrahepatic cholangiocarcinoma in an experimental mouse model.

The prognosis of intrahepatic cholangiocarcinoma (ICC) is based on tumor localization; however, the mechanism remains unknown. Therefore, we investigated the biological characteristics of perihilar and peripheral ICC in a mouse model. The model was established by the administration of three oncogenic plasmids harboring myristoylated AKT, mutated human YAP, and pCMV-Sleeping Beauty into the mice. The perihilar and peripheral ICC tumors that developed in the same mouse were assessed for the expression of cell adhesion factors and driver genes with immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR). The perihilar ICC tumors were irregularly shaped, whereas the peripheral tumors were mostly circular, similar to the differences found in patients. Alpha-smooth muscle actin was strongly expressed in the perihilar tumors at 10weeks, and vimentin expression was significantly up-regulated in the perihilar ICC at 14weeks. Fgfr2 level significantly increased in peripheral ICC at 10weeks, whereas Idh2 expression was up-regulated in perihilar ICC. Despite diffuse injection of oncogenic plasmid, expression of driver genes and oncogenes in ICC tumor cells differs depending on the tumor localization, resulting in changes in epithelial-mesenchymal transition, which may explain the different outcomes of patients with peripheral and perihilar ICC.

Intrahepatični holangiokarcinom sa fudroajantnim tokom

Cholangiocarcinoma is a malignant tumor originating from the ductal epithelium. It is divided into intrahepatic, gallbladder carcinoma and peripheral cholangiocarcinoma. The prevalence depends on the region, ethnicity, gender, and localization of the tumor. The most common symptoms are jaundice, pain, nausea, weight loss. The tumor is mostly found in the advanced stage when local and distant metastases are detectable. Median survival rate in patients who are in an advanced inoperable stage is 3.9 months. A 60-year-old patient came in January 2018 with pain in the epigastrium, weight loss and nausea. Objectively positive Murphy sign and enlarged liver were found. The ultrasound showed a lobulated, heterogeneous, fatty liver with a tumor mass in the right liver lobe, measuring more than 12 cm in diameter. Laboratory findings: Alpha-fetoprotein 13.0 ng/mL, carcinoembryonic antigen 7.25 mg/ml, carbohydrate antigen 19-9 56.7 U/ml, erythrocyte sedimentation rate 29, bilirubin 24.7 mmol/L, alanine aminotransferase 32.0 U/L, aminotransferase 56 U/L, alkaline phosphatase 181 U/L, C-reactive protein 43.1 µg/mL, uric acid 561 µmol/L. Computerized tomography showed an enlarged, lobular, non-homogeneous liver and non-homogeneous, as well as hetero-dense changes of indistinct contours, measuring 98x90x80 mm and 8x16 mm. All these findings were confirmed by magnetic resonance. Chest x-ray showed multiple metastases. Liver biopsy confirmed primary malignancy of the bile. The patient was treated palliatively and passed away in March, two months after the initially occurrence of disease symptoms.

Contrast-enhanced ultrasound (CEUS) has excellent diagnostic accuracy in differentiating focal liver lesions: results from a Swiss tertiary gastroenterological centre.

Focal liver lesions (FLLs) are common on conventional ultrasound. Contrast-enhanced ultrasound (CEUS) is highly accurate for differentiating between benign and malignant FLLs, with an accuracy comparable to that of contrast-enhanced CT and contrast-enhanced MRI. Notably, there is no evidence supporting the routine use of CEUS for evaluating benign and malignant FLLs in Switzerland. In this study, we assessed the use of CEUS in a clinical routine setting in a tertiary Swiss gastroenterology centre. We analysed all CEUS investigations performed on new or unclear FLLs in our department between November 2011 and March 2013. In all patients, the CEUS results (benign versus malignant FLLs) were compared with CT or MRI findings. To avoid interobserver variation, CEUS was performed by a single experienced gastroenterologist using one ultrasound device (Acuson Sequoia 512®, Siemens, Erlangen, Germany). All patients were examined using the intravenous application of 1.5–2 ml Sonovue®. An FLL with arterial enhancement with wash-out in any vascular phase was defined as a malignant FLL. Malignant FLLs were confirmed by histology. The study included 112 patients. None of them experienced side effects after injection of Sonovue®. The final diagnoses included malignant FLLs (n = 37) and benign FLLs (n = 75) that ranged in size from 7 to 120 mm. The biopsy-proven malignant FLLs (n = 37) included hepatocellular carcinoma, metastatic cancers, peripheral cholangiocarcinoma and primary B-cell lymphoma. CEUS correctly identified 36 out of 37 malignant FLLs, showing a sensitivity of 96–97.2% and a negative predictive value (NPV) of 94.1–98.5%. In contrast, CT/MRI did not identify three metastatic cancers, one HCC, one peripheral cholangiocarcinoma and one primary lymphoma in the liver as malignant FLLs, resulting in a sensitivity of 80.6–80.9% and an NPV of 78.9–89.8%. All these malignant FLLs were correctly classified by CEUS. In daily clinical practice, CEUS is a fast imaging tool which uses a renal-independent contrast agent and shows excellent accuracy for differentiating between malignant and benign FLLs in about five minutes. The use of CEUS helps to avoid false negative results from CT/MRI and improves sensitivity. CEUS should be the first diagnostic step for investigating new or unclear FLLs.

Cystic Degeneration of Peripheral Intrahepatic Cholangiocarcinoma: An Atypical Presentation

Cholangiocarcinomas are primary malignant tumors of the liver that arises from the epithelium lining the small intra and extrahepatic bile ducts, and has numerous histologic types and growth patterns. At computed tomography (CT) and magnetic ressonance (MR), it has various appearences which motivated the present study; we present a case within an atypical presentation. The objective is to show the variety of differential diagnoses before an atypical aspect and the importance of the imaging methods for the diagnosis. Cholangiocarcinoma is still an uncommon neoplasm, and CT and MR are crucial for accurate diagnosis and for differentiation from other hepatic tumorous and nontumorous lesions.

Contrast-enhanced ultrasonography appearances of intrahepatic peripheral cholangiocarcinoma

Objective To investigate the contrast-enhanced ultrasonography appearances characteristics of intrahepatic peripheral cholangiocarcinoma(ICC) and to improve the diagnosis level of ICC on contrast-enhanced ultrasonography. Methods Thirty cases with ICC confirmed by pathological examinations of surgeries were retrospectively analyzed for findings of ultrasonography, clinic and pathology, to explore the typical contrast-enhanced ultrasonography appearances and the correlation with pathological differentiation. Results On contrast-enhanced ultrasonography, 30 lesions showed enhancement on the arterial phase and appeared hypo-echoic enhancement on the portal phase, which displayed fast-in and fast-out enhancement pattern. During the hepatic arterial phase of contrast-enhanced ultrasonography, 10 lesions showed peripheral enhancement, 10 lesions showed relatively homogeneous hyper-enhancement, 6 lesions showed heterogeneous enhancement, 2 lesions showed iso-enhancement, and 2 lesions showed hypo-enhancement. To the 30 lesions, the average initial time of enhancement was (18.81±4.66)s (12-28 s), the average time of washing-out was (36.00±12.30)s (18-60 s). There was no significant difference in time of washing-in and washing-out among different pathological differentiation groups(P>0.05). Conclusions ICC often shows fast-in and fast-out enhancement pattern on contrast-enhanced ultrasonography, and the time of washing-out is generally in late arterial phase or early portal phase, but there is no significant difference in time of washing-in and washing-out among different pathological differentiation groups. Key words: Contrast-enhanced ultrasonography; Intrahepatic peripheral cholangiocarcinoma

Role of a pre-operative radiological scoring system in determining resectability for potentially resectable hilar cholangiocarcinoma

AimsCholangiocarcinoma is a rare cancer arising from the biliary tree. Case series indicate that 25–40% of all borderline resectable primary tumours are potentially resectable. The Memorial Sloane Kettering System (MSKCC) stratifies patients for resectability by longitudinal and radial extension of the hilar tumour. The Bismuth-Corlette system describes the longitudinal extension of the tumour within the biliary duct system. We sought to validate and, if possible, augment these two scores within an independent validation cohort. MethodsPatients diagnosed with hilar cholangiocarcinoma between January 2009 and December 2016 were analysed from a prospectively held database. Patients with distal cholangiocarcinoma, peripheral cholangiocarcinoma and gallbladder cancer were excluded. Comparison of surgical findings to pre-operative radiological imaging was undertaken at the time of surgery. ResultsThe validation cohort was formed of 198 patients, of which, 55 (27.8%) patients underwent resection. Logistic regression analyses identified that BC score, MSKCC score, age at diagnosis and left artery involvement were all significant independent predictor's univariately. BC score explained 28% of the variability in resectability compared to 26% explained by MSKCC. In combination, the model consisting of BC score, age at diagnosis and left artery involvement explained 39% of variability in resectability compared to the 34% explained same model including MSKCC score instead of BC score. ConclusionIn this cohort an augmented BC score, incorporating left hepatic artery involvement, is more discriminative in predicting resectability than the current MSKCC system.

Laparoscopic Hilar Lymph Node Sampling in Patients With Biliary Tract Cancers That are Rarely Associated With Nodal Metastasis

Among the various types of biliary tract cancer, patients with single, small (<5 cm), peripheral intrahepatic cholangiocarcinoma (ICC), or small (<2 cm) gallbladder tumors (GBTs) rarely develop lymph node (LN) metastasis. We investigated a laparoscopic approach for hilar LN sampling in such cases. Among the 176 patients with biliary tract cancer who were treated from January 2012 to March 2017, 21 (ICC, n=4; GBT, n=17) met the above indications. All patients were treated by a laparoscopic approach with R0 resection. After determining the pathologic diagnosis, 9 patients with GBT and all 4 patients with ICC underwent laparoscopic LN sampling; the mean numbers of sampled LNs were 2.6 and 7.3, respectively; no patients had metastasis. The mean operating times for GBT and ICC were 223 and 379 minutes, respectively; the mean blood loss was 23 mL and 171 mL. With the exception of 1 patient who developed intrahepatic metastasis of ICC at the opposite liver lobe, all of the patients were recurrence free. A laparoscopic approach could be safely applied under our indications.

Perioperative and long-term outcome of intrahepatic cholangiocarcinoma involving the hepatic hilus after curative-intent resection: comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma

BackgroundIntrahepatic cholangiocarcinoma with hepatic hilus involvement has been either classified as intrahepatic cholangiocarcinoma or hilar cholangiocarcinoma. The present study aimed to investigate the clinicopathologic characteristics and short- and long-term outcomes after curative resection for hilar type intrahepatic cholangiocarcinoma in comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma. MethodsA total of 912 patients with mass-forming peripheral intrahepatic cholangiocarcinoma, 101 patients with hilar type intrahepatic cholangiocarcinoma, and 159 patients with hilar cholangiocarcinoma undergoing curative resection from 2000 to 2015 were included from two multi-institutional databases. Clinicopathologic characteristics and short- and long-term outcomes were compared among the 3 groups. ResultsPatients with hilar type intrahepatic cholangiocarcinoma had more aggressive tumor characteristics (eg, higher frequency of vascular invasion and lymph nodes metastasis) and experienced more extensive resections in comparison with either peripheral intrahepatic cholangiocarcinoma or hilar cholangiocarcinoma patients. The odds of lymphadenectomy and R0 resection rate among patients with hilar type intrahepatic cholangiocarcinoma were comparable with hilar cholangiocarcinoma patients, but higher than peripheral intrahepatic cholangiocarcinoma patients (lymphadenectomy incidence, 85.1% vs 42.5%, P < .001; R0 rate, 75.2% vs 88.8%, P < .001). After curative surgery, patients with hilar type intrahepatic cholangiocarcinoma experienced a higher rate of technical-related complications compared with peripheral intrahepatic cholangiocarcinoma patients. Of note, hilar type intrahepatic cholangiocarcinoma was associated with worse disease-specific survival and recurrence-free survival after curative resection versus peripheral intrahepatic cholangiocarcinoma (median disease-specific survival, 26.0 vs 54.0 months, P < .001; median recurrence-free survival, 13.0 vs 18.0 months, P = .021) and hilar cholangiocarcinoma (median disease-specific survival, 26.0 vs 49.0 months, P = .003; median recurrence-free survival, 13.0 vs 33.4 months, P < .001). ConclusionMass-forming intrahepatic cholangiocarcinoma with hepatic hilus involvement is a more aggressive type of cholangiocarcinoma, which showed distinct clinicopathologic characteristics, worse long-term outcomes after curative resection, in comparison with peripheral intrahepatic cholangiocarcinoma and hilar cholangiocarcinoma.

Intrahepatic peripheral cholangiocarcinoma misdiagnosised by imaging: a case report

Intrahepatic peripheral cholangiocarcinoma misdiagnosised by imaging: a case report

Primary lesions that may imitate metastatic tumors histologically: A selective review.

Several primary pathologic entities in diverse anatomic locations have the potential to simulate metastatic neoplasms histologically. Their misinterpretation as such may result in needless and extensive clinical evaluations that are intended to detect a presumed malignancy at another site. More importantly, mistakes of this type can deprive patients of surgical excisions that could be curative. This presentation considers a review of selected primary lesions that can simulate metastases. They include hemangioblastoma, glioblastoma and meningioma with epithelial metaplasia, choroid plexus carcinomas, primary neuroendocrine carcinomas in unusual locations, special forms of sinonasal and salivary glandular adenocarcinoma, clear-cell thyroid carcinomas, unusual microscopic subtypes of pulmonary adenocarcinoma, epithelioid myomelanocytomas ("sugar tumors"), mesotheliomas, primary thymic carcinomas, endodermal choristomas of the interatrial myocardium, peripheral cholangiocarcinoma, adrenocortical carcinoma, adenocarcinomas of the urinary bladder, mucinous and "rhabdoid" tumors of the ovaries, rete testis adenocarcinomas, interdigitating dendritic-cell sarcoma of lymph nodes, selected sweat gland carcinomas, cutaneous Merkel cell carcinoma, primary dermal and subcutaneous melanoma, mucosal and visceral melanomas, epithelioid sarcoma, clear-cell sarcoma, and adamantinoma of long bones. Differential diagnostic observations are emphasized in reference to those lesions.

Differentiating peripheral cholangiocarcinoma in stages T1N0M0 and T2N0M0 from hepatic hypovascular nodules using dynamic contrast-enhanced MRI

Because cholangiocarcinoma shows no specific clinical signs or symptoms and presents with non-specific biological and tumor markers in the early stages, MRI findings often lack typical features before this lesion becomes symptomatic and might be mistaken for other liver lesions. An evaluation of relevant radiological findings in nodular cholangiocarcinoma (≤3 cm) in stages T1N0M0 and T2N0M0 is urgently needed. In our study, we compared two groups of liver hypovascular nodules and found that a distinct margin and enhanced area/nodule size >2/3 in the delayed phase were more frequently observed in cholangiocarcinoma cases than in metastatic nodule cases in which markedly high signal intensity on T2WI was common (p < 0.05). The results also revealed that in the both the portal and delayed phases, an enhanced area/nodule size >2/3 favored cholangiocarcinoma, whereas the presence of regional markedly higher SI on T2WI favored benign nodules. Furthermore, signs of peripheral washout in the delayed phase only appeared in cholangiocarcinoma cases.

Dichotomy in intrahepatic cholangiocarcinomas based on histologic similarities to hilar cholangiocarcinomas.

Intrahepatic cholangiocarcinomas were classified into two types based on their microscopic appearance. Tumors with histologic similarities to hilar cholangiocarcinomas (predominantly ductal adenocarcinomas with minor tubular components, if present, restricted to the invasive front) were defined as the perihilar type, whereas the others were classified as peripheral cholangiocarcinomas. Among the 47 cases examined in the present study, 26 (55%) were classified as the perihilar type, whereas 21 (45%) were the peripheral type. The perihilar type had higher pT stages and more frequently showed a periductal-infiltrating gross appearance and microscopic perineural infiltration than peripheral cholangiocarcinomas. The presence of low-grade biliary intraepithelial neoplasia in the adjacent bile ducts was only found in perihilar cholangiocarcinomas (6/21, 29%). The immunophenotype also differed between the two types with MUC5AC and MUC6 being more commonly expressed in the perihilar type. One-third of perihilar cholangiocarcinomas lacked the expression of SMAD4, suggesting SMAD4 mutations, whereas the loss of BAP1 expression and IDH1 mutations were almost restricted to the peripheral type (35 and 15%, respectively). Patients with perihilar cholangiocarcinoma had worse overall survival than those with peripheral cancer (P=0.027). A multivariate analysis identified the histologic classification as an independent prognostic factor (P=0.005, HR=3.638). Comparisons between intrahepatic and hilar cholangiocarcinomas also revealed that the molecular features and prognosis of perihilar cholangiocarcinomas were very similar to those of hilar cholangiocarcinomas. In conclusion, this histology-based classification scheme of intrahepatic cholangiocarcinomas will be useful and clinically relevant because it represents different underlying molecular features and has an independent prognostic value.

ROLE OF MULTIPHASE STUDY OF LIVER LESIONS ON 128 SLICE DUAL SOURCE COMPUTED TOMOGRAPHY WITH CYTOLOGY OR HISTOPATHOLOGICAL CORRELATION

Introduction: Dual source Multidetector Computed Tomography (MDCT) provides multiphase study of various liver lesions for better detection and characterization. This study aims to detect and characterize the liver lesions in multiphase Computed Tomography (CT) with cytological and histopathological correlation to confirm the diagnosis. Material and Methods: This cross-sectional study included 65 patients who were referred to the Radiology Department of Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India with clinical features jaundice, pain in abdomen, nausea and vomiting. All patients were evaluated by five phase CT (unenhanced, early and late arterial, portal venous and delayed scan)of liver with Siemens128 slice dual source spiral CT. Protocols with a scan delay of 06 seconds, 09 seconds, 45 seconds and 180-300 secondsfrom contrast bolus was preselected for early and late arterial, portovenous and delayed scans. Results: Sixty five (age 10yrs- 90yrs) patients were included in the study. Most common neoplasm was metastases 33(51%).Hepatocellular carcinoma (HCC) were 18(28%), hemangioma 10(15%), peripheral intrahepatic cholangiocarcinoma 1and 3 were nonneoplastic which included hepatic abscesses and hydatid cyst.Most common pattern of enhancement of metastasis in arterial phase was hypodense with peripheral enhancement and most were hypodense in portal venous phase. Portal venous phase had highest grade for hypovascular metastases and arterial phase had high grade to detect hypervascular metastasis. Delayed scan was better for smaller lesions less than 1cm.The sensitivity to detect metastases was 94%. Most common pattern of enhancement in HCC (variegated or heterogeneous enhancementin arterial phase with rapid washout in the portal venous phase. Total sensitivity to detect HCC was 83.3%. Hemangioma showed peripheral globular enhancement in arterial phase. In portal venous and delayed phase showed progressive enhancement with more centripetal filling. Sensitivity was 90% in case of hemangiomas. Conclusion: Multiphasic CT scan is a good non-invasive tool and can be used as first line imaging modality for differentiating benign and malignant liver lesions.

Small intrahepatic peripheral cholangiocarcinomas as mimics of hepatocellular carcinoma in multiphasic CT.

Liver transplant guidelines for diagnosing hepatocellular carcinoma (HCC) do not mandate pathologic confirmation; instead, 'classic' imaging features alone are deemed satisfactory. Intrahepatic peripheral mass forming cholangiocarcinoma (IHPMCC) is a relative contraindication for transplantation due to high rate of recurrence and poor prognosis. This study examines the imaging findings of IHPMCC, to aid in the identification and differentiation from potentially confounding cases of HCC. After IRB approval, 43 tissue-proven cases of IHPMCC on multiphase CT were retrospectively reviewed by 2 fellowship-trained radiologists. Tumor size, presence of cirrhosis, tumor capsule, vascular invasion, tumor markers, and enhancement pattern were assessed. A grading system was assigned as determined by enhancement pattern to background liver on arterial, portal venous, and equilibrium phases, ranging from typical HCC to typical IHPMCC enhancement pattern. Analysis based on our grading system shows 5 (11.6%) tumors demonstrating grade 1-2 enhancement, 9 (21%) grade 3-4 enhancement, and 29 (67.4%) grade 5 enhancement. Kruskal-Wallis test comparing CA19-9 between the five groups, Wilcoxin rank-sum test comparing tumor markers with presence or absence of tumor capsule, vascular invasion and cirrhosis, and nonparametric Pearson's correlation coefficient comparing tumor markers to tumor size were not statistically significant (p > 0.05). Typical enhancement pattern of IHPMCC consisting of arterial phase hypoenhancement with progressive, centripetal-delayed enhancement is present in the majority of cases (68%). Five cases (11.7%) showed enhancement features potentially mimicking HCC, all of which are under 3.5 cm in size. Thus, small hyperenhancing lesions in a cirrhotic liver should be carefully scrutinized in light of differing therapy options from HCC, particularly in transplant situations.